Awake insertion of the Bonfils Retromolar Intubation Fiberscope in five patients with anticipated difficult airways

Traditionally, an awake intubation is performed by flexible fiberoptic laryngoscopy. However, many new devices have been developed to assist anesthesiologists with both routine and difficult airway management, one of which is the Bonfils Retromolar Intubation Fiberscope. This device may be more beneficial than the flexible fiberoptic laryngoscope since it can readily navigate through soft tissue and physically lift airway structures, is more affordable, durable, and easier to clean. This case series demonstrates successful use of the Bonfils Scope in five patients for awake orotracheal intubation with anticipated difficult airways.     

Air Insufflation of the Stomach Following Laparoscopic Pyloromyotomy May Not Detect Perforation

Background:

Undetected perforation during laparoscopic pyloromyotomy can be fatal. Detecting a perforation at the time of laparoscopic pyloromyotomy is difficult. The purpose of this study was to determine whether air insufflation of the stomach reliably detects perforation during laparoscopic pyloromyotomy.

Case Reports:

Between 2007 and 2008, 71 patients underwent laparoscopic pyloromyotomy and 2 patients (3.3%) had perforation. Insufflating the stomach with air did not demonstrate the perforation in either case. Both perforations were detected by careful inspection of the myotomy; a small amount of mucus was seen at the perforation site. Both patients underwent open suture repair with an omental patch and had unremarkable postoperative courses.

Conclusions:

Air insufflation of the stomach during laparoscopic pyloromyotomy does not reliably rule out perforation. As with all procedures with potential complications, a high index of suspicion and careful inspection of the entire myotomy may help detect perforation.     

Teaching Residents Pediatric Fiberoptic Intubation of the Trachea: Traditional Fiberscope with an Eyepiece versus a Video-assisted Technique Using a Fiberscope with an Integrated Camera

Background: The authors' hypothesis was that a video-assisted technique should speed resident skill acquisition for flexible fiberoptic oral tracheal intubation (FI) of pediatric patients because the attending anesthesiologist can provide targeted instruction when sharing the view of the airway as the resident attempts intubation.

Methods: Twenty Clinical Anesthesia year 2 residents, novices in pediatric FI, were randomly assigned to either the traditional group (traditional eyepiece FI) or the video group (video-assisted FI). One of two attending anesthesiologists supervised each resident during FI of 15 healthy children, aged 1-6 yr. The time from mask removal to confirmation of endotracheal tube placement by end-tidal carbon dioxide detection was recorded. Intubation attempts were limited to 3 min; up to three attempts were allowed. The primary outcome measure, time to success or failure, was compared between groups. Failure rate and number of attempts were also compared between groups.

Results: Three hundred patient intubations were attempted; eight failed. On average, the residents in the video group were faster, were three times more likely to successfully intubate at any given time during an attempt, and required fewer attempts per patient compared to those in the traditional group.     

Intraaortic Balloon Assist Through Cannulation of the Ascending Aorta

This report describes a survivor and the technique of intraaortic balloon assistance through cannulation of the ascending aorta. Other sites of balloon insertion and their complications are briefly discussed. The thoracic aorta route for balloon assistance has proved effective and may well be preferable when significant aortoiliac disease exists.     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Reply to the Letter to the Editor: Not the Last Word: Rethinking the Resident Research Requirement

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