Ultrasound-guided sphenopalatine ganglion block for effective analgesia during awake fiberoptic nasotracheal intubation: A case report

BACKGROUND Awake fiberoptic nasotracheal intubation(AFNI)is the preferred airway ma-nagement strategy for patients with difficult airways.However,this procedure can cause significant physical and psychological distress.This case report explores the application of a sphenopalatine ganglion(SPG)block as an alternative anal-gesic modality to mitigate the discomfort associated with AFNI.CASE SUMMARY A 63-year-old female with a history of right maxillary osteosarcoma underwent craniotomy for a suspected malignant brain lesion.The patient’s medical history included prior surgery,chemotherapy,and radiation therapy,resulting in signi-ficant jaw impairment and limited neck mobility.Considering the anticipated air-way challenges,AFNI was planned.A SPG block was performed under real-time ultrasound guidance,providing effective analgesia during nasotracheal intuba-tion.CONCLUSION The SPG block represents a promising analgesic approach in AFNI,offering po-tential benefits in alleviating pain involving the nasal and nasopharyngeal regions as well as improving patient cooperation.

Awake laparoscopic cholecystectomy:A case report and review of literature

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most widely practiced surgical procedures in abdominal surgery.Patients undergo LC during general anaesthesia;however,in recent years,several studies have suggested the ability to perform LC in patients who are awake.We report a case of awake LC and a literature review.CASE SUMMARY A 69-year-old patient with severe pulmonary disease affected by cholelithiasis was scheduled for LC under regional anaesthesia.We first performed peridural anaesthesia at the T8-T9 level and then spinal anaesthesia at the T12-L1 level.The procedure was managed in total comfort for both the patient and the surgeon.The intra-abdominal pressure was 8 mmHg.The patient remained stable throughout the procedure,and the postoperative course was uneventful.CONCLUSION Evidence has warranted the safe use of spinal and epidural anaesthesia,with minimal side effects easily managed with medications.Regional anaesthesia in selected patients may provide some advantages over general anaesthesia,such as no airway manipulation,maintenance of spontaneous breathing,effective postoperative analgesia,less nausea and vomiting,and early recovery.However,this technique for LC is not widely used in Europe;this is the first case reported in Italy in the literature.Regional anaesthesia is feasible and safe in performing some types of laparoscopic procedures.Further studies should be carried out to introduce this type of anaesthesia in routine clinical practice.

Awake robotic liver surgery:A case report

BACKGROUND In recent years,minimally invasive liver resection has become a standard of care for liver tumors.Considering the need to treat increasingly fragile patients,general anesthesia is sometimes avoided due to respiratory complications.Therefore,surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach.Epidural anesthesia has been shown to reduce respiratory complications,especially in elderly patients with pre-existing lung disease.CASE SUMMARY A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma.The patient was suffering from hypertension,diabetes and chronic obstructive pulmonary disease.The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%.We planned a combined spinal–epidural anesthesia with conscious sedation to avoid general anesthesia.No modification of the standard surgical technique was necessary.Hemodynamics were stable and bleeding was minimal.The postoperative course was uneventful.CONCLUSION Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

Wide-awake结合肌骨超声下腕管综合征针刀手术治疗的临床观察

目的:观察局麻无止血带技术(wide-awake)结合肌骨超声在腕管综合征(CTS)针刀手术中的应用效果。方法:选取江西中医药大学附属医院2019年7月—2021年5月收治的CTS患者52例,随机数字表法分为观察组(n=26)和对照组(n=26),观察组使用wide-awake结合肌骨超声CTS针刀手术治疗,对照组采用传统针刀手术治疗。比较2组视觉模拟评分(VAS)、出血量、Levine腕管综合征问卷评分、肌电图指标和疗效,记录不良事件。结果:术前、术中和术后观察组患者VAS评分和术中出血量均显著低于对照组(P<0.05);术后2组Levine腕管综合征问卷功能和症状评分均明显降低(P<0.05),且观察组显著低于对照组(P<0.05);2组术后肌电图指标有显著改善(P<0.05),且观察组明显优于对照组(P<0.05);观察组疗效优于对照组(P<0.05);观察组未见不良事件,对照组不良事件1例。结论:wide-awake结合肌骨超声疗法疗效显著,可有效降低CTS针刀手术时患者的疼痛感和出血量,改善临床症状且安全性可靠。

Wide-awake技术在掌骨骨折手术中的应用

目的介绍完全清醒(Wide-awake)的无血无痛无止血带技术在掌骨骨折手术中的应用效果。方法2017年10月-2018年12月,应用Wide-awake技术对57例患者行掌骨骨折内固定术和内固定取出术,其中骨折内固定术46例(克氏针26例,空心钉11例,钢板9例),内固定取出术11例。术前的注射疼痛、术中和术后的疼痛均使用视觉模拟评分法(VAS)评估,术中评估术区出血情况,术后观察麻醉持续时间及并发症、术区皮肤的血供。结果在不使用止血带的情况下,Wide-awake技术可达到较好的止血效果,并且术前注射时仅有第一针的疼痛(VAS评分为2~4分),术中软组织操作无疼痛(VAS评分为0分),骨操作仅有轻微的疼痛(VAS评分为1~2分)。术后麻醉效果可持续2~3 h,均未出现术区皮肤的缺血坏死和麻醉并发症。结论 Wide-awake技术安全有效,无需止血带,止血效果良好,术区视野清晰,操作简单,性价比高,可广泛应用于急、门诊手术。

Awake thoracoscopic surgery under epidural anesthesia: is it really safe?

Thoracoscopic surgeries usually require single-lung ventilation under general anesthesia because of the need to obtain a sufficient working space.In patients with impaired pulmonary function,if the patient can undergo general anesthesia,a more selected collapse of the lung is considered to be beneficial for intraoperative oxygenation.The selective bronchial blockade of the lobe to be resected has been reported by several investigators （1-3）.Mukaida and coworkers first reported thoracoscopic surgery for pnenmothorax under local and epidural anesthesia in 1998 in high-risk patients contraindicated for general anesthesia （4）.

Microdialysis in awake macaque monkeys for central nervous system pharmacokinetics

Background: The brain bioavailability of novel small molecules developed to address central nervous system disease is classically documented through ex vivo or in vivo analyses conducted in rodent models. Data acquired in rodent models are, however,not easily transferrable to human as the pharmacokinetic and pharmacodynamics profiles of the species are quite different.Methods: Using drugs selected for their differential transport across the blood-brain barrier, we here demonstrate the feasibility of brain microdialysis in normal vigil macaque monkey by measuring brain extracellular fluid bioavailability of carbamazepine, digoxin, oxycodone, and quinidine.Results: All drugs, but digoxin, were found in dialysate samples. Drugs that are substrate of P-glycoprotein show a difference of bioavailability or brain pharmacokinetic parameters between rodents and primates.Conclusion: Data suggest that brain microdialysis in vigil macaque monkey, the species of choice for classic pharmacokinetic/pharmacodynamics studies could help predicting human brain bioavailability of a small molecule depending on the protein involved in the efflux transport from the brain.

Awake craniotomy for auditory brainstem implant in patients with neurofibromatosis type 2:Four case reports

BACKGROUND The auditory brainstem implant(ABI)is a significant treatment to restore hearing sensations for neurofibromatosis type 2(NF2)patients.However,there is no ideal method in assisting the placement of ABIs.In this case series,intraoperative cochlear nucleus mapping was performed in awake craniotomy to help guide the placement of the electrode array.CASE SUMMARY We applied the asleep-awake-asleep technique for awake craniotomy and hearing test via the retrosigmoid approach for acoustic neuroma resections and ABIs,using mechanical ventilation with a laryngeal mask during the asleep phases,utilizing a ropivacaine-based regional anesthesia,and sevoflurane combined with propofol/remifentanil as the sedative/analgesic agents in four NF2 patients.ABI electrode arrays were placed in the awake phase with successful intraoperative hearing tests in three patients.There was one uncooperative patient whose awake hearing test needed to be aborted.In all cases,tumor resection and ABI were performed safely.Satisfactory electrode effectiveness was achieved in awake ABI placement.CONCLUSION This case series suggests that awake craniotomy with an intraoperative hearing test for ABI placement is safe and well tolerated.Awake craniotomy is beneficial for improving the accuracy of ABI electrode placement and meanwhile reduces non-auditory side effects.

Awake fiberoptic intubation and use of bronchial blockers in ankylosing spondylitis patients

BACKGROUND Patients with ankylosing spondylitis(AS)combined with severe cervical fusion deformity have difficult airways.Awake fiberoptic intubation is the standard treatment for such patients.Alleviating anxiety and discomfort during intubation while maintaining airway patency and adequate ventilation is a major challenge for anesthesiologists.Bronchial blockers(BBs)have significant advantages over double-lumen tubes in these patients requiring one-lung ventilation.AIM To evaluate effective drugs and their optimal dosage for awake fiberoptic nasotracheal intubation in patients with AS and to assess the pulmonary isolation effect of one-lung ventilation with a BB.METHODS We studied 12 AS patients(11 men and one woman)with lung or esophageal cancer who underwent thoracotomy with a BB.Preoperative airway evaluation found that all patients had a difficult airway.All patients received an intramuscular injection of penehyclidine hydrochloride(0.01 mg/kg)before anesthesia.In the operating room,dexmedetomidine(0.5μg/kg)was infused intravenously for 10 min,with 2%lidocaine for airway surface anesthesia,and a 3%ephedrine cotton swab was used to contract the nasal mucosa vessels.Before tracheal intubation,fentanyl(1μg/kg)and midazolam(0.02 mg/kg)were administered intravenously.Awake fiberoptic nasotracheal intubation was performed in the semi-reclining position.Intravenous anesthesia was administered immediately after successful intubation,and a BB was inserted laterally.The pre-intubation preparation time,intubation time,facial grimace score,airway responsiveness score during the fiberoptic introduction,time of end tracheal catheter entry into the nostril,and lung collapse and surgical field score were measured.Systolic blood pressure(SBP),diastolic blood pressure(DBP),and heart rate(HR)were recorded while entering the operation room(T1),before intubation(T2),immediately after intubation(T3),2 min after intubation(T4),and 10 min after intubation(T5).After surgery,all patients were followed for adverse reactions such as epistaxis,sore throat,hoarseness,and dysphagia.RESULTS All patients had a history of AS(20.4±9.6 years).They had a Willson's score of 5 or above,grade III or IV Mallampati tests,an inter-incisor distance of 2.9±0.3 cm,and a thyromental(T-M)distance of 4.8±0.7 cm.The average pre-intubation preparation time was 20.4±3.4 min,intubation time was 2.6±0.4 min,facial grimace score was 1.7±0.7,airway responsiveness score was 1.1±0.7,and pulmonary collapse and surgical exposure score was 1.2±0.4.The SBP,DBP,and HR at T5 were significantly lower than those at T1-T4(P<0.05).While the values at T1 were not significantly different from those at T2-T4(P>0.05),they were significantly different from those at T5(P<0.05).Seven patients had minor epistaxis during endotracheal intubation,two were followed 24 h after surgery with a mild sore throat,and two had hoarseness without dysphagia.CONCLUSION Patients with AS combined with severe cervical and thoracic kyphosis should be intubated using fiberoptic bronchoscopy under conscious sedation and topical anesthesia.Proper doses of penehyclidine hydrochloride,dexmedetomidine,fentanyl,and midazolam,combined with 2%lidocaine,administered prior to intubation,can provide satisfactory conditions for tracheal intubation while maintaining the comfort and safety of patients.BBs are safe and effective for onelung ventilation in such patients during thoracotomy.

Intraoperative awake anesthesia applied for tumor excision in cerebral functional areas

Objective:To observe the feasibility and safety of awake anesthesia for tumor excisions in pa- tients with brain tumors involving cerebral functional areas.Methods:Fifty patients with brain tumors in- volving cerebral functional areas,ASAⅠ-Ⅱgrade,were enrolled in this study.Propofol and remifentanil were used for total intravenous anesthesia,and a laryngeal mask airway(LMA)was inserted for the air- way opening and synchronized intermittent mandatory ventilation(SIMV).At the surgeon's request for an intraoperative wake-up test,the propofol infusion was stopped advance of 10-15 min,the remifentanil in- fusion rate was decreased to 0.050-0.075μg/kg from 0.10-0.20μg/kg per min for easing surgical pain. The LMA was removed until the patient awakened.The anesthesiologist then kept up an on-going neuro- logical examination.After that,anesthesia was re-deepened and LMA was re-inserted until the whole surgery was accomplished.Results:Forty-six of 50 patients(92%)were successfully awakened and 4 (8%)failed to complete the intraoperative wake-up test because of dyspnea,over-sedation,or severe hy pertension.No severe complications occurred during the whole process.Conclusions:During the awake anesthetic period,the intraoperative wake-up test combined with navigation,evoked potential and ultra- sound techniques can help surgeons excise maximumly and precisely the brain tumors near to or in the functional areas.

A Comparative Study between Dexmedetomidine versus Fentanyl on Intubating Conditions and Side Effects during Awake Fiberoptic Nasal Intubation under Topical Anesthesia in Patients Underwent Elective Surgical Operation

Awake fiber optic intubation is the gold standard technique for management of anticipated difficult airway. In spite of availability of several sedatives, at higher doses these drugs cause respiratory depression and sensorium. This study was conducted to evaluate and compare the efficacy of Dexmedetomidine or Fentanyl for sedation during AFOI. Sixty patients, aged 20 - 40 years undergoing AFOI were made into two groups, group D Dexmedetomidine 1 mcg/kg, and group F Fentanyl 2 μg/kg, both drugs was diluted with 50 ml saline to be infused over 10 minutes). Demographic data, patient cough score, sedation score and post-intubation score were compared between two groups. Cough score ≤ 2 was 25 patients in group D compared with 2 patients in group F, post intubation score 1 in group D was 24 vs. 2 in group F, mean Ramsy sedation score in group D was 3 vs. 2.1 in group F, SpO2 ≥ 95% in group D was 28 vs. 5 patients in group F, insignificant rise in MAP from 93 to 96 mmhg in group D (P = 0.347), but there was significant rise from 92.3 to 118.18 (P ≤ 0.0001) in group F, there was significant decrease in HR from 77.4 to 71 (P = 0.005) vs. significant rise from 77 to 114 (P ≤ 0.0001) in group F. Thus, we can conclude that Dexmedetomidine provides better intubating condition, sedation, less respiratory depression and hemodynamic stability than fentanyl for AFOI, without adversely affecting airway.

Awake Craniotomy and Coaching

Background: The importance of monitoring cognition during awake craniotomy has been well described in previous studies. The relevance of being coached during such a procedure has received less attention and questions still remain unanswered about what factors are the most important herein. Objective: The aim of this study was to qualitatively analyze what factors were, according to our patients, important in being coaching during awake craniotomy. Methods: Twenty-six patients who underwent awake craniotomy received a questionnaire about their experiences during the procedure. The questions concerned different aspects of the pre-operative part, the operation itself and coaching aspects. Answers were qualitatively analyzed by two investigators and per question, different answer categories were made. Results: Two thirds of the 20 patients who responded to the questionnaire reported anxiety in the days before or during the operation, varying from general anxiety for being awake during surgery to anxiety for very specific aspects such as opening the skull. The constant presence of the neuropsychologist and a transparent communication during the procedure were most frequently (65% of all the answers) reported as helpful in staying calm. Conclusion: Results of this descriptive study show that patients experience different anxieties before and during an awake craniotomy and give more insight into what factors are important for patients in being coached during such an operation. This study gives directions for clinicians in improving their role as a coach.

Conscious Sedation and Awake Fiberoptic Intubation in a Patient with Difficult Mask Ventilation—A Case Report

Since maxillofacial malignancy is a common cause of facial defects and disfigurement of the face that may make fitting of a mask difficult and cause air leakage from the side, thus making mask ventilation difficult. In addition, distorted anatomy of the airway and base of the skull in such patients may cause difficult intubation (DI). We experienced a case with a huge facial defect due to maxillary carcinoma, in which difficult mask ventilation (DMV) and DI were predicted. After evaluation by three-dimensional airway computed tomography, the airway was secured with conscious sedation using dexmedetomidine, and awake fiberoptic intubation was safely performed. Three-dimensional airway computed tomography seems to be a good tool for successful intubation when DMV and DI are predicted.

The Dance Drama Awakeing Lion Becoming a Hit

On February 22z a national dance drama 一 A wakening Lion , which was created by the Guangzhou Song and Dance Theater, was again staged in the Guangzhou Opera House.The dance drama consists of the background of Sanyuanli Struggle against British Invaders and the core element of the national intangible cultural heritage ——Cantonese lion dance. It won the 11^th Lotus Dance Award in December 2018. And it was popular with young audiences. When it was performed firstly to the public, the tickets were quickly sold out.

Anesthetic technique for awake artery malformation clipping with motor evoked potential and somatosensory evoked potential: A case report

BACKGROUND Awake craniotomy has been widely used for tumor resection,epilepsy surgery,deep brain stimulation,and carotid endarterectomy.The report on awake artery malformation clipping is rare,especially for anesthesia management.CASE SUMMARY A 62-year-old female diagnosed with malformation of anterior cerebral artery at the right side.We clipped the artery malformation with intraoperative neuromonitoring(IONM)in awake craniotomy.Spontaneous respiration was maintained throughout the procedure by nasopharyngeal airway during the surgery successfully.CONCLUSION The technique of monitoring anesthesia care can be performed successfully for the patient with IONM.

Awake extracorporeal membrane oxygenation support for a critically ill COVID-19 patient:A case report

BACKGROUND A critically ill coronavirus disease 2019(COVID-19)patient complicated by acute respiratory distress syndrome is reported.The patient survived following treatment with awake veno-venous extracorporeal membrane oxygenation(ECMO).CASE SUMMARY A 53-year-old male patient attended our hospital following a cough for 11 d and fever for 9 d.According to his computed tomography(CT)scan and real-time reverse transcription–polymerase chain reaction assay of a throat swab,nucleic acid was positive,confirming that he had COVID-19.He was subsequently transferred to the intensive care unit due to respiratory failure.The patient received antiviral drugs,a small dose of glucocorticoid,and respiratory support,including mechanical ventilation,but the treatment effect was poor.On the 28th day after admission,veno-venous ECMO and prone position ventilation(PPV)were performed,combined with awake ECMO and other comprehensive rehabilitation measures.On the 17th day of ECMO,the patient started to improve and his chest CT and lung compliance improved.ECMO was discontinued after 27 days,and mechanical ventilation was also discontinued after 9 days.The patient was then transferred to the rehabilitation department.CONCLUSION COVID-19 can damage lung tissues and cause evident inflammatory exudation,thus affecting oxygenation function.Awake ECMO,PPV,and comprehensive rehabilitation are effective in patients with critical COVID-19 and respiratory failure.

Wide-awake麻醉技术在手部肌腱功能重建中的应用

目的介绍在手部肌腱功能重建术中使用完全清醒的无止血带局部麻醉技术(Wide-awake麻醉技术)的方法和临床疗效。方法回顾性分析2016年1月-2021年3月应用Wide-awake麻醉技术行前臂肌肉肌腱转位功能重建术治疗的31例手部功能部分丧失患者的临床资料。分别通过使用视觉模拟评分法(VAS)对局麻操作即时(第1针刺入皮肤)、术中、术后24 h的疼痛程度进行评分,术后6周采用手指总主动活动度(Total active movement,TAM)系统评价法评定功能恢复情况;观察Wide-awake技术在手术中的应用效果及患手远期功能恢复疗效。结果术中应用Wide-awake麻醉技术后,手术切口止血及麻醉效果均满意。Wide-awake麻醉技术属于局部麻醉,术中患者可按照术者要求进行主动活动患手以评价肌腱缝合质量及调节肌腱张力;术后未出现麻醉并发症,切口均一期愈合。31例均获随访,随访时间6~11个月,平均8个月,根据TAM系统评价标准:优19例,良7例,中5例,差0例,优良率为83.9%(26/31)。结论在手部肌腱功能重建手术中应用Wide-awake麻醉技术,术中及术后麻醉效果满意,远期患手功能恢复良好,且术中与患者进行沟通,可更加准确地判断肌腱重建的效果,术后未出现麻醉并发症,疗效确切且安全有效。

Wide-awake技术在示指固有伸肌腱转位修复拇长伸肌腱术中的应用

目的介绍完全清醒的无止血带局部止血麻醉(Wide a wake local anesthesia no tourniquet)技术在示指固有伸肌腱转位修复拇长伸肌腱术的应用效果。方法2019年12月-2021年2月,在完全清醒无止血带局部麻醉下对12例拇长伸肌腱损伤进行示指固有伸肌腱转位手术,术后予石膏外固定3~4周,14 d拆线,术后3周白天拆除外固定,逐渐加大康复功能训练,夜间继续佩戴外固定1周。术后对患指功能恢复情况随访。结果术后12例拇指及手背伤口均一期愈合,全部获得5个月以上随访,平均12个月。术后拇指抬高丢失0~2.4 cm,平均1.8 cm;拇指屈曲丢失0~3.0 cm,平均1.6 cm;示指背伸丢失0°~15°,平均3°。按SEEM评分标准:优8例,良3例,可1例,优良率达91.7%。结论局麻清醒技术在示指固有伸肌腱转位修复拇长伸肌腱手术中应用安全有效,术中出血少,术后临床效果好,住院时间短,值得推广。

Efficacy and safety of awake prone positioning in the treatment of non-intubated spontaneously breathing patients with COVID-19-related acute respiratory failure:A systematic review and meta-analysis

Background Since the beginning of the coronavirus disease 2019(COVID-19)pandemic,prone positioning has been widely applied for non-intubated,spontaneously breathing patients.However,the efficacy and safety of prone positioning in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure remain unclear.We aimed to systematically analyze the outcomes associated with awake prone positioning(APP).Methods We conducted a systematic literature search of PubMed/MEDLINE,Cochrane Library,Embase,and Web of Science from January 1,2020,to June 3,2022.This study included adult patients with acute respiratory failure caused by COVID-19.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines were followed,and the study quality was assessed using the Cochrane risk-of-bias tool.The primary outcome was the reported cumulative intubation risk across randomized controlled trials(RCTs),and the effect estimates were calculated as risk ratios(RRs;95%confidence interval[CI]).Results A total of 495 studies were identified,of which 10 fulfilled the selection criteria,and 2294 patients were included.In comparison to supine positioning,APP significantly reduced the need for intubation in the overall population(RR=0.84,95%CI:0.74–0.95).The two groups showed no significant differences in the incidence of adverse events(RR=1.16,95%CI:0.48–2.76).The meta-analysis revealed no difference in mortality between the groups(RR=0.93,95%CI:0.77–1.11).Conclusions APP was safe and reduced the need for intubation in patients with respiratory failure associated with COVID-19.However,it did not significantly reduce mortality in comparison to usual care without prone positioning.