Klippel-Feil Syndrome (KFS) continues to pose significant challenges for anesthesiologists. Beyond the expected complexities of managing difficult airways in these patients, they often present with systemic anomalies that can elevate the risk of morbidity during surgeries conducted under anesthesia. Furthermore, laparoscopic procedures bring about additional physiologic changes that must be taken into consideration when planning the anesthetic care for these individuals. This report details the anesthetic management of a 29-year-old female diagnosed with Klippel-Feil Syndrome (KFS) and concomitant Müllerian duct aplasia-Renal agenesis-Cervicothoracic Somite dysplasia (MURCS) as well as Chiari Type 1 Malformation, who underwent a successful pelvic laparoscopic surgery. The airway was secured through awake fiberoptic-guided intubation while general anesthesia was maintained with a combination of sevoflurane inhalation and remifentanil infusion. Intraoperatively, the team prioritized neuroprotection, lung-protective ventilation strategies, and renal preservation measures. The anesthetic management of patients with KFS necessitates a comprehensive assessment of their anomalies. Incorporating these considerations into the anesthetic management will help mitigate the procedure's adverse effects and lead to favorable patient outcomes.
Anesthesia ; Airway Management ; Klippel-Feil Syndrome ; Laparoscopy

OBJECTIVE: To review the research progress of injection sites of local infiltration analgesia (LIA) in total knee arthroplasty (TKA). METHODS: The relevant domestic and foreign literature in recent years was extensively reviewed. The neuroanatomy of the knee, and the research progress of the selection and the difference of effectiveness between different injection sites of LIA in clinical studies were summarized. RESULTS: Large concentrations of nociceptors are present throughout the various tissues of the knee joint. Patellar tendon, subpatellar fat pad, lateral collateral ligament insertions, iliotibial band insertions, suprapatellar capsule, and posterior capsule were more sensitive to pain. Most current studies support injections into the lateral capsule, collateral ligament, retinaculum, quadriceps tendon, fat pad, and subcutaneous tissue. Whether to inject into the back of the knee and subperiosteum is controversial. CONCLUSION The relative difference of knee tissue sensitivity to pain has guiding significance for the selection of LIA injection site after TKA. Although researchers have conducted clinical trials on injection site and technique of LIA in TKA, there are certain limitations. The optimal scheme has not been determined yet, and further studies are needed.
Humans ; Arthroplasty, Replacement, Knee/methods* ; Pain, Postoperative/prevention & control* ; Pain Management/methods* ; Analgesia/methods* ; Knee Joint/anatomy & histology* ; Anesthesia, Local/methods*

According to literature reports, the injury rate of the athletes in Olympic Winter Games recent years was as high as 10%-14%. Combined with the background of corona virus disease 2019 (COVID-19), the medical insurance work of the 24th Olympic Winter Games held in Beijing had put forward more complicated requirements and more severe challenges. In order to better optimize anesthesia management, this article summarized the perioperative treatment of athletes in Olympic Winter Games, the safety protection strategy of medical staff under general anesthesia, and the potential impact of peri-operative drugs on athletes. Anesthesiologists, as the core members of the rescue team, should be familiar with the particularity of operative anesthesia of athletes, sum up relevant experience to ensure the safety of perioperative patients. So all kinds of technical measures should be taken in the process of operation to minimize the indoor pollution caused by the patient's cough. For example, all the patients should wear N95 masks from the ward to the operating room, and after the operation, wear the N95 masks back to the ward. Although the International Olympic Committee had banned more than 200 drugs for participants and athletes who had to strictly follow International Olympic Committee requirements during anesthesia, the athletes were no longer participating in this Olympic Winter Games, so opioids (sufentanil and remifentanil) and glucocorticoid (dexamethasone) could be used according to the actual needs of surgery and anesthesia. Five athletes in Yanqing competition area underwent surgical anesthesia in Peking University Third Hospital Yanqing Hospital. All the five patients received general anesthesia, of whom four underwent orthopaedic surgery and one underwent laparoscopic cholecystectomy. General anesthesia with laryngeal mask airway was the first choice in the five patients. And the pain after orthopaedic surgery was severe and nerve block technique could effectively relieve the pain after surgery. Three patients received ultrasound-guided nerve block analgesia, the postoperative analgesia lasted 36 h. After the operation, non-steroidal anti-inflammatory drug (NSAID) was infused intravenously in the ward and all the patients recovered uneventfully. As the core member of the trauma rescue team, anesthesiologists should be familiar with the particularity of the athletes' surgical anesthesia, do a good job in medical security, and summarize relevant experience to ensure the life safety of the perioperative patients.
Anesthesia/methods* ; Anniversaries and Special Events ; Athletic Injuries/surgery* ; Beijing/epidemiology* ; COVID-19/prevention & control* ; Humans ; Pain Management/methods* ; Sports

INTRODUCTION: General anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia and aspiration. The aim of this retrospective review was to define the incidence of failed and difficult intubation in parturients undergoing general anaesthesia for Caesarean delivery at a high-volume obstetric hospital in Singapore. METHODS: All parturients who underwent Caesarean delivery under general anaesthesia from 2013 to 2016 were identified and their medical records were reviewed to extract pertinent data. Difficult intubation was defined as 'requiring more than one attempt at intubation or documented as such, based on the opinion of the anaesthetist'. A failed intubation was defined as 'inability to intubate the trachea, with subsequent abandonment of intubation as a means of airway management'. RESULTS: Records of 660 Caesarean sections under general anaesthesia were extracted. The mean age of the parturients was 32.1 ± 5.5 years and the median body mass index was 27.5 (interquartile range 24.6-31.1) kg/m². Rapid sequence induction with cricoid pressure was employed for all patients, with thiopentone and succinylcholine being administered for 91.2% and 98.1% of patients, respectively. There were 33 difficult intubations among 660 patients, yielding an incidence of 5.0%. Junior trainees performed about 90% of all intubations and 28 (84.8%) out of 33 difficult intubations. Repeat intubations were performed by senior residents/fellows (57.1%) and consultants (14.3%). No instance of failed intubation was reported. CONCLUSION The local incidence of difficult obstetric intubation was one in 20. No failure of intubation was observed.
Adult ; Airway Management ; Anesthesia, General ; Cesarean Section ; Female ; Humans ; Intubation, Intratracheal ; Pregnancy ; Retrospective Studies

Fiberoptic-guided intubation (FOI) has been an indispensable component of difficult airway management especially in instances where anatomical limitations precluded use of conventional direct laryngoscopy. Its use, however, is not without risks.

This paper presents a 4-year-old female with a limited mouth opening scheduled for an elective oral commissurotomy who developed signs and symptoms of tension pneumothorax immediately following a successful fiberoptic nasotracheal intubation. Passive insufflation of high-flow oxygen through a flexible fiberoptic bronchoscope preloaded with a tight-fitting endotracheal tube led to accumulation of air. This caused lung hyperinflation and subsequently, pneumothorax.

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.
Airway Management ; methods ; Airway Obstruction ; complications ; Anesthesia ; methods ; Bronchoscopy ; methods ; Equipment Design ; Fiber Optic Technology ; Humans ; Intubation, Intratracheal ; instrumentation ; methods ; Laryngoscopes ; Manikins ; Obesity ; complications ; Respiratory System ; Skull Fractures ; complications

INTRODUCTION: Paediatric epidurals can present technical challenges due to wide variations in age and weight among children, ranging from neonates to teenagers. This study evaluated the skin-to-epidural distance in the thoracic and lumbar regions to determine the relationship between age, weight and ethnicity and depth to the epidural space in our Singapore paediatric population. METHODS: Data from the Acute Pain Service was prospectively collected over 16 years. Details included patient demographics, level of epidural performed and distance from skin to epidural space. Multivariable regression analysis was performed to determine the association of weight, age, ethnicity and gender with the depths to the thoracic and lumbar epidural spaces. A simple linear regression was calculated to predict the depth to both thoracic and lumbar epidural spaces based on body weight. Equations were formulated to describe the relationship between weight and depth of epidural space. RESULTS: A total of 616 midline epidurals were studied. Regression analysis was performed for 225 thoracic epidurals and 363 lumbar epidurals. Our study revealed a clear correlation between skin-to-lumbar epidural distance and weight in children. The best correlation was demonstrated between skin-to-lumbar epidural distance and body weight (R = 0.729). This relationship was described by the formula: depth (mm) = (0.63 × weight [kg]) + 9.2. CONCLUSION Skin-to-lumbar epidural distance correlated with weight in children. Our results highlighted the clinical significance of differences between Southeast Asian paediatric populations when compared to other populations.
Adolescent ; Anesthesia, Epidural ; adverse effects ; methods ; Body Weight ; Child ; Child, Preschool ; Epidural Space ; anatomy & histology ; Female ; Humans ; Infant ; Infant, Newborn ; Lumbar Vertebrae ; anatomy & histology ; Male ; Multivariate Analysis ; Pain Management ; methods ; Pediatrics ; methods ; Regression Analysis ; Singapore ; Skin ; anatomy & histology ; Thoracic Vertebrae ; anatomy & histology

STUDY DESIGN: Prospective, randomized, double blind, placebo-controlled study.PURPOSE: To compare clonidine and pregabalin with placebo for the attenuation of postoperative pain after thoracolumbar spinal surgery and instrumentationOVERVIEW OF LITERATURE: Spine surgery is associated with moderate to severe postoperative pain that needs to be controlled to improve patient’s outcome. Alpha 2 agonists (e.g., clonidine) and gabapentenoids (e.g., pregabalin) are successfully used as part of a multimodal analgesic regimen.METHODS: Total 75 patients were enrolled and randomly allocated into three groups. Group P received pregabalin (150 mg), group C received clonidine (150 mcg), and group N received placebo 90 minutes preoperatively. A standard anesthesia protocol comprising fentanyl, thiopentone, vecuronium, nitrous oxide, and oxygen in isoflurane was used for all patients. Postoperative recovery profile, pain, time for first analgesic, 24-hour analgesic requirement, sedation, and hemodynamic parameters were noted.RESULTS: Recovery profile was similar in all three groups; however, the patients in group P and C were more sedated (p<0.05). Group N patients had a higher Visual Analog Scale (VAS) score (p<0.05) and the time for first analgesic was also lower (p=0.02). Postoperative (24-hour) analgesic requirement was maximum in group N, followed by that in group C and group P. The VAS score was highest in the control group; however, after 12 hours, it was similar in all groups.CONCLUSIONS: Postoperative pain and analgesic requirement is significantly attenuated by preoperative administration of a single dose of clonidine (150 mcg) or pregabalin (150 mg); pregabalin was more effective. Thus, their use offers a reasonable strategy for pain management in patients undergoing spine surgery.
Analgesics ; Anesthesia ; Clonidine ; Fentanyl ; Hemodynamics ; Humans ; Isoflurane ; Nitrous Oxide ; Oxygen ; Pain Management ; Pain, Postoperative ; Pregabalin ; Prospective Studies ; Spine ; Thiopental ; Vecuronium Bromide ; Visual Analog Scale

BACKGROUND: Air-QⓇ laryngeal mask airway (LMA) is a second-generation supraglottic airway device (SAD) providing adequate airway control despite the unfavorable airway anatomy in children. Several studies have assessed it as a conduit for tracheal intubation and compared its efficacy with that of other SADs, but there are no studies comparing the laryngeal view with midline and rotational insertion techniques of Air-Q. Therefore, this study compared the fiber-optic bronchoscopic (FOB) assessment of the Air-Q position using these two insertion techniques.METHODS: This randomized controlled trial included 80 patients of the American Society of Anesthesiologists physical status I/II of either sex (age group 5–12 years, weight 10–30 kg), who were scheduled for elective surgery in the supine position under general anesthesia. The patients were randomly subjected to rotational and midline technique groups (n = 40, each), and appropriate sized Air-Q, based on the weight of the patient, was inserted using the technique allocated to each patient. Time taken and number of attempts for successful insertion of the devices and any complications after removal of device were studied.RESULTS: FOB grade 1 (ideal position) was seen in 29/40 (72.5%) and 19/40 (47.5%) children subjected to the rotational and classic midline techniques, respectively (P = 0.045). The time taken to successfully insert the Air-Q was significantly lesser in the rotational technique group (7.2 ± 1.5 s) than in the classic midline technique group (10.2 ± 2.1 s) (P < 0.001), whereas complications were similar in both groups.CONCLUSIONS: The rotational technique was associated with better FOB view, and was faster than the classic midline technique of Air-Q insertion in pediatric patients.
Airway Management ; Anesthesia, General ; Child ; Humans ; Intubation ; Laryngeal Masks ; Prospective Studies ; Supine Position

High-flow nasal oxygenation (HFNO) is a promising new technique for anesthesiologists. The use of HFNO during the induction of anesthesia and during upper airway surgeries has been initiated, and its applications have been rapidly growing ever since. The advantages of this technique include its easy set-up, high tolerability, and its abilities to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide to some extent. HFNO, via a nasal cannula, can provide oxygen both to patients who can breathe spontaneously and to those who are apneic; further, this technique does not interfere with bag-mask ventilation, attempts at laryngoscopy for tracheal intubation, and surgical procedures conducted in the airway. In this review, we describe the techniques associated with HFNO and the advantages and disadvantages of HFNO based on the current state of knowledge.
Airway Management ; Anesthesia ; Anoxia ; Carbon Dioxide ; Catheters ; Humans ; Intubation ; Intubation, Intratracheal ; Laryngoscopy ; Oxygen ; Ventilation