BackgroundThe purpose of our study was to organize the literature regarding the efficacy of modern videolaryngoscopes in oral endotracheal intubation, then perform a quality assessment according to recommended external criteria and make recommendations for use.MethodsInclusion criteria included devices with recent studies of human subjects. A total of 980 articles were returned in the initial search and 65 additional items were identified using cited references. After exclusion of articles failing to meet study criteria, 77 articles remained. Data were extracted according to the rate of successful intubation and improvement of glottic view compared with direct laryngoscopy. Studies were classified according to whether they primarily examined subjects with normal airways, possessing risk factors for difficult direct laryngoscopy, or following difficult or failed direct laryngoscopy.ResultsThe evidence of efficacy for videolaryngoscopy in the difficult airway is limited. What evidence exists is both randomized prospective and observational in nature, requiring a scheme that evaluates both forms and allows recommendations to be made.ConclusionsIn patients at higher risk of difficult laryngoscopy we recommend the use of the Airtraq, CTrach, GlideScope, Pentax AWS and V-MAC to achieve successful intubation. In difficult direct laryngoscopy (C&L >/= 3) we cautiously recommend the use of the Airtraq, Bonfils, Bullard, CTrach, GlideScope, and Pentax AWS, by an operator with reasonable prior experience, to achieve successful intubation when used in accordance with the ASA practice guidelines for management of the difficult airway. There is additional evidence to support the use of the Airtraq, Bonfils, CTrach, GlideScope, McGrath, and Pentax AWS following failed intubation via direct laryngoscopy to achieve successful intubation. Future investigation would benefit from precise qualification of the subjects under study, and an improvement in overall methodology to include randomization and blinding.

Background: Pituitary neurosurgery executed via the transsphenoidal endonasal approach is commonly performed for pituitary adenomas. Reasons for prolonged hospital stay include postoperative headache and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to decrease 6 hours postoperative morphine PCA (patient-controlled analgesia) use by patients. Methods: Forty-nine patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block (0.5% ropivacaine with epi 1:200,000) or placebo/sham (0.9% normal saline). The primary endpoint of the study was systemic morphine PCA opioid consumption by the two groups in the first 6-hours postoperatively. The secondary endpoints included (1) pain exposure experienced postoperatively, (2) incidence of postoperative nausea and vomiting, and (3) time to eligibility for PACU discharge. Results: Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6 hours postoperatively between the block and placebo/sham groups. There was, however, a slight visual tendency in the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point and then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints. Conclusion: It was found that a 6-hour postoperative headache after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigeminovascular system and perhaps is neuro-modulated by other brain nuclei. (ClinicalTrials.gov NCT04670614, Date of Registration 17/12/2020)

Background: Pituitary neurosurgery executed via the transsphenoidal endonasal approach is commonly performed for pituitary adenomas. Reasons for prolonged hospital stay include postoperative migraine headache pain and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to reduce pain exposure and thus 6 hours post-operative morphine PCA (patient-controlled analgesia) use by patients. Methods: 49 patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block (0.5% ropivacaine with epi 1:200,000) or placebo/sham (0.9% normal saline). The primary endpoint was the pain exposure and resulting systemic morphine PCA opioid consumption by the two groups in the first 6-hours post-operatively. The secondary endpoints included (1) incidence of post-operative nausea and vomiting and (2) time to eligibility for PACU discharge. Results: Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6-hours post-operatively between the block and placebo/sham groups. There was, however, a slight visual tendency of the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints. Conclusion: 6-hour post-operative migraine headache pain after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigemino-vascular system and perhaps is neuro-modulated by other brain nuclei. ClinicalTrials.gov NCT04670614, Date of Registration 17/12/2020

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