No abstract

Airway management in patients with periglottic tumour is a high-risk procedure with potentially serious consequences. There is no consensus on how best to secure the airway in this group of patients. We conducted a feasibility study of awake tracheal intubation using a King Vision videolaryngoscope with a channelled blade in a cohort of 25 patients, with a periglottic tumour requiring diagnostic or radical surgery. We used 10% and 4% lidocaine to topicalise the airway and midazolam and remifentanil for sedation. We recorded the success rate, number of attempts, time to obtain glottic view, time to intubation and complications. Twenty-three of the 25 patients (92%, 95%CI 75-98%) were intubated with the awake videolaryngoscope-assisted technique, with 17/23 (74%, 95%CI 54-87%) intubations achieved at the first attempt. Five patients required two and one patient, three attempts at intubation. Two patients (8%, 95%CI 2-25%) could not tolerate the procedure due to inadequate topical anaesthesia. Median (IQR [range]) times to obtain glottic view and to intubate were 19 (17-22 [10-30]) s and 49 (42-71 [33-107]) s, respectively. Traces of blood in the airway were observed in 4/25 (16%, 95%CI 6-35%) patients. Although airway management in this group of patients was expected to be difficult, successful awake intubation with the King Vision videolaryngoscope was achieved in the majority of patients within less than a minute. This study highlights a number of potential advantages of awake videolaryngoscope-assisted intubation over other awake methods of securing the airway in patients with upper airway obstruction due to periglottic mass.

BACKGROUND Reducing pain and minimising the use of opioids after caesarean section are crucial to enhancing maternal recovery and promoting mother-newborn interaction. Various techniques have been implemented to improve analgesia. We compared the analgesic efficacy of posteromedial quadratus lumborum block with that of wound infiltration following elective caesarean section. OBJECTIVE We hypothesised that within a multimodal analgesia approach, posteromedial quadratus lumborum block would, due to its potential to relieve visceral pain, result in a 15% reduction in 24-h postoperative opioid consumption compared with wound infiltration. DESIGN A double-blind, randomised, placebo-controlled clinical study. SETTING A single-centre study between August 2019 and May 2020. PATIENTS One hundred and sixteen women were randomly allocated into two groups. In the quadratus lumborum group, 20 ml 0.9% saline was injected into the surgical wound followed by bilateral posteromedial quadratus lumborum block using 20 ml 0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25% levobupivacaine was injected into the surgical wound followed by a bilateral posteromedial quadratus lumborum injection with 20 ml 0.9% saline per side. MAIN OUTCOME MEASURES The primary outcome was opioid (piritramide) consumption at 24 h. Secondary outcomes were piritramide consumption at 48 h, time-to-first analgesic request, pain scores at rest and with movement, surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation, pruritus and complications. RESULTS Piritramide consumption in 24 h was significantly lower with posteromedial quadratus lumborum block (1.5 ± 1.8 mg) than with wound infiltration (2.2 ± 1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI -1.3 to -0.03). In those who required piritramide, time-to-first analgesic request was significantly longer with posteromedial quadratus lumborum block 11 [7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scores were low, with no differences recorded at rest and with movement. There were no differences in time-to-ambulation and time-to-breastfeed between the groups. CONCLUSION As a component of multimodal post-caesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioid consumption compared with wound infiltration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04000308