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Paper 1 Answers
Published in James Wigley, Saran Shantikumar, Andrew Paul Monk, Stuart Blagg, Get Through, 2014
James Wigley, Saran Shantikumar, Andrew Paul Monk, Stuart Blagg
The LEMON assessment can be used to predict difficult intubation, as follows. L = look externally for characteristics that are known to cause difficult intubation or ventilation, such as a short, muscular neck, a receding chin or an overbite.E = evaluate the 3-3-2 rule as follows: the distance between the incisors should be 3 finger breadths; the distance between the hyoid bone and chin should be at least 3 finger breadths; and the distance between the thyroid notch and floor of the mouth should be at least 2 finger breadths. M = Mallampati score, as follows: class 1 – soft palate, uvula, fauces and pillars visible; class 2 – soft palate, uvula, fauces (but not pillars) visible; class 3 – soft palate and base of uvula visible; class 4 – hard palate only visible. O = obstruction: any cause that can cause airway obstruction, and thus make laryngoscopy and ventilation difficult (e.g. trauma, peritonsillar abscess). N = neck mobility: reduced neck mobility makes intubation difficult and immobilized patients in a hard collar (such as trauma patients in whom a cervical spine fracture has not yet been ruled out) will clearly have no neck movement.
Assessment and Examination of the Larynx
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
Jean-Pierre Jeannon, Enyinnaya Ofo
Pre-operative assessment must be carried out in order that both surgeon and anaesthetist are prewarned of potential problems. Mild to moderate chronic airway obstruction may exist undetected, as these patients may have compensated over time compared to individuals who present with acute severe airway dysfunction. The presence or absence of stridor at rest or on exertion, lying flat, or when bending down, decreased exercise tolerance and nocturnal dyspnoea when lying supine are all indicative of a problem. An assessment of the patient’s respiratory reserve is essential. Those patients with respiratory failure will tend to desaturate rapidly if there is prolonged or difficult intubation. A difficult airway can be anticipated in medical conditions such as rheumatoid arthritis, obstructive sleep apnoea, acromegaly and mucopolysaccharidosis, and in craniofacial syndromes, particularly Treacher Collins and Pierre Robin syndromes. Specific features include short neck, receding jaw, maximal mouth opening less than three fingerbreadths, inability of the lower jaw to protrude beyond the upper jaw (jaw slide) and a short thyromental distance less than three fingerbreadths indicating high larynx. The Mallampati score, which classifies visibility of oropharyngeal structures, is used to predict the ease of endotracheal intubation. The anaesthetist usually carefully assesses these specific features, but some appreciation of the potential problems by the surgeon is important. Prediction of potential airway difficulty is a complex business but can be rewarding when severe or obvious problems are identified. When there are no obvious problems, evaluation is imperfect and safe airway management depends on the adoption of a strategy that is able to respond to unexpected difficulty with intubation or oxygenation.
Nurse Led Sedation: The Clinical and Echocardiographic Outcomes of the 5-Year Emory Experience
Published in Structural Heart, 2020
Patricia Keegan, John C. Lisko, Norihiko Kamioka, Samuel Maidman, Jose N. Binongo, Jane Wei, Ratna Vadlamudi, J. Kirk Edwards, Nishant Vatsa, Aneesha Maini, Shawn Reginauld, Patrick Gleason, James Stewart, Chandan Devireddy, Peter C. Block, Adam Greenbaum, Robert A. Guyton, Vasilis C. Babaliaros
All patients deemed to be candidates for minimalist TAVR were also screened for NLS. On initial assessment, all patients were screened using the American Society of Anesthesiologists (ASA) Score and Mallampati score. An ASA score < 4 with a Mallampati score < 2 resulted in further screening to rule out a history of an adverse reaction to anesthesia. Patients with an ASA score > 4 or with a Mallampati score > 2 were referred for general anesthesia evaluation. Only patients meeting all criteria were eligible to undergo NLS. A dedicated nurse provided sedation and patient assessment for each TAVR and was not assigned other responsibilities during the procedure. The sedation nurse determined the initial dose of midazolam, up to 0.5 mg and fentanyl 12.5 mg as needed for sedation and pain control per protocol. Flumazenil and Naloxone were available in all cases (Figure 2). In accordance with Joint Commission requirements, patients were assessed every five minutes for vital signs, level of consciousness, oxygen saturation, and pain score. Level of consciousness was assessed as 0: Unconscious, 1: Sedate but responsive, and 2: Alert. The target level of sedation was 1: Sedate but responsive. Pain was patient reported and scaled from 1–10, with 10 signifying maximum pain. Analgesia was provided based on patient reported pain.
Comparison of postoperative pain scores and dysphagia between anterior palatoplasty and uvulopalatal flap surgeries
Published in Acta Oto-Laryngologica, 2018
Elvan Yüksel, Murad Mutlu, Ömer Bayır, Melike Yüceege, İstemihan Akın, Güleser Saylam, Ali Özdek, Hikmet Fırat, Mehmet Hakan Korkmaz
Detailed anamnesis was collected from the patients and their relatives who were admitted with the complaints of snoring, daytime sleepiness and/or witnessed apnea. All patients underwent routine otorhinolaryngologic examinations. In the examinations, especially, nasal structure and nasal passage opening, the condition of soft palate, the length of uvula, Mallampati score, the size of tonsilla palatina and body mass index (BMI) were evaluated. Flexible nasopharyngoscopy was performed in all patients. The degree of narrowing in retropalatal and retroglossal regions was determined with the Müller maneuver [9]. Daytime sleepiness of patients was evaluated with Epworth sleepiness scale (ESS). After all those processes were completed, the patients were directed to the Sleep Center in our hospital for PSG evaluations.
Ultrasonography versus conventional methods (Mallampati score and thyromental distance) for prediction of difficult airway in adult patients
Published in Egyptian Journal of Anaesthesia, 2020
B. S. Abdelhady, M. A. Elrabiey, A. H. Abd Elrahman, E. E. Mohamed
The study was performed at Benha University Surgical Hospital, Egypt .The study was conducted from June 2018 to January 2020.The study was approved by Institutional Ethical committee of Benha University Hospitals and was recorded on clinicaltrial.gov(NCT03799055,principal investigator: Baher Abdelhady). Written informed consent was obtained from each patient during the preoperative visit. We enrolled patients (18–60 years old) with an American Society of Anesthesiologists physical status classification score of I to III, scheduled for elective surgical procedure requiring endotracheal intubation and body mass index less than 40 kg/m2. The exclusion criteria were patient refusal, unable to give consent, pre-existing airway malformations or pathology like facial or cervical fractures, maxillofacial abnormalities, cervical tumors or goiter, history of difficult or intubation, patients with tracheostomy tubes, pregnant patients and body mass index greater than 40 kg/m2. During pre-anesthetic evaluation of the patients, demographic variables were collected from each patient and clinical screening tests to predict a difficult airway were performed in the form of Mallampati score, thyromental distance and ultrasonographic measured distance from skin to epiglottis (DSE). During Mallampati score assessment, patients were seated, head held in neutral position, mouth open as wide as possible and tongue protruded out maximally and patients were instructed not to speak. Thyromental distance (in centimeters) was measured with the patient’s neck fully extended with closed mouth. Distance was measured from the thyroid notch to the tip of the mentum.