BACKGROUND: Endobronchial ultrasound (EBUS) is widely used to diagnose lung cancer. Monitored anesthesia care (MAC) can enhance patient comfort and procedural conditions during EBUS. EBUS under MAC is usually safe but can lead to various complications.
METHODS: A 34-year-old male who had increased sputum for two months showed an enlarged paratracheal lymph node and planned for lymph node biopsy by EBUS. During EBUS under MAC, an unexpected oxygen saturation decline required intervention. After intubation, copious frothy fluid was suctioned from the bronchi, and oxygenation was recovered. A narrowed trachea and the EBUS bronchoscope might have resulted in upper airway obstruction, and suction performed under these conditions might have caused pulmonary edema. The patient received non-invasive ventilation and high-flow nasal cannula and recovered without complications.
CONCLUSIONS: When there is an expected risk of upper airway obstruction during EBUS, careful preoperative evaluation and preparation are essential to prevent negative pressure pulmonary edema.

UNASSIGNED: Induction of anesthesia for emergency procedures, without prior gastric preparation and incomplete fasting, is associated with the risk of reflux of stomach contents and aspiration. This study aimed to evaluate the effect of intravenous (IV) metoclopramide administration on gastric emptying in opium users, candidate for procedural sedation and analgesia (PSA).
UNASSIGNED: In the present case-control study, opium-dependent (case) and non-dependent (control) patients in need of PSA were administered with 10 mg IV metoclopramide after undergoing gastric ultrasonography for determination of its area and contents. Then, 30 minutes after the administration of metoclopramide, the area and contents of the stomach were measured again and compared with the measures obtained before the intervention.
UNASSIGNED: 135 patients were evaluated in three groups of 45, including the case, control, and placebo groups. The three groups were similar regarding mean age (p = 0.068), sex (p = 0.067), weight (p = 0.596), height (p = 0.671), body mass index (BMI) (p = 0.877), duration of fasting (p = 0.596), and type of gastric contents (p = 0.124). Mean antral cross-sectional area (CSA) of the study participants in the case, control, and placebo groups before the administration of the drug was 8.49 ± 1.40, 8.31 ± 2.56, and 6.56 ± 1.72 cm2, respectively. Mean gastric area in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention. Mean antral gastric grade of gastric contents in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention.
UNASSIGNED: It seems that metoclopramide administration in opium users in need of PSA leads to a significant decrease in mean gastric area and increases gastric emptying.

BACKGROUND: In most cases, palliative care is prescribed to adults diagnosed with cancer. The definition of the most suitable therapy for an effective sedation in terminal cancer patients still represents one of the most challenging goals in medical practice. Due to their poor health, the correct dosing of drugs used for deep palliative sedation in terminal cancer patients, often already on polypharmacological therapy, can be extremely complicated, also considering possible drug-to-drug interactions that could lead to an increased risk of overdose and/or incongruous administration with fatal outcomes. The case of a terminal cancer patient is presented, focusing on the \"adequacy\" of administered therapy.
METHODS: A young male, affected by Ewing sarcoma, attending a palliative care at his own home, died soon after midazolam administration. Toxicological and histological analyses were performed on body fluids and organ fragments.
CONCLUSIONS: Morphological reliefs evidenced a neoplastic mass, composed of lobulated tissue with a lardy, pinkish-gray consistency, extending from the pleural surface to the lung parenchyma, also present at the sacrum region (S1-S5), at the anterior mediastinum level, occupying the entire left pleural cavity, and infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. The brain presented edema and congestion. Toxicological analyses evidenced blood midazolam concentrations in the range of 0.931-1.690 µg/mL, while morphine was between 0.266 and 0.909 µg/mL. Death was attributed to cardiorespiratory depression because of a synergic action between morphine and midazolam. The pharmacological interaction between midazolam and morphine is discussed considering the clinical situation of the patient. The opportunity to proceed with midazolam administration is discussed starting from guidelines recommendation. Finally, professional liability outlines are highlighted.

UNASSIGNED: Palliative sedation is sometimes interrupted by undesired arousals. Pupillometry has been used in anesthesiology to monitor pain and sedation but has never been used during palliative sedation.
UNASSIGNED: A 48 years-old patient, with multi-metastatic cancer, underwent palliative sedation to manage global suffering. On the second day, the patient experienced arousal which required medication adjustments to ensure pain relief and increased sedation.
UNASSIGNED: Depth of sedation is monitored with clinical scales, such as the Richmond Agitation-Sedation Scale. But these scales do not measure brain stem activity and are poor at predicting arousal.
UNASSIGNED: During palliative sedation, an infrared pupillometer was used to monitor pupil size and pupillary reactivity (Neurolight®, IDMed®, Marseille, France).
UNASSIGNED: The pupillary light reflex was depressed during deep sedation. In our case, we observed a low-normal reflex along with dilated pupil before arousal.
UNASSIGNED: Our case suggests that reflex intensity and pupil size might predict arousals during palliative sedation.
UNASSIGNED: Prospective studies are needed to confirm our findings. Pupillometry\'s acceptability should also be questioned from patient\'s, families\', and caregivers\' perspectives.

Although the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. Acute respiratory distress syndrome due to SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus 2) often requires intensive care follow-up. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement. The pandemic has raised many challenges in managing critically ill older adults, a population preferentially killed by COVID-19. The mortality and morbidity rates are extremely high in critically ill patients with COVID-19. Recent studies have reported the potential development of a hypercoagulable state in COVID-19. Viral infections and hypoxia may cause these state. It is increasingly reported that thromboembolic events are associated with a poor prognosis. Due to these thromboembolic complications, COVID-19 patients often have neurological symptoms. These symptoms may not be observed in intensive care patients who are sedated. We report one case who was sedated COVID-19 pneumonia and who was later diagnosed with cerebral venous thrombosis with cranial imaging when he could not awaken even though sedation was discontinued. Since COVID-19 causes intense thrombotic susceptibility due to cytokine storm, cerebrovascular thromboembolic complications associated with COVID-19 infection should be considered first and foremost for unconsciousness ventilated patients. Severe and potentially cerebral thrombosis may prolong the patient´s stay in intensive care.

Bronchiolitis obliterans is rarely described in the nonlung transplant anesthesia literature. This case report describes a 27-year-old female patient with idiopathic bronchiolitis obliterans and dental anxiety who safely received intravenous deep sedation using diphenhydramine, dexmedetomidine, and ketamine in an ambulatory community dental clinic. This report outlines the anesthetic plan developed following a thorough preoperative assessment and review of the key anesthetic considerations of idiopathic bronchiolitis obliterans (eg, potential respiratory complications and appropriateness for the ambulatory dental environment) and discusses the careful anesthetic management of this patient using deep sedation to facilitate comprehensive restorative dentistry.

BACKGROUND: There have been a few reports on the early rehabilitation of patients with coronavirus disease (COVID-19), and none on the effectiveness and adverse events of early mobilization for mechanical ventilation patients (other than COVID-19) during deep sedation. This report indicates that sitting without adverse events is possible in patients with severe COVID-19 pneumonia during deep sedation with muscle relaxation.
METHODS: A 65-year-old man with a history of diabetes mellitus, lacunar infarction, and Parkinson\'s disease was admitted to a local hospital for pneumonia due to COVID-19. After admission, the patient was managed on a ventilator under deep sedation with muscle relaxants and sedatives. Twelve days after admission, the patient was transferred to our hospital due to his worsening respiratory status.
METHODS: Pneumonia due to COVID-19 was diagnosed using a polymerase chain reaction-dependent method.
METHODS: The day following transfer, a physical therapist started passive range of motion training and sitting.
RESULTS: The period spanning his initial rehabilitation to muscle relaxant medication interruption was 9 days, and he underwent 7 rehabilitation sessions. The patient was unable to sit during only one of the 7 sessions due to pre-rehabilitation hypoxemia. In 5 of the 6 sitting sessions, PaO2/FiO2 transiently decreased but recovered by the time of subsequent blood sampling. The patient\'s PaCO2 decreased during all sessions. His blood pressure did not drastically decrease in any sitting session, except the first. Sputum excretion via sputum suction increased during sitting, and peak inspiratory pressure did not change.
CONCLUSIONS: The patient eventually died of pneumonia due to COVID-19. However, sitting during deep sedation with muscle relaxants did not cause any serious adverse events nor did it appear to cause obvious negative respiratory effects.

Patients with burns to the head and neck may be difficult to intubate or ventilate via facemask. Furthermore, post-burn scarring and microstomia may reduce the success of rescue supraglottic airway placement. While awake tracheal intubation using a flexible intubation scope is considered the optimal technique for these patients, it may not always be feasible in the pediatric population. We report a case of successful management of a difficult airway in a child with extensive post-burn head and neck deformity using a noninvasive positive pressure system to aid with inhalational induction and deep sedation during intubation using a flexible scope.

UNASSIGNED: Fiberoptic intubation is a powerful and safe technique to deal with airway difficulty, but it requires a lot of training to be able to perform correctly. There are various specialized oral airways for fiberoptic intubation, but none of them have perfect functionality.
UNASSIGNED: A 75-year-old male (body weight 71.6 kg, height 159.3 cm, body mass index 28.22 kg/m2) was diagnosed with acute appendicitis, and it was decided to do a laparoscopic appendectomy. After the induction of general anesthesia, it was impossible to insert the direct laryngoscope deep enough for vocal cord visualization without damaging the teeth because of limited mouth opening. We successfully performed fiberoptic intubation with a newly modified Guedel airway via a longitudinal channel on the convex side and a distal opened lingual end.
UNASSIGNED: Our modified Guedel airway can be useful in assisting fiberoptic intubation in unexpectedly difficult airway situations.

UNASSIGNED: The ongoing coronavirus pandemic is challenging, especially in severely affected patients who require intubation and sedation. Although the potential benefits of sedation with volatile anesthetics in coronavirus disease 2019 patients are currently being discussed, the use of isoflurane in patients with coronavirus disease 2019-induced acute respiratory distress syndrome has not yet been reported.
UNASSIGNED: We performed a retrospective analysis of critically ill patients with hypoxemic respiratory failure requiring mechanical ventilation.
UNASSIGNED: The study was conducted with patients admitted between April 4 and May 15, 2020 to our ICU.
UNASSIGNED: We included five patients who were previously diagnosed with severe acute respiratory syndrome coronavirus 2 infection.
UNASSIGNED: Even with high doses of several IV sedatives, the targeted level of sedation could not be achieved. Therefore, the sedation regimen was switched to inhalational isoflurane. Clinical data were recorded using a patient data management system. We recorded demographical data, laboratory results, ventilation variables, sedative dosages, sedation level, prone positioning, duration of volatile sedation and outcomes.
UNASSIGNED: Mean age (four men, one women) was 53.0 (± 12.7) years. The mean duration of isoflurane sedation was 103.2 (± 66.2) hours. Our data demonstrate a substantial improvement in the oxygenation ratio when using isoflurane sedation. Deep sedation as assessed by the Richmond Agitation and Sedation Scale was rapidly and closely controlled in all patients, and the subsequent discontinuation of IV sedation was possible within the first 30 minutes. No adverse events were detected.
UNASSIGNED: Our findings demonstrate the feasibility of isoflurane sedation in five patients suffering from severe coronavirus disease 2019 infection. Volatile isoflurane was able to achieve the required deep sedation and reduced the need for IV sedation.