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The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article. Potential conflicts of interest for all group members in the past 5 years were compiled and distributed before the first conference call. Last, group members were reminded that conflicts of interest extend beyond financial relationships and may include personal experiences, how a participant earns a living, and the participant’s previously established “stake” in an issue., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

We present a unique, practical, and safe approach to the clinical management of a young male with a large tongue hemangioma who presented for serial surgical treatment of the lesion. Laser ablation was undertaken in the operating room under topical anesthesia with remifentanil analgosedation without the use of supplemental oxygen. Significant involution of the hemangioma was achieved without complication while the patient was awake, cooperative, and able to protect his airway. The application of remifentanil infusion for analgosedation during airway surgery is described. The utility of pharmacokinetic modeling in these applications is discussed along with the use of non-invasive respiratory inductance plethysmography to monitor ventilation during opioid sedation. The concept of analgosedation for airway surgery is introduced and relative risk versus benefit considerations of the approach in comparison to general anesthesia are discussed. This approach can be conceived of as an ORL endoscopy suite model for limited airway procedures. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Spontaneous breathing is the default mode of ventilation for procedures in gastrointestinal (GI) endoscopy. Sedative–hypnotic medications profoundly impair respiratory control and airway patency. Fundamental physiology of hypoventilation is reviewed in the context of the patient presenting for interventional endoscopy. The endoscopy setting presents unique challenges for airway management and ventilation. These include a shared airway, patient-positioning, and out-of-Operating Room location. Strategies to support airway patency, oxygenation, and ventilation that are commonly employed in the controlled setting of the operating room can be effectively adapted to the GI endoscopy suite. Techniques discussed include nasal airway devices/CPAP, pressure-support ventilation, jet ventilation, and inhaled mask anesthesia. Endoscopic procedures are amenable to a variety of approaches for airway management, maintenance of oxygenation, and ventilation. Important considerations include (1) patient comorbidities, (2) nonstandard positioning, (3) the concept of a shared airway, (4) anesthetic-associated respiratory depression and upper airway collapse, and (5) type and duration of the procedure (lower endoscopy, upper endoscopy, or ERCP). This review provides practical strategies while addressing elements of basic physiology for the anesthesia provider in the GI endoscopy setting. [Copyright &y& Elsevier]

Study Objective: Wrong-site nerve blocks (WSBs) are a significant, though rare, source of perioperative morbidity. WSBs constitute the most common type of perioperative wrong-site procedure reported to the Pennsylvania Patient Safety Authority. This systematic literature review aggregates information about the incidence, patient consequences, and conditions that contribute to WSBs, as well as evidence-based methods to prevent them.Design: A systematic search of English-language publications was performed, using the PRISMA process.Main Results: Seventy English-language publications were identified. Analysis of four publications reporting on at least 10,000 blocks provides a rate of 0.52 to 5.07 WSB per 10,000 blocks, unilateral blocks, or "at risk" procedures. The most commonly mentioned potential consequence was local anesthetic toxicity. The most commonly mentioned contributory factors were time pressure, personnel factors, and lack of site-mark visibility (including no site mark placed). Components of the block process that were addressed include preoperative nerve-block verification, nerve-block site marking, time-outs, and the healthcare facility's structure and culture of safety.Discussion: A lack of uniform reporting criteria and divergence in the data and theories presented may reflect the variety of circumstances affecting when and how nerve blocks are performed, as well as the infrequency of a WSB. However, multiple authors suggest three procedural steps that may help to prevent WSBs: (1) verify the nerve-block procedure using multiple sources of information, including the patient; (2) identify the nerve-block site with a visible mark; and (3) perform time-outs immediately prior to injection or instillation of the anesthetic. Hospitals, ambulatory surgical centers, and anesthesiology practices should consider creating site-verification processes with clinician input and support to develop sustainable WSB-prevention practices. [ABSTRACT FROM AUTHOR]