Article Notes
Matthew Smith
Although Taiwan has geographic, commercial and social proximity to China, it stands as a stark example of success in response to the SARS-CoV-II pandemic.
"Despite being close to China, Taiwan has stopped the COVID-19 with general screening strategy and encouraging people in Taiwan to wear a mask. Taiwan reported the first COVID-19 case on January 21, 2020. About 850,000 and 400,000 of Taiwan's 23 million citizens live and work in mainland China, respectively."
Many factors have contributed to this success, beginning with Taiwan's memory and lessons drawn from the 2003 SARS-I pandemic.
Two notable factors are Taiwan's national health service, with it's ubiquitous and affordable access to acute medical care:
"Taiwanese people … can go to the emergency department of the nearest hospital for relevant medical examinations (including sampling and testing for COVID-19, blood tests, and X-ray imaging test) with out-of-pocket medical expenses of less than NT$ 600 (USD 20). People with high suspicion of COVID-19 infection will be admitted to isolation wards, and those who have tested positive for COVID-19 can only be discharged home after three consecutive respiratory specimens test negative for the virus. … patients will have to pay less than NT$ 3000 (USD 100) out-of-pocket for medical services."
And their management of mask access, production and subsequent widespread public use:
"The daily production capacity of face mask manufacturers in Taiwan before the outbreak was 1.88 million face masks ... Currently, Taiwan is capable of producing 20 million face masks per day and will boost its production capacity to 25 million face masks per day."
Daniel Jolley
Why is this important?
Indications for the use of laryngeal mask airways (LMAs) increasingly challenge our airway choice for surgical procedures where endotracheal intubation has been the norm. Thyroid surgery, with its limited anaesthetic access to the airway and potential for airway obstruction, has not typically been a first choice for LMA use.
Proponents point to avoiding muscle relaxants and reducing throat pain and laryngeal trauma as the main benefits.
What did they do?
Gong and team randomised 138 ASA 1 & 2 adults to either flexible (reinforced) LMA or intubation with an ETT (7.0 or 7.5 mm). Notably any patients with surgical complexity or BMI > 30 kg/m2 were excluded. The study was single-blinded.
Concluding
The researchers reported the upper 95%-CI for estimated mean difference in peak airway pressure as +0.96 cmH2O, and for endtidal-CO2 +1.99 mmHg – neither of which are clinically significant.
They concluded that flexible-LMA was non-inferior to ETT in terms of PAP and ET-CO2.
Hang on...
The relevance of this study to most thyroid surgical patients is however limited at best. Not only were common groups of patients excluded (ie. BMI > 30) but one of the major arguments for LMA use (avoiding muscle relaxants) was irrelevant: all patients were paralysed with rocuronium.
Further, in 7% of the LMA cases severe air-leak occured and the surgical team were asked to cease or reduce tracheal traction.
Be smart
Although the journal editors conclude in their Key Points that "FLMA is a safe alternative for experienced anesthesiologists in thyroid surgery" this seems quite a stretch given that this small study was neither powered for safety and only investigated airway ventilation performance as a narrow surrogate for acceptability.
Additionally the authors themselves highlight very real surgical concerns that LMA use can distort pharyngeal anatomy with serious consequences.
Not dissimilar to arguments for LMA use in GA caesarean section, the use of an LMA for thyroid surgery edges toward 'just because we can, does not mean we should'.
Daniel Jolley
Fascinating introspection from an experienced psychiatrist on the ways the pandemic has subtly (and perhaps not-so-subtly) changed his interactions with patients and his perspective on his role as caregiver.
"...among the many unknown — and potentially positive — outcomes of the pandemic, one may be the more widespread realization that “acting like a doctor” ideally involves less acting and more authenticity."
Daniel Jolley
Why is this interesting?
Digital radiology systems (PACS) allow point-of-care enhancement and adjustment of x-ray images. 'Inverted grayscale' viewing has been advocated as a way to improve the ability to detect small pneumothoraces on posterior-anterior chest x-rays (CXR).
This case-control cross-over study challenges this practice.
What did they do?
The researchers used CXRs of 106 adult patients with a known spontaneous pneumothorax and 162 matched-controls without pneumothorax, but who had presented with pneumothorax-consistent symptoms.
Using a senior radiologist as the gold standard diagnostician, two groups of five emergency physicians were then allocated to identify the presence of a pneumothorax in all 268 CXRs – one group using inverted grayscale and the other the conventional digital view.
To ensure the groups were comparable, the researchers also had each review a random selection of both inverted and conventional images, and compared how the group diagnostic sensitivities correlated.
Bottom-line:
Surprisingly, the sensitivity of pneumothorax detection was higher for conventional imaging than when using inverted grayscale (91.7% vs 84.5%). Specificity was comparable.
Be smart…
Although the researchers showed the inferiority of isolated inverted-grayscale imaging compared to conventional, it is a technique almost always used alongside first viewing a CXR with conventional contrast. Thus even if inferior, it is unlikely to undermine the diagnostic sensitivity of standard CXR reporting.
Daniel Jolley
Figure 2 from the study shows overall recovery and for each domain between neostigmine (N) and sugammadex (S) at each time point (15 min, 40 min and Post-Op Day 1).
A significant difference was observed in physiological recovery at 15 min after surgery, but not for overall recovery or any other domain.
Daniel Jolley
Relevant from the same research group:
Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review (BMJ Open 2017).
Daniel Jolley