There is a paucity of literature on extubation technique and a lack of consensus regarding the definition of smooth extubation. This narrative review paper defines an ideal extubation, otherwise known as a “smooth extubation,” reviews perioperative criteria for extubation and risks and adverse events related to extubation, and explores various perioperative techniques that can be used to achieve a smooth extubation while caring for an uncomplicated patient without significant risk factors for extubation failure. In light of the evolving practice during the SARS CoV2 (COVID-19) pandemic to minimize aerosol generation and infection transmission, smooth extubation is particularly important.

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees. Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice. Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students. Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.

Background: This survey aims to identify the relative value and the critical components of anesthesiology letters of recommendation(LORs) from the perspective of Program Directors (PDs) and Associate/Assistant Program Directors (APDs). Knowledge and insights originating from this survey might add to the understanding of the anesthesiology residency selection process and mitigate unintended linguistic biases. Methodology: Anonymous online surveys were sent to anesthesiology PDs/APDs from the Accreditation Council for Graduate Medical Education (ACGME) accredited anesthesiology residency Programs in the USA (US), as listed on the ACGME website and the American Medical Association Fellowship and Residency Electronic Interactive Database (AMA FREIDA) Residency Program Database. The survey authors were blinded to the identity of the respondents. Results: 62 out of 183 (33.8%) invited anesthesiology PDs/APDs completed the survey anonymously. In our survey, LORs are reported as more important in granting an interview than in making the rank list. 64% of respondents prefer narrative LORs. 77.4% of respondents look for specific keywords in LORs. Keywords such as ‘top % of students’ and ‘we are recruiting this candidate’ indicate a strong letter of recommendation while keywords such as ‘I recommend to your program’ or non-superlative descriptions indicate a weak letter of recommendation. Other key components of LORs include the specialty of the letter-writer, according to 84% of respondents, with anesthesiology as the most valuable specialty. Although narrative LORs are preferred, 55.1% of respondents are not satisfied with the content of narrative LORs. Conclusion: LORs containing specific keywords play an important role in the application to anesthesiology residency, particularly when submitted by an anesthesiologist. While narrative LORs are still the preferred format, most of our respondents feel they need improvements. The authors suggest specific LOR improvements including creating formalized LOR training, adding a style guide, and applying comparative scales, with standardized vocabulary in the narrative LOR.

Recent randomized clinical trials have demonstrated strong efficacy of endovascular therapy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions; in the USA alone, tens of thousands of patients annually may benefit. The impact of the type of anesthesia used during mechanical thrombectomy on patient outcomes remains controversial. This review discusses the current literature on the effects of anesthesia type on patient outcome following endovascular stroke therapy. EVT is the standard of treatment for intracranial large vessel occlusions. Recent studies show that general anesthesia is associated with negative clinical outcome in AIS patients undergoing EVT. Two of the possible mechanisms of this finding are systolic hypotension and hypocapnia. However, the only published randomized controlled studies to date, sedation vs. intubation for endovascular stroke treatment and anesthesia during stroke showed no difference in short-term clinical outcome between EVT patients treated with general anesthesia and conscious sedation and improved longer-term outcome in the general anesthesia group. Retrospective reports, and the 2015 American Heart Association/American Stroke Association Guideline (focused update of the 2013 guidelines for the early management of patients with AIS regarding endovascular treatment) based on these reports, are in favor of sedation (conscious sedation) over general anesthesia for endovascular stroke thrombectomy. However, the two randomized controlled prospective studies published provide inconclusive evidence as to the best anesthetic practice for endovascular stroke therapy. More randomized clinical trials are needed to optimize anesthetic patient care in AIS.

The aim of this study was to compare the measure of grip strength against other validated methods of measuring frailty. This was a single-center, cross-sectional study that took place at the Westchester Medical Center Pre-Procedural Testing Clinic. The patient population included n = 73 patients ≥65 years of age evaluated for elective surgery. During the study, patients’ grip strength, CFS-I (Clinical Frailty Score of Investigator), CFS-P (Clinical Frailty Score of Participant), and FRAIL (Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight) scores were measured. Grip strength correlated negatively with the CFS-I, CFS-P, and FRAIL scores for females. Reduced grip strength in females correlated with higher frailty scores and vice versa. Male grip strength showed no significant relationship with the frailty scales. In addition, multivariate linear regression analysis revealed that the independent measure that demonstrated a significant inverse association with grip strength was age (β= -0.43, p = <0.001). There exists a difference in the utility of grip strength as a measure of frailty between males and females.

Awake craniotomies for tumor resections allow for the preservation of eloquent cortex; however, they are high-risk surgeries that require careful patient selection and meticulous anesthetic management. Patients with significant preoperative language deficits may be unable to participate in intraoperative language mapping, increasing the risk of a failed surgery. Furthermore, anesthetic agents given for sedation and analgesia during the initial portion of the surgery may exacerbate existing language deficits. We present a case of an asleep-awake-asleep craniotomy for a left temporal lobe glioma using intraoperative neuronavigation, 5-aminolevulinic acid fluorescence, and awake speech mapping for a patient with a significant preoperative language deficit, for whom sedation had to be meticulously titrated to optimize intraoperative language testing. Anesthetic titration was aided by bispectral index monitoring, ultimately allowing successful awake speech mapping and tumor resection.