Journal of Clinical Anesthesia

Editorial Board

2012-02-01

Does anesthetic technique influence cancer?

Mark J. Young, Theodore A. Alston — 2011-12-08

The spread of cancer involves a plethora of factors, all of which may be influenced by anesthesia. In most cases, significant exposure to anesthesia is of brief duration. However, the timing of anesthesia for oncologic surgery coincides with the stirring of the hornet's nest. It is thus intriguing to wonder if anesthesia technique has an impact on disease recurrence. Definitive clinical trials of this question will be technically formidable, but in this issue of the Journal of Clinical Anesthesia Drs. Conrick-Martin, Kell, and Buggy offer an interesting meta-analysis of a carefully chosen aspect of the overall question . They ask whether lymphocytes active against neoplastic cells are more detectable in cases in which epidural or intrathecal anesthesia/analgesia was performed in order to spare opioids.

Meta-analysis of the effect of central neuraxial regional anesthesia compared with general anesthesia on postoperative natural killer T lymphocyte function

Ian Conrick-Martin, Malcolm R. Kell, Donal J. Buggy — 2012-02-01

Abstract: Study Objective: To compare the effect of central neuraxial (spinal or epidural) anesthesia with general anesthesia on postoperative natural killer (NK) T lymphocyte function.Design: Meta-analysis.Setting: University-affiliated hospital.Measurements: A systematic search of the medical literature from 1966 to 2009 yielded 5 eligible studies with a total of 184 patients who received neuraxial blockade. Natural killer T lymphocyte function was studied.Main Results: There was significant heterogeneity between the studies [I2 = 94.4% (95% CI= 90.3-96.2%)]. Overall fixed-effect odds ratio was 0.86 (0.66-1.14, P = 0.25). The random-effect odds ratio was 1.13 (0.26-4.92, P = 0.79).Conclusion: Anesthetic technique does not appear to significantly affect postoperative NK T lymphocyte function. Given the heterogeneity observed, further clinical studies in cancer patients of the effect of anesthetic technique on immune function in general, and NK T lymphocyte function in particular, are needed.

The optimal dose of esmolol and nicardipine for maintaining cardiovascular stability during rapid-sequence induction

Young-Eun Moon, Sang-Hoon Lee, Jaemin Lee — 2011-06-23

Abstract: Study Objective: To determine the optimal dose of esmolol in combination with nicardipine in effectively blocking undesirable cardiovascular responses during rapid-sequence induction.Design: Prospective, randomized clinical comparison study.Setting: Operating room of a university hospital.Patients: 200 ASA physical status 1 and 2 patients requiring general anesthesia with endotracheal tube placement.Interventions: Patients were randomly allocated into one of 4 groups: Group E0 (no esmolol; control), Group E0.25 (esmolol 0.25 mg/kg), Group E0.5 (esmolol 0.5 mg/kg), and Group E1.0 (esmolol 1.0 mg/kg). All patients received 20 μg/kg of nicardipine, and esmolol was then given according to group allocation. Ninety seconds later, thiopental sodium 5 mg/kg and succinylcholine 1.0 mg/kg were injected. Endotracheal intubation was performed 60 seconds after injection of the anesthetic agents.Measurements: Systolic (SBP), diastolic (DBP), and mean arterial (MAP) pressures; heart rate (HR), and rate-pressure product (RPP) were measured 30 seconds before and after intubation, and at 1, 3, 5, and 10 minutes after intubation. Rate changes using baseline values as the standard [rate changes = measured value/baseline value × 100 (%)] were calculated.Main Results: Significant attenuations in SBP, MAP, HR, and RPP after intubation were noted in the experimental groups as compared with the control group (P < 0.05). Rate changes in HR in Groups E0.5 and E1.0 were significantly lower than those in Group E0.25 immediately and one minute after intubation (P < 0.05). No difference in rate changes in HR were noted between the E0.5 and E1.0 groups.Conclusions: The combination of nicardipine 20 μg/kg and esmolol 0.5 mg/kg most effectively attenuates the cardiovascular responses during rapid-sequence induction.

Perioperative considerations in patients with Gitelman syndrome: a case series

Joel D. Farmer, Gurinder M. Vasdev, David P. Martin — 2012-02-01

Abstract: Study Objective: To determine the perioperative considerations for low-risk and high-risk surgery in patients with Gitelman syndrome.Design: Retrospective chart review.Setting: University-affiliated medical center.Patients: 42 patients with Gitelman syndrome.Measurements: Of the 42 patients with Gitelman syndrome, 5 underwent procedures requiring anesthesia: mastectomy, spinal fusion, thyroidectomy, tonsillectomy, and bronchoscopy. The anesthesia record and all associated laboratory tests and clinical notes associated with those procedures were recorded.Main Results: No acute electrolyte abnormalities or postoperative complications occurred with these procedures in patients with Gitelman syndrome.Conclusion: Gitelman syndrome is a mild disorder when appropriately managed.

Laryngoscopy in conscious patients with remifentanil: how useful is an “awake look”?

Sanjiv Gupta, Robert MacNeil, Gregory Bryson — 2012-02-01

Abstract: Study Objective: To determine the sensitivity and specificity of direct laryngoscopy in the conscious patient as a diagnostic test for difficult direct laryngoscopy in the unconscious patient.Design: Prospective case series.Setting: Various operating rooms in a Canadian tertiary-care hospital.Patients: 81 ASA physical status 1, 2, and 3 subjects undergoing elective surgery.Interventions: A bolus of midazolam was given and a continuous infusion of remifentanil was started and adjusted as needed. Direct laryngoscopy was performed in the conscious subject. No topical anesthesia was applied to the upper airway.Measurements: The modified Cormack-Lehane grade was recorded with each subject conscious and unconscious. Other data collected before the intervention included age, gender, height, weight, body mass index, Mallampati class, thyromental distance, mouth opening, previous history of failed or difficult intubation, history of hypertension or obstructive sleep apnea, and routine use of beta blockers. The time of intravenous placement, total dose and duration of remifentanil infusion, and time of endotracheal tube placement were recorded. The lowest oxygen saturation, lowest and highest systolic blood pressure and heart rate, and presence or absence of gagging, coughing, or chest wall rigidity were also noted. Subjects were also asked to complete a questionnaire in the recovery room regarding recall and the degree of discomfort experienced.Main Results: 43 of 81 subjects were graded 1 or 2a when the laryngoscopy was done in the conscious subject. Six of the 38 subjects who were graded as a difficult laryngoscopy (grade 2b or higher) when they were conscious also remained a difficult laryngoscopy when unconscious and paralyzed. Sensitivity and specificity of direct laryngoscopy in the conscious subject as a diagnostic test for difficult direct laryngoscopy in the unconscious subject were 100% [95% confidence interval (CI) 0.52 to 1] and 57% (95% CI 0.47 to 0.70), respectively.Conclusions: Using remifentanil as the sole analgesic allows evaluation of the larynx with direct laryngoscopy in a conscious patient. A poor Cormack-Lehane grade in a conscious patient may or may not improve with general anesthesia.

Comparison of the Magill forceps and the Boedeker (curved) intubation forceps for removal of a foreign body in a Manikin

Ben H. Boedeker, Mary A. Barak Bernhagen, David J. Miller, D. John Doyle — 2012-02-01

Abstract: Study Objective: To compare the straight Magill and the curved Boedeker Intubation Forceps in foreign body removal in a manikin with a difficult airway using the videolaryngoscope.Design: Prospective comparative study.Setting: University Medical Center.Subjects: 17 medical providers, 16 anesthesia staff, and one respiratory therapist.Measurements: The observed Cormack-Lehane (CL) glottic view and success/failure of the removal attempts were recorded.Main Results: The CL scores obtained using the Magill and Boedeker forceps were not significantly different (P = 0.3984). However, the differences in success rates for removal of the foreign object using standard (0 = success, 17 = failure) and Boedeker forceps (0 = failure, 17 = success) were strongly significant (P < 0.0001).Conclusion: The curve of the Boedeker Intubation Forceps allows both the tip of the forceps and the glottic opening to be simultaneously visible in the field of view during videolaryngoscopy, making removal of glottic foreign bodies easier.

Tramadol-metoclopramide or remifentanil for patient-controlled analgesia during second trimester abortion: a double-blinded, randomized controlled trial

2012-02-01

Abstract: Study Objective: To compare patient-controlled analgesia (PCA) with tramadol with PCA with remifentanil in second trimester abortion.Design: Prospective, randomized double-blinded studySetting: University-affiliated medical center.Patients: 30 ASA physical status 1 and 2 patients undergoing a second trimester abortion.Interventions: Patients received PCA with either tramadol or remifentanil. Analgesia was initiated in the tramadol group by an initial loading dose of tramadol 1.0 mg/kg with 10 mg of metoclopramide followed by a PCA bolus of 0.3 mg/kg/mL of tramadol every 5 minutes. For remifentanil, which does not require a loading dose, a placebo of 100 mL of 0.9% normal saline was given followed by PCA of 0.4 μg/kg/mL every two minutes.Measurements: Women were evaluated for pain via verbal analog score (VAS; 0-100), sedation, nausea, blood pressure, pulse, and respiratory rate. On the day of discharge, women were analyzed for overall satisfaction. Primary outcome was pain scores and general satisfaction.Main Results: Analysis by time yielded no statistically significant difference in VAS scores between the groups at any point except 16-20 hours after induction of labor, when pain was lower in the tramadol group (11.3 ± 18.1 vs. 36.7 ± 27.4; P = 0.04). The average VAS score was low in both groups, with no significant differences noted between groups (P = 0.74). Satisfaction scores were high in both groups, with no significant differences noted between them (P = 0.89).Conclusion: Both drugs are acceptable choices for pain control in patients undergoing second trimester abortions.

Relationship between body mass index and blood pressure elevation during electroconvulsive therapy

Shunsuke Takagi, Ken Iwata, Atsuo Nakagawa — 2012-02-01

Abstract: Study Objective: To evaluate the relationship between body mass index (BMI) and blood pressure (BP) elevation during electroconvulsive therapy (ECT).Design: Descriptive epidemiological study.Setting: Operating room of a university-affiliated hospital.Patients: All patients who received ECT at the Tokyo Metropolitan Hiroo Hospital from May 2005 to March 2009.Interventions: All patients received routine ECT treatment.Measurements: Systolic BP (SBP) elevation during ECT, BMI, baseline SBP, age, electroencephalographic seizure duration, ECT stimulating dose, diagnosis, and gender were all recorded.Main Results: Patients with higher BMI tended to have greater SBP elevation after ECT. There was no correlation between elevated SBP and other factors. The degree of elevation of SBP after ECT was linearly related to BMI.Conclusion: BMI correlates with BP elevation during ECT.

Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions

2012-02-01

Abstract: Study Objective: To assess the interest in and barriers to pursuing global health outreach (GHO) experiences for anesthesiology residents in the United States.Design: Survey instrument.Setting: Academic department of anesthesiology.Subjects: Anesthesiology residents who were members of the American Society of Anesthesiologists (ASA).Measurements: An online survey was administered to residents in anesthesiology via the ASA membership database. Descriptive statistics, including means, frequencies, and percentages were calculated.Main Results: 91% of participants indicated an interest in GHO, of whom fewer than half (44%) had done a GHO medical mission. Seventy-nine percent reported that GHO affected their current practice or education; 33% commented they were now less wasteful with supplies and resources. Permission from work or obtaining work coverage were the primary barriers for both those with and without previous GHO participation. Of all respondents, 78% agreed that the availability of a GHO residency track would influence their ranking of that program for training, and 71% would pursue a GHO fellowship if available.Conclusions: Anesthesiology residents have an interest in residency and fellowship GHO programs. Formalization of GHO programs during training may reduce work-related barriers associated with GHO participation and broaden academic program recruitment.

Nerve stimulator versus ultrasound guidance for placement of popliteal catheters for foot and ankle surgery

2012-02-01

Abstract: Study Objective: To determine whether ultrasound guidance improves the quality of continuous popliteal block when compared with a nerve stimulator after major foot and ankle surgery.Design: Prospective, randomized, double-blinded clinical trial.Setting: Operating room, Postanesthesia Care Unit (PACU), and hospital wards of a university-affiliated hospital.Patients: 45 ASA physical status 1, 2, and 3 patients undergoing elective major foot and ankle surgery.Interventions: Placement of a popliteal sciactic nerve catheter using either nerve stimulator or ultrasound guidance. In the PACU, a continuous infusion of ropivacaine 0.2% was started at a basal rate of 4 mL/hr and adjusted in a standardized fashion to maintain visual analog scale (VAS) pain scores < 4. All patients also received intravenous (IV) patient-controlled analgesia with hydromorphone and oral opioids.Measurements: VAS pain scores at rest and with physical therapy, ropivacaine use, opioid use, and opioid-related side effects were recorded.Main Results: Cummulative ropivacaine use was lower in patients whose catheter was placed by ultrasound than by nerve stimulator guidance (mean 50 vs 197 mL, P < 0.001). Pain scores at rest and during activity were similar between groups. Cumulative opioid consumption (mean 858 vs 809 mg oral morphine equivalents) and daily frequencies of nausea (5% to 33% vs 0 to 24%) and pruritus (0 to 21% vs 0 to 24%) were similar between groups. Length of hospital stay was similar between groups (3.5 vs 3.7 days).Conclusions: Ultrasound guidance was associated with less local anesthetic consumption than with the nerve stimulator; however, there was little clinical benefit, as all other outcomes were similar between groups.

Propofol-related infusion syndrome induced by “moderate dosage” in a patient with severe head trauma

Thorsten Annecke, Peter Conzen, Ludwig Ney — 2012-02-01

Abstract: Propofol is widely used for sedating critically ill adult patients because of its rapid onset and short recovery times, even after prolonged use. Propofol may be associated with a life-threatening syndrome, propofol-related infusion syndrome (PRIS), which includes cardiac failure, severe metabolic acidosis, renal failure, and rhabodomyolysis. The pathophysiology is incompletely understood. Propofol-related infusion syndrome seems to be dose-related, and it occurs generally in patients undergoing long-term (> 48 hrs) sedation at higher doses (> 4 mg/kg/hr). A case of PRIS in a patient after severe head injury is presented.

Noninvasive positive pressure ventilation in the management of acute respiratory failure due to osteogenesis imperfecta

2012-02-01

Abstract: The development of acute respiratory failure (ARF) secondary to respiratory tract infection is a common event in patients affected with osteogenesis imperfecta type III. Noninvasive positive pressure ventilation (NPPV) is increasingly administered to treat severe ARF of various origin. The use of NPPV in two patients with severe ARF secondary to osteogenesis imperfecta type III is presented.

Neurolytic transversus abdominis plane block in the palliative treatment of intractable abdominal wall pain

Bryan Sakamoto, Sanjay Kuber, Kenneth Gwirtz, Ahmed Elsahy, Michael Stennis — 2012-02-01

Abstract: A 45 year old man with metastatic colon cancer presented with uncontrollable abdominal wall pain. Transversus abdominis plane (TAP) block with ropivacaine and methylprednisolone was performed with excellent pain relief, which allowed a significant weaning of the patient's opioid requirements. A second TAP block was performed with a 33% ethanol solution (ethanol and ropivacaine) with excellent pain relief. The neurolytic block appeared to offer better pain control for more than 5 days after placement until the patient finally succumbed to his illness.

Successful management of rocuronium-induced anaphylactic reactions with sugammadex: a case report

2011-12-08

Abstract: Sugammadex, a new reversal agent for rocuronium, encapsulates the rocuronium molecule and results in rapid reversal of rocuronium-induced neuromuscular blockade. A case in which sugammadex was used to treat an anaphylactic reaction that occurred after rocuronium is presented. The binding/encapsulation of rocuronium by sugammadex may selectively eliminate the antigenic quaternary ammonium activity of circulating rocuronium, and prevent the propagation of rocuronium-induced anaphylaxis.

Opioid-free single-incision laparoscopic (SIL) cholecystectomy using bilateral TAP blocks

Kai Matthes, Mark A. Gromski, Benjamin E. Schneider, Joan E. Spiegel — 2011-12-02

Abstract: A 30 year old woman who was 8 weeks postpartum with a history of cholelithiasis and gallstone pancreatitis, and who was status-post endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, was treated with a single-incision laparoscopic (SIL) cholecystectomy. A transversus abdominis plane block (TAP) was performed after induction of anesthesia. The patient required no intraoperative or postoperative opioids.

Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities

Adam I. Levine, Brigid C. Flynn, Ethan O. Bryson, Samuel DeMaria — 2012-02-01

Abstract: In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.

Making the personal statement more personal

James W. Heitz — 2012-02-01

I read with keen interest the article by Max et al., regarding the inadequacies of the personal statement in predicting success during residency . Their finding, that the personal statement in the typical anesthesiology residency application revolves around one of 13 common themes and that most essays share common elements, surely resonates with members of Resident Selection Committees. The commonality noted across the essays limits their utility in distinguishing between candidates. In addition, over one in 20 essays contains elements of plagiarism .

Target-controlled infusion of propofol and anesthesia induction

Yun B. Sun, Yong X. Liang, Miao N. Gu, Shi D. Wang — 2012-02-01

We read with interest the recent paper of Min et al , regarding the use of a small dose of propofol on intubation conditions. They studied 102 ASA physical status 1 and 2 patients undergoing elective surgery with general anesthesia and found that administration of an additional dose of propofol (0.5 mg/kg) before intubation may significantly improve intubation conditions without increasing the frequency of hypotension. However, is this approach the most appropriate for anesthesia induction?

Rare cause of light failure of a Macintosh 4 blade

Thomas E. Schulte, Ankit Agrawal — 2012-02-01

A rare cause of light failure in a Macintosh 4 blade during direct laryngoscopy is reported. Laryngoscope malfunction is a frequently encountered equipment failure in the operating room . The usual causes of laryngoscope malfunction encountered are a failing light source, defective bulb, or faulty contact between the blade and the handle or in the socket . In another case, the blade separated at the weld line, causing the laryngoscope to be fractured .

Paralyzed by beauty

Carlos Brun, John G. Brock-Utne — 2012-01-09

A 46 year old woman, who appeared younger than her stated age, presented for a general anesthetic to rule out ovarian cancer. She had normal laboratory values and she denied medical or surgical history other than one diagnostic laparoscopy. The patient denied plastic surgery in front of her husband, but a chin implant surgery was noted in her chart. On the way to the operating room, she again denied any surgeries. We noted that she had chin implant, breast implant, blepharoplasty, and rhinoplasty scars.

Intractable neuropathic pain due to ulnar nerve entrapment treated with cannabis and ketamine 10%

Jan M. Keppel Hesselink, David J. Kopsky — 2012-01-09

Since 1994, various case reports, pilot studies, and clinical trials have documented the efficacy and safety of ketamine in the treatment of chronic neuropathic pain . Due to its unique mechanism of action, ketamine is a highly interesting drug for the treatment of therapy-resistant chronic pain syndromes, and it may be administered in various ways, such as via oral, sublingual, intranasal, rectal, and transdermal routes. Long periods of decreased pain may be induced by relatively short courses of ketamine intravenously (IV). Complex Regional Pain Syndrome Type 1 patients suffering from severe pain were successfully treated for 4 days with a continuous infusion of low-dose S-ketamine over 11 weeks, without a reemergence of their pain. However, one of the troublesome clinical aspects of (IV) ketamine is the reemergence of pain after some weeks, and thus the necessity to re-administer ketamine infusions .

Electrical velocimetry demonstrates the increase in cardiac output and decrease in systemic vascular resistance accompanying cesarean delivery and oxytocin administration

Thomas L. Archer, Benjamin E. Conrad, Preetham Suresh, Maryam Tarsa — 2012-02-01

Electrical velocimetry is a new type of impedance cardiography, which is easy to use and noninvasive. In 6 nonobstetric studies, electrical velocimetry correlated well with more established methods of measuring cardiac output (CO) such as thermodilution and echocardiography . In obstetrics, electrical velocimetry has been used to measure the hemodynamic changes associated with intravenous (IV) magnesium sulfate, hydralazine, and labetalol in preeclampsia , IV indigo carmine during bladder repair , and during an episode of fetal heart rate (HR) deceleration associated with magnesium administration .

Cost-cutting capital investment proposals in chronic pain management

David R. Sinclair — 2012-01-12

Several cost-saving and cost-containment studies have focused on reducing unnecessary costs through practice modifications during the perioperative period . In chronic pain management, cost-cutting proposals involving capital investments rather than clinical decision-making must be considered. Cost-cutting investment decisions are intended to improve cost-effectiveness and efficiency by reducing labor or material costs . To reduce costs and improve revenue cycle management in the hospital ambulatory and emergency department settings, self-serve, digital, touch screen kiosks have been implemented . These kiosks expedite the check-in process by allowing patients to preregister, make payments, and update information . In the chronic pain management setting, these functions may be accomplished at self-serve kiosks. The digital technology and computer components may range from $25,000 to $100,000, and justifying the savings from a large capital expenditure is difficult.

New technique using an Airtraq optical laryngoscope in emergencies

Yasuhiko Imashuku, Hirotoshi Kitagawa, Masahiro Kura, Hideki Otada — 2011-12-05

The Airtraq optical laryngoscope (Prodol, Ltd, Vizcaya, Spain) is a useful tool during difficult intubation, as it provides the operator with an improved view of the glottis . However, the Airtraq requires extra time to prepare the endotracheal tube (ETT; lubrication and placement in the Airtraq lateral channel with the tip aligned with the end). When “cannot intubate-cannot ventilate” situations occur unexpectedly, most anesthesiologists use techniques that may be accessed quickly. We describe a new technique with the Airtraq during an emergency.

Tracheal pouch and Murphy eye

Pragnyadipta Mishra, Senthilkumar Sadhasivam, Mohamed Mahmoud, Ximena Soler — 2012-01-12

Microcuff tracheal tubes (MTT) with an ultra-thin, high volume-low pressure cuff are now routinely used in the care of pediatric patients. The Murphy eye is omitted from the MTT to incorporate the cuff without adding additional length, so as to keep the tip at a safe distance from the carina (Magill tube) . We share our experience in a complex-airway patient, where a major airway problem was overcome by artificially creating a Murphy eye in a MTT.

Journal of Clinical Anesthesia

Editorial Board

Table of Contents

Does anesthetic technique influence cancer?

Meta-analysis of the effect of central neuraxial regional anesthesia compared with general anesthesia on postoperative natural killer T lymphocyte function

The optimal dose of esmolol and nicardipine for maintaining cardiovascular stability during rapid-sequence induction

Perioperative considerations in patients with Gitelman syndrome: a case series

Laryngoscopy in conscious patients with remifentanil: how useful is an “awake look”?

Comparison of the Magill forceps and the Boedeker (curved) intubation forceps for removal of a foreign body in a Manikin

Tramadol-metoclopramide or remifentanil for patient-controlled analgesia during second trimester abortion: a double-blinded, randomized controlled trial

Relationship between body mass index and blood pressure elevation during electroconvulsive therapy

Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions

Nerve stimulator versus ultrasound guidance for placement of popliteal catheters for foot and ankle surgery

Propofol-related infusion syndrome induced by “moderate dosage” in a patient with severe head trauma

Noninvasive positive pressure ventilation in the management of acute respiratory failure due to osteogenesis imperfecta

Neurolytic transversus abdominis plane block in the palliative treatment of intractable abdominal wall pain

Successful management of rocuronium-induced anaphylactic reactions with sugammadex: a case report

Opioid-free single-incision laparoscopic (SIL) cholecystectomy using bilateral TAP blocks

Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities

Making the personal statement more personal

Target-controlled infusion of propofol and anesthesia induction

Rare cause of light failure of a Macintosh 4 blade

Paralyzed by beauty

Intractable neuropathic pain due to ulnar nerve entrapment treated with cannabis and ketamine 10%

Electrical velocimetry demonstrates the increase in cardiac output and decrease in systemic vascular resistance accompanying cesarean delivery and oxytocin administration

Cost-cutting capital investment proposals in chronic pain management

New technique using an Airtraq optical laryngoscope in emergencies

Tracheal pouch and Murphy eye