The Lost Airway.

Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.

The Difficult Airway.

Airway management is a cornerstone of anesthetic practice, and difficulty with airway management has potentially grave implications-failure to secure a patent airway can result in hypoxic brain injury or death in a matter of minutes. The difficult airway in otolaryngologic surgery requires careful planning and close communication between the anesthesiologist and ENT or head and neck surgeon. Knowledge of predictive factors and a detailed preoperative evaluation can be used to predict which airway strategies are likely to be successful and which are likely to fail.

Evaluation of saline versus gel as contact medium for ultrasonographic image quality.

OBJECTIVES: Evaluate the time taken to visualize the internal jugular vein and carotid arteries, and subjective image quality assessed on a 0-100 visual analogic scale, on an ultrasound model using either traditional ultrasound gel or normal saline. METHODS: Twenty-two anesthesiology residents and twenty anesthesiology faculty were blinded and randomized into four separate groups using gel and saline as a conduction medium, in different sequences. RESULTS: Subjective image quality was 12.2 ± 4.2 better with gel than with saline (P < 0.01). Image acquisition time did not differ significantly between the two mediums. There was no significant difference in subjective image quality or time to image acquisition between faculty and residents. CONCLUSIONS: Internal jugular vein and carotid artery identification time using ultrasonography were similar between gel and saline as conduction mediums. The difference in subjective image quality did not appear clinically relevant. Better image quality resulted in less time taken to identify the structures, as expected. We conclude that saline may be an effective alternative medium to gel for vessel imaging and access guidance. Further study in a clinical setting is warranted.

Subglottic perioperative airway-tube inflation via randomized evaluation with variable syringe size (Spair-Tire) study.

INTRODUCTION: Risks of endotracheal tube cuff (ETTC) over inflation must be balanced with the need to achieve a minimum pressure of 20 cm H2 O. Methods have been developed to estimate adequate ETTC pressurization but do not provide accurate endotracheal tube cuff pressure (ETCP) measurements. Hence, different sized syringes may play a role in determining ETCP. OBJECTIVES: Determine optimal syringe size for recommended ETCP. METHODS: Two hundred patients were randomized to use of either a 10-mL syringe (standard syringe) or a 5-mL syringe (study group) for ETTC inflation. Following the insertion of the endotracheal tube, the ETTC was inflated per the attending anesthesiologist. Within 10 minutes of intubation, ETCP was measured with a hospital-provided manometer. RESULTS: The percentage of in range cuff pressures for the 5-mL group was 10.53% and 6.78% for the 10-mL group. 84.21% (n = 64) of the study group and 91.53% (n = 54) of the control group had cuff pressures exceeding 30 cmH2 O. Although our study did not demonstrate that syringe size was predictive of ideal cuff pressure ranges, the average cuff pressure for the 5-mL group was 55.8 cm H2 O versus 68.8 cm H2 O in the 10-mL group. CONCLUSION: Although both 5- and 10-mL syringes resulted in elevated cuff pressures after intubation, 5-mL syringes resulted in a lower degree of elevation. Use of a 5-mL syringe should be considered when inflating the endotracheal cuff to possibly reduce patient harm secondary to elevated cuff pressures. Further studies assessing smaller syringe sizes to reduce cuff pressures are warranted.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study.

BACKGROUND: Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. MATERIALS AND METHODS: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. RESULTS: There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. CONCLUSIONS: IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Flexible optical intubation via the Ambu Aura-i vs blind intubation via the single-use LMA Fastrach: a prospective randomized clinical trial.

STUDY OBJECTIVE: This study was designed to compare the Ambu Aura-i to the single-use LMA Fastrach regarding time to intubation, success rate, and airway morbidity in patients undergoing elective surgery requiring general anesthesia. DESIGN: Prospective, randomized controlled trial. SETTING: Academic medical center. PATIENTS: Sixty-five adult patients scheduled for elective surgery requiring general anesthesia. INTERVENTIONS: Patients were randomized into 2 groups. Group A (n=33) were intubated using Ambu Aura-i and the Ambu aScope 2, a disposable flexible intubating scope, whereas those in group B (n=33) were blindly intubated using the Intubating Laryngeal Mask Airway (ILMA). MEASUREMENTS: First-attempt intubation success rate, overall intubation success rate, time to intubation, incidence of airway morbidity. MAIN RESULTS: The data demonstrated that time for endotracheal intubation in the ILMA group was significantly shorter than in the Ambu Aura-i group (P<.05). There was no difference in the first-attempt intubation success rate (Aura-i=26/33, 78.8%; ILMA=27/33, 81.8%; P=.757) or the overall intubation success rate (Aura-i=29/33, 87.9%; ILMA=31/33, 93.9%; P=.392) between the groups. Four patients (12%) in the Ambu Aura-i group had a failed intubation; 1 was due to a failure of the aScope monitor, whereas 3 were due to inability to visualize the glottis. Two patients (7%) in the ILMA group had a failed intubation due to esophageal intubation. There was no statistically significant difference in airway morbidity between the 2 groups. CONCLUSIONS: The data suggest that intubation with the ILMA is faster but that first-attempt and overall intubation success rates were comparable in both groups. The results suggest that although the flexible intubating scope-guided Aura-i does not outperform blind intubation via the ILMA, the technique is comparable in terms of first-attempt and overall intubation success rate.

Reliability of a faculty evaluated scoring system for anesthesiology resident applicants (Original Investigation).

STUDY OBJECTIVE: To assess reliability and reproducibility of a recently instituted anesthesiology resident applicant interview scoring system at our own institution. DESIGN: Retrospective evaluation of 2 years of interview data with a newly implemented scoring system using randomly assigned interviewing faculty. SETTING: Interview scoring evaluations were completed as standard practice in a large academic anesthesiology department. SUBJECTS: All anesthesiology resident applicants interviewed over the 2013/14 and 2014/15 seasons by a stable cohort of faculty interviewers. Data collection blinded for both interviewers and interviewees. INTERVENTIONS: None for purposes of study - collation of blinded data already used as standard practice during interview process and analysis. MEASUREMENTS: None specific to study. MAIN RESULTS: Good inter-rater faculty reliability of interview scoring (day-of) and excellent inter-faculty reliability of application review (pre-interview). CONCLUSIONS: Development of a department-specific interview scoring system including many elements beyond traditional standardized tests shows good-excellent reliability of faculty scoring of both the interview itself (including non-technical skills) and the application resume.

Is there a gold standard for management of the difficult airway?

Numerous practice guidelines have been developed to assist clinicians in the management of the difficult airway. The nature of difficult airway management, however, does not provide a practical way of comparing different guidelines or algorithms; no evidence supports one set of guidelines over another. Nevertheless they play an important role in patient safety as dissemination of such guidelines encourages airway practitioners to consider their strategies and formulate specific plans for the management of a predicted or unexpected difficult airway.

Extubación del paciente perioperatorio con una vía aérea difícil / Extubation of the perioperative patient with a difficult airway

Existe un volumen importante de literatura dedicada al tema del manejo de la vía aérea difícil, y se han desarrollado una serie de algoritmos y recomendaciones para el manejo seguro de pacientes en riesgo de una intubación difícil. Sin embargo, solo recientemente se ha despertado una mayor conciencia acerca de la extubación de la vía aérea difícil, pues aun cuando sea un procedimiento programado, suele estar plagado de complicaciones. La importancia de desarrollar estrategias pre-programadas para la extubación de la vía aérea difícil a fin de aumentar la seguridad del paciente y sus desenlaces se hace evidente a partir de los datos del ASA Closed Claims Analysis y del reciente Cuarto Proyecto Nacional de Auditoría del Reino Unido sobre complicaciones mayores en el manejo de la vía aérea. La clave para un manejo exitoso de los pacientes en riesgo de extubación difícil es efectuar una evaluación precisa de riesgo, aplicar estrategias apropiadas y la preparación tanto del médico como de la institución.

A considerable amount of literature has been dedicated to the topic of difficult airway management and a number of algorithms and recommendations have been established to safely manage patients at risk for difficult intubation. Only recently, however, has extubation of the difficult airway gained more awareness since this procedure, although elective, is often fraught with complications. The importance of developing pre-planned strategies for extubation of the difficult airway to improve patient safety and outcomes is apparent from data from both the ASA Closed Claims Analysis and the UK's recent Fourth National Audit Project of major complications of airway management. The key to successful management of patients at risk for difficult extubation is accurate risk assessment, application of appropriate strategies, and preparedness by both the individual practitioner and the institution.

Tracheal extubation.

Tracheal extubation in both the critical care and anesthesia setting is not only an important milestone for patient recovery, but also a procedure that carries a considerable risk of complication or failure. Mechanical ventilation is associated with significant complications that are time-dependent in nature, with a longer duration of intubation resulting in a higher incidence of complications, including ventilator-associated pneumonia, and increased mortality. Extubation failure and subsequent re-intubation are associated with an overall increase in the duration of mechanical ventilation, increased mortality, a greater need for tracheostomy, and higher medical costs. These risks demand that the process of extubation be managed by practitioners with a detailed understanding of the causes of extubation failure and the potential complications. A pre-established extubation plan with considerations made for the possible need for re-intubation is of the utmost importance.