Evaluation of the Fourth-Generation FloTrac/Vigileo System in Comparison With the Intermittent Bolus Thermodilution Method in Patients Undergoing Cardiac Surgery.

OBJECTIVES: The aim of this study was to evaluate the accuracy, precision, and trending ability of the fourth-generation FloTrac/Vigileo system (version 4.00; Edwards Lifesciences, Irvine, CA) by comparing cardiac output derived from FloTrac/Vigileo system (COAP) with that measured by a pulmonary artery catheter (COTD), and to determine the effects of hemodynamic variables on the bias between COTD and COAP. DESIGN: A prospective study. SETTING: University hospital. PARTICIPANTS: Thirty patients undergoing elective cardiac surgery using cardiopulmonary bypass. INTERVENTIONS: Including hemodynamic variables, COTD and COAP were measured simultaneously at the following 10 time points: after the induction of anesthesia, at the start of operation, after sternotomy, before and after the administration of heparin, before and after the administration of protamine, at the start of sternal closure, at the end of operation, and on arrival to intensive care unit. MEASUREMENTS AND MAIN RESULTS: In total, 280 pairs of datasets were obtained. Bland-Altman analysis showed a bias of -0.41 L/min, a precision of 0.72 L/min, and limits of agreement of -1.85 and 1.03 L/min, with a percentage error of 37.1%. The concordance rate determined by 4-quadrant plot analysis and the polar concordance rate were 76% and 79%, respectively. The linear mixed-effect model revealed that the bias was influenced strongly by the difference in pulse pressure between the radial and femoral artery (p < 0.001), and the systemic vascular resistance index (p < 0.001). CONCLUSION: The fourth-generation FloTrac/Vigileo system still lacks accuracy and trending ability in cardiac surgery, and the discrepancy in cardiac output measurement depends on the peripheral vascular tone. Further improvement of this system is needed.

Effect of Cricoid Pressure on the Insertion Efficacy of Six Supraglottic Devices: A Crossover Randomized Simulation Trial.

BACKGROUND: No study has ever compared the efficacy of various types of supraglottic devices (SGDs) for securing the airway under cricoid pressure. OBJECTIVE: This study aimed to evaluate the efficacy of six SGDs, LMA-ProSeal (ProSeal), LMA-Classic (Classic), Laryngeal Tube (LT), LMA-Supreme (Supreme), air-Q (air-Q), and i-gel (i-gel), in airway management under cricoid pressure using a manikin. METHODS: Fifteen novice doctors and 16 experienced doctors used the six SGDs under cricoid or sham pressure on an adult manikin. Insertion time, successful ventilation rate, and subjective insertion difficulty on a visual analogue scale (VAS) were measured. RESULTS: Both novice and experienced doctors had a significantly lower ventilation success rate under cricoid pressure than under sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs. Novice doctors required a significantly longer insertion time under cricoid pressure than under sham pressure with all SGDs. Experienced doctors required a significantly longer insertion time under cricoid pressure than with sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs. Subjective insertion difficulty on VAS was significantly higher under cricoid pressure than under sham pressure with all six SGDs. CONCLUSION: Ventilation success rate under cricoid pressure was significantly lower than under sham pressure when using the ProSeal, Classic, and LT, but not when using the other three SGDs in both novice and experienced doctors.

Evaluation of gum-elastic bougie combined with direct and indirect laryngoscopes in vomitus setting: A randomized simulation trial.

PURPOSE: Videolaryngoscopes may not be useful in the presence of vomitus due to blurred images on the monitor. The objective of our study is to compare the utility of gum-elastic bougie (GEB) application for tracheal intubation with the Macintosh laryngoscope (McL), which is a direct laryngoscope, with that of the Pentax-AWS Airwayscope® (AWS) and McGRATH® MAC (McGRATH) in simulated vomitus settings. METHODS: Sixteen novice doctors performed tracheal intubation on an adult manikin using McL, AWS, and McGRATH with or without GEB under normal and vomitus simulations. RESULTS: In the normal setting the tracheal intubation was successful with the three laryngoscopes regardless of GEB application. In the vomitus setting, the intubation success rate did not significantly improve using McL, while it did using McGRATH or AWS. In the normal settings, GEB application significantly lengthened the intubation time in all three laryngoscopes. By contrast, in the vomitus settings, GEB application significantly shortened the intubation time in all three laryngoscopes. For the comparison of three laryngoscopes, the intubation time did not differ significantly in normal setting, while it was significantly longer in McG and AWS trials than McL trial. CONCLUSION: The GEB application facilitates the tracheal intubation in the vomitus setting using McGRATH and AWS in adult simulation.

[Anesthetic Management of Simultaneous Right Lobectomy and Esophagectomy with a Double-lumen Tracheal Tube and Bronchial Blocker].

Anesthestic management with prolonged one-lung ventilation is difficult, especially when the patient continues smoking habit. Here, we report a successful one-lung ventilation and protection with combined use of double-lumen endotracheal tube and bronchial blocker. A 68-year-old man (height 153 cm; weight, 45 kg) was scheduled for simultaneous surgery of right lobectomy and esophagectomy. He kept smoking to the operation day. To protect the ventilated lung, we guided the bronchial lumen of the DLT to the left bronchus under fiberoptic bronchoscope (FOB) guide and inflated the bronchial cuff. Next, we inserted the bronchial blocker from the tracheal lumen of the DLT and inflated the cuff in the left bronchus under FOB guidance. We performed continuous suctioning of the right trachea via the inner lumen of BB. During the operation, non-negligible amount of blood and sputum was aspirated from the inner lumen of the BB. Furthermore, there was no visible blood inflow in the left bronchus. We could protect the ventilated lung with double cuff, i. e. bronchial cuff of DLT in the left bronchus and BB cuff in the right bronchus. Simultaneous operation was uneventfully performed and no oxygenation or ventilation trouble was observed during the operation.

[Simulation-based Perioperative Team Training in the Operating Room].

Here, we report the development of a simulation-based perioperative training course. Participants were anesthesiologists and operating room nurses. Three different courses were held with different themes, such as airway management, circulation management and central venous management. The courses included a lecture and simulation training with scenario-based discussions or a simulator. At the end of each course, participants discussed problems associated with medical safety in the context of each theme. Participants commented not only on changes in their views regarding individual technical or non-technical improvements, but also on general medical safety in the operating room. Our findings suggest that simulation-based perioperative team training may serve as a vehicle to promote operating room safety.

[Anesthetic Management of Right Lower Lobectomy in a Patient with Marfan Syndrome].

We report a case of partial lobectomy in a patient with Marfan syndrome. A 56-year-old woman with Marfan syndrome was scheduled for partial lobectomy for suspected lung cancer under general anesthesia. She underwent a Bentall operation and mitral valve replacement 10 months before and strict blood pressure management was required. After induction of general anesthesia with propofol and fentanyl, topical intratracheal lidocaine anesthesia was performed using the Pentax-AWS Airwayscope (AWS) for visualization, allowing for the Soft-tipped Tube Exchanger (TE-Soft) to be inserted into the trachea. Next, a double-lumen tracheal tube was uneventfully intubated via the TE-Soft with minimal change in vital signs. During the operation, pressure-controlled ventilation was performed to minimize the risk of pneumothorax. After the operation, under continuous administration of landiorol and dexmedetomidine, the double-lumen tracheal tube was extubated uneventfully. Strict airway and circulation management is needed for lung or vessel preservation in patients whose conditions are complicated by Marfan syndrome.

Evaluation of the efficacy of six supraglottic devices for airway management in dark conditions: a crossover randomized simulation trial.

PURPOSE: During out-of-hospital cardiopulmonary resuscitation, several factors can render tracheal intubation more difficult, such as when rescuers must secure the airway in complete darkness or with limited illumination. The purpose of this study was to evaluate the efficacy of six supraglottic devices (SGDs), ProSeal(®) (ProSeal), Classic(®) (Classic), Supreme(®) (Supreme), Laryngeal Tube(®) (LT), air-Q(®) (air-Q), and i-gel(®) (i-gel), for airway management under light and dark conditions using a manikin. METHODS: Seventeen novice doctors and 15 experienced doctors performed insertion of six SGDs under light and dark conditions using an adult manikin. Insertion time, successful ventilation rate, and subjective insertion difficulty on a visual analogue scale (VAS) were measured. RESULTS: Both novice and experienced doctors had a significantly lower ventilation success rate in the dark than in the light when ProSeal and Classic were used, but not with the other four SGDs. Novice doctors required a significantly longer insertion time in the dark than in the light with all SGDs. Experienced doctors required a significantly longer insertion time in the dark than in the light with ProSeal or Classic, but not with the other four SGDs. VAS was significantly higher for both novice and experienced doctors when ProSeal and Classic were used, as compared with the other four SGDs in the dark. CONCLUSIONS: Compared to ProSeal and Classic, Supreme, i-gel, LT, and air-Q are more effective for airway management in the dark. Our findings suggest that anatomically shaped SGDs may help novice doctors secure the airway under dark conditions.

Comparison of mechanical and manual bone marrow puncture needle for intraosseous access; a randomized simulation trial.

BACKGROUND: During resuscitation, when it is difficult or impossible to establish peripheral venous access, intraosseous route (IO) is considered as an alternative to a central venous line. However, it is sometimes difficult for obtain IO access with conventional manual bone puncture needle. Recently, powered mechanical bone marrow needle was developed. We compared the performance of the manual and mechanical bone marrow puncture needle for adult, child and infant simulation. METHODS: 22 anesthesiologists, who has never used bone marrow puncture needle, performed manual (Dickman™, Cook Medical) or mechanical (EZ-IO™, Teleflex) bone marrow puncture to simulated adult, child and infant tibia. Puncture success rate, insertion time, and subjective difficulty utilizing visual analogue scale was assessed. RESULTS: In adult settings, with the manual bone marrow needle, only 3 of 22 participants could succeed in the IO route keep, while all participants did in the mechanical bone marrow puncture needle (P < 0.001). In child and infant settings, all trials were successful in both manual and mechanical bone marrow puncture needles (P = 1.00). In adult simulations, IO insertion took significantly longer with manual bone marrow puncture (54.8 ± 15.8 s) than without compressions (3.7 ± 2.1 s; P < 0.001). In child and infant simulations, the IO insertion time was significantly smaller in mechanical trials than in manual ones (child simulation; manual 9.3 ± 4.6 s, mechanical 2.2 ± 0.8 s, P < 0.001, infant simulation; manual 2.0 ± 1.1 s, mechanical 1.5 ± 0.8 s, P = 0.003). Although the VAS score was not significantly higher with manual trials than in mechanical trials among the three simulations (adult simulation, P < 0.001, child simulation, P < 0.001, infant simulation P = 0.006). CONCLUSIONS: We conclude that in simulations managed by anesthesiologists who had no clinical experiences with bone marrow puncture, the mechanical bone puncture needle performed better than the manual one for emergency IO route access.

[A case of impossible ventilation after induction of anesthesia in a patient with massive nasal bleeding].

We report a case of impossible ventilation in a patient with severe nasal bleeding. A 47-year-old man with intractable nasal bleeding was scheduled for emergent hemostasis under general anesthesia. He also had alcohol-related cirrhosis and was highly obese (165 cm, 93 kg). Although he sufficiently fasted and did not experience nausea in the supine position, we planned crash intubation in the head-elevated position with the Pentax-AWS Airwayscope (AWS) in order to avoid vomiting after induction of anesthesia. After fentanyl, propofol, and rocuronium administration, the patient vomited a large amount of blood, which led to a deterioration of SpO2. Mask ventilatidn was impossible even after oral suctioning. We intubated the trachea with the Macintosh laryngoscope and suctioned blood from the trachea; SpO2 gradually improved and the trachea was washed with a large amount of normal saline. The patient was transferred to the intensive care unit and extubated uneventfully on day 3 postoperatively.

Shifts in endotracheal tube position due to chest compressions: a simulation comparison by fixation method.

BACKGROUND: Endotracheal tube placement during resuscitation is important for definite tracheal protection. Accidental extubation due to endotracheal tube displacement is a rare event that can result in severe complications. OBJECTIVE: This study evaluated how endotracheal tube displacement is affected by tape vs. tube holder fixation using a manikin and auto-chest compression machine simulation. METHODS: The endotracheal tube was placed in either a shallow or a deep position, with the tube cuff at the center of the glottis or 26 cm from the incisors in an advanced lifesaving simulator. Trials were performed five times in each setting with: no fixation; Durapore® tape fixation; Multipore® tape fixation; and Thomas tube holder® fixation. After 10 min of automated chest compressions, endotracheal tube shift was measured. Statistical analysis was performed with one-way repeated analysis of variance or χ(2) test, with p < 0.05 considered significant. RESULTS: In the shallow setting, endotracheal tube extubation occurred in all trials with no fixation, Durapore, and Multipore. In contrast, no extubation occurred in the Tube holder trials (p < 0.05). In the deep setting, no extubation was confirmed in any trial. Relative to no fixation (0.56 ± 0.11 cm), endotracheal tube shift was significantly less in the Durapore tape, Multipore tape, and Tube holder groups (p < 0.05). Of the three fixation methods, Tube holder (0.04 ± 0.05 cm) showed significantly less shift (p < 0.05) relative to Durapore (0.28 ± 0.04 cm) and Multipore (0.32 ± 0.08 cm). CONCLUSION: Endotracheal tube displacement occurs less with Tube holder fixation than with Durapore tape or Multipore tape during simulation of continuous chest compressions.

[Pentax-AWS Airwayscope for awake tracheal intubation in the face-to-face sitting position in an emergency patient with acute exacerbation of aortic stenosis].

We report a successful awake tracheal intubation in an emergency patient with acute exacerbation of aortic stenosis using the Pentax-AWS Airwayscope (AWS). An 83-year-old woman was admitted to our emergency department for severe dyspnea due to exacerbation of aortic stenosis. Her Sp(O2) was 92-93% even after administration of 10 l x min(-1) oxygen through a reservoir-attached face mask. As she could not remain in the supine position, emergency tracheal intubation in the sitting position was required. After topical anesthesia with 8% lidocaine and careful administration of midazolam, the AWS was inserted into her mouth in the sitting, face-to-face position. The AWS allowed for visualization of the glottis and safe placement of the tracheal tube. Sufficient spontaneous ventilation was maintained during interventions with minimum vital sign changes. Awake intubation in the sitting position with the AWS may be helpful in resolving cardiovascular crisis in patients unable to maintain the supine position.

[Successful one-lobe ventilation in a patient combined with multiple bulla and interstitial pneumonia].

Respiratory management of interstitial pneumonia during general anesthesia is challenging, especially for one-lung ventilation. We report the successful left-side one-lung ventilation after left lower lobectomy. A 79-year-old man with interstitial pneumonia was scheduled for right side bulla resection. After epidural anesthesia at T8-9, under dexmedetomidine and propofol sedation and regional anesthesia with lidocaine, a double-lumen tube was inserted with a Macintosh laryngoscope preserving spontaneous breathing. Next, we continuously administered propofol at 1.5-2.0 microg x ml(-1) in target-controlled infusion manner, 0.8 microg x kg(-1) x hr(-1) dexmedetomidine and 50 mg x hr(-1) aminophylline for minimizing hypoxic vasocontriction. The bispectral index was maintained within 40-60 by titrating the dose of propofol. Analgesia was performed with epidural 100 microg fentalyl and 6 ml of 0.375% ropivacaine administration. The lowest Spo2 during one-lobe ventilation was 88% which recovered to 97% by oxygen administration to right lung with no pressure. We could keep about 3-4 l of minute volume and accumulation of Paco2 was acceptable. The patient was under one-lobe (left upper lobe) ventilation with spontaneous breathing during the operation. Open bulla resection was performed uneventfully. There were no complications from one-lobe ventilation and the patient was extubated in the operating room. One-lung ventilation, which preserves spontaneous breathing is considered effective for preventing barotrauma in patients with interstitial pneumonia. Dexmedetomidine as well as propofol or aminophylline may be effective avoiding hypoxic vasoconstriction. Furthermore, we could perform one-lobe ventilation with left-upper lobe with maintaining sufficient oxygenation and ventilation.