Simulación de intubación pediátrica con videolaringoscopio de bajo costo en contexto de pandemia por COVID-19 / Simulation of pediatric intubation using a low-cost videolaryngoscope in the setting of the COVID-19 pandemic

En pacientes con infección por SARS-CoV-2 la intubación endotraqueal es un procedimiento con riesgo elevado de contagio. La videolaringoscopia complementa la protección del profesional, pero los videolaringoscopios comerciales son caros y no siempre están disponibles en las terapias intensivas pediátricas argentinas. El objetivo fue describir la práctica de intubación en un modelo de cabeza de simulación de lactante con un videolaringoscopio artesanal de bajo costo.Quince pediatras sin experiencia previa con el dispositivo participaron de una práctica de intubación en una cabeza de simulación con un videolaringoscopio artesanal. El tiempo promedio del primer intento fue de 116,4 segundos (intervalo de confianza del 95 % [IC95 %]: 84,8-148,0) y, el del siguiente fue de 44,2 segundos (IC95 %: 27,7­60,6). El tiempo disminuyó de forma significativa en el segundo intento (p : 0,0001). El dispositivo permitió la intubación exitosa en todos los intentos acortando la duración del procedimiento en la segunda práctica

In patients with SARS-CoV-2 infection, endotracheal intubation is a procedure with a high risk for transmission. A videolaryngoscopy is a supplementary level of health care provider protection, but commercial videolaryngoscopes are expensive and not always available in pediatric intensive care units in Argentina. Our objective was to describe intubation practice using an infant head mannequin with a low-cost, handcrafted videolaryngoscope.Fifteen pediatricians with no prior experience using the device participated in an intubation practice in a head mannequin with a handcrafted videolaryngoscope. The average time for the first attempt was 116.4 seconds (95 % confidence interval [CI]: 84.8-148.0) and, for the second one, 44.2 seconds (95 % CI: 27.7-60.6). Time decreased significantly for the second attempt (p: 0.0001).A successful intubation was achieved with the device in all attempts, and the procedure duration decreased with the second practice

Simulation of pediatric intubation using a low-cost videolaryngoscope in the setting of the COVID-19 pandemic. / Simulación de intubación pediátrica con videolaringoscopio de bajo costo en contexto de pandemia por COVID-19.

In patients with SARS-CoV-2 infection, endotracheal intubation is a procedure with a high risk for transmission. A videolaryngoscopy is a supplementary level of health care provider protection, but commercial videolaryngoscopes are expensive and not always available in pediatric intensive care units in Argentina. Our objective was to describe intubation practice using an infant head mannequin with a low-cost, handcrafted videolaryngoscope. Fifteen pediatricians with no prior experience using the device participated in an intubation practice in a head mannequin with a handcrafted videolaryngoscope. The average time for the first attempt was 116.4 seconds (95 % confidence interval [CI]: 84.8- 148.0) and, for the second one, 44.2 seconds (95 % CI: 27.7-60.6). Time decreased significantly for the second attempt (p: 0.0001). A successful intubation was achieved with the device in all attempts, and the procedure duration decreased with the second practice.

En pacientes con infección por SARS-CoV-2 la intubación endotraqueal es un procedimiento con riesgo elevado de contagio. La videolaringoscopia complementa la protección del profesional, pero los videolaringoscopios comerciales son caros y no siempre están disponibles en las terapias intensivas pediátricas argentinas. El objetivo fue describir la práctica de intubación en un modelo de cabeza de simulación de lactante con un videolaringoscopio artesanal de bajo costo. Quince pediatras sin experiencia previa con el dispositivo participaron de una práctica de intubación en una cabeza de simulación con un videolaringoscopio artesanal. El tiempo promedio del primer intento fue de 116,4 segundos (intervalo de confianza del 95 % [IC95 %]: 84,8-148,0) y, el del siguiente fue de 44,2 segundos (IC95 %: 27,7­60,6). El tiempo disminuyó de forma significativa en el segundo intento (p : 0,0001). El dispositivo permitió la intubación exitosa en todos los intentos acortando la duración del procedimiento en la segunda práctica.

Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes.

BACKGROUND: Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health. METHODS: We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions. RESULTS: The SUD plastic handle generates an estimated 16-18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5-6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4-5 uses, and reusable blades 5-7 uses, before loss. CONCLUSIONS: LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.

A low-cost alternative for nasolaryngoscopy simulation training equipment: a randomised controlled trial.

OBJECTIVES: Flexible nasolaryngoscopy is a key diagnostic procedure used in many specialities. Simulation-based teaching is beneficial for endoscopy training, but it is expensive. This study assessed whether an inexpensive simulation model is an effective training method for flexible nasolaryngoscopy. METHODS: A three-armed, randomised, controlled trial was performed. One group received no simulation training, while two others were trained with either a high-cost or a low-cost model. All candidates then performed flexible nasolaryngoscopy on a volunteer. Their ability to perform this task was assessed by the patient discomfort score and time taken by a blinded expert. RESULTS: Simulation-based teaching reduced patient discomfort and improved candidate skill level. Low-cost model training did not have a negative effect when compared with high-cost model training. CONCLUSION: Simulated flexible nasolaryngoscopy training may be more accessible with the use of an effective low-cost model.

Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?

Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.

Inexpensive video-laryngoscopy guided intubation using a personal computer: initial experience of a novel technique.

Video-laryngoscopy may provide an enhanced view of laryngeal structures compared to direct visualization. Commercial video-laryngoscopes are often expensive, limiting its adoption for routine use. We describe our initial experience using an inexpensive custom made device. Patients >15 years age, were randomly chosen, after informed consent, for video-laryngoscopy. A custom device easily assembled using an USB endoscopic camera, a conventional Macintosh laryngoscope blade size 3 or 4, and a personal computer was used. Patients with Mallampati class 1-3 were chosen. Video-laryngoscopy was recorded and reviewed. Twenty-four patients aged 16-68 years, of mean weight 58.46 ± 12.54 (40-86) kg were studied. The glottis could be visualized and intubation could be performed in all patients with 22/24 patients on first attempt. Mean duration of laryngoscopy was 22.17 ± 12.78 (7-59) s. Time taken for intubation, was mean of 28.58 ± 21.01 (9-89) s. Three patients with anticipated difficult airways could be intubated on the first attempt. Minor blood staining of the airway was seen in the video in two patients. Cormack-Lehane laryngoscopy grade visualized was 1 in 9/24, 2 in 15/24 patients. Percentage of glottic opening score was 62.29 ± 28.40 (20-100) %. Real-time video could be captured in all cases. The custom-made, inexpensive, video-laryngoscopy device is safe and reliable for clinical use. Real-time visualization and endotracheal intubation were successful in all patients, including those with anticipated difficult airway. Further, this device helps in archiving the video of intubation.

A cost analysis of reusable and disposable flexible optical scopes for intubation.

BACKGROUND: Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities. METHODS: The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied. RESULTS: During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes. CONCLUSION: At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment.

Cost-effectiveness analysis of flexible optical scopes for tracheal intubation: a descriptive comparative study of reusable and single-use scopes.

STUDY OBJECTIVE: To calculate the costs per intubation of reusable fiberoptic scopes versus single-use intubation scopes. DESIGN: Open-label retrospective study. SETTING: University-affiliated hospital. MEASUREMENTS: The one-year intubation records of intubations performed with reusable intubation scopes, the one-year maintenance costs of these scopes, and their three-year repair cost records were analyzed. A total of 166 intubations were performed with reusable fiberoptic scopes in 2009. Calculations to assess the costs per intubation based on the documented records at our institution were made. The total cost of an intubation, the repair-to-intubation ratio, and the repair cost per intubation were determined. MAIN RESULTS: The total cost of an intubation at our institution in 2009, using reusable scopes, was $119.75 [US dollars (USD)], which included $20.15 (purchasing), $53.48 (repair), $33.16 (maintenance), and $12.96 (labor). The repair-to-intubation ratio was 1:55. Repair costs were $53.48 per intubation and $2,959.44 per instance of repair. CONCLUSIONS: The Ambu aScope, a single-use intubation scope, is a new addition to video laryngoscopy. The price should range within 10% of our intubation cost ($120.00 to $132.00 per single-use intubation scope).

A simple, inexpensive, and effective light- carrying laryngoscopic blade for orotracheal intubation of rats.

The research paradigm of using large laboratory animals, in which oroendotracheal intubations are relatively easy, is shifting toward the use of small animals, such as rodents, in which oropharyngeal access is limited, the arytenoid cartilage cycles are faster, and the glottis is much smaller. The considerable growth recently seen in preclinical imaging studies is accompanied by an increased number of rats and mice requiring in vivo intubation for airway management. Tracheal access is important for ventilation, administration of inhaled anesthetics, instillation of drugs or imaging agents, and maintenance of airway patency to reduce mortality during and after operations. I fashioned a light-carrying laryngoscopic blade (laryngoscope) from readily available acrylic-polymethyl methacrylate tubing and used it to perform rapid, effective tracheal intubation in rats. The laryngoscope design and intubation techniques are presented.

Audit of nasendoscope disinfection practice.

INTRODUCTION: Several options exist with regard to flexible pharyngo-laryngoscope sterilisation. We audited the use of disposable sheaths in our department over a six-month period. METHODS: A cost-analysis was performed and the advantages and disadvantages of this system were compared with several alternative options. RESULTS: We found that the overall cost of disposable sheaths averaged l4008 per month over a six-month period. We subsequently introduced chlorine dioxide (ClO2) wipes as a means of disinfection. Chlorine dioxide wipes have enabled a monthly saving of l3145 over sheath usage. Additionally, they meet health regulation requirements and are a convenient, cost-effective alternative to sheaths. DISCUSSION: The limiting factors, including time and financial issues, involved in nasendoscope disinfection are discussed. CONCLUSIONS: We have found chlorine dioxide wipes to be a satisfactory alternative means of nasendoscope disinfection. Possible time constraints aside, there are no advantages of sheath use over our current method. Chlorine dioxide wipes are also preferable from a financial point of view.

EndoSheath endoscopic system.

To address the problems inherent in reprocessing endoscopes--the time required (about an hour per use), the difficulty of the process, and the adverse consequences of endoscope contamination--Vision Sciences Inc. introduced the EndoSheath endoscopic system. It consists of a disposable sheath that fits over a specially designed reusable fiberoptic endoscope. When an endoscopic procedure is completed, the sheath is discarded, and the endoscope is wiped with alcohol and reused. We evaluated one of the EndoSheath products--a sheathed sigmoidoscope--for its suitability in an endoscopy suite. We examined the unit and surveyed a number of users. We found that, although it would considerably shorten the time between endoscopic procedures, the unit was not well suited for an endoscopy suite because it provided no more protection than would be afforded by a carefully followed reprocessing protocol. However, users informed us that the sigmoidoscope and one other product--a nasopharyngo-laryngoscope--would likely be useful in a doctor's office or a hospital clinic.