In-situ simulation for the detection of latent risk threats in a hyperbaric medicine department.

Simulation (SIM) can be used in the quality improvement process to discover latent risk threats (LRTs) by running in-situ simulation cases in the clinical environment. We utilized this methodology in the hyperbaric chamber to run six in-situ SIM sessions between February 2017 and January 2019. The debriefing portion of each SIM was used to discuss and document all discovered LRTs. These safety threats were aggregated and categorized, resulting in a total of 22 unique LRTs. LRTs included problems or challenges with equipment, team education, policy/processes, communications, and medications. At a three-month follow-up, the hyperbaric leadership team had addressed each of the 22 unique LRTs. SIM can be used to identify, categorize and prioritize LRTs in an effective manner, in order to improve the health care delivery system in a hyperbaric medicine department.

Thirty-five alternatives to positive airway pressure therapy for obstructive sleep apnea: an overview of meta-analyses.

INTRODUCTION: Positive airway pressure (PAP) devices are generally considered to be the first-line treatment of choice for most adults with obstructive sleep apnea (OSA). However, there are several alternatives. It is important for patients and their sleep providers to be aware of the most up-to-date information regarding the current international literature. Areas covered: The objective is to provide an overview of the meta-analyses evaluating non-PAP treatments for OSA. Four authors searched four databases, including PubMed/MEDLINE through 30 November 2017, for meta-analyses evaluating non-PAP therapies as treatment for OSA. Thirty-five non-PAP treatments were identified and were categorized based on the following anatomical subsites: (1) nose, (2) palate and oropharynx, (3) tongue, (4) skeletal surgery and jaw repositioning, and (5) other surgical and medical interventions. Treatments identified included surgeries, drugs, behavior modifications, nonsurgical weight loss, medical devices, body positioning, and oxygen treatment. Expert commentary: The 35 treatments described vary in their effectiveness in treating OSA in adults. In general, isolated nasal treatments are the least effective, whereas treatments that bypass the upper airway, significantly open the upper airway, and/or address multiple levels of the upper airway are more effective in improving apnea-hypopnea index and lowest oxygen saturation.

An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients.

BACKGROUND: The need for 1-lung ventilation in school age, pediatric patients is uncommon and as a result there are relatively few devices available to facilitate lung isolation in this population. Furthermore, little is known about the efficacy and techniques of placement of the currently available devices. One of the newest devices available that may be appropriate in this age group is the EZ-Blocker. AIMS: We aimed to examine our initial experience with the EZ-Blocker to evaluate the performance of this device with respect to potential improvements in technique and patient selection going forward. METHODS: We performed a retrospective chart review of all pediatric patients who underwent 1-lung ventilation with an EZ-Blocker since the blocker became available at our institution. We recorded demographics, details of placement, intraoperative course, number of repositions, and any postoperative morbidity related to blocker placement or 1-lung ventilation. RESULTS: We were able to correctly place the EZ-Blocker and achieve lung isolation in 8 of 11 patients. There was a single episode of repositioning required during 1-lung ventilation with an EZ-Blocker. CONCLUSION: The EZ-Blocker was successful in providing lung isolation for a majority of our school age patients. Size constraints in children <6 years of age, excessive secretions, and distortions of tracheal anatomy seemed to be the greatest hindrances to successful placement and positioning of the device. Once correctly positioned, however, the EZ-Blocker may be more stable than the Arndt endobronchial blocker.

A feasibility study of awake videolaryngoscope-assisted intubation in patients with periglottic tumour using the channelled King Vision® videolaryngoscope.

Airway management in patients with periglottic tumour is a high-risk procedure with potentially serious consequences. There is no consensus on how best to secure the airway in this group of patients. We conducted a feasibility study of awake tracheal intubation using a King Vision® videolaryngoscope with a channelled blade in a cohort of 25 patients, with a periglottic tumour requiring diagnostic or radical surgery. We used 10% and 4% lidocaine to topicalise the airway and midazolam and remifentanil for sedation. We recorded the success rate, number of attempts, time to obtain glottic view, time to intubation and complications. Twenty-three of the 25 patients (92%, 95%CI 75-98%) were intubated with the awake videolaryngoscope-assisted technique, with 17/23 (74%, 95%CI 54-87%) intubations achieved at the first attempt. Five patients required two and one patient, three attempts at intubation. Two patients (8%, 95%CI 2-25%) could not tolerate the procedure due to inadequate topical anaesthesia. Median (IQR [range]) times to obtain glottic view and to intubate were 19 (17-22 [10-30]) s and 49 (42-71 [33-107]) s, respectively. Traces of blood in the airway were observed in 4/25 (16%, 95%CI 6-35%) patients. Although airway management in this group of patients was expected to be difficult, successful awake intubation with the King Vision videolaryngoscope was achieved in the majority of patients within less than a minute. This study highlights a number of potential advantages of awake videolaryngoscope-assisted intubation over other awake methods of securing the airway in patients with upper airway obstruction due to periglottic mass.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]. / Interdisziplinär konsentierte Stellungnahme zum Atemwegsmanagement mit supraglottischen Atemwegshilfen in der Kindernotfallmedizin: Larynxmaske ist State-of-the-art.

BACKGROUND: Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. MATERIAL AND METHODS: Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. DISCUSSION: Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

Lidocaína: análise do uso intravenoso para atenuar os reflexos cardiovasculares da laringoscopia e intubação traqueal / Lidocaine: analysis of the intravenous use to mitigate the cardiovascular reflexes of laryngoscopy and tracheal intubation

A lidocaína é um anestésico local do tipo aminoamida, com ação antiarritmica, analgésica, sedativa e anti-inflamatória. Devido a tais efeitos, a lidocaína por via venosa é largamente utilizada para atenuar os efeitos cardiovasculares da intubação traqueal, que podem levar a alterações marcantes na pressão arterial (PA) e na frequência cardíaca (FC). Essas alterações hemodinâmicas indesejáveis podem aumentar a morbidade e mortalidade per e pós-operatórias. A lidocaína usada por via intravenosa se mostrou eficaz na atenuação de reflexos cardiovasculares resultantes da intubação traqueal, em todas as idades. Foi eficaz na prevenção do aumento da FC, exceto em crianças e da pressão arterial sistólica, diastólica e média, em todas as faixas etárias. Houve diminuição da incidência de arritmias e alterações eletrocardiográficas, na dose de 1,5 mg/kg.

Lidocaine is a local anesthetic of the amino amide type, with antiarrhythmic, analgesic, sedative and anti-inflammatoryactions actions. Because of such effects, intravenous lidocaine is widely used to mitigate the cardiovascular effects of tracheal intubation, which can lead to marked changes in blood pressure (BP) and heart rate (HR). These undesirable hemodynamic changes may increase per and postoperative morbidity and mortality. The lidocaine used intravenously was effective in attenuating cardiovascular reflexes from tracheal intubation, at all ages. It was effective in preventing the increase in HR, except in children, and systolic, diastolic and mean blood pressure in all age groups. There was a decrease in the incidence of arrhythmias and ECG changes at a dose of 1.5 mg/kg.

Essentials of airway management, oxygenation, and ventilation: part 1: basic equipment and devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice whether providing local anesthesia alone or in combination with procedural sedation. Part 2 of this series will address advanced airway devices, including supraglottic airways and armamentarium for tracheal intubation and invasive airway procedures.

Alternative airways for the pediatric emergency department.

Securing the pediatric airway in the emergency setting is an uncommon event that is complicated by anatomic, physiologic, and environmental factors. Even more uncommonly, practitioners are faced with the added complication of a difficult airway, and the question of what alternatives to traditional endotracheal intubation are available and most useful may arise. Timely and effective intervention determines the patient's clinical outcome. The purpose of this review was to detail specific alternative airway management strategies and tools for use in the pediatric emergency department.