Teaching airway teachers: a post-course quantitative and qualitative survey.

BACKGROUND: Airway management is a crucial skill for many clinicians. Besides mastering the technical skills of establishing a patent airway, human factors including leadership and team collaboration are essential. Teaching these human factors is often challenging for instructors who lack dedicated training. Therefore, the European Airway Management Society (EAMS) developed the Teach-the-Airway-Teacher (TAT) course. METHODS: This online post-course survey of TAT-course participants 2013-2021 investigated the impact of the TAT-course and the status of airway management teaching in Europe. Twenty-eight questions e-mailed to participants (using SurveyMonkey) assessed the courses' strengths and possible improvements. It covered participants' and workplace details; after TAT-course considerations; and specifics of local airway teaching. Data were assessed using Excel and R. RESULTS: Fifty-six percent (119/213) of TAT-participants answered the survey. Most were anaesthetists (84%), working in university level hospitals (76%). Seventy-five percent changed their airway teaching in some way, but 20% changed it entirely. The major identified limitation to airway teaching in their departments was "lack of dedicated resources" (63%), and the most important educational topic was "Teaching non-technical skills" (70%). "Lecturing " was considered less important (37%). Most surveyed anaesthesia departments lack a standardized airway teaching rotation. Twenty-one percent of TAT-participants rated their departmental level of airway teaching overall as inadequate. CONCLUSIONS: This survey shows that the TAT-course purpose was successfully fulfilled, as most TAT-course participants changed their airway teaching approach and did obtain the EAMS-certificate. The feedback provided will guide future TAT-course improvements to advance and promote a comprehensive approach to teaching airway management.

Human Factors and Airway Management in COVID-19 Patients: The Perfect Storm?

The SARS-CoV-2 pandemic heavily impacted healthcare workers, increasing their physical and psychological workload. Specifically, COVID-19 patients' airway management is definitely a challenging task regarding both severe and acute respiratory failure and the risk of contagion while performing aerosol-generating procedures. The category of anesthesiologists and intensivists, the main actors of airway management, showed a poor psychological well-being and a high stress and burnout risk. Identifying and better defining the specific main SARS-CoV-2-related stressors can help them deal with and effectively plan a strategy to manage these patients in a more confident and safer way. In this review, we therefore try to analyze the relevance of human factors and non-technical skills when approaching COVID-19 patients. Lessons from the past, such as National Audit Project 4 recommendations, have taught us that safe airway management should be based on preoperative assessment, the planning of an adequate strategy, the optimization of setting and resources and the rigorous evaluation of the scenario. Despite, or thanks to, the critical issues and difficulties, the "take home lesson" that we can translate from SARS-CoV-2 to every airway management is that there can be no more room for improvisation and that creating teamwork must become a priority.

Emergency in obese patients: a reply to SOBA UK.

Emergency settings in obese people require tailored multidisciplinary protocols and pathways to manage these complex patients. For this reason, we would like to foresee a proficient cooperation with the UK Society for Obesity and Bariatric Anaesthesia (SOBA) and other societies: obesity is a worldwide problem, and an international and multidisciplinary cooperation is desirable, if not needed. As demonstrated for bariatric surgery, a standardizing anesthesiologic and critical approach and an experienced multidisciplinary staff, trained and equipped to manage obese patients, are related to better outcomes. Similarly, as recently pointed out for airway management safety, we believe that the presence of an obese lead should be a desirable goal to reach in the next future, especially when thinking of emergency situations and the need for resuscitation of obese patients. A worldwide problem calls for worldwide cooperation.

Airway management for one lung ventilation during COVID-19 pandemic: a survey within Italian anesthesiologists.

BACKGROUND: Airway management for thoracic surgery represents a high risk setting for SARS-CoV-2 infection diffusion due to complex and invasive airway instrumentation and techniques. RESULTS: An 18-item questionnaire was submitted to the 56 members of the Thoracic subcommittee of the SIAARTI Cardio-Thoraco-Vascular Research Group to provide a snapshot of current situation and national variability of devices and procedures for airway management during the COVID-19 pandemic. The response rate was 64%. Eighty-three percent of anesthetists declared that they modified their airway management strategies. The Hospital Management considered necessary to provide a complete level 3 personal protective equipment for thoracic anesthetists only in 47% of cases. Double-lumen tube and bronchial blocker were preferred by 53% and 22% of responders to achieve one-lung ventilation respectively. Over 90% of responders considered the videolaryngoscope with separate screen and rapid sequence induction/intubation useful to minimize the infection risk. Thirty-nine percent of participants considered mandatory the bronchoscopic check of airway devices. Vivasight-DL was considered comfortable by more than 50% of responders while protective box and plastic drape were judged as uncomfortable by most of anesthetists. CONCLUSIONS: The survey reveals many changes in the clinical practice due to SARS-CoV-2 outbreak. A certain diffusion of new devices such as the VivaSight-DL and barrier enclosure systems emerged too. Finally, we found that most of Italian hospitals did not recognize thoracic anesthesia as a high-risk specialty for risk of virus diffusion.

Emergencies in obese patients: a narrative review.

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

Effectiveness of spinal anesthesia in transanal endoscopic microsurgery: a 3-year experience.

BACKGROUND: The feasibility and safety of transanal endoscopic microsurgery (TEM) performed under spinal anesthesia (SA) has been recently demonstrated. This retrospective study compared the differences in opioid consumption and postoperative recovery in patients undergoing TEM under GA and SA. METHODS: All consecutive patients who underwent TEM at Città della Salute e della Scienza Hospital of Turin (Italy) between January 2012 and December 2015 were enrolled. Data related to demographic characteristics, surgery, anesthesia management and postoperative course were recorded from the hospital electronic registry of medical records. Patients were treated according to a standardized protocol by a team of three anesthesiologists with experience in both GA and SA. RESULTS: The study included 148 patients: 77 in GA group and 71 in SA, with no switch among groups. Hospital length of stay was shorter in SA group (3 vs. 4 days, P=0.0201). SA patients were earlier mobilized and applied to oral postoperative intake (18 vs. 24 hours and 24 vs. 48 hours, respectively, P<0.0001). Peri-procedural complications, postoperative nausea, vomiting and pain were comparable between groups. Percentage of patients requiring postoperative rescue therapy with Tramadol was similar between groups, but SA patients received a lower opioid dosage (176.6±67.8 mg vs. 238.3±79.5 mg, P=0.0011). Operating room occupancy times was longer in GA group (120 vs. 100 minutes, P=0.0008). CONCLUSIONS: SA seems to be the treatment of choice, when not contraindicated, in patients undergoing TEM, allowing a reduction in perioperative opioid consumption and a faster postoperative recovery.

Ventilatory and hemodynamic management of potential organ donors: an observational survey.

OBJECTIVE: To determine the current standard ventilatory and cardiovascular management in potential organ donors. DESIGN: Prospective, multiple-center, observational survey. SETTING: A total of 15 intensive care units in 13 hospitals in Piedmont, Italy. PATIENTS: A total of 34 brain-dead patients enrolled in 6 months. MEASUREMENTS AND MAIN RESULTS: Demographics and reasons for lung transplant exclusion were recorded. Ventilatory and hemodynamic variables were compared before and after confirmation of brain death. A total of 23 potential donors were ineligible for lung donation based on pulmonary status and age. Of the 11 eligible lung donors, only two donated the lungs because five had Pao2/Fio2 ratios of <300 and four were ineligible for logistic problems. Tidal volume was 10 +/- 2 mL/kg, positive end-expiratory pressure was 3.3 +/- 2.7 cm H2O, Fio2 was 50% +/- 18% before brain death diagnosis, and no changes were made after brain death confirmation. In potential lung donors, apnea tests were performed with apneic oxygenation after disconnection from the ventilator in all cases; tracheal suction was performed with an open circuit in eight cases, and no recruitment maneuvers were performed. Crystalloid infusion was increased after diagnosis of brain death from 187 +/- 151 to 275 +/- 158 mL/hr (p < .05), and central venous pressure increased from 6 +/- 3 to 7 +/- 3 mm Hg (p < .05). Inotropic support was used in 24 donors (70%). CONCLUSIONS: Five of 11 potential lung donors (45%) had a Pao2/Fio2 ratio of <300, making them ineligible for lung donation. After the diagnosis of brain death, ventilatory management remained the same, no maneuvers for prevention of derecruitment of the lung were performed, and cardiovascular management was modified to optimize peripheral organ perfusion. These data represent the current standard of care for ventilatory management of potential organ donors and may be suboptimal in preserving lung function.