RESUMO
With increasing specialization, more collaborative relationships have developed between anesthesiologists and surgeons. Specialization has influenced not only relationships but also communication between anesthesiologists and surgeons. This article considers the nature and scope of these transitions in recent histories of both professions.
Assuntos
Anestesiologistas , Cirurgiões , Comunicação , Humanos , Navios , EspecializaçãoRESUMO
BACKGROUND: In patients who undergo surgery for oropharyngeal masses, intubation is almost always successful. However, technical aspects of airway management, including bag mask ventilation and oxygenation, may still be difficult. Although rates of airway difficulty and intubation success in these patients have been studied, these data may not reflect difficulty with individual components of the intubation process. We hypothesized that rates of complications with individual elements of the intubation process would not be reflected in the rate of eventual intubation success. To test our hypothesis, we observed the process of airway management and resulting complications with oxygenation and bag mask ventilation in patients with oropharyngeal masses undergoing otorhinolaryngology procedures under general anesthesia. METHODS: Forty-four patients with oropharyngeal masses scheduled for surgery were observed during the process of airway management. Observers recorded the number of airway devices used, the overall number of intubation attempts, the number and type of manual maneuvers required during bag mask ventilation, and the incidence of oxygen desaturation. The eventual intubation success rate was also recorded. RESULTS: All 44 patients (100%; 95% CI, 92%-100%) were successfully intubated. Thirty-six (81.8%) of 44 patients were intubated asleep and 8 (18.2%) of 44 were intubated awake using flexible fiberoptic bronchoscopy. Thirty-one (86.1%) of 36 patients who were intubated asleep received bag mask ventilation before intubation, while the other 5 patients underwent a rapid sequence induction. Twenty-seven (61.4%) of 44 patients (95% CI, 45%-75%) had ≥1 complication during airway management. Ten (23%) of 44 patients (95% CI, 11%-37%) required ≥3 attempts to intubate, 21 (68%) of 31 patients (95% CI, 49%-83%) had difficult mask ventilation, and 15 patients (34%; 95% CI, 20%-50%) experienced desaturation (oxygen saturation measured by pulse oximetry, <95%). CONCLUSIONS: We found that, although all patients were successfully intubated, clinicians frequently encountered complications with both intubation and mask ventilation. These complications required frequent use of additional manual maneuvers during mask ventilation and a high incidence of oxygen desaturation. The difficulty of airway management in patients with oropharyngeal masses may not be effectively assessed by success rate alone.
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Manuseio das Vias Aéreas/métodos , Intubação Intratraqueal/métodos , Neoplasias Orofaríngeas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Broncoscopia , Feminino , Tecnologia de Fibra Óptica , Humanos , Máscaras Laríngeas/efeitos adversos , Laringoscopia , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigênio , Estudos Prospectivos , Respiração Artificial/métodos , VentilaçãoRESUMO
OBJECTIVE: To compare the standard intraluminal approach with the placement of the 9-French Arndt endobronchial blocker with an extraluminal approach by measuring the time to positioning and other relevant intraoperative and postoperative parameters. DESIGN: A prospective, randomized, controlled trial. SETTING: University hospital. PARTICIPANTS: The study comprised 41 patients (20 intraluminal, 21 extraluminal) undergoing thoracic surgery. INTERVENTION: Placement of a 9-French Arndt bronchial blocker either intraluminally or extraluminally. Comparisons between the 2 groups included the following: (1) time for initial placement, (2) quality of isolation at 1-hour intervals during one-lung ventilation, (3) number of repositionings during one-lung ventilation, and (4) presence or absence of a sore throat on postoperative days 1 and 2 and, if present, its severity. MEASUREMENTS AND MAIN RESULTS: Median time to placement (min:sec) in the extraluminal group was statistically faster at 2:42 compared with 6:24 in the intraluminal group (p < 0.05). Overall quality of isolation was similar between groups, even though a significant number of blockers in both groups required repositioning (extraluminal 47%, intraluminal 40%, p > 0.05), and 1 blocker ultimately had to be replaced intraoperatively. No differences in the incidence or severity of sore throat postoperatively were observed. CONCLUSIONS: A statistically significant reduction in time to placement using the extraluminal approach without any differences in the rate of postoperative sore throat was observed. Whether placed intraluminally or extraluminally, a significant percentage of Arndt endobronchial blockers required at least one intraoperative repositioning.
Assuntos
Brônquios/cirurgia , Broncoscopia/instrumentação , Intubação Intratraqueal/instrumentação , Ventilação Monopulmonar/instrumentação , Toracoscopia/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Broncoscopia/efeitos adversos , Broncoscopia/métodos , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Masculino , Pessoa de Meia-Idade , Ventilação Monopulmonar/efeitos adversos , Ventilação Monopulmonar/métodos , Faringite/diagnóstico , Faringite/etiologia , Estudos Prospectivos , Distribuição Aleatória , Toracoscopia/efeitos adversos , Toracoscopia/métodosRESUMO
STUDY OBJECTIVE: To determine quantitative differences in several routinely measured ventilation parameters using a standardized anesthetic technique and 3 different ventilation modalities in patients younger than 1 year with a ProSeal laryngeal mask airway (PLMA). DESIGN: Randomized prospective study. SETTING: Tertiary care pediatric hospital. PATIENTS: Thirty-nine American Society Anesthesiologists classifications 1 to 2, pediatric patients younger than 1 year. INTERVENTIONS: Three different ventilation strategies (spontaneous ventilation [SV], pressure support ventilation [PSV], and pressure-controlled ventilation [PCV]) were randomly applied to patients who underwent a standardized mask induction with sevoflurane/oxygen and propofol 2 mg/kg and fentanyl 2 µg/kg administered intravenously followed by PLMA insertion. Patients were maintained on sevoflurane and N2O. MEASUREMENTS: We measured the differences in end-tidal CO2 (etco2), tidal volume (TV), and respiratory rate (RR) over time between SV, PSV, and PCV. These data were recorded at 5-minute intervals. MAIN RESULTS: etco2 (mm Hg) was not significantly higher in the SV vs PSV (P=2.11) and SV vs PCV (P=.24). TV (mL/kg) was significantly lower in SV vs PSV (P<.005) and SV vs PCV (P<.005). RR was not significantly higher in SV vs PSV (P=.43), but was significantly higher in SV vs PCV (P<.005). Three patients in the SV group and 1 patient in the PSV group failed to initiate SV and required PCV and were thus excluded from analysis. CONCLUSIONS: All 3 modes of ventilation using a PLMA were safe in children younger than 1 year. Although we did not observe a statistically significant increase in etco2, differences in TV and RR, and the small but significant incidence of apnea may make PSV or PCV more optimal ventilation strategies in children younger than 1 year when using a PLMA.
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Máscaras Laríngeas , Respiração Artificial/instrumentação , Feminino , Humanos , Lactente , Masculino , Respiração Artificial/métodos , Testes de Função Respiratória/métodos , Testes de Função Respiratória/estatística & dados numéricos , Taxa Respiratória , Volume de Ventilação PulmonarRESUMO
STUDY OBJECTIVE: To determine quantitative differences in several routinely measured ventilation parameters using a standardized anesthetic technique and 3 different ventilation modalities in pediatric patients with a ProSeal laryngeal mask airway (PLMA). DESIGN: Randomized prospective study. SETTING: Pediatric hospital of a tertiary care academic medical center. PATIENTS: Thirty-three, American Society of Anesthesiologists classification 1-2, pediatric patients (12 months to 5 years). INTERVENTIONS: Three different ventilation strategies: spontaneous ventilation (SV), pressure support ventilation (PSV), and pressure-controlled ventilation (PCV) were randomly applied to patients who underwent a standardized mask induction with sevoflurane/oxygen and propofol 3 mg/kg and morphine 0.05 mg/kg administered intravenously followed by PLMA insertion. Patients were maintained on sevoflurane and N2O. MEASUREMENTS: We measured the differences in end-tidal CO2 (Etco2), tidal volume, and respiratory rate over time between SV, PSV, and PCV. These data were recorded at 5-minute intervals. MAIN RESULTS: Etco2 (mm Hg) was significantly higher in the SV vs PSV (P=.016) and vs PCV (P<.001). Tidal volume (mL/kg) was significantly lower in SV vs PSV (P<.001) and vs PCV (P<.001). Respiratory rate (breaths/min) was significantly higher in SV vs PSV (P<.001) and vs PCV (P=.005). CONCLUSIONS: All 3 modes of ventilation using a PLMA were safely used. Our SV group was noted to have a significantly higher Etco2 when compared with PSV and PCV with a mean Etco2 over time in excess of 55 mm Hg. PSV and PCV were found to be more appropriate ventilation strategies to more optimally control Etco2 over time in these patients.
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Dióxido de Carbono/análise , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Taxa Respiratória , Analgésicos Opioides/administração & dosagem , Anestesia por Inalação , Anestésicos Inalatórios/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Capnografia , Dióxido de Carbono/fisiologia , Pré-Escolar , Feminino , Humanos , Lactente , Máscaras Laríngeas , Masculino , Éteres Metílicos/administração & dosagem , Morfina/administração & dosagem , Propofol/administração & dosagem , Estudos Prospectivos , Distribuição Aleatória , Respiração Artificial/instrumentação , Sevoflurano , Volume de Ventilação Pulmonar/fisiologiaRESUMO
The laryngeal mask airway (LMA) Classic™ and Air-Q® are supralaryngeal devices used for airway management in routine and difficult pediatric airways. We describe a novel two-stage technique of insertion of the LMA Classic™ awake prior to induction of anesthesia, to assure oxygenation and ventilation, and after induction removal and placement of the Air-Q® for intubation using the flexible fiberoptic bronchoscope. The LMA Classic's™ pliable design and relatively small size allow it to be easily placed in awake infants. In contrast, the Air-Q® is an excellent device for intubation because of its larger internal diameter and removable 9 mm adapter. Our goal was to reduce unpredictability and potentially increase the safety of induction of anesthesia and intubation in infants with Pierre Robin sequence. By using these devices in a two-stage approach we created a technique for consistent oxygenation, ventilation, and intubation in these infants.
RESUMO
BACKGROUND: One-lung ventilation (OLV) is frequently employed to improve surgical exposure during video-assisted thoracoscopic surgery (VATS) and thoracotomy in adults and children. Because of their small size, children under the age of 2 years are not candidates for some of the methods typically used for OLV in adults and older children, such as a double-lumen endotracheal (DLT) tube or intraluminal use of a bronchial blocker. Due to this, the clinician is left with few options. One of the most robust approaches to OLV in infants and small children has been the extraluminal placement of a 5 French (5F) Arndt endobronchial blocker (AEB). AIM: The aim of this retrospective study was to examine and describe our experience with placement and management of an extraluminal 5F AEB for thoracic surgery in children <2 years of age. METHODS: We retrospectively examined the anesthetic records for details of AEB placement, arterial blood gas (ABG) data, and intraoperative analgesic prescription in 15 children under the age of 2 years undergoing OLV with a 5F AEB for thoracic surgery at our institution from January 2010 through January 2016. RESULTS: We were able to successfully achieve lung isolation in 14 of 15 patients using a 5F AEB that was bent 35-45° 1.5 cm proximal to the inflatable cuff. In 13 of 15 patients, we were able to place the AEB into final position with the aid of video-assisted fiberoptic bronchoscopy. In two patients, fluoroscopy was required to place the 5F AEB into the left mainstem due to poor visualization of the carina and rapid desaturation during bronchoscopy. In one of these patients, even though the blocker appeared to be correctly placed by fluoroscopy, adequate lung isolation was not observed. Intraoperatively, we observed significant degrees of hypercarbia in most patients without oxygen desaturation. Analgesic regimens lacked consistency and varied among patients. Open thoracotomy procedures tended to receive more aggressive narcotic regimens than video-assisted thoracoscopic surgery (VATS) procedures. Fourteen of 15 patients were extubated in the immediate postoperative period. CONCLUSIONS: Our technique of placing a 35-45° bend in the AEB, extraluminal placement, and observed manipulation with a video-assisted flexible fiberoptic bronchoscope (FFB) within the trachea can be used to achieve consistent lung isolation in patients <2 undergoing thoracic surgery. When the use of a FFB proves unsuccessful, fluoroscopy can provide an alternative solution to successful placement. Significant respiratory derangements without long-term sequelae will occur in a majority of these patients during OLV. Several different approaches to intraoperative analgesia did not impede extubation in the early postoperative period.
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Manuseio das Vias Aéreas/instrumentação , Ventilação Monopulmonar/instrumentação , Extubação , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/métodos , Analgésicos Opioides/uso terapêutico , Anestesia , Gasometria , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fluoroscopia , Humanos , Lactente , Recém-Nascido , Cuidados Intraoperatórios/estatística & dados numéricos , Intubação Intratraqueal/métodos , Masculino , Ventilação Monopulmonar/efeitos adversos , Ventilação Monopulmonar/métodos , Estudos Retrospectivos , Decúbito Dorsal , Cirurgia Torácica Vídeoassistida/instrumentação , Cirurgia Torácica Vídeoassistida/métodos , Toracotomia/instrumentação , Toracotomia/métodosRESUMO
There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it difficult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a difficult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient's risk of oxygen desaturation, and/or aspiration. For patients who may be difficult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic broncho-scope. Overall, geriatric-focused airway management is necessary to decrease complications in this patient population.
Assuntos
Envelhecimento/fisiologia , Manuseio das Vias Aéreas/métodos , Sistema Respiratório/anatomia & histologia , Sistema Respiratório/fisiopatologia , Humanos , Laringe/anatomia & histologia , Laringe/fisiopatologia , Boca/anatomia & histologia , Boca/fisiopatologia , Cavidade Nasal/anatomia & histologia , Cavidade Nasal/fisiopatologia , Pescoço/fisiopatologiaRESUMO
OBJECTIVES: We compared three primary outcomes of pausing the magnetic resonance imaging (MRI) scan, emergence quality and respiratory complications. AIM: To measure and compare the quality between sevoflurane and propofol in children undergoing MRI scans. BACKGROUND: No randomized controlled trial exists comparing the quality between sevoflurane and propofol for MRI. METHODS/MATERIALS: Two hundred unpremedicated children (18 months to 7 years) scheduled for brain MRI scans were recruited. After induction with sevoflurane, children were randomized to receive sevoflurane [general anesthesia with sevoflurane (GAS)] via laryngeal mask airway (LMA) or propofol [general anesthesia with propofol (GAP)] bolus and infusion for their scan. The three primary outcomes of pausing the MRI scan (P), agitation (A), and respiratory complications (R) were compared. Timeliness of care was also measured. RESULTS: No MRI scan pauses were found in 92% and 80% in the GAS and GAP groups. The median and interquartile A scores were 3 (0, 7) in GAS and 0 (0, 4) in GAP groups respectively. There was no difference in respiratory complications between GAS and GAP (P = 0.62). The median and interquartile postanesthesia care unit (PACU) times were 25 (18, 34) for GAS and 31 (25, 44) for GAP (P = 0.0001). The median and interquartile total times were 78 (69, 90) for GAS and 88 (78, 100) for GAP (P = 0.0002). CONCLUSION: Our study compared the three primary outcomes of pausing, agitation, and respiratory complications between the two groups, and we found no difference in respiratory complications. However, the GAP group had more pausing and less agitation than the GAS group.
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Anestesia Geral , Anestesia por Inalação , Anestesia Intravenosa , Anestésicos Inalatórios , Anestésicos Intravenosos , Imageamento por Ressonância Magnética , Éteres Metílicos , Propofol , Algoritmos , Anestesia Geral/efeitos adversos , Anestesia por Inalação/efeitos adversos , Anestesia Intravenosa/efeitos adversos , Apneia/prevenção & controle , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Intubação Intratraqueal , Masculino , Movimento , Agitação Psicomotora/prevenção & controle , Agitação Psicomotora/psicologia , Qualidade da Assistência à Saúde , Mecânica Respiratória/efeitos dos fármacos , Sevoflurano , Resultado do TratamentoAssuntos
Barreiras de Comunicação , Atenção à Saúde , Idioma , Características Culturais , Humanos , MultilinguismoAssuntos
Pediatria/métodos , Mascaramento Perceptivo/fisiologia , Radiologia/métodos , Criança , Sedação Consciente , Fluoroscopia/métodos , Humanos , Lactente , Recém-Nascido , Imageamento por Ressonância Magnética/métodos , Sacarose/administração & dosagem , Tomografia Computadorizada por Raios X/métodos , Gravação de Videoteipe , Água/administração & dosagemRESUMO
An increasing number of children now undergo magnetic resonance imaging (MRI) under sedation. MRI requires a cool environment. Because children have a larger surface area to body weight ratio than adults and because active warming devices are not MRI compatible, hypothermia as a result of passive heat loss is a risk. Absorption of radiofrequency radiation generated by the scanning process, however, may partially offset this heat loss. To determine the effect of absorbed radiofrequency radiation on body temperature during MRI, we measured pre-MRI and post-MRI tympanic temperatures in 30 children who underwent brain MRI while sedated with chloral hydrate and covered with a hospital gown and blanket. The mean (+/- sd) age was 14.9 +/- 8.6 mo, and weight was 9.8 +/- 2.8 kg. During an average scan duration of 42 +/- 13 min, mean tympanic temperatures increased 0.5 degrees C from 36.9 degrees C +/- 0.4 degrees C to 37.4 degrees C +/- 0.3 degrees C; (95% CI difference, 0.3 degrees C to 0.7 degrees C; P < 0.001). Our findings suggest that children sedated with chloral hydrate for brain MRI did not become hypothermic but rather had increased body temperature despite minimal barriers to heat loss and no active warming. These results imply that aggressive measures to prevent passive heat loss during MRI studies may not be needed in all patients.