Seven years on from the Canadian Airway Focus Group Difficult Airway Guidelines: an observational survey.

PURPOSE: Numerous clinical guidelines are available for management of the unanticipated difficult airway. It is unclear if practice recommendations are endorsed on regional, local, or individual levels. The objective of this observational study was to examine local and regional use of airway guidelines by anesthesiologists within a hospital partnership in Southwestern Ontario. METHODS: Using a paper survey, distributed locally to consultant and trainee anesthesiologists in a tertiary hospital, we examined individual clinical and educational practices regarding guideline use in airway management. Respondents were asked to report which published guideline they used for unanticipated airway difficulty. The effectiveness of dissemination of the national Canadian airway guidelines-the Canadian Airway Focus Group (CAFG) Difficult Airway Guidelines-was examined. We invited anesthesia department heads within the regional hospital partnership to complete an electronic survey investigating departmental adoption of guidelines. RESULTS: The response rate was 70% locally (79/112 anesthesiologists) and 52% regionally (11/21 department heads). Approximately 80% (64/79) of respondents reported using a formal clinical guideline if unanticipated difficulty with airway management was encountered. Seventy-two per cent of respondents (57/79) were aware of the published CAFG guidelines. Approximately 30% (16/51) of consultant anesthesiologists reported using the CAFG guidelines in clinical practice. Within the hospital partnership, 36% (4/11) of departments formally endorsed use of a specific airway management guideline. CONCLUSIONS: Despite widespread awareness of the national CAFG Difficult Airway Guidelines, they are not widely adopted in clinical practice. Further research is warranted to explore barriers to adoption of airway management guidelines for both individual anesthesiologists and anesthesia departments.

RéSUMé: OBJECTIF: De nombreuses lignes directrices cliniques sont disponibles pour la prise en charge des voies aériennes difficiles non anticipées. Nous ne savons pas si ces recommandations de pratique sont suivies aux niveaux régional, local ou individuel. L'objectif de cette étude observationnelle était d'examiner l'utilisation locale et régionale des lignes directrices sur les voies aériennes par des anesthésiologistes provenant d'un partenariat hospitalier dans le sud-ouest de l'Ontario. MéTHODE: À l'aide d'une enquête papier, distribuée localement aux anesthésiologistes et aux résidents en anesthésiologie d'un hôpital de soins tertiaires, nous avons examiné les pratiques cliniques et éducatives individuelles concernant l'utilisation des lignes directrices dans la prise en charge des voies aériennes. On a demandé aux répondants de divulguer les lignes directrices publiées qu'ils utilisaient lorsqu'ils étaient confrontés à des difficultés imprévues au niveau des voies aériennes. L'efficacité de diffusion des lignes directrices nationales canadiennes sur les voies aériennes­les Lignes directrices sur les voies aériennes difficiles du Canadian Airway Focus Group (CAFG)­a été examinée. Nous avons invité les chefs des départements d'anesthésiologie au sein du partenariat hospitalier régional à remplir un sondage électronique sur l'adoption des lignes directrices par leur département. RéSULTATS: Le taux de réponse était de 70 % au niveau local (79/112) et de 52 % au niveau régional (11/21 chefs de département). Environ 80 % (64/79) des répondants ont déclaré avoir utilisé des lignes directrices cliniques officielles en cas de difficultés imprévues dans la prise en charge des voies aériennes. Soixante-douze pour cent des répondants (57/79) avaient connaissance des lignes directrices publiées par le CAFG. Environ 30 % (16/51) des anesthésiologistes ont déclaré avoir utilisé les lignes directrices du CAFG dans leur pratique clinique. Au sein du partenariat hospitalier, 36 % (4/11) des départements ont officiellement appuyé l'utilisation d'une ligne directrice spécifique pour la prise en charge des voies aériennes. CONCLUSION: Malgré une importante sensibilisation aux Lignes directrices nationales sur les voies aériennes difficiles du CAFG, ces dernières ne sont pas largement adoptées dans la pratique clinique. D'autres recherches sont nécessaires pour explorer les obstacles à l'adoption de lignes directrices pour la prise en charge des voies aériennes tant par les anesthésiologistes que par les départements d'anesthésie.

Imatinib mesylate treatment in two patients with idiopathic hypereosinophilic syndrome.

OBJECTIVE: To report 2 clinical cases of hypereosinophilic syndrome (HES) refractory to standard therapy and the variable responses to imatinib mesylate, and to review previously reported cases of imatinib mesylate use in the treatment of hypereosinophilia. case summaries: Two male patients were diagnosed with idiopathic HES complicated with organ involvement. Both were treated with imatinib mesylate after failing to respond to or being unable to tolerate standard therapy. In one patient, treatment with imatinib mesylate 100 mg/day produced resolution of symptoms and peripheral blood cell counts within 6 days. The patient has successfully maintained normal blood cell counts and has been without symptoms for more than one year after starting imatinib mesylate. The other patient failed to respond to imatinib mesylate even at the maximum dose (up to 400 mg/day). DISCUSSION: Imatinib mesylate was considered an appropriate alternative for standard therapy of HES based on the evidence that other treatments used for chronic myelogenous leukemia have also been successful in treating HES. Three small studies have supported this hypothesis. However, not all patients with HES respond to imatinib mesylate therapy. The cases presented here illustrate the marked difference. CONCLUSIONS: Imatinib mesylate has shown some promise in the treatment of HES. However, until the etiology of idiopathic hypereosinophilia and the role of imatinib mesylate in the resolution of this disease are determined, it will continue to be difficult to predict the responsiveness of a patient to imatinib mesylate therapy.

Cutaneous dalteparin reactions associated with antibodies of heparin-induced thrombocytopenia.

OBJECTIVE: To report widespread cutaneous lesions due to low-molecular-weight heparin therapy associated with heparin-induced thrombocytopenia (HIT), but without evidence of thrombocytopenia, and to review previously reported cases of skin reactions related to heparin therapy. CASE SUMMARY: A 59-year-old white man with a subtotally resected glioblastoma developed febrile neutropenia and pneumonia secondary to chemotherapy. The development of an upper extremity thrombosis, following insertion of a peripherally inserted central venous catheter, was treated with subcutaneous dalteparin. Cutaneous lesions developed distant from the site of injection. The diagnosis of HIT was confirmed despite stable platelet counts. Dalteparin therapy was discontinued immediately, and anticoagulation was maintained with warfarin. The skin lesions resolved without further complications. DISCUSSION: Numerous cases of heparin-induced cutaneous reactions have been reported. The majority of these describe a local reaction at the heparin injection site with or without associated thrombocytopenia. The case presented here is unique in that the observed skin reaction was distant to the injection site and occurred without thrombocytopenia, but with detectable heparin-dependent antibodies. CONCLUSIONS: Although a skin reaction is a rare complication of heparin therapy, it can be a clinical indicator of HIT despite normal platelet counts. Patients who develop skin lesions should have their heparin therapy discontinued and a diagnosis of HIT investigated.