Supraglottic airway versus endotracheal tube during interventional pulmonary procedures - a retrospective study.

BACKGROUND: As the field of interventional pulmonology (IP) expands, anesthesia services are increasingly being utilized when complex procedures of longer duration are performed on sicker patients with high risk co-morbidities and lung pathology. Yet, evidence on the optimal anesthetic management for these patients remains lacking. Our aim was to characterize the airway management and, secondarily anesthetic maintenance patterns used for IP procedures at our institution. METHODS: From 2894 identified encounters, charts of 783 patients undergoing an IP procedure with general anesthesia over a 5-year period, employing an endotracheal tube (ETT) or a supraglottic airway (SGA) for airway maintenance, were identified and reviewed after exclusions. Patients posted for a concurrent thoracic surgical procedure and those already intubated at presentation were excluded. Baseline patient demographics, procedure, proceduralist type, anesthesia maintenance modality, neuromuscular blocking drug (NMBD) use, and airway management characteristics were extracted and analyzed. RESULTS: Inhaled general anesthesia with an ETT for airway maintenance was most commonly employed; however, SGAs were used in one-third of patients with a very low conversion rate (0.4%), and their use was associated with a significant reduction in NMBD use. CONCLUSIONS: In this large series of patients receiving general anesthesia for IP procedures, inhaled anesthetic agents and ETTs were favored. However, in appropriately selected patients, SGA use was effective for airway maintenance and allowed for a reduction in NMBD use, which may have implications in this patient population who may have an increased risk for pulmonary complications and warrants further investigation.

Understanding medical device regulation.

PURPOSE OF REVIEW: The purpose of this article is to provide a structural and functional understanding of the systems used for the regulation of medical devices in the USA and European Union (EU). RECENT FINDINGS: Safe and effective anesthesia care depends heavily on medical devices, including simple, low risk devices to complex life-supporting and life-sustaining devices. In the USA and EU, the Food and Drug Administration and European Commission, respectively, provide regulatory oversight to ensure medical devices are reasonably safe and effective when used for their intended purposes. Unfortunately, practicing anesthesiologists generally have little or no understanding of how medical devices are regulated, nor do they have sufficient knowledge of available adverse event reporting systems. SUMMARY: The US and EU medical device regulatory systems are similar in many ways, but differ in important ways too, which impacts the afforded level of safety and effectiveness assurance. In both systems, medical devices are classified and regulated on a risk basis, which fundamentally differs from drug regulation, where uniform requirements are imposed. Anesthesia providers must gain knowledge of these systems and be active players in both premarket and postmarket activities, particularly with regard to vigilance and adverse event/device failure reporting.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial.

BACKGROUND: Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration. METHODS: This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts. RESULTS: Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) Vte in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB. DISCUSSION: In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs. CONCLUSION: We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02237443 . Registered August 28, 2014.

A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty.

The aim of this study was to compare perioperative analgesia provided by single-injection adductor canal block (ACB) to continuous femoral nerve catheter (FNC) when used in a multimodal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared outcome data for 148 patients receiving a single-injection ACB to 149 patients receiving an FNC. The mean length of stay (LOS) in the ACB group was 2.67 (±0.56) and 3.01 days (±0.57) in the FNC group (P<0.0001). The median ambulatory distances for the adductor group were further than the femoral group for postoperative days 1 (P<0.0001) and 2 (P=0.01). Single-injection ACB offered similar pain control and earlier discharge compared to continuous FNC in patients undergoing TKA.

Personal hand gel for improved hand hygiene compliance on the regional anesthesia team.

PURPOSE: Hand hygiene reduces healthcare-associated infections, and several recent publications have examined hand hygiene in the perioperative period. Our institution's policy is to perform hand hygiene before and after patient contact. However, observation suggests poor compliance. This is a retrospective review of a quality improvement database showing the effect of personal gel dispensers on perioperative hand hygiene compliance on a regional anesthesia team. METHODS: Healthcare providers assigned to the Acute Pain Service were observed for compliance with hand hygiene policy during a quality improvement initiative. Provider type and compliance were prospectively recorded in a database. Team members were then given a personal gel dispensing device and again observed for compliance. We have retrospectively reviewed this database to determine the effects of this intervention. RESULTS: Of the 307 encounters observed, 146 were prior to implementing personal gel dispensers. Compliance was 34%. Pre- and post-patient contact compliances were 23 and 43%, respectively. For 161 encounters after individual gel dispensers were provided, compliance was 63%. Pre- and post-patient contact compliances were 53 and 72%, respectively. Improvement in overall compliance from 34 to 63% was significant. CONCLUSION: On the Acute Pain Service, compliance with hand hygiene policy improves when individual sanitation gel dispensing devices are worn on the person.

Magnesium sulfate with lidocaine for preventing propofol injection pain: a randomized, double-blind, placebo-controlled trial.

PURPOSE: Propofol injection pain, despite various strategies, remains common and troublesome. This study aimed to test the hypothesis that pretreatment with the combination of intravenous lidocaine and magnesium would have an additive effect on reducing propofol injection pain. METHODS: After institutional review board (IRB) approval and informed consent, we performed a prospective, double-blind, placebo-controlled, randomized trial. Subjects were randomly assigned to pretreatment with either lidocaine (50 mg), magnesium sulfate (0.25 mg), lidocaine (50 mg) plus magnesium sulfate (0.25 mg), or 0.9 % sodium chloride. Following pretreatment, propofol (50 mg) was administered, and subjects were questioned regarding injection site pain and observed for behavioral signs of pain. RESULTS: Two hundred subjects were enrolled and 158 subjects (39 placebo, 38 lidocaine, 44 magnesium sulfate, and 37 lidocaine plus magnesium sulfate) received their assigned pretreatment intervention. Intergroup baseline characteristics were similar. The proportion of subjects reporting propofol injection pain was highest in those pretreated with magnesium sulfate (57 %), followed by those pretreated with placebo (46 %), lidocaine plus magnesium sulfate (41 %), and then lidocaine (29 %; p = 0.011). When adjusted for age, gender, diabetes mellitus, chronic pain, tobacco use, and selective-serotonin reuptake inhibitor use, the pain response scale scores were significantly reduced by lidocaine pretreatment compared to magnesium sulfate and placebo (p = 0.031 and p = 0.0003, respectively). CONCLUSIONS: In this double-blind, placebo-controlled, randomized trial, the combination of intravenous magnesium sulfate and lidocaine offered no additional benefit for the relief of propofol injection pain compared to intravenous lidocaine alone. An improved, receptor-based understanding of the mechanism of propofol injection pain is still needed.

Cardiac arrest is a predictor of difficult tracheal intubation independent of operator experience in hospitalized patients.

BACKGROUND: Placement of advanced airways has been associated with worsened neurologic outcome in survivors of out-of-hospital cardiac arrest. These findings have been attributed to factors such as inexperienced operators, prolonged intubation times and other airway related complications. As an initial step to examine outcomes of advanced airway placement during in-hospital cardiac arrest (IHCA), where immediate assistance and experienced operators are continuously available, we examined whether cardiopulmonary resuscitation efforts affect intubation difficulty. Additionally, we examined whether or not the use of videolaryngoscopy increases the odds of first attempt intubation success compared with traditional direct laryngoscopy. METHODS: The study setting is a large urban university-affiliated teaching hospital where experienced airway managers are available to perform emergent intubation for any indication in any out-of-the-operating room location 24 hours a day, 7 days-a-week, 365 days-a-year. Intubations occurring in all adults >18 years-of-age who required emergent tracheal intubation outside of the operating room between January 1, 2008 and December 31, 2012 were examined retrospectively. Multivariate logistic regression was used to estimate the odds of difficult intubation during IHCA compared to other emergent non-IHCA indications with adjustment for a priori defined potential confounders (body mass index, operator experience, use of videolaryngoscopy versus direct laryngoscopy, and age). RESULTS: In adjusted analyses, the odds of difficult intubation were higher when taking place during IHCA (OR=2.63; 95% CI 1.1-6.3, p=0.03) compared to other emergent indications. Use of video versus direct laryngoscopy for initial intubation attempts during IHCA, however, did not improve the odds of success (adjusted OR = 0.71; 95% CI 0.35-1.43, p = 0.33). CONCLUSIONS: Difficult intubation is more likely when intubation takes place during IHCA compared to other emergent indications, even when experienced operators are available. Under these conditions, direct laryngoscopy (versus videolaryngoscopy) remains a reasonable first choice intubation technique.

Systematic review of the use of retrievable inferior vena cava filters.

PURPOSE: To review the available literature on retrievable inferior vena cava (IVC) filters to examine the effectiveness and risks of these devices. MATERIALS AND METHODS: Investigators searched MEDLINE for clinical trials evaluating retrievable filters and reviewed the complications reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. Food and Drug Administration (FDA). RESULTS: Eligibility criteria were met by 37 studies comprising 6,834 patients. All of the trials had limitations, and no studies were randomized. There were 11 prospective clinical trials; the rest were retrospective studies. Despite the limitations of the evidence, the IVC filters seemed to be effective in preventing pulmonary embolism (PE); the rate of PE after IVC placement was 1.7%. The mean retrieval rate was 34%. Most of the filters became permanent devices. Multiple complications associated with the use of IVC filters were described in the reviewed literature or were reported to the MAUDE database; most of these were associated with long-term use (> 30 days). At the present time, the objective comparison data of different filter designs do not support superiority of any particular design. CONCLUSIONS: In high-risk patients for whom anticoagulation is not feasible, retrievable IVC filters seem to be effective in preventing PE. Long-term complications are a serious concern with the use of these filters. The evidence of the effectiveness and the risks was limited by the small number of prospective studies.

Fiberoptic-guided tracheal tube placement through the air-Q® Intubating Laryngeal Airway: a performance study in a manikin.

PURPOSE: This study characterizes the performance and success rate for fiberoptic-guided tracheal tube placement through the air-Q(®) Intubating Laryngeal Airway (air-Q). METHODS: Using a manikin, anesthesia trainees and staff anesthesiologists, experienced in fiberoptic-guided intubation, performed five consecutive fiberoptic-guided tracheal tube placements via the air-Q. Participant characteristics, procedure segment times, total procedure times, and observed failures were recorded. Linear mixed effect models with random slopes and intercepts were used to assess participant performance. RESULTS: Ten anesthesia trainees and ten staff anesthesiologists participated. Anesthesia trainees were younger and had practiced for fewer years compared to staff anesthesiologists. Gender was equally distributed between the groups. Both segmental and overall procedure times decreased from the first to the fifth trial among all participants, independent of experience level and gender. Overall mean procedure time decreased from 102 ± 31 to 68 ± 14 s, representing a relative time reduction of 33% and a mean time difference of 34 s [95% confidence interval (CI) 22-47 s; p < 0.0001]. Tracheal tube placement was successful in all attempts; however, three tracheal tube dislodgements occurred during air-Q removal (overall procedure success 97%). CONCLUSIONS: Fiberoptic-guided tracheal tube placement through the air-Q can be performed in a clinically acceptable period of time with high success by operators skilled in fiberoptic-guided intubation. Tracheal tube dislodgement during air-Q removal remains a potential risk that should be emphasized.

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study.

INTRODUCTION: Emesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% - 0.11% in fasted patients undergoing general anesthesia and 0% - 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy and airway decontamination (SALAD) involves maneuvering a suction catheter into the hypopharynx, while performing laryngoscopy and endotracheal intubation. Intentional esophageal intubation (IEI) involves blindly intubating the esophagus to control emesis before endotracheal intubation. Both are previously described techniques for endotracheal intubation in the setting of massive emesis. This study compares the SALAD and IEI techniques with the traditional approach of ad hoc, rigid suction catheter airway decontamination and endotracheal intubation in the setting of massive simulated emesis. METHODS: Senior anesthesiology and emergency medicine (EM) residents were randomized into three trial arms: the traditional, IEI, or SALAD. Each resident watched an instructional video on the assigned technique, performed the technique on a manikin, and completed the trial simulation with the SALAD simulation manikin. The primary trial outcome was aspirate volume collected in the manikin's lower airway. Secondary outcomes included successful intubation, intubation attempts, and time to successful intubation. We also collected pre- and post-simulation demographics and confidence questionnaire data. RESULTS: Thirty-one residents (21 anesthesiology and 10 EM residents) were randomized. Baseline group characteristics were similar. The mean aspirate volumes collected in the lower airway (standard deviation [SD]) in the traditional, IEI, and SALAD arms were 72 (45) milliliters per liter (mL), 100 (45) mL, and 83 (42) mL, respectively (p = 0.392). Intubation success was 100% in all groups. Times (SD) to successful intubation in the traditional, IEI, and SALAD groups were 1.69 (1.31) minutes, 1.74 (1.09) minutes, and 1.74 (0.93) minutes, respectively (p = 0.805). Overall, residents reported increased confidence (1.0 [0.0-1.0]; P = 0.002) and skill (1.0 [0.0-1.0]; P < 0.001) in airway management after completion of the study. CONCLUSION: The intubation techniques provided similar performance results in our study, suggesting any one of the three can be employed in the setting of massive emesis; although this conclusion deserves further study. Residents reported increased confidence and skill in airway management following the experience, suggesting use of the manikin provides a learning impact.

Use of an Airway Exchange Catheter-Assisted Extubation With Continuous End-Tidal Carbon Dioxide Monitoring in a Pediatric Patient With a Known Difficult Airway: A Case Report.

Tracheal extubation in children with known difficult airways is associated with an increased risk of adverse events. Currently, there is no reliable measure to predict the need for emergent reintubation due to airway inadequacy. Airway exchange catheter-assisted extubation has been shown to be a useful adjunct in decreasing the risk of adverse events due to failed extubation. We report a case of using an airway exchange catheter-assisted extubation with continuous end-tidal carbon dioxide monitoring for a pediatric patient with a known difficult airway.

Two methods for teaching basic upper airway sonography.

STUDY OBJECTIVE: The purpose of this study was to evaluate and compare hands-on gel phantom versus instructional video teaching methods to improve anesthesia residents and staff members' ability to correctly identify airway structures using ultrasound on a human volunteer. DESIGN: Randomized, controlled trial. SETTING: Simulation laboratory. STUDY SUBJECTS: Fifty-four anesthesiology resident and staff members (27 anesthesiologists and 27 anesthesiology residents) at the University of Wisconsin-Madison. INTERVENTIONS: Study subjects were randomized into one of three groups: control (standard medical knowledge), video training, or gel phantom training. After providing study instructions and training (if relevant), study subjects were asked to perform sonoanatomy identification of the thyroid cartilage, cricoid cartilage, cricothyroid membrane, and the tracheal rings in both the transverse and longitudinal views. Study subjects then returned 14 to 24 days following initial assessment for evaluation of skills retention. They were again instructed to identify the same airway structures as during the initial assessment with scoring performed by the same assessor. MAIN RESULTS: All group characteristics were similar at baseline and follow-up. Both training tools produced a learning effect at baseline and follow-up compared to standard anesthesia training. No differences in overall airway structure identification success between groups receiving video versus gel airway phantom training were observed. CONCLUSIONS: Use of either a low cost, airway gel phantom training model for hands-on training or a simple instructional teaching video can be used in a single training session to improve staff anesthesiologist and anesthesia resident knowledge and skills for ultrasound identification of upper airway anatomy.

A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock.

BACKGROUND: Torso hemorrhage remains a leading cause of potentially preventable death within trauma, acute care, vascular, and obstetric practice. A proportion of patients exsanguinate before hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive hemostasis. A systematic review was conducted to characterize the current clinical use of REBOA and its effect on hemodynamic profile and mortality. METHODS: A systematic review (1946-2015) was conducted using EMBASE and MEDLINE. Original studies on human subjects, published in English language journals, were considered. Articles were included if they reported data on hemodynamic profile and mortality. RESULTS: A total of 83 studies were identified; 41 met criteria for inclusion. Clinical settings included postpartum hemorrhage (5), upper gastrointestinal bleeding (3), pelvic surgery (8), trauma (15), and ruptured aortic aneurysm (10). Of the 857 patients, overall mortality was 423 (49.4%); shock was evident in 643 (75.0%). Pooled analysis demonstrated an increase in mean systolic pressure by 53 mm Hg (95% confidence interval, 44-61 mm Hg) following REBOA use. Data exhibited moderate heterogeneity with an I of 35.5. CONCLUSION: REBOA has been used in a variety of clinical settings to successfully elevate central blood pressure in the setting of shock. Overall, the evidence base is weak with no clear reduction in hemorrhage-related mortality demonstrated. Formal, prospective study is warranted to clarify the role of this adjunct in torso hemorrhage. LEVEL OF EVIDENCE: Systematic review, level IV.

Teaching sonoanatomy to anesthesia faculty and residents: utility of hands-on gel phantom and instructional video training models.

STUDY OBJECTIVE: Thousands of patients worldwide annually receive neuraxial anesthesia and analgesia. Obesity, pregnancy, and abnormal spinal anatomy pose challenges for accurate landmark palpation. Further, spinal sonoanatomy is not uniformly taught in residency education, even though its use has previously been shown to improve identification of relevant structures and decrease procedural complications and failure rates. The aim of this study was to evaluate the use of hands-on gel phantom and instructional video training for teaching spinal sonoanatomy among anesthesiology faculty and residents. DESIGN: Twenty-three residents and 27 anesthesiologists were randomized to gel phantom, video teaching, and control groups. SETTING: Academic Hospital. MEASUREMENTS: Successful identification of spinal sonoanatomy was attempted on a human volunteer before and immediately after the respective intervention and 3 weeks later. Perceived knowledge and training modality satisfaction were assessed using modified Likert scales. INTERVENTIONS: Gel phantom and video teaching groups compared with control (no intervention). MAIN RESULTS: Both interventions significantly improved spine sonoanatomy identification accuracy. Logistic regression analysis demonstrated both interventions improved the odds of transverse process (gel 12.61, P = .013; video 7.93, P = .030) and lamina (gel 65.12, P = .003; video 8.97, P = .031) identification. Perceived knowledge of basic spinal anatomy and spinal sonoanatomy improved in the intervention versus control groups. Mean (SD) modified Likert scale scores for learning satisfaction (1 = unsatisfied, 10= very satisfied) were 8.1 (1.5) and 8.0 (1.7) for hands-on gel phantom and instructional video training participants, respectively. CONCLUSION: Use of hands-on gel phantom or instructional video training can improve anesthesia staff and resident knowledge of lumbar spine sonoanatomy.

An easily made, low-cost phantom for ultrasound airway exam training and assessment.

BACKGROUND: Recent manuscripts have described the use of ultrasound imaging to evaluate airway structures. Ultrasound training tools are necessary for practitioners to become proficient at obtaining and interpreting images. Few training tools exist and those that do can often times be expensive and rendered useless with repeated needle passes. METHODS: We utilised inexpensive and easy to obtain materials to create a gel phantom model for ultrasound-guided airway examination training. RESULTS: Following creation of the gel phantom model, images were successfully obtained of the thyroid and cricoid cartilages, cricothyroid membrane and tracheal rings in both the sagittal transverse planes. CONCLUSION: The gel phantom model mimics human airway anatomy and may be used for ultrasound-guided airway assessment and intervention training. This may have important safety implications as ultrasound imaging is increasingly used for airway assessment.

The GlideScope for videolaryngoscopy-assisted nasotracheal-to-orotracheal tube exchange in the intensive care unit in a patient with a known difficult airway.

A 77 year old, nasally intubated man with a history of repeated episodes of airway obstruction requiring intubation due to recurrent laryngitis and a hypopharyngeal mass, needed nasotracheal-to-orotracheal tube exchange. The GlideScope videolaryngoscope was inserted, achieving a full view of the glottic inlet with the nasotracheal tube in situ. An endotracheal tube (ETT) loaded on a GlideRite Rigid Stylet was advanced through the oropharynx into view. Advancement of this ETT to the glottic opening was tested and achieved. With both tracheal tubes in view, the nasotracheal tube cuff was deflated and withdrawn from the glottic opening. While maintaining videoscopic visualization, the orotracheal tube was advanced through the vocal cords into the trachea. The benefits of this technique versus existing alternatives are discussed.

Evaluation of the GlideScope Direct: A New Video Laryngoscope for Teaching Direct Laryngoscopy.

Background. Teaching direct laryngoscopy is limited by the inability of the instructor to simultaneously view the airway with the laryngoscopist. Our primary aim is to report our initial use of the GlideScope Direct, a video-enabled, Macintosh laryngoscope intended primarily as a training tool in direct laryngoscopy. Methods. The GlideScope Direct was made available to anyone who planned on performing direct laryngoscopy as the primary technique for intubation. Novices were those who had performed <30 intubations. Results. The GlideScope Direct was used 123 times as primarily a direct laryngoscope while the instructor viewed the intubation on the monitor. It was highly successful as a direct laryngoscope (93% success). Salvage by indirect laryngoscopy occurred in 7/9 remaining patients without changing equipment. Novices performed 28 intubations (overall success rate of 79%). In 6 patients, the instructor took over and successfully intubated the patient. Instructors used the video images to guide the operator in 16 (57%) of those patients. Seven different instructors supervised the 28 novices, all of who subjectively felt advantaged by having the laryngoscopic view available. Conclusions. The GlideScope Direct functions similarly to a Macintosh laryngoscope and provides the instructor subjective reassurance, while providing the ability to guide the trainee laryngoscopist.