Introduction
Risks of endotracheal tube cuff (ETTC) over inflation must be balanced with the need to achieve a minimum pressure of 20 cm H2O. Methods have been developed to estimate adequate ETTC ...pressurization but do not provide accurate endotracheal tube cuff pressure (ETCP) measurements. Hence, different sized syringes may play a role in determining ETCP.
Objectives
Determine optimal syringe size for recommended ETCP.
Methods
Two hundred patients were randomized to use of either a 10‐mL syringe (standard syringe) or a 5‐mL syringe (study group) for ETTC inflation. Following the insertion of the endotracheal tube, the ETTC was inflated per the attending anesthesiologist. Within 10 minutes of intubation, ETCP was measured with a hospital‐provided manometer.
Results
The percentage of in range cuff pressures for the 5‐mL group was 10.53% and 6.78% for the 10‐mL group. 84.21% (n = 64) of the study group and 91.53% (n = 54) of the control group had cuff pressures exceeding 30 cmH2O. Although our study did not demonstrate that syringe size was predictive of ideal cuff pressure ranges, the average cuff pressure for the 5‐mL group was 55.8 cm H2O versus 68.8 cm H2O in the 10‐mL group.
Conclusion
Although both 5‐ and 10‐mL syringes resulted in elevated cuff pressures after intubation, 5‐mL syringes resulted in a lower degree of elevation. Use of a 5‐mL syringe should be considered when inflating the endotracheal cuff to possibly reduce patient harm secondary to elevated cuff pressures. Further studies assessing smaller syringe sizes to reduce cuff pressures are warranted.
Full text
Available for:
FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Clinicians intuitively recognize that faster time to hemostasis is important in bleeding trauma patients, but these times are rarely reported.
Prospectively collected data from the Pragmatic ...Randomized Optimal Platelet and Plasma Ratios trial were analyzed. Hemostasis was predefined as no intraoperative bleeding requiring intervention in the surgical field or resolution of contrast blush on interventional radiology (IR). Patients who underwent an emergent (within 90 minutes) operating room (OR) or IR procedure were included. Mixed-effects Poisson regression with robust error variance (controlling for age, Injury Severity Score, treatment arm, injury mechanism, base excess on admission missing values estimated by multiple imputation, and time to OR/IR as fixed effects and study site as a random effect) with modified Bonferroni corrections tested the hypothesis that decreased time to hemostasis was associated with decreased mortality and decreased incidence of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), multiple-organ failure (MOF), sepsis, and venous thromboembolism.
Of 680 enrolled patients, 468 (69%) underwent an emergent procedure. Patients with decreased time to hemostasis were less severely injured, had less deranged base excess on admission, and lower incidence of blunt trauma (all p < 0.05). In 408 (87%) patients in whom hemostasis was achieved, every 15-minute decrease in time to hemostasis was associated with decreased 30-day mortality (RR, 0.97; 95% confidence interval CI, 0.94-0.99), AKI (RR, 0.97; 95% CI, 0.96-0.98), ARDS (RR, 0.98; 95% CI, 0.97-0.99), MOF (RR, 0.94; 95% CI, 0.91-0.97), and sepsis (RR, 0.98; 95% CI, 0.96-0.99), but not venous thromboembolism (RR, 0.99; 95% CI, 0.96-1.03).
Earlier time to hemostasis was independently associated with decreased incidence of 30-day mortality, AKI, ARDS, MOF, and sepsis in bleeding trauma patients. Time to hemostasis should be considered as an endpoint in trauma studies and as a potential quality indicator.
Therapeutic/care management, level III.
BACKGROUND:The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) study evaluated the effects of plasma and platelets on hemostasis and mortality after hemorrhage. The pulmonary ...consequences of resuscitation strategies that mimic whole blood, remain unknown.
METHODS:A secondary analysis of the PROPPR study was performed. Injured patients predicted to receive a massive transfusion were randomized to 1:1:1 versus 1:1:2 plasma-platelet-red blood cell ratios at 12 Level I North American trauma centers. Patients with survival >24 h, an intensive care unit (ICU) stay, and a recorded PaO2/FiO2 (P/F) ratio were included. Acute respiratory distress syndrome (ARDS) was defined as a P/F ratio < 200, with bilateral pulmonary infiltrates, and adjudicated by investigators.
RESULTS:Four hundred fifty-four patients were reviewed (230 received 1:1:1, 224 1:1:2). Age, sex, injury mechanism, and regional abbreviated injury scale (AIS) scores did not differ between cohorts. Tidal volume, positive end-expiratory pressure, and lowest P/F ratio did not differ. No significant differences in ARDS rates (14.8% vs. 18.4%), ventilator-free (24 vs. 24) or ICU-free days (17.5 vs. 18), hospital length of stay (22 days vs. 18 days), or 30-day mortality were found (28% vs. 28%). ARDS was associated with blunt injury (OR 3.61 1.53–8.81 P < 0.01) and increasing chest AIS (OR 1.40 1.15–1.71 P < 0.01). Each 500 mL of crystalloid infused during hours 0 to 6 was associated with a 9% increase in the rate of ARDS (OR 1.09 1.04–1.14 P < 0.01). Blood given at 0 to 6 or 7 to 24 h were not risk factors for lung injury.
CONCLUSION:Acute crystalloid exposure, but not blood products, is a potentially modifiable risk factor for the prevention of ARDS following hemorrhage.
One of the biggest challenges for anesthesia practitioners during airway management is the maintenance of adequate oxygenation and ventilation during difficult and emergency airway situations. ...Providing nasal ventilation during the “apneic period”, defined as the time between the end of bag-mask ventilation and successful placement of an appropriate airway device, may allow for improved oxygenation throughout the process in which the airway is secured. The SuperNO2VA™ mask (Revolutionary Medical Devices, USA) is a newly developed nasal mask that delivers non-invasive positive pressure nasal ventilation that is designed to provide continuous oxygenation and ventilation during anesthetic induction until the airway is secured.
The purpose of this study was to evaluate the clinical performance of the SuperNO2VA™ mask for nasal oxygenation and ventilation during pre-induction, post-induction, laryngoscopy, and tracheal intubation in adult patients requiring general anesthesia.
Following IRB/ethical board approval and written informed consent, 30 adult patients, ages 18 years or older, with an ASA status I-III, who were scheduled for an elective surgery that required general anesthesia and tracheal intubation, were enrolled into this study. Patient demographic characteristics and intervening outcomes were all recorded. The SuperNO2VA™’s efficacy was evaluated by the measurement and recorded values of peak airway pressures, tidal volumes, minimal oxygen saturation values (while the airway was secured), as well as, an objective assessment grading scale for mask ventilation. The time required to secure the airway, including laryngoscopy, was also recorded.
The SuperNO2VA™ nasal mask provided adequate oxygenation and successful ventilation in 29 of 30 patients, resulting in an overall success rate of 97% (95% confidence interval: 83%–100%). One patient was unable to be successfully ventilated by the SuperNOVA™ mask and was noted a Grade IV. The mean duration of laryngoscopy was 50.7 ± 23.2 s, with an average SpO2 of 99.6 ± 0.8% calculated for this interval. The lowest observed SpO2 for the 29 patients at preoxygenation, pre-induction, pre-ETT insertion, during laryngoscopy, post-intubation, and in the PACU was 95, 97, 97, 97, 98, and 94%, respectively. The average for the lowest SpO2 during the entire airway procedure was 98.1 ± 7.0%. And the average peak airway pressure, for all 29 patients, was 17.97 ± 3.95 mmHg, with a mean tidal volume of 573.7 ± 40.7 mL.
This observational study demonstrated that the SuperNO2VA™ mask facilitates non-invasive positive pressure ventilation while providing adequate oxygenation and ventilation during pre-induction, post-induction, laryngoscopy, and tracheal intubation in elective surgical patients. Conversely, considering the novelty of this particular study, further research is warranted to determine its usefulness in patients with known/predicted difficult airways, or even during emergent situations.
•Rapid desaturation can be problematic during airway management.•Oxygenation and ventilation techniques are limited during laryngoscopy/intubation.•Supplemental nasal oxygen administration may help prolong the apneic period.•SuperNO2VA™ mask delivers non-invasive positive pressure ventilation via nasal path.•SuperNO2VA™ mask provides adequate oxygenation and ventilation during laryngoscopy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
According to both national and international difficult airway guidelines, supraglottic airway devices (SGADs) can be used as either ventilatory devices or as intubation conduits, if tracheal ...intubation is desired. The Totaltrack® VLM was recently developed as a second-generation SGAD that allows continuous visualization, uninterrupted oxygenation, and positive pressure ventilation during both intubation and extubation.
To evaluate the functionality and ease of use of the Totaltrack® VLM regarding the adequacy of oxygenation during tracheal intubation under continuous visualization and ventilation.
Following IRB approval, thirty adult (>18 yo) patients, with Mallampati classifications I-III and mouth openings > 2 cm, scheduled for elective surgery requiring general anesthesia and tracheal intubation were included in this study. In order to assess the feasibility and performance of the Totaltrack® VLM, various measurements were collected, including lowest oxygen saturation (SpO2) during the intubation procedure, number of attempts required to intubate, time taken until CO2 detection and intubation, and a subjective assessment describing the level of difficulty of the intubation process (1 Very Easy - 5 Not Possible).
The Totaltrack® VLM was successfully placed and facilitated tracheal intubation in 25 patients (83.3%, 95% confidence interval: 65.3%–94.4%) during the first intubation attempt. The minimum SpO2 was 98.5% ± 4.3% (mean ± SD) during Totaltrack® VLM intubation. The median time required for initial ventilation, for all 30 patients, was 16.1s. The median time required for the entire intubation procedure and a successful intubation was 34.3s and 13.9s, respectively. The median ease-of-use score for laryngoscopy, intubation, and overall use, was Easy (2), as measured by a numeric rating scale (NRS) with an interquartile range of 1–3, based on the total 30 patients. The Totaltrack® VLM provided an overall intubation success rate of 93.3% (95% CI: 77.9%-99.2), with an overall ventilation success rate of 100%.
This study demonstrated that the Totaltrack® VLM provided satisfactory functionality as a ventilatory device and intubation conduit, while adequately oxygenating patients during tracheal intubation. However, considering the novelty of this particular study, further research is warranted, to determine its usefulness in patients with known or predicted difficult airways.
•Supraglottic airway devices (SGADs) are used as either a ventilatory device or intubation conduit.•There is limited published evidence regarding SGADs efficacy and/or safety.•Some second generation SGADs provide access to the esophagus and gastric contents.•The Totaltrack® VLM allows simultaneous ventilation and intubation with continuous visualization.•The Totaltrack® VLM has many features and clinical indications for its intended use.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Patient positioning is critical in establishing an optimal laryngeal view during various airway management techniques, including direct laryngoscopy. The “sniffing” position, in which all 3 axes are ...aligned, has been the traditional method for direct laryngoscopy. 1, 2 The AirSPACE™ is a new positioning device that was developed to facilitate patient positioning during laryngoscopy via mechanical head and neck manipulation, potentially improving the visualization of laryngeal structures.
The purpose of this study was to evaluate the performance of the AirSPACE™ device, as measured by the percentage of the Modified Cormack-Lehane (C-L) classification system, Grade's III or IV specifically, for glottic visualization during the first attempt of laryngoscopy and intubation.
Following IRB approval, 30 adult (≥18 y/o) patients with ASA status classifications I-III, requiring tracheal intubation and general anesthesia, participated in this study. In order to assess the performance of the device, various measurements were obtained, including the initial C-L airway grade view during the first attempt, the C-L grade view after repositioning (if necessary), the time required for patient repositioning, the time required to obtain an optimal view of the glottis and CO2 detection, the time required to fully set up the AirSPACE™ device onto the designated OR table, the number of attempts required for a successful intubation, the minimum oxygen saturation (SpO2) while the airway was being secured, the method of laryngoscopy performed, subjective assessment evaluations from utilizing the AirSPACE™, and safety reporting of any adverse events.
Of the 30 patients enrolled in the study, only 3 (10.0%, 95% confidence interval: 2.1%–26.5%) were recorded with a C-L Grade III or IV, with an average repositioning time of 29.3 ± 8.4s. The frequency of initial C-L grade views was: I, 50.0%; IIa, 16.7%; IIb, 23.3%; III, 6.7%; and IV, 3.3%. For the 3 patients who required repositioning, 2 demonstrated improvement in the glottic view after repositioning, while one demonstrated no improvement. The time required to obtain an optimal view of the glottis and that for CO2 detection was 19.7 ± 13.8s and 42.6 ± 22.0s, respectively. The average time required to set up the AirSPACE™ device was 4.29 ± 1.81 min. The average minimum oxygenation during intubation was 99.7± 0.6%. Direct laryngoscopy (90%) was the preferred method when performing laryngoscopy and intubation, when compared to indirect (10%) during the study period. Nearly half of the laryngoscopists assessed the difficulty of laryngoscopy and difficulty of ETT delivery as 1 (Very Easy), 43.3% and 46.7%, respectively, whereas 68.8% assessed AirSPACE™ device ease of use as 1 (Very Easy).
This study demonstrated that the AirSPACE™ device is an effective positioning mechanism that provided the laryngoscopist with a highly favorable glottic view initially. Yet, further research is warranted in evaluating the AirSPACE™’s effectiveness in improving glottic visualization of less favorable and more difficult airways on a much larger spectrum.
•Patient positioning is critical in establishing a patent airway.•Proper head and neck positioning can optimize one's laryngeal view.•The “sniffing” position has been the traditional method for direct laryngoscopy.•The AirSPACE™ device facilitates patient positioning via mechanical capabilities.•The AirSPACE™ device provides ‘real-time’ airway manipulation during laryngoscopy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
AbstractBackgroundOne factor that contributes to the difficulty during intubation is poor visualization of the airway anatomy during laryngoscopy. AimTo compare the efficacy and first-pass success ...rate of the King Vision® Video Laryngoscopes against the GlideScope® Video Laryngoscope in patients with anticipated difficult airways. Methods225 adult patients scheduled for surgery requiring general anesthesia and tracheal intubation that met ≥2 of the following inclusion criteria: Mallampati classification (MP) III-IV, inter-incisor distance < 4 cm, neck circumference > 43 cm, and/or thyromental distance < 6 cm were randomized into 3 groups: GlideScope® (GS; n = 75), King Vision® – Channeled (KV-Ch; n = 75), and King Vision® – Non-Channeled (KV-NCh; n = 75). Intubation time and number of intubation attempts were collectively considered as the primary objective, amongst resident anesthesiologists. ResultsThe rate of success of tracheal intubation was 96% for GS, 81.3% for KV-Ch, and 96% for KV-NCh. Furthermore, first-pass success was highest for the KV-NCh at 89.3%, with GS and KV-Ch having a significant difference ( P = 0.0083). ConclusionThe GS and KV-NCh performed similarly in facilitating successful tracheal intubation during the first attempt. In contrast, the KV-Ch was less successful overall.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
10.
Use of the McGRATH™ MAC: To view or not to view? Normand, Katherine C.; Vargas, Leslie A.; Burnett, Tyrone ...
Trends in anaesthesia & critical care,
April 2018, 2018-04-00, Volume:
19
Journal Article
Peer reviewed
Due to the life-threatening consequences that a failed tracheal intubation entails, many efforts have been made to identify specific patient features, which may predict difficulty during tracheal ...intubation. In addition, debate exists as to whether or not video-assisted laryngoscopy (VAL) should replace direct laryngoscopy and if airway practitioners will lose their skills associated with direct laryngoscopy, now that VAL use has increased in clinical practice.
This study was designed to determine the first attempt success rate of tracheal intubation with the McGRATH™ MAC laryngoscope using direct visualization in patients with known difficult airways, as well as exploring the possibility of identifying a particular direct Cormack-Lehane (C-L) grade view where indirect (video) visualization can be most beneficial during laryngoscopy and intubation.
Following IRB/ethical board approval and written informed consent, 100 adult patients (age > 18 years) with an ASA status I-III and a BMI < 50 kg/m2 who met ≥ 2 of the following inclusion criteria: Mallampatti class: III-IV, reduced mouth opening < 4 cm, neck circumference (>40 cm for females, > 43 cm for males), thyromental distance < 6 cm, ratio of the patient's height to thyromental distance ≥ 23.5 cm, sternomental distance < 12 cm, requiring general anesthesia for an elective surgery, were enrolled into this study. Patient demographic characteristics and intervening outcomes, such as initial modified C-L grade view for both direct and indirect laryngoscopy, first-attempt success rate, and the time required for a successful intubation with the McGRATH™ MAC, were recorded.
Out of the 94 patients that were included in the data analysis, 72 (76.6%) were successfully intubated via direct laryngoscopy and 16 (17%) were successfully intubated via indirect (video) laryngoscopy on the first attempt with the McGRATH™ MAC (P = 0.59). This translates to an overall first-attempt success rate of 96.15% (n = 88). Six patients required a second attempt for tracheal intubation, in which indirect (video) laryngoscopy was then performed, representing an 83% second attempt success rate (n = 5; 5.3%). One patient (1.1%) required a third intubation attempt and an alternative device was used to secure the airway (n = 1; Table 1). The most common initial C-L grade view during the first attempt was a 2b (28.7%), which accounted for 36.1% of the 72 patients that were successfully intubated via direct laryngoscopy (n = 26). A noticeable C-L grade view improvement was observed with the use of the McGRATH™ MAC using the indirect view. Thus, the most common initial indirect C-L grade view during the first attempt was a 1 (54.3%), which accounted for 65.3% of the 72 patients that were successfully intubated via direct laryngoscopy (n = 47).
The McGRATH™ MAC is a versatile laryngoscope that allows both direct and indirect (video) laryngoscopy to be performed, simultaneously if needed, with a favorable chance of successful intubation during the first attempt. VAL with the McGRATH™ MAC exhibited an enhanced glottic view and served as a successful rescue airway device during inadequate glottic visualization and/or unsuccessful tracheal intubation, after failing with the same device when direct laryngoscopy was performed.
•Direct laryngoscopy is a common technique for tracheal intubation.•Indirect (video) laryngoscopy is associated with increasing first-attempt success.•Difficult airways and failed tracheal intubation may lead to fatal complications.•McGRATH™ MAC combines both direct and indirect glottic visualization.•McGRATH™ MAC facilitates first-attempt success during laryngoscopy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
PDF
