The dislocation rate of oral versus nasal airway exchange catheters (AEC) in the postoperative care unit (PACU) are unknown. Our aim was to establish dislocation rates and to assess the usefulness of ...waveform capnography to detect dislocation.
In this non-randomized, prospective observational trial at the University Hospital Bern, Switzerland, we included 200 patients admitted to PACU after extubation via AEC, having provided written informed consent. The study was approved by the local ethical committee. AEC position was assessed by nasal fiberoptic endoscopy at beginning of PACU stay and before removal of the AEC. Capnography was continuously recorded via the AEC. Additional measurements included retching and coughing of the patient, and re-intubation, if necessary.
Data from 182 patients could be evaluated regarding dislocation. Overall dislocation rate was not different between oral and nasal catheters (7.2% vs. 2.7%, p = 0.16). Retching was more often noted in oral catheters (26% vs. 8%, p < 0.01). Waveform capnography was unreliable in predicting dislocation (negative predictive value 17%). Re-intubation was successful in all five of the nine re-intubations where an AEC was still in situ. In four patients, the AEC was already removed when re-intubation became necessary, and re-intubation failed once, with a front of neck access as a rescue maneuver.
We found no difference in dislocation rate between nasal and oral position of an airway exchange catheter. However, nasal catheters seemed to be tolerated better. In the future, catheters like the staged extubation catheter may further increase tolerance.
The study was registered in a clinical study registry ( ISRCTN 96726807 ) on 10/06/2010.
Background
Recent data from the randomized SUSTAIN CSX trial could not confirm clinical benefits from perioperative selenium treatment in high-risk cardiac surgery patients. Underlying reasons may ...involve inadequate biosynthesis of glutathione peroxidase (GPx3), which is a key mediator of selenium's antioxidant effects. This secondary analysis aimed to identify patients with an increase in GPx3 activity following selenium treatment. We hypothesize that these responders might benefit from perioperative selenium treatment.
Methods
Patients were selected based on the availability of selenium biomarker information. Four subgroups were defined according to the patient's baseline status, including those with normal kidney function, reduced kidney function, selenium deficiency, and submaximal GPx3 activity.
Results
Two hundred and forty-four patients were included in this analysis. Overall, higher serum concentrations of selenium, selenoprotein P (SELENOP) and GPx3 were correlated with less organ injury. GPx3 activity at baseline was predictive of 6-month survival (AUC 0.73;
p
= 0.03). While selenium treatment elevated serum selenium and SELENOP concentrations but not GPx3 activity in the full patient cohort, subgroup analyses revealed that GPx3 activity increased in patients with reduced kidney function, selenium deficiency and low to moderate GPx3 activity. Clinical outcomes did not vary between selenium treatment and placebo in any of these subgroups, though the study was not powered to conclusively detect differences in outcomes.
Conclusions
The identification of GPx3 responders encourages further refined investigations into the treatment effects of selenium in high-risk cardiac surgery patients.
Graphical Abstract
Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural ...weaknesses and improve quality, but incidents are often underreported.
This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method.
Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers.
Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.
Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for ...airway management can reduce the incidence.
This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events.
At study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio RR=0.74; 95% confidence interval CI, 0.66–0.83; P<0.01). As secondary outcomes, the following events decreased: Cormack–Lehane grade 3 or 4 (4.3–2.9%; RR=0.67; 95% CI, 0.52–0.85; P<0.01); difficult bag-mask ventilation (3.8–2.7%; RR=0.69; 95% CI, 0.54–0.89; P<0.01); hypoxaemia (3.8–2.9%; RR=0.75; 95% CI, 0.59–0.96; P=0.03); unplanned use of special equipment (3.2–2.0%; RR=0.62; (95% CI, 0.47–0.83; P<0.01); oesophageal intubation (1.3–0.8%; RR=0.61; 95% CI, 0.39–0.96; P=0.03); bleeding (0.8–0.2%; RR=0.30; 95% CI, 0.14–0.63; P<0.01); insufficient spontaneous breathing (0.3–0.0%; RR=0.09; 95% CI, 0.01–0.68; P<0.01); communication errors (0.1–0.0%; RR=0; 95% CI, 0–NA; P=0.03).
Implementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management.
NCT02743767.
Minor adverse airway events play a pivotal role in the safety of airway management. Changes in airway management strategies can reduce such events, but the broader impact on airway management remains ...unclear.
Minor, frequently occurring adverse airway events were audited before and after implementation of changes to airway management strategies. We used two Bayesian networks to examine conditional probabilities of subsequent airway events and to compute the likelihood of certain events given that certain previous events occurred.
Independent of sex, age, and American Society of Anesthesiologists physical status, targeted changes to airway management strategies reduced the risk of a first event. Obese patients were an exception, in whom no risk reduction was achieved. Frequently occurring event sequences were identified, for example the most likely event to follow difficult bag-mask ventilation was a Cormack–Lehane grade ≥3, with a risk of 14.3% (95% credible interval CI, 11.4–17.2%). An impact of the targeted changes was detected on the likelihood of some event sequences, for example the likelihood of no consecutive event after a tracheal tube-related event increased from 43.3% (95% CI, 39.4–47.6%) to 56.4% (95% CI, 52.0–60.5%).
Identification of risk patterns and typical structures of event sequences provides a clinically relevant perspective on airway incidents. It further provides a means to quantify the impact of targeted airway management changes. These targeted changes can influence some event sequences, but overall, the benefit results from the cumulative effect of improvements in multiple events. Targeted airway management changes with knowledge of risk patterns and event sequences can potentially further improve patient safety in airway management.
NCT02743767.
An influence of polymorphic cytochromes P450 (CYP) 2D6 genetic variants on antiemetic efficacy of ondansetron has been suggested. However, the role of CYP3A in ondansetron metabolism and efficacy has ...been unclear. In this study, we evaluated the hypothesis that genotype-dependent CYP2D6 and CYP3A activity selectively influences plasma concentrations of ondansetron enantiomers. Additionally, the effects of doubling the ondansetron dose on genotype-dependent plasma concentrations were investigated.
Patients received IV ondansetron 4 or 8 mg for emesis prophylaxis before emergence from anesthesia. The CYP2D6-dependent activity score representing no, decreased, normal, or increased CYP2D6 enzyme activity as well as CYP3A low (CYP3A5*3/*3) and high expressor status (CYP3A5 wt/wt or wt/*3) were determined. Plasma concentrations of R- and S-ondansetron enantiomers were measured by liquid chromatography-tandem mass spectrometry. Area under the plasma concentration-time curves (AUCs) of R- and S-ondansetron were associated with CYP2D6 and CYP3A5 genotype-dependent enzyme activity.
Complete data of 141 subjects were analyzed. Concentrations of S-ondansetron differed between CYP2D6 activity groups (P = 0.01) with highest values in patients with no CYP2D6 activity (mean 95% confidence interval: 362.5 238.3/486.7 h · ng/mL) and lowest values in those with increased activity (149.6 114.5/184.8 h · ng/mL) compared with subjects displaying genotypes resulting in reduced or normal CYP2D6 activity (263.6 228.8/298.8, 255.4 228.2/282.7 h · ng/mL). AUC of R-ondansetron was 2 times higher in CYP3A5 low expressors compared with high expressors (281.5 248.6/314.3 vs 142.5 92.4/192.7 h · ng/mL; P = 0.003). Doubling the ondansetron dose increased plasma concentrations only in individuals with low CYP3A activity, but not in individuals with high enzyme activity (P < 0.001).
The metabolism of ondansetron seems to be enantioselective. In this postoperative setting, CYP2D6 activity scores correlated with concentrations of S-ondansetron, whereas CYP3A5 expressor status mainly influenced concentrations of R-ondansetron. Genetically and environmentally determined CYP2D6 and CYP3A enzyme activity might have implications for antiemetic efficacy.
There are scant data on the dimensional compatibility of cricothyroidotomy equipment and related airway anatomy. We compared the dimensional design of devices for cricothyroidotomy with anatomical ...airway data for adult patients.
For all available cricothyroidotomy equipment the outer diameter was recorded from manufacturer information or, if not available, measured using a sliding calliper. Outer diameters were compared with recently published mean (standard deviation sd) values for the height of the cricothyroid membrane obtained from computed tomography, separately for males (7.9 2.2 mm) and for females (5.9 1.7 mm).
Twenty-one cricothyroidotomy sets (10 uncuffed, 11 cuffed) with 15 differently designed devices were included. Inner diameters of the tubes ranged from 3.5 to 6.0 mm and outer diameters from 5.0 to 11.7 mm. The outer diameter of the 15 different tubes was found to be greater than the mean membrane height of the adult male cricothyroid membrane in eight devices and greater than the mean membrane height for female adults in 10 devices. Considering the lower range of cricothyroid membrane height, 12 tube outer diameters would be too large for male adults and all 15 for female adults in this range.
The outer diameter of many devices currently marketed for cricothyroidotomy are oversized for adult airway anatomy, particularly for females. For emergency front-of-neck access through the cricothyroid membrane, anatomical data suggest that cricothyroidotomy devices with outer tube diameters of <7 mm for male and <6 mm for female adult patients should be preferred.
The objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM).
A retrospective review of patients with AMM at a tertiary ...pediatric surgical oncology centre (January 2011–December 2016) was performed. We analyzed data on clinical presentation, mode of tissue diagnosis, anesthetic techniques, and complications.
Of the 44 patients admitted with AMM (median age 11 years, 27 males and 17 females), 22 had respiratory symptoms. Imaging revealed tracheobronchial compression in 26 children. Twenty patients had a lymph node biopsy. Ten patients had image-guided core biopsy of the mediastinal mass, and 2 had mediastinoscopic biopsy of a paratracheal lymph node. One patient with likely recurrence of a relapsed metastatic ethmoid carcinoma did not have a biopsy. The diagnosis was made from alternative tissues, such as pleural fluid in 4 and peripheral blood in 7 patients. Twenty-five anesthetics were assessed, as 14 patients required no or only local anesthesia, and 5 had unavailable anesthetic notes. Eighteen of 25 patients were anesthetized maintaining spontaneous breathing, mostly by means of ketamine sedation. There were no major anesthetic complications.
Safe tissue diagnosis of anterior mediastinal masses can be obtained by a personalized multidisciplinary approach. Use of alternative tissues, local anesthesia, and ketamine sedation help minimize the need for general anesthesia, muscle paralysis, and controlled ventilation.
IV (Case Series with no Comparison Group).
Start-up delays of syringe pump assemblies can impede the timely commencement of an effective drug therapy when using microinfusions in hemodynamically unstable patients. The application of the ...venting principle has been proposed to eliminate start-up delays in syringe pump assemblies. However, effectively delivered infusion volumes using this strategy have so far not been measured. This invitro study used two experimental setups to measure the effect of the venting principle compared to a standard non-venting approach on delivered start-up infusion volumes at various timepoints, backflow volumes, flow inversion and zero drug delivery times by means of liquid flow measurements at flow rates of 0.5, 1.0 and 2.0 mL/h. Measured delivered initial start-up volumes were negative with all flow rates in the vented and non-vented setup. Maximum backflow volumes were 1.8 95% CI 1.6 to 2.3 times larger in the vented setup compared to the non-vented setup (p < 0.0001). Conversely, times until flow inversion were 1.5 95% CI 1.1 to 2.9 times shorter in the vented setup (p < 0.002). This led to comparable zero drug delivery times between the two setups (p = 0.294). Start-up times as defined by the achievement of at least 90% of steady state flow rate were achieved faster with the vented setup (p < 0.0001), but this was counteracted by the increased backflow volumes. The application of the venting principle to the start-up of microinfusions does not improve the timely delivery of drugs to the patient since the faster start-up times are counteracted by higher backflow volumes when opening the three-way stopcock.
Video-laryngoscopes are marketed for intubation in difficult airway management. They provide a better view of the larynx and may facilitate tracheal intubation, but there is no adequately powered ...study comparing different types of video-laryngoscopes in a difficult airway scenario or in a simulated difficult airway situation.
The objective of this trial is to evaluate and to compare the clinical performance of three video-laryngoscopes with a guiding channel for intubation (Airtraq™, A. P. Advance™, King Vision™) and three video-laryngoscopes without an integrated tracheal tube guidance (C-MAC™, GlideScope™, McGrath™) in a simulated difficult airway situation in surgical patients. The working hypothesis is that each video-laryngoscope provides at least a 90% first intubation success rate (lower limit of the 95% confidence interval >0.9). It is a prospective, patient-blinded, multicenter, randomized controlled trial in 720 patients who are scheduled for elective surgery under general anesthesia, requiring tracheal intubation at one of the three participating hospitals. A difficult airway will be created using an extrication collar and taping the patients' head on the operating table to substantially reduce mouth opening and to minimize neck movement. Tracheal intubation will be performed with the help of one of the six devices according to randomization. Insertion success, time necessary for intubation, Cormack-Lehane grade and percentage of glottic opening (POGO) score at laryngoscopy, optimization maneuvers required to aid tracheal intubation, adverse events and technical problems will be recorded. Primary outcome is intubation success at first attempt.
We will simulate the difficult airway and evaluate different video-laryngoscopes in this highly realistic and clinically challenging scenario, independently from manufacturers of the devices. Because of the sufficiently powered multicenter design this study will deliver important and cutting-edge results that will help clinicians decide which device to use for intubation of the expected and unexpected difficult airway.
NCT01692535.
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