Arnaud Robitaille

Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy.

BACKGROUND: The optimal tracheal intubation technique for patients with potential cervical (C) spine injury remains controversial. Using continuous cinefluoroscopy, we conducted a prospective study comparing C-spine movement during intubation using direct laryngoscopy (DL) or GlideScope® videolaryngoscopy (GVL), with uninterrupted manual in-line stabilization of the head by an assistant. METHODS: Twenty patients without C-spine pathology were studied. After induction of general anesthesia with neuromuscular blockade, both DL and GVL were performed on every patient in random order. Cinefluoroscopic images of C-spine movement during GVL and DL were acquired and divided into four stages: a baseline image before airway manipulation, glottic visualization, insertion of the endotracheal tube into the glottis, and tracheal intubation. Peak segmental motion from the occiput to C5 was measured offline for each patient and each stage, averages were calculated, and movements induced by each instrument were compared using a two-way ANOVA. Also studied were the proportion of patients with occiput-C1 rotation exceeding 10, 15, or 20 degrees, and the quality of glottic visualization. RESULTS: No significant difference was found between DL and GVL regarding average segmental spine movement at any level (P values between 0.22 and 0.70). During both techniques, motion was mainly an extension concentrated in the rostral C-spine and occurred predominantly during glottic visualization. The proportion of patients with occiput-C1 extension of more than 10, 15, or 20 degrees was not significantly different. Glottic visualization was significantly better with GVL compared with DL. CONCLUSION: During intubation under general anesthesia with neuromuscular blockade and manual in-line stabilization, the use of GVL produced better glottic visualization, but did not significantly decrease movement of the nonpathologic C-spine when compared with DL.

Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope.

BACKGROUND:The GlideScope® videolaryngoscope allows equal or superior glottic visualization compared with direct laryngoscopy, but predictive features for difficult GlideScope intubation have not been identified. We undertook this prospective study to identify patient characteristics associated with difficult GlideScope intubation. METHODS:Demographic and morphometric factors were recorded preoperatively for 400 patients undergoing anesthesia with endotracheal intubation. After induction, direct laryngoscopy was performed in all patients to assess the Cormack and Lehane grade of glottic visualization followed by GlideScope intubation. The number of attempts and time needed for intubation were recorded. Univariate and multivariate analyses were performed to identify the characteristics associated with difficult GlideScope intubation. RESULTS:Intubation required 1, 2, and 3 attempts in 342, 48, and 9 participants, respectively, with one failure. Mean time for intubation was 21 ± 14 s. After univariate analysis, the following characteristics were significantly correlated (P < 0.05) with longer time to intubate and/or multiple attempts: older age, male sex, history of snoring, high Mallampati class, small mouth opening, short sternothyroid and manubriomental distances, large neck circumference, high upper lip bite test score, and high Cormack and Lehane grade during direct laryngoscopy. However, after introducing these variables in nominal logistic and proportional hazard multiple regression models, only high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, and short sternothyroid distance were significantly associated with multiple attempts or lengthier intubations. CONCLUSION:Despite a high success rate, intubation with the GlideScope is likely to be more challenging in patients with high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, or short sternothyroid distance.

Simulation-based assessment of anesthesiology residents’ competence: development and implementation of the Canadian National Anesthesiology Simulation Curriculum (CanNASC)

The specialty of anesthesiology will soon adopt the Competence By Design (CBD) approach to residency education developed by the Royal College of Physicians and Surgeons of Canada (RCPSC). A foundational component of CBD is frequent and contextualized assessment of trainees. In 2013, the RCPSC Anesthesiology Specialty Committee assembled a group of simulation educators, representing each of the 17 Canadian anesthesiology residency programs, to form the Canadian National Anesthesiology Simulation Curriculum (CanNASC) Task Force. The goals were to develop, implement, and evaluate a set of consensus-driven standardized mannequin-based simulation scenarios that every trainee must complete satisfactorily prior to completion of anesthesiology residency and certification. Curriculum development followed Kern’s principles and was accomplished via monthly teleconferences and annual face-to-face meetings. The development and implementation processes included the following key elements: 1) Curriculum needs assessment: 368 of 958 invitees (38.4%) responded to a national survey resulting in 64 suggested scenario topics. Use of a modified Delphi technique resulted in seven important and technically feasible scenarios. 2) Scenario development: All scenarios have learning objectives from the National Curriculum for Canadian Anesthesiology Residency. Standardized scenario templates were created, and the content was refined and piloted. 3) Assessment: A validated Global Rating Scale (GRS) is the primary assessment tool, informed by using scenario-specific checklists (created via a modified Delphi technique) and the Anesthesia Non-Technical Skills GRS. 4) Implementation: Standardized implementation guidelines, pre-brief/debrief documents, and rater training videos, guide, and commentary were generated. National implementation of the scenarios and program evaluation is currently underway. It is highly feasible to achieve specialty-based consensus on the elements of a national simulation-based curriculum. Our process could be adapted by any specialty interested in implementing a simulation-based curriculum incorporating competency-based assessment on a national scale.RésuméLa spécialité de l’anesthésiologie adoptera prochainement une approche de La compétence par conception (CPC) à la formation en résidence, mise au point par le Collège royal des médecins et chirurgiens du Canada (CRMCC). Une des compétences fondamentales de la CPC est l’évaluation fréquente et contextualisée des stagiaires. En 2013, le Comité de spécialité en anesthésiologie du CRMCC a réuni un groupe d’enseignants en simulation, chacun représentant l’un des 17 programmes canadiens de résidence en anesthésiologie, afin de créer le Groupe de travail sur le Programme national de simulation en anesthésiologie au Canada (CanNASC). Les objectifs de ce groupe de travail étaient de mettre au point, mettre en œuvre et évaluer un ensemble de scénarios de simulation sur mannequin; ces scénarios seraient standardisés et approuvés par consensus, et chaque stagiaire devrait les compléter de façon satisfaisante avant de pouvoir terminer sa résidence et sa certification en anesthésiologie. La mise au point du programme s’est fondée sur les principes de Kern et s’est faite par l’entremise de téléconférences mensuelles et de réunions annuelles en personne. Les éléments clés suivants ont fait partie des processus de mise au point et de mise en œuvre: 1) Évaluation des besoins du programme: 368 personnes sur 958 personnes invitées (38,4%) ont répondu à un sondage national qui a donné jour à 64 sujets de scénario proposés. Grâce à une méthode de Delphes modifiée, sept scénarios importants et réalisables d’un point de vue technique ont vu le jour. 2) Mise au point des scénarios: Tous les scénarios comportent des objectifs d’apprentissage tirés du Programme national pour la résidence en anesthésiologie au Canada. Des modèles de scénario standardisés ont été créés, et le contenu a été peaufiné et soumis à des essais pilotes. 3) Évaluation: Une Échelle d’évaluation globale (ÉÉG) validée constitue le principal outil d’évaluation; elle s’appuie sur des listes de contrôle spécifiques à chaque scénario (créées grâce à une méthode de Delphes modifiées) et l’EEG des compétences non techniques en anesthésie. 4) Mise en œuvre: Des directives de mise en œuvre standardisées, des documents préparatoires et de rétroaction, et des vidéos de formation, un guide et des commentaires destinés aux évaluateurs ont été générés. La mise en œuvre nationale des scénarios et l’évaluation du programme est en cours. Il est tout à fait possible d’atteindre un consensus dans la spécialité quant aux éléments d’un programme national de simulation. Notre processus peut être adapté à chaque spécialité intéressée à mettre en œuvre un programme fondé sur la simulation et intégrant une évaluation fondée sur les compétences à l’échelle nationale.

Airway management in the patient with potential cervical spine instability: Continuing Professional Development

PurposeSecuring the airway of a patient with a potentially unstable cervical spine (C-spine) is a complex and challenging task. The objective of this continuing professional development module is to review the current knowledge essential for airway management in the face of potential C-spine instability and, at the same time, to underline areas of uncertainty and limitations in the literature.Principal findingsIn low-risk patients—defined by strict criteria derived from large multicentre studies—the C-spine can be considered stable or “cleared” without imaging. In all other patients, at least a thin-section computed tomographic examination of the spine from the occiput to T1 should be obtained, including sagittal and coronal multiplanar reconstructed images. Until the C-spine is cleared, it should be immobilized in the neutral position using a rigid cervical collar, sandbags, tape, and a backboard. During airway management, the anterior part of the cervical collar should be removed, and manual in-line stabilization should be applied. Some airway techniques, such as fibreoptic bronchoscopy and the Trachlight®, have been shown to induce less C-spine movement than direct laryngoscopy; however, the impact of such airway management on outcome is uncertain.ConclusionAdequate airway management in the patient with potential C-spine injury demands an understanding of C-spine anatomy, the criteria required to clear the C-spine, and the indications, techniques, and pitfalls of C-spine immobilization. When choosing an airway technique, minimization of C-spine motion should be considered, but the method of choice should also incorporate the broader clinical context.RésuméObjectifLa prise en charge des voies aériennes chez un patient présentant une colonne cervicale potentiellement instable est une tâche complexe. L’objectif de ce module de développement professionnel continu est de passer en revue les connaissances actuelles essentielles à la prise en charge des voies aériennes dans les cas d’instabilité potentielle de la colonne cervicale, tout en soulignant les zones d’incertitude et les limites de la littérature existante.Constatations principalesChez les patients à faible risque, définis à l’aide de critères rigoureux obtenus d’études multicentriques d’envergure, la colonne cervicale peut être considérée comme stable, ou ‘normale’, sans avoir recours à l’imagerie. Chez tous les autres patients, il convient de réaliser au minimum un examen par tomodensitométrie en tranches minces de la colonne entre l’occiput et T1, comprenant des images reconstituées de plans sagittaux et frontaux multiples. Jusqu’à ce qu’on ait confirmé la stabilité de la colonne cervicale, celle-ci devrait être immobilisée en position neutre à l’aide d’un collet cervical rigide, de sacs de sable, de ruban adhésif et d’une planche dorsale. Pendant la prise en charge des voies aériennes, la partie antérieure du collet cervical devrait être retirée et une stabilisation manuelle en ligne appliquée. Il a été démontré que certaines techniques de prise en charge des voies aériennes, comme la bronchoscopie à fibre optique et le Trachlight®, induisaient moins de mouvement au niveau de la colonne cervicale que la laryngoscopie directe; toutefois, l’impact de telles mesures de prise en charge des voies aériennes sur le pronostic des patients est inconnu.ConclusionUne prise en charge des voies aériennes adaptée du patient présentant une lésion potentielle de la colonne cervicale exige une compréhension de l’anatomie de la colonne cervicale, des critères d’évaluation de la stabilité de la colonne cervicale, et des indications, techniques et pièges de l’immobilisation de la colonne cervicale. Le choix d’une technique de prise en charge des voies aériennes devrait tenir compte de la minimisation de la mobilité de la colonne cervicale, mais devrait également porter attention au contexte clinique dans son ensemble.

Predictors of Difficult Intubation with the Bonfils Rigid Fiberscope.

BACKGROUND:Endotracheal intubation is commonly performed via direct laryngoscopy (DL). However, in certain patients, DL may be difficult or impossible. The Bonfils Rigid Fiberscope® (BRF) is an alternative intubation device, the design of which raises the question of whether factors that predict difficult DL also predict difficult BRF. We undertook this study to determine which demographic, morphologic, and morphometric factors predict difficult intubation with the BRF. METHODS:Four hundred adult patients scheduled for elective surgery were recruited. Patients were excluded if awake intubation, rapid sequence induction, or induction without neuromuscular blocking agents was planned. Data were recorded, including age, sex, weight, height, American Society of Anesthesiologist classification, history of snoring and sleep apnea, Mallampati class, upper lip bite test score, interincisor, thyromental and sternothyroid distances, manubriomental distances in flexion and extension, neck circumference, maximal neck flexion and extension, neck skinfold thickness at the cricoid cartilage, and Cormack and Lehane grade obtained via DL after paralysis was confirmed. Quality of glottic visualization (good or poor), as well as the number of intubation attempts and time to successful intubation with the BRF, was noted. Univariate analyses were performed to evaluate the association between patient characteristics and time required for intubation. Variables that exhibited a significant correlation were included in a multivariate analysis using a standard least squares model. A P < 0.05 was considered significant. RESULTS:Glottic visualization with the BRF was good in 396 of 400 (99%) cases. On the first attempt, 390 patients were successfully intubated with the BRF; 6 patients required >1 attempt; 4 patients could not be intubated by using the BRF alone. These 4 patients were intubated by using a combination of DL and BRF (2 patients), DL and a Frova bougie (1 patient), and DL and an endotracheal tube shaped with a semirigid stylet (1 patient). Mean time for successful intubation was 26 ± 13 seconds. Multivariate analysis showed that decreased mouth opening (P = 0.008), increased body mass index (P = 0.011), and higher Cormack and Lehane grade (P = 0.038) predicted longer intubation times, whereas shorter thyromental distance predicted slightly shorter intubation times (P < 0.0001). CONCLUSIONS:Mouth opening, body mass index, and high Cormack and Lehane grade predict longer intubation times, as with DL. Decreasing thyromental distance predicts slightly shorter intubation times with the BRF, possibly because of a design initially optimized for a pediatric population with receding chins. These findings, along with the high success rate of BRF in this study, and the possibility of further increasing success rates by combining BRF with DL, help define the role of BRF intubation in contemporary airway management.

Principles of Airway Management, 4th Edition

The fourth edition of Principles of Airway Management is a comprehensive work covering virtually all aspects of the adult and pediatric airway that any professional can hope to learn from a textbook. Indeed, its 15 chapters encompass the following topics: anatomy of the airway, evaluation of the airway, basic emergency airway management and cardiopulmonary resuscitation, basic equipment for airway management, the LMA and other supraglottic devices, advanced airway devices (including fibreoptic laryngoscopes, videolaryngoscopes, stylets, and light wands), indications and preparation of the patient for tracheal intubation, techniques of intubation, the difficult airway, pediatric airway management, fibreoptically guided airway management techniques, surgical options in airway management, mechanical ventilation and respiratory care, extubation strategies, and, finally, complications of airway management. This book is well written throughout, and the comprehensive table of contents and index enable the reader to easily find information in this lengthy textbook. The tables and figures have been improved in this edition and most are of good quality. The references are up-to-date. While the preponderance of expertise in airway management can be acquired only through experience, both novices and experts alike will gain insight into airway management by consulting this book. It provides the basic information useful to the beginner and the more advanced content useful to the expert. The book strikes the right balance between theoretical and technical information, which is another important quality. The authors offer the greatest extent of practical ‘‘how to’’ information in a textbook, notably because of the numerous figures. Although this 742-page textbook is indeed quite complete, some advanced techniques, e.g., rigid bronchoscopy, jet ventilation, and lung isolation, are covered hastily and without much technical detail. This is unfortunate since an expert might consult this textbook specifically for information regarding these perhaps less commonly used techniques. In contrast, some topics, e.g., cardiopulmonary resuscitation, are reviewed in surprising detail for a textbook dealing with airway management. Overall, this fourth edition of Principles of Airway Management constitutes a very good reference for any individual or organization interested in airway management. The depth of information goes well beyond that available in more ‘‘general’’ anesthesia textbooks, such as Miller’s Anesthesia, Seventh Edition by Ronald D. Miller and Clinical Anesthesia, Sixth Edition by Paul Barash.

Successful management of a neck hematoma following simulation training

Simulation-based education is gaining widespread acceptance in many medical specialties as an effective method to teach technical and non-technical skills. The ultimate goal of simulation is to improve health care and patient safety. Boet et al. [1] published a review on simulation-based crisis resources management (CRM) teaching, looking for evidence that it can lead to improved workplace practices and patient safety. Amongst hundreds of studies pertaining to CRM, he found only nine that were relevant, and only one that showed reduced mortality. Elaborating and putting forward studies designed to measure the impact of simulation on patient safety and outcomes is by no mean an easy task [2]. Indeed, most studies present various problems, such as biases introduced by the use of historical cohorts rather than control groups, and sample sizes based on convenience rather than power analysis. Furthermore, many significant outcomes such as mortality and major morbidity rates need to be measured over an extended period of time, which leaves room for variables other than the introduction of a simulation-based teaching program to play a confounding role [2]. These are some of the reasons why the majority of publications in simulation-based teaching are focusing mostly if not exclusively on measuring participants’ satisfaction and performance in a simulated environment. At the Universite de Montreal, we developed surgical high-fidelity simulation-based CRM scenarios focusing on teamwork. The specific simulation based training on CRM, which includes this airway management scenario, is given only once a year, in the beginning of their second year of residency. This highly appreciated training [3] place surgical residents in rare and urgent situations, but within a safe simulated environment. One of these scenarios focuses on the management of neck hematoma after thyroidectomy. It teaches a step-by-step approach that emphasizes, amongst other things, the need for bedside evacuation in the setting of significant and life-threatening airway obstruction (figure 1). The purpose of this case report is to describe how a postgraduate year 3 (PGY 3) surgical residents used and credited the training acquired during a simulation-based CRM scenario for positively influencing a patients outcome.

High-fidelity simulation of transcutaneous cardiac pacing: characteristics and limitations of available high-fidelity simulators, and description of an alternative two-mannequin model.

Introduction Transcutaneous cardiac pacing (TCP) is a potentially lifesaving technique that is part of the recommended treatment for symptomatic bradycardia. Transcutaneous cardiac pacing however is used uncommonly, and its successful application is not straightforward. Simulation could, therefore, play an important role in the teaching and assessment of TCP competence. However, even the highest-fidelity mannequins available on the market have important shortcomings, which limit the potential of simulation. Methods Six criteria defining clinical competency in TCP were established and used as a starting point in the creation of an improved TCP simulator. The goal was a model that could be used to assess experienced clinicians, an objective that justifies the additional effort required by the increased fidelity. Results The proposed 2-mannequin model (TMM) combines a highly modified Human Patient Simulator with a SimMan 3G, the latter being used solely to provide the electrocardiography (ECG) tracing. The TMM improves the potential of simulation to assess experienced clinicians (1) by reproducing key features of TCP, like using the same multifunctional pacing electrodes used clinically, allowing dual ECG monitoring, and responding with upper body twitching when stimulated, but equally importantly (2) by reproducing key pitfalls of the technique, like allowing pacing electrode misplacement and reproducing false signs of ventricular capture, commonly, but erroneously, used clinically to establish that effective pacing has been achieved (like body twitching, electrical artifact on the ECG, and electrical capture without ventricular capture). Conclusions The proposed TMM uses a novel combination of 2 high-fidelity mannequins to improve TCP simulation until upgraded mannequins become commercially available.