Carlos A. Artime

Is There a Gold Standard for Management of the Difficult Airway

Numerous practice guidelines have been developed to assist clinicians in the management of the difficult airway. The nature of difficult airway management, however, does not provide a practical way of comparing different guidelines or algorithms; no evidence supports one set of guidelines over another. Nevertheless they play an important role in patient safety as dissemination of such guidelines encourages airway practitioners to consider their strategies and formulate specific plans for the management of a predicted or unexpected difficult airway.

Flexible optical intubation via the Ambu Aura-i vs blind intubation via the single-use LMA Fastrach: a prospective randomized clinical trial

STUDY OBJECTIVE This study was designed to compare the Ambu Aura-i to the single-use LMA Fastrach regarding time to intubation, success rate, and airway morbidity in patients undergoing elective surgery requiring general anesthesia. DESIGN Prospective, randomized controlled trial. SETTING Academic medical center. PATIENTS Sixty-five adult patients scheduled for elective surgery requiring general anesthesia. INTERVENTIONS Patients were randomized into 2 groups. Group A (n=33) were intubated using Ambu Aura-i and the Ambu aScope 2, a disposable flexible intubating scope, whereas those in group B (n=33) were blindly intubated using the Intubating Laryngeal Mask Airway (ILMA). MEASUREMENTS First-attempt intubation success rate, overall intubation success rate, time to intubation, incidence of airway morbidity. MAIN RESULTS The data demonstrated that time for endotracheal intubation in the ILMA group was significantly shorter than in the Ambu Aura-i group (P<.05). There was no difference in the first-attempt intubation success rate (Aura-i=26/33, 78.8%; ILMA=27/33, 81.8%; P=.757) or the overall intubation success rate (Aura-i=29/33, 87.9%; ILMA=31/33, 93.9%; P=.392) between the groups. Four patients (12%) in the Ambu Aura-i group had a failed intubation; 1 was due to a failure of the aScope monitor, whereas 3 were due to inability to visualize the glottis. Two patients (7%) in the ILMA group had a failed intubation due to esophageal intubation. There was no statistically significant difference in airway morbidity between the 2 groups. CONCLUSIONS The data suggest that intubation with the ILMA is faster but that first-attempt and overall intubation success rates were comparable in both groups. The results suggest that although the flexible intubating scope-guided Aura-i does not outperform blind intubation via the ILMA, the technique is comparable in terms of first-attempt and overall intubation success rate.

Pharmacology of Sedative Drugs Used in Out of Operating Room Anesthesia

Due to the minimally-invasive nature of many out of operating room procedures, patient comfort and appropriate procedural conditions can oftentimes be achieved without general anesthesia. Depending on the nature of the procedure, mild, moderate, or deep sedation may be appropriate. This chapter presents the pharmacology of various drugs used for sedation. Pharmacologic considerations for obese and elderly patients are also presented.

Scheduled Intravenous Acetaminophen Improves Patient Satisfaction with Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study

Background: Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. Materials and Methods: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. Results: There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1±0.4 vs. 6.9±0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. Conclusions: IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control.

Reliability of a faculty evaluated scoring system for anesthesiology resident applicants (Original Investigation)

STUDY OBJECTIVE To assess reliability and reproducibility of a recently instituted anesthesiology resident applicant interview scoring system at our own institution. DESIGN Retrospective evaluation of 2 years of interview data with a newly implemented scoring system using randomly assigned interviewing faculty. SETTING Interview scoring evaluations were completed as standard practice in a large academic anesthesiology department. SUBJECTS All anesthesiology resident applicants interviewed over the 2013/14 and 2014/15 seasons by a stable cohort of faculty interviewers. Data collection blinded for both interviewers and interviewees. INTERVENTIONS None for purposes of study - collation of blinded data already used as standard practice during interview process and analysis. MEASUREMENTS None specific to study. MAIN RESULTS Good inter-rater faculty reliability of interview scoring (day-of) and excellent inter-faculty reliability of application review (pre-interview). CONCLUSIONS Development of a department-specific interview scoring system including many elements beyond traditional standardized tests shows good-excellent reliability of faculty scoring of both the interview itself (including non-technical skills) and the application resume.

All Work Hours Are Not Equal

To the Editor: We read Baird et al.’s1 recent description of gender differences and trends in the anesthesiology workforce with great interest. As members of a large, vibrant academic level 1 trauma center with busy transplant and neurosurgical services, we observe that several issues raised by the 2013 RAND survey are relevant. We are a particularly diverse faculty group with a greater proportion of female anesthesiologists (49%) than represented in the study (26%). At first glance, the conclusion that female anesthesiologists receive lower total and hourly compensation irrespective of the fewer hours worked is alarming. However, the context for this is the significantly three-fold greater part-time (defined as less than 35 h/week) employees in the female group, which in itself may explain the apparent discrepancy as 11% of that gender cohort. In a busy facility such as ours with increasing hospital demand for expansion of services, an employee working part-time in a 7 Am to 3 or 5 pm shift adds value to meeting the elective needs of the operating room. However, a significant proportion of urgent and emergency service is provided after hours, on weekends, and on public holidays, and it is both plausible and logical for the larger full-time (by definition, larger male) cohort taking these calls to receive greater compensation. If, as the authors suggest, marital status and the presence of children affect gender hours, then on-call overnight and weekend hours must be valued more significantly than routine office hours. With reasonable call shifts (14 h on weekdays and 12 h on weekends) and generous use of postcall days, it is not surprising that a faculty member taking calls, irrespective of gender, may not have significantly total increased hours compared to a weekday-only anesthesiologist. However, with increasing hospital demands, the flexibility of on-call faculty members to take additional preand/or postcall shifts is increasingly valuable and facilitates management of the daily schedule. Given the increasing proportion of female anesthesiologists in almost all age groups documented in the article, there will also be an increasing proportion of part-time anesthesiologists, which may negatively impact both the on-call cohort and flexibility in schedule management. For these population. The intuition of Dr. pivalizza et al. regarding the conduct of reasonable clinicians is therefore unsupported. Carette et al. raise the important point that using non–age-adjusted mAC values might have affected our conclusions. They could be right in that “single high” (age) might be much more important than “triple low” and that some of the patients in our study included in the “triple low” group might only have had “double low” (low mean arterial pressure and low bispectral index) when considering age-adjusted mAC. We chose the methodology in our study to approximate the approach that was used by Sessler et al.,5 who chose not to use ageadjusted mAC values. But our findings would not have changed substantially had we used age-adjusted mAC. Based on the population in our study, the low mAC cutoff would likely have shifted from the (arbitrary) 0.8 age-unadjusted value to about 0.9 age-adjusted mAC.6,7 Furthermore, although age was associated with 30and 90-day mortality in the multivariable analyses, “triple low” remained independently linked to death despite the inclusion of age as a variable in the models. It is also notable that age was one of the variables used in our propensity score matching. In conclusion, we apologize if the letter writers or readers were alarmed by our study or our conclusions. We wish to clarify that we do not believe that our findings mandate any changes in clinical practice, and we remain skeptical that “triple low” is causally implicated in postoperative death.