Glenio B. Mizubuti

A survey of focused cardiac ultrasonography training in Canadian anesthesiology residency programs

To the Editor, Focused cardiac ultrasonography (FoCUS) is being increasingly used by anesthesiologists, intensivists, and emergency physicians to assess patients in perioperative and acute care settings. Accordingly, FoCUS training has recently been incorporated in many Canadian anesthesiology residency programs. Although a recent study demonstrated that FoCUS training in anesthesiology training programs in the United States is uncommon, little is known about the penetration of FoCUS in Canadian training programs. Given the value of perioperative FoCUS and the likelihood that it may become a mandatory part of residency training, the purpose of this study was to assess the current state of FoCUS training in anesthesiology residency programs in Canada. After local research ethics committee approval was obtained (June 2015), a survey was sent by mail and e-mail to the 17 program directors of Canadian anesthesiology residency training programs in September 2015. Of the 17 surveys sent, 13 (77%) were returned. Among them, 12 (92%) programs thought that FoCUS training should be a mandatory part of residency training. The overall percentage (range) of staff anesthesiologists using FoCUS was 12 (3-25) % across all programs. Staff anesthesiologists who regularly using FoCUS were either exclusively or mainly trained in transesophageal echocardiography (TEE) in ten (77%) departments and equally trained in TEE and transthoracic echocardiography in three (23%) departments. Nine (75%) programs currently have mandatory (n = 3, 25%), elective (n = 3, 25%), or medicine elective (n = 3, 25%) rotations in FoCUS. The remaining three (25%) programs offer teaching in FoCUS but with no formal rotation. Training was supervised exclusively by anesthesiologists in five (42%) programs, by anesthesiologists in combination with cardiologists or intensivists in five (42%) programs, and by cardiologists or intensivists (without involvement of anesthesiologists) in two (17%) programs. Five (42%) programs had set minimum targets for FoCUS studies performed during training. The average (range) target was 49 (25-90) studies. Details of the amount and type of didactic training are presented in the Table. All of the programs with a mandatory rotation had more than 20 hr of didactic training and a required minimum number of studies to be performed. Identified barriers to implementation of a FoCUS program included the lack of manpower (n = 6, 46%), expertise (n = 6, 46%), a standardized curriculum and standardized training requirements (n = 5, 39%), and necessary equipment (n = 4, 31%). At the time of the survey, the availability of FoCUS training in Canadian anesthesiology residency training programs was considerably variable. Program directors do appear, however, to recognize its importance for future anesthesiologists, with a large majority offering formal or elective rotations. Most programs offer at least ten hours of didactic training using a combination of lectures, online resources, bedside teaching, and simulation. Some experts propose that basic FoCUS competence can be achieved with as little as 12 hr of didactic and practical training. These levels are currently being surpassed by a majority of the programs. Although no minimum requirements for training currently exist for perioperative FoCUS, most programs with a formal rotation meet recent critical care G. Mizubuti, MD, MSc R. Allard, MD, FRCPC A. M.-H. Ho, MD, FRCPC, FCCP M. Cummings, MD, FRCPC R. C. Tanzola, MD, FRCPC (&) Department of Anesthesiology & Perioperative Medicine, Queen’s University, Kingston, ON, Canada e-mail: tanzolar@kgh.kari.net

Proactive Use of Plasma and Platelets in Massive Transfusion in Trauma: The Long Road to Acceptance and a Lesson in Evidence-Based Medicine.

1618 www.anesthesia-analgesia.org December 2016 • Volume 123 • Number 6 Copyright

Inattentional blindness in anesthesiology: A simulation study

STUDY OBJECTIVES Inattentional blindness is the psychological phenomenon of inability to see the unexpected even if it is in plain view. We hypothesized that anesthesiologists may overlook unexpected intraoperative events whereas medical students, lacking in intraoperative monitoring experience and knowledge, may be more likely to notice such events. DESIGN A simulation study using a video of a simulated septic patient undergoing abdominal surgery. SETTING A large academic center. PARTICIPANTS 31 certified anesthesiologists and 46 upper-year medical students. INTERVENTIONS None. Participants watched a video of a simulated surgery and scored the abnormalities they saw. MEASUREMENTS These abnormalities included abnormal physiologic parameters consistent with the condition of the simulated septic patient, and two unexpected but plausible events: head movement and a leaky central line catheter. MAIN RESULTS Students were significantly more likely than anesthesiologists to notice head movement (p<0.001).

Intubação seletiva do brônquio principal esquerdo em unidade de terapia intensiva neonatal

BACKGROUND Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. CASE SUMMARY A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphys eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. CONCLUSION Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.

Comments on “Anesthesia of thoracic surgery in children”

Sir—We have read with interest Semmelmann et al’s review and wish to expand the discussion on several related issues. Semmelmann et al suggest placement of the bronchial blocker (BB) within the endotracheal tube (ETT) lumen starting from an ETT (ID) size of 5 mm. We feel it important to point out that an ETT ID of 4.5 mm can comfortably accommodate a BB (eg, 4Fr Fogarty catheter or Arndt 5Fr) and a 1.8 mm fiberscope and still allows positive pressure ventilation. There are situations in which there is already an ETT in situ and pushing a BB between the larynx and the ETT is difficult. Intraluminal placement in that case is much easier. Semmelmann et al fail to point out that one of the hazards of BB is retrograde displacement into the trachea (13% in 1 series). This immediately causes complete airway obstruction, necessitating BB deflation, leading to bilateral ventilation and interruption of surgery for repositioning. Sometimes, retrograde migration is due to the surgeon struggling to control bleeding, and repeated interruption is most unwelcome and dangerous. To eliminate the possibility of blocker migrating into the trachea, we thread the BB through the Murphy eye of the ETT and pass the ETT distally such that its tip is very close to the carina. With this arrangement, the blocker is extremely stable. Semmelmann et al tout the advantages of thoracoscopic surgery over thoracotomy. However, they have neglected to mention musculoskeletal sequelae, severe complications that the anesthesiology literature largely ignores. The surgical literature is replete with reports of musculoskeletal (scoliosis, winged scapula, chest asymmetry, fusion of the ribs, etc.) and breast maldevelopment years after chest surgery in childhood. Suspected causes include pleural scaring, disturbed innervation and vascularity of serratus anterior and latissmus dorsi muscles on the operated side, causing imbalance. Thoracoscopic surgery leads to much lower incidences of deformities (33% vs 100% for thoracotomy in 1 study). Even thoracotomy that spares the latissimus and serratus muscles and incises the intercostal muscles tangential to the ribs results in a scoliosis incidence of 54% vs 9% for thoracoscopic surgery. There are also reports with much lower incidences. An unstable BB that repeatedly finds its way into the trachea may force the frustrated surgeon to convert from thoracoscopy to open thoracotomy. On thoracic epidural placement, the high flexibility of the pediatric rib cage may theoretically increase the risk of accidental dural puncture. When a blunt Tuohy needle is advanced, the rib cage is pushed forward by the blunt needle. At some point, the rib cage can spring back and the needle tip can go pass the dura. Although this mechanism may theoretically increase the risk of spinal cord injury, no permanent neurological injuries were reported in previous observational prospective series published in the Journal (see ADARPEF study 2010, and “The national pediatric epidural audit”, 2007). Nevertheless, threading the epidural catheter via a caudal or lumbar entry site is our preferred technique. Alternatively, erector spinae block also greatly reduces this theoretical danger and may be as effective as paravertebral block in adults and in children. One-third of tracheoesophageal fistulas are very close to, at, or below the carina, making the textbook approach of positioning the ETT tip between the carina and the fistula impossible in these cases. We agree with Semmelmann et al that when the fistula is small and the lungs are compliant, insufflation of the stomach is avoidable with gentle positive pressure ventilation; however that is not always the case. Our Plan B is to put a 3Fr Fogarty catheter with its tip bent posteriorly into the trachea immediately prior to endotracheal intubation. If the fistula is too close to the carina, meaning that the textbook approach (Plan A) is impossible, we promptly slide the blocker into the fistula followed by inflation and the ETT tip can be placed proximal to the fistula.

Tracheal Intubation: The Proof is in the Bevel

BACKGROUND Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. DISCUSSION The ETT bevel orientation is the main determinant of which mainstem bronchus the ETT enters when advanced too distally, despite a common belief that attributes a higher incidence of right mainstem bronchial intubation to the straighter angle sustained by the right mainstem bronchus. Likewise, a bougie- or fiberscope-assisted tracheal intubation can be impeded by the ETT tip hooking onto laryngeal structures; a 90-degree counterclockwise turn of the ETT (such that the bevel is facing posteriorly) prior to advancing it toward the larynx produces a first-pass success rate of 100%. Similarly, a posterior-facing bevel is believed to improve the ease of passage through the back of the nasal cavity when performing nasotracheal intubation. If resistance is met after the ETT tip has reached the laryngeal vicinity, further counterclockwise rotation may change the plane and incident angle of the ETT tip, facilitating passage through the vocal cords. Clockwise twisting of the ETT reduces the incident angle in the sagittal plane, thereby facilitating videolaryngoscopy-assisted tracheal intubation. Finally, a posterior-facing ETT bevel is the least likely to intubate a tracheoesophageal fistula. CONCLUSIONS Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.

Retrograde Extrusion of Coronary Thrombus During Urgent Aortocoronary Bypass Surgery: A Case Report

A 73-year-old man underwent urgent coronary artery bypass grafting after an acute myocardial infarction. An angiogram had revealed multivessel disease with a circumflex artery lesion suspected as the primary culprit. On separation from cardiopulmonary bypass, transesophageal echocardiography revealed a new mobile mass in the aortic root. Cardiopulmonary bypass was reinstituted and a large thrombus emanating from the left coronary ostium was surgically removed. We hypothesize that the thrombus had originated from coronary retrograde extrusion during venous grafting. This case illustrates an unusual source of emboli during coronary artery bypass grafting and emphasizes the importance of perioperative transesophageal echocardiography for the prevention of potentially catastrophic outcomes.

Chest Compression-Only Cardiopulmonary Resuscitation

1330 www.anesthesia-analgesia.org anesthesia & anaLgesia patients with witnessed ventricular fibrillation results in significant survival advantage over positive-pressure ventilation using a bag-mask technique. Head-tilt–chinlift produces adequate airway patency in 91% of anesthetized patients. Our point is when the International Liaison Committee on Resuscitation eliminated rescue breathing by lay rescuers, they threw the baby out with the bath water. Ventilation is vital in all resuscitations. This is even more so in cardiac arrests because of noncardiac primary causes and in rural areas, where ambulance response time to provide defibrillation is long. We are of the opinion that if a second bystander is present, he or she should pull back the chin (no different from what anesthesiologists routinely do when transporting patients to the postanesthesia care unit) such that passive ventilation is possible during chest compression. In a recent international cardiology conference, 1 of us raised that point after a lecture on CPR. The speaker responded by saying that there is no RCT on the subject, shutting down further discussion. Although we fully agree that there is a need to conduct RCTs, which could take years, common sense suggests that we should incorporate chin lift, whenever possible, into untrained bystander-performed CPR for witnessed and nonwitnessed arrests until proven otherwise. All in all, as stated by Lurie et al,1 “some would argue that current approaches to cardiac arrest are fatally flawed.” We think that the underappreciation of passive ventilation for outof-hospital resuscitation by untrained bystanders for witnessed arrest fits this assertion.