Jagtar Singh Heir

Video Laryngoscopy Versus Direct Laryngoscopy for Double-Lumen Endotracheal Tube Intubation: A Retrospective Analysis

OBJECTIVE The authors hypothesized that video laryngoscopy (VL) facilitated double-lumen tube (DLT) insertion compared with direct laryngoscopy (DL). DESIGN A retrospective analysis. SETTING An academic hospital. PARTICIPANTS Patients older than 18 years of age undergoing thoracic surgery requiring DLT placement between 2005 and 2011. INTERVENTIONS Patients without airway predictors of difficult intubation who were intubated under DL with Macintosh (DL-MAC, n = 40) or Miller (DL-MIL, n = 44) blades and VL with McGrath MAC (Aircraft Medical, Edinburgh, UK) and C-MAC (Karl Storz, Tuttlingen, Germany) laryngoscopes (n = 46) were included in the study. Patients who were intubated with both VL devices were grouped into a VL group. MEASUREMENTS Patients in all 3 groups had comparable preoperative demographics. Mallampati scores and ease of manual ventilation after the induction of anesthesia were also similar in all groups. The Cormack Lehane (C-L) grade views were significantly higher in patients in the DL-MAC than in the DL-MIL and VL groups (p < 0.006). The number of intubation attempts was similar in all 3 groups; however, the percentage of intubation reported to be difficult was higher in the DL-MAC than in the other 2 groups (p = 0.014). No damage to the airway was found in any of the groups. CONCLUSION DLT placement using VL appeared to overcome some of the limitations of DL-MAC but was similar to DL-MIL. The authors speculated that the ease of placement was related to the improved visualization of the vocal cords because there was a significantly greater number of C-L views 3 and 4 in the DL-MAC group as compared with the VL and DL-MIL groups. Hence, the authors advocate using VL, particularly when the laryngoscopist is inexperienced using DL-MIL for DLT placement.

A Retrospective Evaluation of the Use of Video-Capable Double-Lumen Endotracheal Tubes in Thoracic Surgery

OBJECTIVE The objective of this study was to evaluate whether the use of a video double-lumen tube reduced the need for fiberoptic bronchoscopy for (1) verification of initial tube placement and for (2) reverification of correct placement after repositioning for thoracotomy. DESIGN A single-center retrospective study. SETTING Thoracic surgery in a medical university hospital. PARTICIPANTS & INTERVENTIONS After institutional review board approval, 29 patients who underwent thoracic surgical procedures using video double-lumen tubes were included in the final retrospective analysis. MEASUREMENTS AND MAIN RESULTS For 27 (93.2%) patients, the use of fiberoptic bronchoscopy was not needed either for initial placement or for verification of correct video double-lumen tube placement upon final positioning of the patient. However, for two patients, fiberoptic bronchoscopy was needed: for (1) one patient with severe left mainstem bronchus distortion as a result of a large left upper lobe tumor, and (2) a second patient with secretions that were difficult to clear. CONCLUSION This study demonstrates that the video double-lumen tube requires significantly less (6.8%) fiberoptic use for both initial placement and verification of final position, in stark contrast to standard practice in which bronchoscopy is always used to verify final positioning of the double-lumen tube. As opposed to intermittent bronchoscopy, the continuous visualization offered by an embedded camera may confer an added measure of safety.

Coronary Stents and Noncardiac Surgery: Current Clinical Challenges and Conundrums

This article discusses how perioperative physicians are currently faced with unique challenges when providing care for surgical patients who have undergone recent percutaneous transluminal coronary angioplasty with drug-eluting stent (DES) placement. Despite adhering to the currently recommended antiplatelet regimens, these patients may still be at risk for sustaining a myocardial infarction secondary to stent thrombosis during the perioperative period. Given the high morbidity and mortality rates associated with perioperative myocardial infarction, it is important that the perioperative care of surgical patients with previous DES placement should be discussed, evaluated, and clarified by all practitioners who may be involved in their care.

Identification of Risk Factors Associated With Postoperative Acute Kidney Injury After Esophagectomy for Esophageal Cancer

OBJECTIVE To identify risks factors associated with acute kidney injury (AKI) after esophageal cancer surgery. DESIGN This was a retrospective study. SETTING Single academic center. PARTICIPANTS Subjects with non-metastatic esophageal cancer. Patients were excluded if they were younger than 18 years and had missing data. MEASUREMENTS AND MAIN RESULTS Primary outcome of the study was AKI according to AKI Network criteria. Demographic and perioperative variables were compared in patients with and without AKI. A multivariate Cox proportional model was used to assess the association between perioperative variables and AKI; p<0.05 was considered statistically significant. AKI was found in 107 (11.9%) of the 898 patients included in the study. The multivariate analysis also showed that BMI (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.11), number of comorbidities (OR 1.52, 95% CI 1.20-1.93, p = 0.001), and preoperative creatinine concentrations (OR 2.37, 95% CI 1.14-4.92, p = 0.02) were independent predictors for AKI. The use of dexamethasone was associated with a reduced risk for AKI. CONCLUSIONS In support of previous reports in the literature, the authors found that AKI was not an uncommon complication after esophageal surgery. Obesity, cardiovascular comorbidities, and high preoperative concentrations were predictors of AKI. Dexamethasone administration during surgery appeared to have a protective effect. This finding opens an opportunity to further study in a randomized controlled trial the efficacy of dexamethasone in the prevention of AKI.

A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery

OBJECTIVE To compare the incidence of fiberoptic bronchoscope (FOB) use (1) during verification of initial placement and (2) for reconfirmation of correct placement following repositioning, when either a double-lumen tube (DLT) or video double-lumen tube (VDLT) was used for lung isolation during thoracic surgery. DESIGN A randomized controlled study. SETTING Single-center university teaching hospital. PARTICIPANTS The study comprised 80 patients who were 18 years or older requiring lung isolation for surgery. INTERVENTIONS After institutional review board approval, patients were randomized prior to surgery to either DLT or VDLT usage. Attending anesthesiologists placed the Mallinckrodt DLT or Vivasight (ET View Ltd, Misgav, Israel) VDLT with conventional laryngoscopy or video laryngoscopy then verified correct tube position through the view provided with either VDLT external monitor or FOB. MEASUREMENTS AND MAIN RESULTS Data collected included: sex, body mass index, successful intubation and endobronchial placement, intubation time, confirmation time of tube position, FOB use, quality of view, dislodgement of tube, and ability to forewarn dislodgement of endobronchial cuff and complications. FOB use for verification of final position of the tube (VDLT 13.2% [5/38] v DLT 100% [42/42], p < 0.0001), need for FOB to correct the dislodgement (VDLT 7.7% [1/13] v DLT 100% [14/14], p < 0.0001), dislodgement during positioning (VDLT 61.5% [8/13] v DLT 64.3% [9/14], p = ns), dislodgement during surgery (VDLT 38.5% [5/13] v DLT 21.4% [3/14], p = ns), and ability to forewarn dislodgement of endobronchial cuff (VDLT 18.4% [7/38] v DLT 4.8% [2/42], p = 0.078). CONCLUSION This study demonstrated a reduction of 86.8% in FOB use, which was a similar reduction found in other published studies.

Facilitating safer surgery and anesthesia in a disaster zone

m ( i t m t q v u a l t On January 12, 2010, a catastrophic earthquake struck Haiti. An estimated 200,000 people were killed, and 300,000 were injured. There was an immediate and ongoing need for health care providers, because the limited health care infrastructure of the impoverished nation was destroyed. We discuss the multiple challenges faced and addressed in the provision of anesthesia and surgery, safely, at a field hospital that was emergently set-up after the earthquake in Haiti (Fig. 1).

A simple approach to facilitating fiberoptic intubation in the difficult airway.

INTRODUCTION Management of the difficult airway remains a complex problem for anesthesiologists, although a number of approaches have been described. Fiberoptic intubation remains one of the more successful and frequently utilized methods to access the difficult airway, but this approach presents a number of challenges as well. These include the presence of blood and secretions in the nasal and pharyngeal airways, edema from transoral attempts, or anatomic distortion from radiation and prior surgery, all of which obscure the endoscopic view. A variety of maneuvers can address these challenges in the perioperative or emergency settings, but often are not optimal. These include the use of the jaw thrust, an Ovassapian transoral airway, or the laryngeal-mask airway (LMA). However, each of these is suboptimal, particularly in patients with altered anatomy or Mallampati class IV airways. Transnasal fiberoptic intubation (TFOI) can be advantageous by circumventing the oral airway, but visualization of the laryngeal airway may also be obscured due to prolapse of the tongue base or pharyngeal walls. In this report, we describe the utilization of a practical and cost-effective adjunct to transnasal fiberoptic intubation in the difficult airway that can be universally implemented by anesthesiologists and otolaryngologists. The simple adaptation of a nasopharyngeal trumpet to serve as a direct conduit to the laryngeal airway for facilitating fiberoptic intubation is described.

Implementation of an Enhanced Surgical Recovery Programme (ESRP) in gynaecologic oncology: Has the development of a preoperative order set improved compliance for preventive analgesia and deep venous thromboembolic (DVT) prophylaxis?

Javier D. Lasala , Jagtar Singh Heir , Gabriel E. Mena , Alpa M. Nick , Larissa A. Meyer , Maria D. Iniesta , Mark F. Munsell , Gloria Salvo , Juan P. Cata , Ifeyinwa Ifeanyi , Vijaya Gottumukkala , Katherine E. Cain , Pedro T. Ramirez . Anaesthesiology, University of Texas MD Anderson Cancer Center, Houston, United States; Gyn Onc & Reproductive Med, University of Texas MD Anderson Cancer Center, Houston, United States; Biostatistics, University of Texas MD Anderson Cancer Center, Houston, United States; 4 Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, United States