James W. Heitz

The Complexities of Tracheal Intubation With Direct Laryngoscopy and Alternative Intubation Devices

Intubation research on both direct laryngoscopy and alternative intubation devices has focused on laryngeal exposure and not the mechanics of actual endotracheal tube delivery or insertion. Although there are subtleties to tracheal intubation with direct laryngoscopy, the path of tube insertion and the direct line of sight are relatively congruent. With alternative intubation devices, this is not the case. Video or optical elements in alternative intubation devices permit looking around the curve of the tongue, without a direct line of sight to the glottic opening. With these devices, laryngeal exposure is generally the simple part of the procedure, and conversely, tube delivery to the glottic opening and advancement into the trachea are sometimes not straightforward. This article presents the mechanical and optical complexities of endotracheal tube insertion in both direct laryngoscopy and alternative devices. An understanding of these complexities is critical to facilitate rapid tracheal intubation and to minimize unsuccessful attempts.

New and emerging analgesics and analgesic technologies for acute pain management.

Purpose of review Recent advances in drug delivery technology have provided new means of delivering medications with improved efficacy and safety. This review details developments in drug delivery recently made available or in development with the potential to better deliver analgesia. Recent findings Patient-controlled analgesia of intravenous medications was a major advance in drug delivery technology that allowed opioids to be administered more effectively and more safely. Extension of this technology to medications not administered intravenously has further broadened therapeutic options in the treatment of acute pain. Improvements in sustained-release formulations and patient-controlled analgesia modalities that are not catheter-based confer the potential to deliver analgesia less invasively. Receptor-specific antagonists allow opioids to be administered with fewer untoward side effects. Summary New routes of administration allow familiar medications to be utilized with greater clinical efficacy. Elimination of the need for indwelling catheters may reduce both the frequency of analgesic gaps and catheter-related complications. Physicians need to be familiar with developments in drug delivery technologies to be able to effectively utilize analgesics as part of well designed multimodal regimens to bring effective and well tolerated analgesia to patients with acute pain.

The Design and Implementation of an Automated System for Logging Clinical Experiences Using an Anesthesia Information Management System

BACKGROUND:Residents in anesthesia training programs throughout the world are required to document their clinical cases to help ensure that they receive adequate training. Current systems involve self-reporting, are subject to delayed updates and misreported data, and do not provide a practicable method of validation. Anesthesia information management systems (AIMS) are being used increasingly in training programs and are a logical source for verifiable documentation. We hypothesized that case logs generated automatically from an AIMS would be sufficiently accurate to replace the current manual process. We based our analysis on the data reporting requirements of the American College of Graduate Medical Education (ACGME). METHODS:We conducted a systematic review of ACGME requirements and our AIMS record, and made modifications after identifying data element and attribution issues. We studied 2 methods (parsing of free text procedure descriptions and CPT4 procedure code mapping) to automatically determine ACGME case categories and generated AIMS-based case logs and compared these to assignments made by manual inspection of the anesthesia records. We also assessed under- and overreporting of cases entered manually by our residents into the ACGME website. RESULTS:The parsing and mapping methods assigned cases to a majority of the ACGME categories with accuracies of 95% and 97%, respectively, as compared with determinations made by 2 residents and 1 attending who manually reviewed all procedure descriptions. Comparison of AIMS-based case logs with reports from the ACGME Resident Case Log System website showed that >50% of residents either underreported or overreported their total case counts by at least 5%. CONCLUSION:The AIMS database is a source of contemporaneous documentation of resident experience that can be queried to generate valid, verifiable case logs. The extent of AIMS adoption by academic anesthesia departments should encourage accreditation organizations to support uploading of AIMS-based case log files to improve accuracy and to decrease the clerical burden on anesthesia residents.

Asymmetric postoperative visual loss after spine surgery in the lateral decubitus position

Postoperative visual loss (POVL) is a rare but potentially devastating complication associated with spine surgery. In 1999, the American Society of Anesthesiologists Committee on Professional Liability established a POVL Registry to examine cases in search of common elements. Most cases of POVL after spine surgery which have been reported to the POVL Registry have been associated with intraoperative prone positioning. We present an atypical case that occurred after spine surgery performed in the lateral decubitus position.

An evidence-based approach to medication preparation for the surgical patient at risk for latex allergy: is it time to stop being stopper poppers?

The prevalence of latex allergy is increasing in surgical patient populations. Avoidance of exposure to the allergen is essential to minimizing perioperative complications in patients suspected to be at risk. Natural rubber latex has historically been ubiquitous in medical devices containing rubber. In 1998, the Food and Drug Administration (FDA) began to require the labeling of medical devices made from natural rubber latex; since that time substantial progress has been made in identifying latex-free alternatives. However, the rubber stoppers commonly found in pharmaceutical vial closures are exempt from FDA labeling requirements. Examination of the clinical and basic science literature regarding pharmaceutical vial closures supports limiting the rubber stopper to a single needle puncture as a safer practice, with the caveat that no strategy exists for the complete elimination of risk as long as stoppers made from natural rubber latex are used in pharmaceutical vials intended for human use.

Oculocardiac Reflex Elicited During Debridement of an Empty Orbit

The oculocardiac reflex (OCR) is a well–described cardiac depressor reflex that may result in significant cardiac rate or rhythm changes, sinus and junctional bradycardia, heart block or asystole. It is also known by the eponym Aschner-Dagnini Reflex, being independently reported in 1908 by both Guiseppe Dagnini and later Bernard Aschner.1,2 The OCR is classically depicted as being precipitated by traction on the extraocular muscles or pressure on the globe. The ophthalmic branch of the trigeminal nerve serves as the afferent pathway and the vagus nerve as the efferent pathway. We report the OCR resulting in episodes of profound bradycardia and brief asystole during manipulation within a previously enucleated empty orbit. CASE REPORT

Use of a tracheoscopic ventilation tube for endotracheal intubation in the difficult airway.

Difficult endotracheal intubation is a clinical challenge for anesthesiologists and other practitioners of airway management. The use of a tracheoscopic ventilation tube, a novel airway device, for endotracheal intubation during general anesthesia in two patients with difficult airways after unsuccessful direct laryngoscopy is presented.

Inopportune breakage of an endotracheal tube T-connector.

References 1 Stone DJ, Gal TJ. Airway management. In: Miller RD (Ed.). Anesthesia, 5th ed. London: Churchill Livingstone Inc.; 2000: 1414–51. 2 Magill IW. Forceps for intratracheal anaesthesia. Br Med J 1920; ii: 670. 3 Dorsch JA, Dorsch SE. Tracheal tubes. In: Dorsch JA, Dorsch SE (Eds). Understanding Anesthesia Equipment. Baltimore: Lippincott, Williams & Wilkins; 1999: 557–78. 4 Marfin AG, Iqbal R, Mihm F, Popat MT, Scott SH, Pandit JJ .Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation. Anaesthesia 2006; 61: 646–50. 5 Bearman AJ. Device for nasotracheal intubation. Anesthesiology 1962; 23: 130–1.

Risk of latex allergy from pharmaceutical vial closures.

tively brief preoperative abstinence from smoking (less than 8 weeks) does not increase pulmonary risk compared with continued smoking. Indeed, we are not aware of any individual study that has found a statistically significant increase in pulmonary complications with brief preoperative abstinence, including the two initial studies by Warner et al. that were interpreted by some authors as raising concerns. The conjectured mechanism responsible for increased risk is a transient increase in cough and sputum production after smoking cessation. However, there is no evidence that cough and sputum production actually increase after smoking cessation, either in an ambulatory population or specifically in anesthetized patients. It does seem clear that more prolonged abstinence from smoking is necessary to reduce the risk of pulmonary morbidity because it takes several weeks for the lungs to recover from the effects of smoking. Thus, although more data would be welcome, we do not believe that there is any evidence to support the possibility that short-term smoking cessation increases pulmonary complications. It is very likely that the longer the duration of abstinence the better in terms of reducing risk of pulmonary and other complications. However, given the power of the teachable moment and the long-term benefits to health, anesthesiologists and others should seize any opportunity at any time to help their patients quit smoking, without fearing that brief preoperative abstinence could worsen outcome. The American Society of Anesthesiologists provides several tools to do so.*

The role of professional medical education societies in fostering professional identity.

Academic Medicine, Vol. 90, No. 8 / August 2015 1002 have been well designed, although with six years and 50,000 patients’ worth of experience, we are getting better) will result in persuasive data that not only promote rapid improvement in care but also generate excitement among frontline clinicians eager to learn more. This excitement is a fundamental requirement if we are to change our health care system for the better.