Kerstin Wyssusek

The Gold in Garbage: Implementing a Waste Segregation and Recycling Initiative

Generally, ORs produce approximately one-fifth to one-third of all waste in a hospital. Before our quality improvement project was performed in our tertiary care facility, all OR waste was disposed of as clinical waste. Disposal of clinical waste is more costly than disposal of general waste. Therefore, accurately segregating waste can have significant financial incentives. Our quality improvement project involved the implementation of processes that segregated general waste in the OR from clinical waste and translated to an almost 60% reduction of waste disposal costs for OR waste. Further, we implemented a recycling program that reclaimed a portion of the general waste. In total, our efforts reduced the amount of clinical waste produced by the OR by 82%, and the amount of total OR waste was reduced by more than 50%.

In reference to Is multidisciplinary team care for head and neck cancer worth it? and Does a multidisciplinary approach to voice and swallowing disorders improve therapy adherence and outcome?

Recently, The Laryngoscope promoted the idea of multidisciplinary team care as the gold standard of practice for head and neck cancer, as advocated by Badran et al., and for voice and swallowing disorders, as evidenced by Litts and Abaza, resulting in improved patient outcome. However, not all oral lesions present with hoarseness and voice changes and may be asymptomatic for some time. Delays between diagnosis and treatment may potentially influence outcome and survival of oral lesions. Anesthesiologists have used direct laryngoscopy as the sole method of laryngoscopy for over 60 years. Videolaryngoscopy has a wider viewing angle (commonly 608 vs. 158 for direct laryngoscopy) and offers better views of the oropharynx and larynx than conventional direct laryngoscopy. The videolaryngoscope blade tip has integrated light-emitting diode lighting and complementary metal-oxide semiconductor optics to provide a magnified image that is transmitted to a screen or monitor. Videolaryngoscopy ensures all members of the operating team engaged in airway management by displaying airway anatomy, understanding the difficulties encountered in managing the airway and the progress through difficult airway algorithms. Incidental discovery of asymptomatic lesions may be found by anesthesiologists at an early stage during routine laryngoscopy and tracheal intubation, sometimes presenting a serious challenge in airway management. Images obtained with videolaryngoscopy can play an important role in 1) offering better airway management options for normal and difficult airway management, 2) diagnosis of early-stage asymptomatic pharyngeal and laryngeal lesions, 3) clear photo documentation of lesions in symptomatic patients to be used for planning airway management (e.g., extubation strategies and planning tumor debulking surgery), 4) evaluating airway patency after intraoral surgery (e.g., free flap transfer, laser excision of tongue cancer, treatment of unilateral vocal cord paralysis, requiring frequent daily evaluations of postsurgery laryngeal edema), and 5) as part of photo-documenting airway lesions following treatment. The latter replaces the surgeon’s traditional freehand drawings documented in the patient’s medical record with an accurate image capture. In summary, videolaryngoscopy image capture may have an impact on early diagnosis, rapid referral, and ongoing tumor surveillance in airway management. A close liaison between anesthesiology and otolaryngology through videolaryngoscopy image capture further improves interdisciplinary communication and patient safety.

Cardiac and Abdominal Pheochromocytomas: Anesthetic Management for a Combined Cardiac and Hepatobiliary Procedure

Pheochromocytomas are functionally active tumors arising from chromaffin cells. They produce and secrete biogenic amines. The majority of pheochromocytomas are intra-adrenal, with only 10% to 20% found outside the adrenal medulla.(1) Pheochromocytomas are a rare cause of hypertension (0.1%-0.6%)(2) and are familial in 15% to 20% of cases. The incidence of metastatic pheochromocytomas varies between 3% and 36% as summarized by Pacalc et al.(3) Mediastinal paragangliomas, however, are extremely uncommon, representing only 2% of all catecholamine-secreting tumors.(4)

In reference to “Review of videolaryngoscopy pharyngeal wall injuries”

We read with interest the article published in The Laryngoscope on pharyngeal wall injuries due to the use of videolaryngoscope (VLS). Greer et al. noticed that otolaryngologists see an increased pattern of soft palate and other palatopharyngeal injuries after the use of VLS. Indeed, it is confirmed earlier that some, but not all, VLSs result in trauma, with the majority following the oral insertion of acute angled VLSs using a rigid stylet. (In most cases, a GlideScope (Verathon, Seattle, WA) was used and incidentally the McGrath Series 5 [Medline Industries, Inc., Mundelein, IL]). In a minority of cases, channeled VLSs (Airtraq [Prodal, Meditec, S.A, Teleflex, Morrisville, NC] and Airway-Scope [Pentax Medical, Tokyo, Japan]) caused a similar problem. Manufacturers of GlideScope (Verathon, Seattle, WA)/ McGrath (Medline Industries Inc., Mundelein, IL) recommend using a stylet during endotracheal tube (ETT) insertion. Having a prestyleted ETT may facilitate the intubation process, but this is far from a universal solution because it comes at a higher incidence of airway trauma, ranging from sore throat to soft palate, tonsillar, and palatopharyngeal trauma, as documented in dozens of publications. We agree with Greer et al. that VLSs offer many benefits, although there is an inherent blind spot during intubation with a VLS that may cause palatal/palatopharyngeal mucosal trauma, and insertion requires more procedural training. Intubators should insert an ETT under direct vision until the palatopharyngeal fold has been passed, and then look at the video monitor screen to guide the tube into the trachea. However, we disagree with the general conclusion that videolaryngoscopy introduces risk to intubation that is not shared by direct laryngoscopy. The potential mucosal injuries are more likely to occur with the use of acute angled blade nonchanneled and channeled VLSs, but not with the Macintosh blades. We are not aware of any publication reporting on similar traumata using classic Macintosh blades, be it for direct or indirect laryngoscopy (C-MAC [Karl Storz, Tuttlingen, Germany], McGrath-MAC [Medline Industries, Inc.], GlideScopeMAC [Verathon], Coopdech-MAC [Daiken Medical, Osaka, Japan] VLSs). We demonstrated in manikins (see figures in Van Zundert et al.) that there is more room next to a Macintosh (video)laryngoscope blade compared to non-Macintosh blade VLSs, which permits not only manipulation of instrumentation (ETT, but also adjuncts such as Magill forceps, stylets, oro-/nasogastric tubes), especially in a narrow cavity, importantly avoiding trauma. Our experience in patients is that Macintosh blade VLSs seldom need a stylet during ETT insertion, both in patients with normal and difficult airways. Anesthesiologists should therefore consider carefully choosing the correct VLS and the correct insertion technique to avoid any airway trauma. Patient/surgical factors, choice of equipment, and the intubator’s technical skills all play an important role.

Only with an optimal position of the supraglottic airway in situ, valid conclusions can be drawn about oropharyngeal airway pressure

We were interested by the recent publication of Banerjee et al. in the Indian Journal of Anaesthesia on the comparison of the ProSeal and the i-gel supraglottic airway devices (SADs) in different head-and-neck positions in anaesthetised paralysed children.[1] The authors did not detect a significant difference in the oropharyngeal leak pressures, fibreoptic gradings and ventilation scores in three positions (neutral and maximum flexion/extension).

Benefits of recording images during video laryngoscopy for early detection of oropharyngeal and laryngeal lesions: implications for “inattentional blindness”

The introduction of video laryngoscopy has significantly improved the success rate of difficult airway management. It offers better options for visual instrumentation of the airway and esophagus and provides a four times larger vertical visual angle of view (60 ) of the oropharynx compared with conventional direct laryngoscopy (15 ). The ability of video laryngoscopes to acquire and store images and/or video clips provides an important underrecognized function. The anesthesiologist may observe a wide array of asymptomatic lesions during routine laryngoscopy performed for tracheal intubation. Images and video clips can be stored in the patient’s medical record for possible referral to the appropriate specialist. This practice is similar to that of gastroenterologists, who regularly retain procedural images for review and planning purposes. Examples of such pathological lesions include cysts in the vallecula, tumours of the epiglottis and posterior pharynx, vocal cord granulomas, and even tonsillar leukoplakia (see Figure for details). It is vital that some of these abnormalities are detected and managed as early as possible as treatment delays may adversely affect outcome and survival.

Verification of nasopharyngeal temperature probes-they are not always where you think they are!

To the Editor We read with interest the study published by Wang et al1 on optimal depth for nasopharyngeal temperature probe positioning for standard temperature monitoring during anesthesia. It involved nasopharyngeal temperature probes at different insertion depths, concluding that “any nasopharyngeal probe insertion depth between 10 and 20 cm well represents core temperature in adults having noncardiac surgery.” Direct laryngoscopy confirmed that when the probe was inserted 20 cm, the tip was in the pharynx, with subsequent estimation of the accuracy of positioning of the nasopharyngeal probes at varying depths. We would suggest that, when these probes were inserted between 14 and 20 cm, they were positioned in the oropharynx or laryngopharynx, not the nasopharynx. Lee et al2 studied optimal nasopharyngeal temperature probe placement and concluded “the closest portion of the nasopharyngeal mucosa to the internal carotid artery is within the upper or midnasopharynx. The depth from the nares to the upper onethird of the nasopharynx is approximately 10 cm. Less than half of nasopharyngeal temperature probes placed blindly by practitioners were optimally positioned.” It is customary that these probes are inserted blindly, once the endotracheal tube is placed by using direct laryngoscopy. Little is known about complications following blind insertion of nasopharyngeal tubes, although, Abu-Gazala et al3 report on too deep insertions with morbidity

Postoperative sore throat - know where your airway is positioned.

It was interesting to read the review article by El-Boghdadly et al. [1] on the incidence of postoperative sore throat following insertion of tracheal tubes (TT) and supraglottic airway devices (SAD) in patients undergoing anaesthesia. An astonishing 62% of postoperative patients report a sore throat, which is often neglected by medical and nursing staff and is not routinely investigated. We should focus on further improving our techniques to reduce this high incidence of complications, mainly as a direct consequence of the instrumentation of the patient’s airway. We compliment the authors on the analysis they performed within this systematic review. Several techniques to reduce the incidence were listed, with most interventions not able to demonstrate major improvements. Comparing results using different devices is difficult as one fundamental item is lacking: how well are airway devices positioned in patients? If we want to compare apples with apples, we need to be absolutely sure that the airway device is positioned correctly in the trachea (TT) or the hypopharynx (SAD). Down-folding of the epiglottis can occur during laryngoscopy and tracheal intubation, which can go unnoticed by the laryngoscopist/ intubator [2, 3]. Ideally, a correctly-sized SAD should be positioned in the hypopharynx with the distal cuff located at the entrance of the oesophagus, blocking the latter, and the epiglottis resting on the outside of the proximal cuff, with the tip of the epiglottis aligned with the rim of the proximal cuff. As such, the SAD tube opening opposes the glottic opening and the entrance to the trachea, allowing for spontaneous breathing and mechanical ventilation. Imaging studies (MRI, radiography and fibreoscopy) have revealed that a variety of malpositioning of SADs occurs in up to 80% of all insertions, with the epiglottis often posteriorly deflected, resulting in partial epiglottis down-folding in the bowl of the airway device in 80% and complete down-folding of the epiglottis in 10% [4–9]. In some instances, this may cause partial or even complete obstruction of the airway, and trauma (oedema, ischemia) to the epiglottis, in particular if the malposition is not detected during long operations, with a sore throat as a likely outcome. There are many reasons why malpositioning of SADs occurs, including initial down-folding of the epiglottis during insertion of the SAD, sideways folding of the epiglottis, distal cuff folding over backwards, distal cuff sitting between the vocal cords, malalignment between the tip of the epiglottis and the rim of the proximal cuff (due to the use of an incorrect size or incorrectly inflated cuff), down-folding of the epiglottis in the bowl of the device (potentially leading to air leaks or airway obstruction), and material used (PVC cuffs show foldings, contrary to silicone cuffs) [10]. The anaesthetist can only be sure about optimal position if the device is inserted with a direct view, using either classic laryngoscopy or videolaryngoscopy. This allows the use of visually-guided manoeuvres to direct the SAD into a final optimal position. Furthermore, El-Boghdadly et al. [1] described themselves, in their review article, that the use of laryngoscope-guided SAD insertion offered the greatest reduction of the incidence of sore throat postoperatively. Until we are able to correctly place devices in the accurate position, we cannot judge whether one particular insertion technique or brand of device is better than the other. Every effort should be made to avoid prolonged times whereby the down-folded epiglottis is trapped between the pharynx and the device (SAD) as well as between the tracheal wall and the tube (TT). If down-folding of the epiglottis is not corrected, the major issue of sore throat after anaesthesia will continue to remain a problem.