Kong Eric You-Ten

Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial.

Background: Misidentification of the cricothyroid membrane in a “cannot intubate-cannot oxygenate” situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. Methods: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex® device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1—easy = visual landmarks; 2—moderate = requires light palpation of landmarks; 3—difficult = requires deep palpation of landmarks; and 4—impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. Results: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult–impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). Conclusion: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour.

Success of cricothyroidotomy depends on accurate identification of anatomical neck landmarks. Anaesthetists palpated the cricothyroid membrane of 28 obese and 28 non‐obese women in labour (cut‐off BMI 30 kg.m−2) and marked the entry point for device insertion with an ultraviolet invisible pen. Ultrasonography was used to mark the midpoint of the cricothyroid membrane and the distance between the two marks was measured. The median (IQR [range]) distance between the two marks was significantly greater in the obese than the non‐obese patients (5 (2–9.5 [0–34]) mm vs 1.8 (0.1–6 [0–15]) mm, respectively; p = 0.02). The cricothyroid membrane was accurately identified with digital palpation in only 39% (11/28) of obese compared with 71% (20/28) of non‐obese patients (p = 0.03). Increased neck circumference in obese patients was significantly associated with inaccuracy in locating the cricothyroid membrane. Percutaneous identification of the cricothyroid membrane in obese women in labour was poor. Pre‐procedural ultrasound may help improved the identification of neck landmarks for cricothyroidotomy.

Task- versus ego-oriented feedback delivered as numbers or comments during intubation training

Learners can focus on mastery (i.e. task orientation) or on learning relative to others (i.e. ego orientation). Previous research suggests task orientations are optimal for learning, a benefit usually linked to the suggestion that qualitative comments are better for learning than quantitative comparisons (i.e. grades). Yet, it is not clear if the observed effects are attributable to the feedback orientation (i.e. task versus ego), feedback format (i.e. comments versus numerical scores), or an interaction between the two. Here, we aimed to clarify the effects of feedback orientation and feedback format during simulation‐based training in endotracheal intubation.

Point-of-care ultrasound (POCUS) of the upper airway

Airway management is a critical skill in the practice of several medical specialities including anesthesia, emergency medicine, and critical care. Over the years mounting evidence has showed an increasing role of ultrasound (US) in airway management. The objective of this narrative review is to provide an overview of the indications for point-of-care ultrasound (POCUS) of the upper airway. The use of US to guide and assist clinical airway management has potential benefits for both provider and patient. Ultrasound can be utilized to determine airway size and predict the appropriate diameter of single-lumen endotracheal tubes (ETTs), double-lumen ETTs, and tracheostomy tubes. Ultrasonography can differentiate tracheal, esophageal, and endobronchial intubation. Ultrasonography of the neck can accurately localize the cricothyroid membrane for emergency airway access and similarly identify tracheal rings for US-guided tracheostomy. In addition, US can identify vocal cord dysfunction and pathology before induction of anesthesia. A rapidly growing body of evidence showing ultrasonography used in conjunction with hands-on management of the airway may benefit patient care. Increasing awareness and use of POCUS for many indications have resulted in technologic advancements and increased accessibility and portability. Upper airway POCUS has the potential to become the first-line non-invasive adjunct assessment tool in airway management.RésuméLa gestion des voies respiratoires constitue une compétence fondamentale pour plusieurs spécialités médicales, dont l’anesthésiologie, la médecine d’urgence et les soins intensifs. Au fil des ans, l’accumulation des données probantes a démontré le rôle de plus en plus important de l’échographie dans la gestion des voies aériennes. L’objectif de cette étude narrative est de fournir une vue d’ensemble des indications de l’échographie au point d’intervention des voies respiratoires supérieures. L’utilisation de l’échographie pour guider et aider la gestion clinique des voies aériennes présente des avantages potentiels pour le praticien et pour le patient. L’échographie peut servir à établir la taille des voies respiratoires et prédire le diamètre approprié des tubes endotrachéaux, des tubes à lumière double et des tubes de trachéotomie. Elle permet aussi de faire la différence entre intubation trachéale, œsophagienne et endobronchique. Au niveau du cou, elle peut localiser avec précision la membrane cricothyroïdienne pour un accès d’urgence aux voies respiratoires et identifier également les anneaux bronchiques pour une trachéotomie échoguidée. De plus, l’échographie peut identifier une atteinte des cordes vocales avant l’induction de l’anesthésie. Un ensemble rapidement croissant de données probantes montre que l’utilisation de l’échographie en association avec la gestion des voies aériennes peut être profitable pour les soins du patient. Une conscience et une utilisation accrues de l’échographie au point d’intervention ont abouti à des progrès technologiques, à une plus grande accessibilité et portabilité. L’échographie des voies aériennes supérieures au point d’intervention pourrait devenir l’outil d’évaluation non invasive de première intention dans la gestion des voies aériennes supérieures.

In collaboration with the Canadian Anesthesiologists’ Society, the Canadian Journal of Anesthesia is proud to publish the best abstracts presented at the Annual Meeting of the Canadian Anesthesiologists’ Society held in Quebec City, Quebec, June 18–22, 2004

tion by a member of the Society. The Richard Knill competition was instituted in memory of Dr. Richard Knill, a foremost researcher in anesthesiology and prominent collaborator to the Canadian Journal of Anesthesia (CJA). The Annual Meeting Committee selects the top abstracts submitted for presentation by members of the Society at the Annual Meeting. The authors are invited to present their results at the Richard Knill competition. Presentations are marked by a jury composed of the members of the Editorial Board of the CJA. In 2004, the Richard Knill Award was presented to Dr. David C. Campbell for his work on Patient Controlled Epidural Analgesia during labour.