Philip M. Jones

Health status predicts long-term outcome in outpatients with coronary disease

Background—Although patient-reported health status measures have been used as end points in clinical trials, they are rarely used in other settings. Demonstrating that they independently predict mortality and hospitalizations among outpatients with coronary disease could emphasize their clinical value. Methods and Results—This study evaluated the prognostic utility of the Seattle Angina Questionnaire (SAQ), a disease-specific health status measure for patients with coronary artery disease. Patients were enrolled in a prospective cohort study from 6 Veterans Affairs General Internal Medicine Clinics. All patients reporting coronary artery disease who completed a SAQ and had 1 year of follow-up were analyzed (n=5558). SAQ predictor variables were the physical limitation, angina stability, angina frequency, and quality-of-life scores. The primary outcome was 1-year all-cause mortality, and a secondary outcome was hospitalization for acute coronary syndrome (ACS). Lower SAQ scores were associated with increased risks of mortality and ACS admissions. Prognostic models controlling for demographic and clinical characteristics demonstrated significant independent mortality risk with lower SAQ physical limitation scores; odds ratios for mild, moderate, and severe limitation were 1.5, 2.0, and 4.0 versus minimal limitation (P <0.001). Odds ratios for mild, moderate, and severe angina frequency were 0.8, 1.2, and 1.6 (P =0.078). The odds ratios for ACS admission among those with mild, moderate, and severe angina frequency were 1.4, 2.0, and 2.2, respectively (P =0.016). Conclusions—SAQ scores are independently associated with 1-year mortality and ACS among outpatients with coronary disease and may serve a valuable role in the risk stratification of such patients.

The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient

AbstractBackgroundPreviously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. MethodsNineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.ConclusionsThe clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.RésuméContexteActif au milieu des années 1990, le Canadian Airway Focus Group (CAFG), un groupe dédié à l’étude des difficultés imprévues dans la prise en charge des voies aériennes, a émis des recommandations sur ce sujet dans une publication datant de 1998. Le CAFG s’est réuni à nouveau pour passer en revue la littérature scientifique récente concernant la prise en charge des voies aériennes. Dans cet article, le CAFG s’est donné pour mission d’émettre des recommandations visant la prise en charge du patient inconscient ou anesthésié qui présente des difficultés d’intubation significatives.MéthodeDix-neuf cliniciens ayant une formation en anesthésie, en médecine d’urgence ou en soins intensifs composent le CAFG actuel. Les participants ont passé en revue des sujets précis en consultant les bases de données Medline, EMBASE et Cochrane. Les résultats de ces revues ont été présentés et discutés dans le cadre de téléconférences et de deux réunions en personne. Lorsqu’indiqué, des recommandations fondées sur des données probantes ou sur un consensus ont été émises. Le niveau de confiance attribué à ces recommandations a aussi été défini.ConclusionLe clinicien doit avoir conscience des lésions qu’il peut infliger lors de tentatives multiples d’intubation trachéale. Il est possible d’éviter de telles lésions en abandonnant rapidement une technique d’intubation infructueuse afin d’opter pour une méthode alternative (ou ‘plan B’) à condition que l’oxygénation par masque facial ou par l’utilisation d’un dispositif supraglottique s’avère possible. Nonobstant la ou les techniques choisies, un maximum de trois tentatives infructueuses mène à la conclusion qu’il s’agit d’un échec d’intubation et devrait inciter le clinicien à adopter une stratégie de retrait. Une situation dans laquelle il est impossible de procéder à l’oxygénation du patient à l’aide d’un masque facial, d’un dispositif supraglottique ou de l’intubation endotrachéale est qualifiée de scénario cannot intubate, cannot ventilate. Il est alors impératif de procéder sans délai à une cricothyrotomie, à moins que l’insertion d’un dispositif supraglottique n’ait été tentée. Celle-ci peut alors être effectuée rapidement et parallèlement à la réalisation de la cricothyrotomie.

The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway

BackgroundAppropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.MethodsTo review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.Principal findingsPreviously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician’s experience, must also be considered in deciding the appropriate strategy.ConclusionsWith an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.RésuméContexteUne planification adaptée est essentielle afin d’éviter la morbidité et la mortalité lorsqu’on prévoit des difficultés dans la prise en charge des voies aériennes. De nombreuses recommandations émises par des sociétés nationales mettent l’emphase sur la gestion des difficultés rencontrées chez le patient inconscient. Toutefois, il n’existe dans la littérature que peu de suggestions sur la façon d’approcher le patient chez qui les difficultés sont prévisibles.MéthodeAfin de passer en revue ce sujet et d’autres, le Canadian Airway Focus Group (CAFG), un groupe dédié à l’étude de la prise en charge des voies aériennes, a été reformé. Les membres du CAFG représentent diverses spécialités soit l’anesthésiologie, la médecine d’urgence et les soins intensifs. Chaque participant avait pour mission de passer en revue des sujets précis. Les résultats de ces revues ont été présentés et discutés dans le cadre de téléconférences et de deux réunions en personne. Lorsqu’indiqué, des recommandations fondées sur des données probantes ou sur un consensus ont été émises. Le niveau de confiance attribué à ces recommandations a aussi été défini.Constatations principalesPlusieurs éléments permettant de prédire la laryngoscopie directe difficile sont connus. Des études plus récentes décrivent aussi les éléments permettant d’anticiper des difficultés lors de la ventilation au masque facial, de la vidéolaryngoscopie, de l’utilisation d’un dispositif supraglottique ou de la réalisation d’une cricothyrotomie. Tous ces éléments doivent être pris en compte lors de l’évaluation du patient chez qui des difficultés sont anticipées lors de la prise en charge des voies aériennes. De nombreuses études rapportent une morbidité accrue liée à des tentatives multiples d’intubation trachéale. Planifier de procéder à l’intubation trachéale après l’induction de l’anesthésie générale n’est donc recommandé que pour les patients chez qui la ou les techniques prévues ne nécessiteront pas plus de trois tentatives. Il est recommandé de prioriser d’emblée une approche vigile dans les cas où des difficultés reliées à l’utilisation du masque facial ou d’un dispositif supraglottique sont prévues. L’établissement d’une stratégie de prise en charge doit tenir compte d’éléments contextuels telles la collaboration du patient, la disponibilité d’aide supplémentaire et de personnel qualifié, et l’expérience du clinicien.ConclusionUne évaluation adaptée des voies aériennes ainsi que les éléments contextuels propres à chaque situation sont les bases qui permettent de déterminer de manière rationnelle si l’intubation trachéale vigile est apte à optimiser la sécurité du patient, ou si la prise en charge des voies aériennes peut être réalisée de manière sécuritaire après l’induction de l’anesthésie générale. Lorsqu’on prévoit des difficultés, une attention particulière doit être portée aux détails nécessaires au succès de l’approche envisagée. De plus, il convient d’avoir un plan en cas d’échec de l’intubation trachéale ou si l’oxygénation du patient s’avérait difficile.

Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope

PurposeThe GlideScope® videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords is sometimes difficult. The goal of the study was to determine which of two ETT angles (60°vs 90°) and cambers (forwardvs reverse) was better, as determined by time to intubation (TTI).MethodsTw o hundred patients requiring orotracheal intubation for elective surgery were randomly allocated to one of four groups: A) 90° angle, forward camber; B) 90° angle, reverse camber; C) 60° angle, forward camber; D) 60° angle, reverse camber. Time to intubation was assessed by a blinded observer. Operators were blinded until the point of intubation. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were recorded.ResultsThe angle of the ETT had an impact on TTI but camber did not. The 90° angle demonstrated a 13% faster TTI than the 60° angle (47.1 ± 21.2 secvs 54.4 ± 28.2 sec,P = 0.042), and it resulted in easier intubation (VAS 16.4 ± 14.2 mmvs 27.3 ± 23.5 mm,P = 0.0001). The overall incidence of a grade 1 or 2 Cormack-Lehane glottic view was 99%.ConclusionsIn a heterogeneous group of operators and patients intubated with the GlideScope®, a 90° ETT angle provided the best result and should be the initial configuration. The camber of the ETT does not affect the time to intubation.RésuméObjectifLe vidéo-laryngoscope GlideScope® offre en général une excellente visualisation glottique; toutefois, il est parfois difficile d’orienter la sonde endotrachéale (SET) entre les cordes vocales. Le but de cette étude était de déterminer lequel de deux angles de SET (60° vs 90°) et quelle cambrure (avant vs arrière) étaient les meilleurs, déterminés selon le temps requis pour l’intubation (TRI).MéthodesDeux cents patients nécessitant une intubation oro-trachéale pour une chirurgie réglée ont été répartis en quatre groupes de façon aléatoire: a) angulation de 90°, cambrure avant; b) angulation de 90°, cambrure arrière; c) angulation de 60°, cambrure avant; d) angulation de 60°, cambrure arrière. Le temps requis pour l’intubation était estimé par un observateur ignorant le groupe d’allocation. Les opérateurs ont été tenus ignorants du groupe d’allocation jusqu’à l’intubation. Une échelle visuelle analogique (VAS) permettait d’estimer la facilité d’intubation. Le nombre de tentatives d’intubation, d’échecs, les grades glottiques ainsi que l’utilisation de manipulation laryngée externe étaient notés.RésultatsL’angulation de la SET a eu un impact sur le TRI mais pas la cambrure. Avec une angulation de 90°, le TRI était de 13% plus rapide qu’avec une angulation de 60° (47,1 ± 21,2 sec vs 54,4 ± 28,2 sec, P = 0,042), et l’ intubation était plus facile (VAS 16,4 ± 14,2 mm vs 27,3 ± 23,5 mm, P = 0,0001). L’incidence globale d’une visualisation glottique Cormack-Lehane de grade I ou 2 a été de 99 %.ConclusionsDans un groupe hétérogène d’opérateurs et de patients intubés avec le GlideScope®, une angulation de la SET de 90° offre le meilleur résultat et devrait être la configuration initiale. La cambrure de la SET n’affecte pas le temps requis pour l’intubation.

Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up

OBJECTIVE Traditionally integrated coronary artery revascularization has been described as a 2-stage procedure. We evaluated the safety and feasibility of 1-stage, simultaneous, hybrid, robotically assisted coronary artery bypass grafting surgery and percutaneous coronary intervention. METHODS Fifty-eight patients underwent simultaneous, integrated coronary artery revascularization in an operating theater equipped with angiographic equipment. Forty-five patients were men. The mean age was 59 years. All internal thoracic arteries were harvested with robotic assistance. All anastomoses were manually constructed through a small anterior non-rib-spreading incision without cardiopulmonary bypass on the beating heart. Immediately after and within the same operative suite, both angiographic confirmation of graft patency and percutaneous coronary intervention were performed. In 52 patients therapeutic anticoagulation was achieved with the direct thrombin inhibitor bivalirudin. RESULTS There were no deaths or wound infections. There was 1 perioperative myocardial infarction. One patient had a stroke, and 3 patients required re-exploration for bleeding. The median lengths of intensive care and hospital stay were 1 and 4 days, respectively. All patients were alive and symptom free at follow-up (mean, 20.2 months; range, 1.1-40.8 months). Long-term angiographic follow-up in 54 patients showed 49 (91%) patent grafts (mean, 9.0 months; range, 4.3-40.8 months). There were 7 in-stent restenoses and 2 occluded stents. CONCLUSION For multivessel coronary artery disease, simultaneous integrated coronary artery revascularization with bivalirudin is safe and feasible. This approach enables complete multivessel revascularization with decreased surgical trauma and postoperative morbidity. Further studies are necessary to better determine patient selection and long-term outcomes.

Cervical spine motion: a fluoroscopic comparison of the AirTraq Laryngoscope versus the Macintosh laryngoscope.

Background:The optimal technique to intubate the trachea in patients presenting with a potential or documented cervical spine (C-spine) injury remains unresolved. Using continuous fluoroscopic video assessment, C-spine motion during laryngoscopy with an AirTraq Laryngoscope® (King Medical Systems, Newark, DE) was compared to that with intubation using a Macintosh blade. Methods:Twenty-four healthy surgical patients gave written consent to participate in a crossover randomized controlled trial; all patients were subjected to both Macintosh and AirTraq laryngoscopy with manual inline stabilization after induction of anesthesia. The C-spine motion was examined at four areas: the occiput-C1 junction, C1-C2 junction, C2-C5 motion segment, and C5-thoracic motion segment. The time required for laryngoscopy was also measured. Results:C-spine motion using the AirTraq was less than that during Macintosh laryngoscopy, averaging 66% less (P < 0.01) at three of the motion segments studied, occiput-C1, C2-C5, and C5-thoracic. There was no difference at the C1-C2 segment. There was no significant difference in the time to accomplish laryngoscopy between the two devices. Conclusions:For patients in whom C-spine movement is undesirable, use of the AirTraq Laryngoscope® may be useful to limit movement without an increase in the duration of intubation.

A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation.

BACKGROUND: In this study, we compared the effectiveness of direct laryngoscopy (DL) and the GlideScope® videolaryngoscope (GVL) for nasotracheal intubation, as judged by the time to intubation (TTI—the primary outcome) and the ease of intubation. METHODS: Seventy patients requiring nasotracheal intubation for elective surgery were randomly allocated to intubation with the GVL or DL. TTI was assessed by a blinded observer. Operators were blinded until the start of laryngoscopy. A Visual Analog Scale assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, amount of bleeding, usage of Magill forceps, and the severity of postoperative sore throat were recorded. RESULTS: The median TTI was 23.2 s faster with the GVL (43.5 s, interquartile range [IQR]: 39.8–67.3) than with DL (66.7 s, IQR: 53.8–89.9), P = 0.0023. Nasotracheal intubation was easier with the GVL than with DL (Visual Analog Scale 10 mm, IQR: 5.5–18, vs 20 mm, IQR: 10–32, P = 0.0041). The incidence of postoperative moderate or severe sore throat was significantly reduced in the GVL group (9% vs 34%, P = 0.018). Glottic exposure was significantly better with the GVL. Magill forceps were not used in the GVL group, but were used 49% of the time in the DL group, P < 0.0001. The incidence and severity of bleeding were similar between groups. CONCLUSIONS: Compared with DL, the GVL has superior performance characteristics when used for nasotracheal intubation and demonstrates an important reduction of postoperative sore throat. The GVL has a clear role in routine nasotracheal intubation.

The GlideScope®-specific rigid stylet and standard malleable stylet are equally effective for GlideScope® use

PurposeThe GlideScope® videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords can be challenging. The goal of the study was to compare the dedicated GlideScope®-specific rigid stylet to the standard malleable stylet, assessed by time to intubation (TTI).MethodsEighty patients requiring orotracheal intubation for elective surgery were randomly allocated to either the GlideScope® rigid stylet (GRS) or a standard malleable stylet to facilitate intubation using the GlideScope®. Time to intubation was recorded by blinded assessors; operators were blinded until after laryngoscopy. The operator assessed the ease of intubation using a visual analogue scale (VAS). The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were documented.ResultsThe median TTI was 42.7 sec (inter-quartile range (IQR) 38.9-56.7) for the GRS group compared to 39.9 sec (IQR 34.1-48.2) for the control group (P = 0.07). The median VAS score for ease of intubation was 20 (IQR 12.0-33.0) for the GRS group compared to 18 (IQR 9.5-29.5) for the control group (P = 0.21). There was no significant difference in TTI or VAS between stylets. The overall incidence of a Cormack-Lehane grade I or II glottic view was 98%.ConclusionsIn a group of experienced operators using the GlideScope®, the dedicated GRS and the standard malleable ETT stylet are equally effective in facilitating endotracheal intubation.RésuméObjectifLe vidéolaryngoscope GlideScope® fournit en général une excellente visualisation glottique, mais diriger une sonde endotrachéale (SET) entre les cordes vocales peut être un défi. L’objectif de cette étude était de comparer le mandrin rigide spécifique au GlideScope® au mandrin flexible standard, évalués par le temps requis pour l’intubation (TTI).MéthodeQuatre-vingts patients nécessitant une intubation orotrachéale pour une chirurgie élective ont été randomisés à être intubés à l’aide soit du mandrin rigide GlideScope® (GRS), soit du mandrin flexible standard pour faciliter l’intubation avec le GlideScope®. Le temps requis pour l’intubation a été mesuré par des évaluateurs en aveugle; les opérateurs étaient également en aveugle jusqu’à ce que la laryngoscopie soit terminée. L’opérateur a évalué la facilité d’intubation à l’aide d’une échelle visuelle analogique (EVA). Le nombre de tentatives d’intubation, le nombre d’échecs, le grade d’intubation et le recours à une manipulation laryngée externe ont été notés.RésultatsLe TTI médian était de 42,7 sec (intervalle interquartile (IQR) 38,9-56,7) pour le groupe GRS comparé à 39,9 sec (IQR 34,1-48,2) pour le groupe témoin (P = 0,07). Le score EVA médian pour la facilité d’intubation était de 20 (IQR 12,0-33,0) pour le groupe GRS comparé à 18 pour le groupe témoin (P = 0,21). Il n’y a pas eu de différence significative dans le TTI ou l’EVA entre les mandrins. L’incidence globale de la visualisation glottique selon l’échelle de Cormack-Lehane de grade I ou II était de 98 %.ConclusionDans un groupe d’opérateurs expérimentés se servant du GlideScope®, le mandrin GRS spécial et le mandrin flexible standard ont la même efficacité pour faciliter l’intubation endotrachéale.

The Recite Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade

BACKGROUND:Postoperative residual neuromuscular blockade (NMB), defined as a train-of-four (TOF) ratio of <0.9, is an established risk factor for critical postoperative respiratory events and increased morbidity. At present, little is known about the occurrence of residual NMB in Canada. The RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study was a prospective observational study at 8 hospitals in Canada investigating the incidence and severity of residual NMB. METHODS:Adult patients undergoing open or laparoscopic abdominal surgery expected to last <4 hours, ASA physical status I–III, and scheduled for general anesthesia with at least 1 dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of neuromuscular relaxation were enrolled in the study. Neuromuscular function was assessed using acceleromyography with the TOF-Watch® SX. All reported TOF ratios were normalized to the baseline values. The attending anesthesiologist and all other observers were blinded to the TOF ratio (T4/T1) results. The primary and secondary objectives were to determine the incidence and severity of residual NMB (TOF ratio <0.9) just before tracheal extubation and at arrival at the postanesthesia care unit (PACU). RESULTS:Three hundred and two participants were enrolled. Data were available for 241 patients at tracheal extubation and for 207 patients at PACU arrival. Rocuronium was the NMB agent used in 99% of cases. Neostigmine was used for reversal of NMB in 73.9% and 72.0% of patients with TE and PACU data, respectively. The incidence of residual NMB was 63.5% (95% confidence interval, 57.4%–69.6%) at tracheal extubation and 56.5% (95% confidence interval, 49.8%–63.3%) at arrival at the PACU. In an exploratory analysis, no statistically significant differences were observed in the incidence of residual NMB according to gender, age, body mass index, ASA physical status, type of surgery, or comorbidities (all P > 0.13). CONCLUSIONS:Residual paralysis is common at tracheal extubation and PACU arrival, despite qualitative neuromuscular monitoring and the use of neostigmine. More effective detection and management of NMB is needed to reduce the risks associated with residual NMB.

Mitigation of rocuronium-induced anaphylaxis by sugammadex: the great unknown.

In the randomised crossover trial comparing the i-gel with the classic LMA, by Janakiraman et al. [1] we noticed an error. In this study, it was stated that, ‘Both devices were lubricated using Aquagel (Adams Healthcare, Leeds, UK) on the tip and posterior surface as recommended by the manufacturers’. However, the correct procedure for lubricating the i-gel, as detailed in the i-gel Instructions For Use [2] and User Guide [3] and supported by photographic images, is to, ‘Grasp the i-gel along the integral bite block and lubricate the front, back and sides of the cuff with a thin layer of lubricant’. The i-gel is manufactured from a soft thermoplastic material, which is naturally tacky until lubricated. It is therefore essential that the device is lubricated correctly, as described in the instructions for use, in order to ensure patient safety and optimum performance.