Richard E. Galgon

Systematic Review of the Use of Retrievable Inferior Vena Cava Filters

PURPOSE To review the available literature on retrievable inferior vena cava (IVC) filters to examine the effectiveness and risks of these devices. MATERIALS AND METHODS Investigators searched MEDLINE for clinical trials evaluating retrievable filters and reviewed the complications reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. Food and Drug Administration (FDA). RESULTS Eligibility criteria were met by 37 studies comprising 6,834 patients. All of the trials had limitations, and no studies were randomized. There were 11 prospective clinical trials; the rest were retrospective studies. Despite the limitations of the evidence, the IVC filters seemed to be effective in preventing pulmonary embolism (PE); the rate of PE after IVC placement was 1.7%. The mean retrieval rate was 34%. Most of the filters became permanent devices. Multiple complications associated with the use of IVC filters were described in the reviewed literature or were reported to the MAUDE database; most of these were associated with long-term use (> 30 days). At the present time, the objective comparison data of different filter designs do not support superiority of any particular design. CONCLUSIONS In high-risk patients for whom anticoagulation is not feasible, retrievable IVC filters seem to be effective in preventing PE. Long-term complications are a serious concern with the use of these filters. The evidence of the effectiveness and the risks was limited by the small number of prospective studies.

A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock.

BACKGROUND Torso hemorrhage remains a leading cause of potentially preventable death within trauma, acute care, vascular, and obstetric practice. A proportion of patients exsanguinate before hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive hemostasis. A systematic review was conducted to characterize the current clinical use of REBOA and its effect on hemodynamic profile and mortality. METHODS A systematic review (1946–2015) was conducted using EMBASE and MEDLINE. Original studies on human subjects, published in English language journals, were considered. Articles were included if they reported data on hemodynamic profile and mortality. RESULTS A total of 83 studies were identified; 41 met criteria for inclusion. Clinical settings included postpartum hemorrhage (5), upper gastrointestinal bleeding (3), pelvic surgery (8), trauma (15), and ruptured aortic aneurysm (10). Of the 857 patients, overall mortality was 423 (49.4%); shock was evident in 643 (75.0%). Pooled analysis demonstrated an increase in mean systolic pressure by 53 mm Hg (95% confidence interval, 44–61 mm Hg) following REBOA use. Data exhibited moderate heterogeneity with an I2 of 35.5. CONCLUSION REBOA has been used in a variety of clinical settings to successfully elevate central blood pressure in the setting of shock. Overall, the evidence base is weak with no clear reduction in hemorrhage-related mortality demonstrated. Formal, prospective study is warranted to clarify the role of this adjunct in torso hemorrhage. LEVEL OF EVIDENCE Systematic review, level IV.

A Comparison of Single-Shot Adductor Canal Block vs Femoral Nerve Catheter for Total Knee Arthroplasty.

Abstract The aim of this study was to compare perioperative analgesia provided by single-injection adductor canal block (ACB) to continuous femoral nerve catheter (FNC) when used in a multimodal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared outcome data for 148 patients receiving a single-injection ACB to 149 patients receiving an FNC. The mean length of stay (LOS) in the ACB group was 2.67 (±0.56) and 3.01 days (±0.57) in the FNC group ( P P P =0.01). Single-injection ACB offered similar pain control and earlier discharge compared to continuous FNC in patients undergoing TKA.

The air-Q(®) intubating laryngeal airway vs the LMA-ProSeal(TM) : a prospective, randomised trial of airway seal pressure.

We performed a prospective, open‐label, randomised controlled trial comparing the air‐Q® against the LMA‐ProSeal™ in adults undergoing general anaesthesia. One hundred subjects (American Society of Anesthesiologists physical status 1–3) presenting for elective, outpatient surgery were randomly assigned to 52 air‐Q® and 48 ProSeal devices. The primary study endpoint was airway seal pressure. Oropharyngolaryngeal morbidity was assessed secondarily. Mean (SD) airway seal pressures for the air‐Q® and ProSeal were 30 (7) cmH2O and 30 (6) cmH2O, respectively (p = 0.47). Postoperative sore throat was more common with the air‐Q® (46% vs 38%, p = 0.03) as was pain on swallowing (30% vs 5%, p = 0.01). In conclusion, the air‐Q® performs well as a primary airway during the maintenance of general anaesthesia with an airway seal pressure similar to that of the ProSeal, but with a higher incidence of postoperative oropharyngolaryngeal complaints.

Teaching sonoanatomy to anesthesia faculty and residents: utility of hands-on gel phantom and instructional video training models

STUDY OBJECTIVE Thousands of patients worldwide annually receive neuraxial anesthesia and analgesia. Obesity, pregnancy, and abnormal spinal anatomy pose challenges for accurate landmark palpation. Further, spinal sonoanatomy is not uniformly taught in residency education, even though its use has previously been shown to improve identification of relevant structures and decrease procedural complications and failure rates. The aim of this study was to evaluate the use of hands-on gel phantom and instructional video training for teaching spinal sonoanatomy among anesthesiology faculty and residents. DESIGN Twenty-three residents and 27 anesthesiologists were randomized to gel phantom, video teaching, and control groups. SETTING Academic Hospital. MEASUREMENTS Successful identification of spinal sonoanatomy was attempted on a human volunteer before and immediately after the respective intervention and 3 weeks later. Perceived knowledge and training modality satisfaction were assessed using modified Likert scales. INTERVENTIONS Gel phantom and video teaching groups compared with control (no intervention). MAIN RESULTS Both interventions significantly improved spine sonoanatomy identification accuracy. Logistic regression analysis demonstrated both interventions improved the odds of transverse process (gel 12.61, P = .013; video 7.93, P = .030) and lamina (gel 65.12, P = .003; video 8.97, P = .031) identification. Perceived knowledge of basic spinal anatomy and spinal sonoanatomy improved in the intervention versus control groups. Mean (SD) modified Likert scale scores for learning satisfaction (1 = unsatisfied, 10= very satisfied) were 8.1 (1.5) and 8.0 (1.7) for hands-on gel phantom and instructional video training participants, respectively. CONCLUSION Use of hands-on gel phantom or instructional video training can improve anesthesia staff and resident knowledge of lumbar spine sonoanatomy.

Evaluation of the GlideScope Direct: A New Video Laryngoscope for Teaching Direct Laryngoscopy

Background. Teaching direct laryngoscopy is limited by the inability of the instructor to simultaneously view the airway with the laryngoscopist. Our primary aim is to report our initial use of the GlideScope Direct, a video-enabled, Macintosh laryngoscope intended primarily as a training tool in direct laryngoscopy. Methods. The GlideScope Direct was made available to anyone who planned on performing direct laryngoscopy as the primary technique for intubation. Novices were those who had performed <30 intubations. Results. The GlideScope Direct was used 123 times as primarily a direct laryngoscope while the instructor viewed the intubation on the monitor. It was highly successful as a direct laryngoscope (93% success). Salvage by indirect laryngoscopy occurred in 7/9 remaining patients without changing equipment. Novices performed 28 intubations (overall success rate of 79%). In 6 patients, the instructor took over and successfully intubated the patient. Instructors used the video images to guide the operator in 16 (57%) of those patients. Seven different instructors supervised the 28 novices, all of who subjectively felt advantaged by having the laryngoscopic view available. Conclusions. The GlideScope Direct functions similarly to a Macintosh laryngoscope and provides the instructor subjective reassurance, while providing the ability to guide the trainee laryngoscopist.

Fiberoptic, wire-guided king laryngeal tube exchange in trauma patients: a case series

Abstract The laryngeal tube is increasingly being used for prehospital airway rescue. However, its exchange for an endotracheal tube can be challenging and risky. No best technique to achieve this end is yet accepted. We report three

The GlideScope for videolaryngoscopy-assisted nasotracheal-to-orotracheal tube exchange in the intensive care unit in a patient with a known difficult airway ☆

A 77 year old, nasally intubated man with a history of repeated episodes of airway obstruction requiring intubation due to recurrent laryngitis and a hypopharyngeal mass, needed nasotracheal-to-orotracheal tube exchange. The GlideScope videolaryngoscope was inserted, achieving a full view of the glottic inlet with the nasotracheal tube in situ. An endotracheal tube (ETT) loaded on a GlideRite Rigid Stylet was advanced through the oropharynx into view. Advancement of this ETT to the glottic opening was tested and achieved. With both tracheal tubes in view, the nasotracheal tube cuff was deflated and withdrawn from the glottic opening. While maintaining videoscopic visualization, the orotracheal tube was advanced through the vocal cords into the trachea. The benefits of this technique versus existing alternatives are discussed.

An easily made, low-cost phantom for ultrasound airway exam training and assessment.

Background: Recent manuscripts have described the use of ultrasound imaging to evaluate airway structures. Ultrasound training tools are necessary for practitioners to become proficient at obtaining and interpreting images. Few training tools exist and those that do can often times be expensive and rendered useless with repeated needle passes. Methods: We utilised inexpensive and easy to obtain materials to create a gel phantom model for ultrasound-guided airway examination training. Results: Following creation of the gel phantom model, images were successfully obtained of the thyroid and cricoid cartilages, cricothyroid membrane and tracheal rings in both the sagittal transverse planes. Conclusion: The gel phantom model mimics human airway anatomy and may be used for ultrasound-guided airway assessment and intervention training. This may have important safety implications as ultrasound imaging is increasingly used for airway assessment.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial

BackgroundTest ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration.MethodsThis study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts.ResultsTwo-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) Vte in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB.DiscussionIn patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs.ConclusionWe conclude that FMV is no worse after NMB than before and is likely to improve airway conditions.Trial RegistrationClinicalTrials.gov Identifier: NCT02237443. Registered August 28, 2014