Thomas Heidegger

Algorithms for management of the difficult airway.

Purpose of review The purpose of this review is to examine recent evidence for the management of the difficult airway. Recent findings Recent findings still recommend the importance of a predefined, simple strategy for both the anticipated and unanticipated difficult airway. For the former, awake fiberoptic intubation is still the ‘gold standard’. For management of the unanticipated difficult airway, the use of the laryngeal mask airway (LMA), intubating laryngeal mask airway (ILMA), the ‘gum elastic bougie’ and fiberoptics are recommended. If intubation and ventilation fails, cannula or surgical cricothyroidotomy should be an early consideration. Summary This review of algorithms for management of the difficult airway strengthens several generally accepted crucial points. What is always needed is expertise, which one can only get and maintain by daily practice.

Fiberoptically-Guided Insertion of Transtracheal Catheters

IMPLICATIONS Regular use of the transtracheal catheter (TTC) both offers an opportunity for training for the difficult airway and facilitates elective endoscopic surgery. Fiberoptic guidance and exploratory puncture improve the insertion of the TTC.

Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial.

Background:Tracheal intubation with neuromuscular blocking agents is associated with a low incidence of minor vocal cord sequelae (8%). The aim of this noninferiority trial was to demonstrate that the frequency of vocal cord sequelae after fiberoptic intubation with a flexible silicone tube without neuromuscular blocking agents was less than 25% (maximum tolerable inferiority). Methods:Two-hundred seventy patients were prospectively randomized to two groups. All intubations were performed by anesthesiologists with extensive experience in fiberoptic and conventional techniques. Fiberoptic nasotracheal intubation consisted of a bolus dose of 2 &mgr;g/kg fentanyl; 0.25 ml cocaine instillation, 10%, into nasal canals; cricothyroid injection of 2 ml lidocaine, 1%; bronchoscopy; administration of 0.3 mg/kg etomidate; and advancing a flexible silicone tube after loss of consciousness. Orotracheal intubation was performed with a polyvinyl chloride tube after induction with 2 &mgr;g/kg fentanyl, 2 mg/kg propofol, and 0.6 mg/kg rocuronium. Patients were examined by laryngoscopy before surgery, 24 h after surgery, and daily until complete restitution. Postoperative hoarseness was assessed by a standardized interview. Results:The incidence of vocal cord sequelae was 11 out of 130 (8.5%) in the fiberoptic group versus 12 out of 129 (9.3%) in the control group (chi-square = 0.057, df = 1, P = 0.81; upper limit of the one-sided 95% confidence interval for the difference: +5.1%). There were no persistent injuries. The incidence of postoperative hoarseness was 4% in both groups. Conclusions:Because fiberoptic intubation without neuromuscular blocking agents is safe regarding vocal cord sequelae, routine use is justified for anesthesiologists experienced in this technique.

The influence of postural changes on gastroesophageal reflux and barrier pressure in nonfasting individuals.

There is controversy regarding optimal body positioning (i.e., head-up, head-down) in awake nonfasting individuals to minimize the risk for pulmonary aspiration of gastric contents as the result of gastroesophageal reflux (GER). In the present study, we investigated GER and intragastric-esophageal barrier pressure by means of multichannel intraluminal impedance measurement and intragastric-esophageal manometry in awake, nonfasting volunteers randomly positioned in a 20° head-up position, the supine position, and a 20° head-down position. No significant difference among positions was found with respect to number of GER episodes per person (0/1/1) or intragastric-esophageal barrier pressure (15.6/19.6/19.4 mm Hg). We conclude that specific body positioning is useless in the prophylaxis of GER in awake nonfasting individuals.

Preoperative administration of esomeprazole has no influence on frequency of refluxes

STUDY OBJECTIVE To examine the effect of esomeprazole in a fixed time setting on gastric content volume, gastric acidity, gastric barrier pressure, and reflux propensity. DESIGN Randomized, controlled, double-blind trial. SUBJECTS 21 healthy, ASA I physical status volunteers. INTERVENTION Esomeprazole was given 12 hours and one hour before investigation. Before the study, a multichannel intraluminal impedance catheter, pH monitoring data logger (PHmetry) catheter, and an intragastric-esophageal manometry catheter were placed nasally after topical anesthesia. MEASUREMENTS Gastric acidity and gastric content volume were determined by PHmetry after aspiration of gastric contents over a nasogastric tube. Gastroesophageal reflux and intragastric-esophageal barrier pressure were investigated by multichannel intraluminal impedance measurement, PHmetry, and intragastric-esophageal manometry. MAIN RESULTS The pH of gastric contents was significantly (P < 0.001) higher after esomeprazole (mean [25th-75th percentile], 4.2 [3.9-4.8] vs 2.0 [1.9-2.7]), and gastric content volume was significantly (P < 0.001) lower (5.0 mL [3.0-12.0] vs 15 mL [10.0-25.0]) in comparison to placebo. No significant difference between esomeprazole and placebo was found with respect to number of refluxes per person, duration of reflux, or barrier pressure. CONCLUSION Esomeprazole in a fixed time setting can markedly increase the pH of gastric contents and decrease gastric content volume, but has no influence on the frequency, duration of refluxes, or gastroesophageal barrier pressure.

Anomalous origin of the left coronary artery: discovery during an ambulatory surgical procedure in a 3‐month old, previously healthy infant

We report a rare coronary anomaly in a 3‐month old symptomless infant with an anomalous origin of the left coronary artery, that became manifest during anaesthesia for an ambulatory procedure, leading to circulatory arrest. Precordial stethoscope and pulse oximeter unequivocally showed a circulatory arrest. Even in ambulatory procedures, a presumed healthy patient may quickly develop a life‐threatening condition because of occult disease. The successful management of such cases depends on efficient and coordinated teamwork.

Airway management: standardization, simplicity, and daily practice are the keys to success.

To the Editor The editorial by Hung and Murphy, although interesting, contains potentially misleading statements. Some have opined that careful evaluation of the airway as part of a preplanned strategy may lead to improved outcome. However, it is potentially dangerous to suggest that the choice of the technique and hence the choice of the equipment is or should be influenced primarily by different circumstances. Advocating such an approach would result in multiple strategies using many different and, at times, unfamiliar airway devices. Only a few studies have focused on effective airway management and, in these, outcome was investigated under the prevailing clinical conditions. A common characteristic of each of these studies was a limitation of techniques and devices and that deviation from the predefined algorithm was recorded infrequently. A key factor regarding safety recorded by highly reliable organizations such as aviation is a standardized process. However, the “recommendations” of Hung and Murphy that airway management is primarily “context sensitive” would guide us in the wrong direction. There are only a few situations wherein we might deviate from our difficult airway guidelines. For example, it is very unlikely that you can perform an awake intubation in an uncooperative patient. Importantly, such situations should be managed by the most experienced physicians. However, if deviation from, rather than adherence to, the guidelines is current practice, the guidelines should be modified accordingly. A second point is the missing commitment to fiberoptic intubation (“unwritten truth”). If the authors mean that there are no prospective randomized studies showing the effectiveness of fiberoptic intubation, they are correct. Unfortunately, there are no prospective randomized studies demonstrating the effectiveness (not efficacy) of most techniques used in daily practice. However, it is generally agreed among airway management practitioners and recommended by many anesthesia societies that fiberoptic intubation should be used for management of the anticipated difficult airway. So, questioning this technique is probably potentially misleading for the average anesthesiologist in practice. Regarding airway management, the message should be: Standardization, simplicity, and daily practice are the keys to success.

Patient satisfaction in out-of-hospital emergency care: a multicentre survey.

Background There is only limited information on patient satisfaction with emergency medical services (EMS). The aim of this multicentre survey was to evaluate patient satisfaction in five out-of-hospital physician-based EMS in Austria and Switzerland. Methods The psychometrically tested and standardized questionnaire ‘patient satisfaction in out-of-hospital emergency care’ was used for this survey. The recruitment of the patients was carried out on the basis of inclusion and exclusion criteria. All questionnaires were sent together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The descriptive statistical analysis was carried out by an external organization to maintain anonymity. Results The response rate of all EMS was 46.7%. High satisfaction rates were achieved for the four quality scales ‘emergency call, emergency treatment, transport and hospital admission’. A significant difference was found between the Swiss and the Austrian dispatch centres in the judgement of the call takers’ social skills. Patient satisfaction with the emergency treatment, for example, reduction of pain, was high in all EMS, independent of whether the EMS is physician (Austria) or physician and emergency medical assistant based (Switzerland). Lowest satisfaction rates were found for items of social skills. Conclusion Patient satisfaction in out-of-hospital physician-based EMS is generally high. There is room for improvement in areas such as the social skills of dispatchers and EMS-team members and the comfort of the patients during transport. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets.