William H. Rosenblatt

The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.

BACKGROUND:Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster. METHODS:We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination. RESULTS:During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment. CONCLUSION:The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

Use of the intubating lma-fastrach in 254 patients with difficult-to-manage airways

Background The laryngeal mask airway (LMA™; LMA North America, Inc., San Diego, CA) has a well-established role in the emergency and elective treatment of patients with difficult-to-manage airways (DA). In this study, the authors report their clinical experience with the intubating LMA (LMA-Fastrach™; LMA North America, Inc., San Diego, CA) in 254 patients with different types of DA. Methods The authors reviewed the anesthetic and medical records of patients with DA in whom the LMA-Fastrach™ was used electively or emergently at four institutions from October 1997 through October 2000. In each case, the number of insertion and intubation attempts was recorded. Success rates for blind and fiberoptically guided intubation through the LMA-Fastrach™ were calculated, up to a maximum of five attempts per patient. Results The LMA-Fastrach™ was used in 257 procedures performed in 254 patients with DA, including patients with Cormack-Lehane grade 4 views; patients with immobilized cervical spines; patients with airways distorted by tumors, surgery, or radiation therapy; and patients wearing stereotactic frames. Insertion of the LMA-Fastrach™ was accomplished in three attempts or fewer in all patients. The overall success rates for blind and fiberoptically guided intubations through the LMA-Fastrach™ were 96.5% and 100.0%, respectively. Conclusions The LMA-Fastrach™ was used successfully in a high percentage of patients who presented with a variety of DA. The clinical experience presented herein indicates that this device may be particularly useful in the emergency and elective treatment of patients in whom intubation with a rigid laryngoscope has failed and in the treatment of patients with immobilized cervical spines.

A multicenter study comparing the ProSealTM and ClassicTM laryngeal mask airway in anesthetized, nonparalyzed patients

Background The laryngeal mask airway ProSeal™ (PLMA™), a new laryngeal mask device, was compared with the laryngeal mask airway Classic™ (LMA™) with respect to: (1) insertion success rates and times; (2) efficacy of seal; (3) fiberoptically determined anatomic position; (4) orogastric tube insertion success rates and times; (5) total intraoperative complications; and (6) postoperative sore throat in nonparalyzed adult patients undergoing general anesthesia, hypothesizing that these would be different. Methods Three hundred eighty-four nonparalyzed anesthetized adult patients (American Society of Anesthesiologists physical status I–II) were randomly allocated to the PLMA™ or LMA™ for airway management. In addition, 50% of patients were randomized for orogastric tube placement. Unblinded observers collected intraoperative data, and blinded observers collected postoperative data. Results First-attempt insertion success rates (91 vs. 82%, P = 0.015) were higher for the LMA™, but after three attempts success rates were similar (LMA™, 100%;PLMA™, 98%). Less time was required to achieve an effective airway with the LMA™ (31 ± 30 vs. 41 ± 49 s;P = 0.02). The PLMA™ formed a more effective seal (27 ± 7 vs. 22 ± 6 cm H2O;P < 0.0001). Fiberoptically determined anatomic position was better with the LMA™ (P < 0.0001). Orogastric tube insertion was more successful after two attempts (88 vs. 55%;P < 0.0001) and quicker (22 ± 18 vs. 38 ± 56 s) with the PLMA™. During maintenance, the PLMA™ failed twice (leak, stridor) and the LMA™ failed once (laryngospasm). Total intraoperative complications were similar for both groups. The incidence of postoperative sore throat was similar. Conclusion In anesthetized, nonparalyzed patients, the LMA™ is easier and quicker to insert, but the PLMA™ forms a better seal and facilitates easier and quicker orogastric tube placement. The incidence of total intraoperative complications and postoperative sore throat are similar.

Metoclopramide : an analgesic adjunct to patient-controlled analgesia

This randomized, double-blind trial evaluated the effect of metoclopramide on the pain and analgesic requirements associated with prostaglandin-induced labor for second-trimester termination of pregnancy. After receiving intrauterine prostaglandin, seven women were given intravenous metoclopramide (10 mg), and eight received saline, concurrent with initiation of patient controlled analgesia (PCA). Group differences were assessed with serial visual analogue scale for pain, interval PCA-morphine consumption, and time to fetal delivery. The metoclopramide group used 54% less PCA morphine (24.1 vs 52.0 mg), had lower visual analogue scale scores, and interval morphine consumption at 2, 4, and 6 h after PCA had been initiated, as well as earlier delivery of the fetus when compared with the control group (P less than 0.05). We conclude that a single dose of metoclopramide reduces the pain and PCA-morphine requirements of patients undergoing prostaglandin-induced labor and may facilitate passage of the fetus. Metoclopramide may have a similar application in treating other types of gynecologic pain.

Preoperative Endoscopic Airway Examination (PEAE) Provides Superior Airway Information and May Reduce the Use of Unnecessary Awake Intubation

BACKGROUND:Development of a perioperative plan for management of patients with airway pathology is a challenge for the anesthesiologist. Lack of comprehensive information regarding the architecture of airway lesions often leads the clinician to consider techniques of awake intubation (AI) to avoid catastrophic outcomes in this population. In one uncontrolled trial, endoscopic visualization of the airway lesion was included in the preoperative anesthetic assessment for planning of airway management. We sought to determine whether visual inspection of airway pathology would change the anesthesiologists approach to the management of these patients. METHODS:Patients presenting for elective diagnostic or therapeutic airway procedures were included in the study. After a standard examination of the airway, a management plan was recorded. Before entering the operating room, and after brief preparation of the nares with a vasoconstrictor and local anesthetic, the patients underwent a preoperative endoscopic airway examination (PEAE) and a final airway management plan was recorded and implemented. Four or more months after the procedure, video recordings of the PEAE were reviewed without other patient identifiers and a remote PEAE plan was recorded, to test for operator bias. RESULTS:One hundred thirty-eight patients were studied. Although AI was initially planned in 44 patients, only 16 of these patients underwent preinduction airway control after PEAE (P > 0.05). Additionally, of the 94 patients for whom the initial plan was airway control after the induction of anesthesia, 8 patients were found to have unexpectedly severe airway pathology on PEAE, and also underwent AI. There was no significant difference between the post-PEAE airway management plan and the remote plan recorded 4 or more months later. CONCLUSIONS:In 26% of the patients studied, PEAE affected the planned airway management. We believe that PEAE can be an essential component of the preoperative assessment of patients with airway pathology; airway visualization reduces the number of unnecessary AIs while providing superior information about the airway architecture. PEAE could be applied to other populations of patients at risk for airway control failure with the induction of anesthesia.

Cost-effective Use of Operating Room Supplies Based on the REMEDY* Database of Recovered Unused Materials

It is estimated that

Central Facilitation of the Glottic Closure Reflex in Humans

200 million worth of prepared materials are discarded unused in operating rooms in the United States each year. Although some of these materials have been successfully recovered for overseas donation, they nevertheless constitute an undesirable burden on health care efficiency. This situation has prompted a reevaluation of the procedures that result in the overpreparation of surgical supplies, in the hope of reducing hospital, patient, and third-party payer expenditures. A database, which was initially developed to track the overseas donation of recovered supplies from Yale-New Haven Hospital, is now being applied to measure approaches to waste reduction. This report summarizes the application of this database to an integrated program designed to modify nursing procedures and physician prespecified supply lists.

Airway management in a patient with Goldenhar syndrome: a case report

The sphincteric function of the larynx, essential to lower airway protection, is most efficiently achieved through strong reflex adduction by both vocal cords. We hypothesize that central facilitation is an essential component of a bilateral adductor reflex and that its disturbance could result in weakened sphincteric closure. Five patients during supraglottic laryngectomy underwent evoked response laryngeal electromyography under 0.5 and 1.0 minimal alveolar concentration (MAC) isoflurane anesthesia. The internal branch of the superior laryngeal nerve was stimulated through bipolar platinum-iridium electrodes, and recording electrodes were positioned in the ipsilateral and contralateral thyroarytenoid muscles. Consistent threshold responses were obtained ipsilaterally from 0.5 to 1.0 MAC anesthesia. However, the contralateral reflex responses approached 0% in successive trials as anesthetic levels approached 1.0 MAC. In human subjects, alteration of central facilitation by deepening anesthesia abolishes the crossed adductor reflex, predisposing to a weakened glottic closure response. A precise understanding of this effect may improve the prevention of aspiration in patients emerging from prolonged sedation or under heavy psychotropic control.

Metoclopramide-enhanced Analgesia for Prostaglandin-induced Termination of Pregnancy

Children with Goldenhar syndrome are known to present airway management challenges for the anesthesiologist. We present the case of a 10-year-old child with Goldenhar syndrome, in whom a flexible Laryngeal Mask Airway (Intavent Orthofix, Ltd, Maidenhead, UK) was successfully used for eye surgery.

Overcoming obstruction during bronchoscope-guided intubation of the trachea with the double setup endotracheal tube

We previously determined that a single dose of metoclopramide could significantly reduce the patient-controlled analgesia (PCA) morphine requirements of women undergoing prostaglandin-induced termination of pregnancy. In the present study, we evaluated whether repeated doses of metoclopramide would further reduce pain and accelerate expulsion of the fetus. After intraamnionic injection of prostaglandin, patients were randomly allocated to receive either 10 mg of intravenous metoclopramide (n = 17) or saline (n = 15), concurrent with the initiation of PCA. A second, identical dose was administered 4 h later. Data included visual analogue scale scores for pain 45 min after each administration of metoclopramide or saline and visual analogue scale and sedation scores every 2 h for the first 10 h, amount of morphine delivered by PCA pump, time of fetal and placental passage, and hospital discharge. Metoclopramide-treated patients experienced significantly earlier fetal and placental passage (P < 0.05). This was associated with a 66% reduction in PCA morphine received by the time of fetal delivery (P < 0.05). In addition, patients in the metoclopramide group were discharged from the hospital significantly sooner (P < 0.05). This difference included fewer second-day hospital stays (P < 0.05). Visual analogue scale scores measured 45 min after each infusion of the study agent were reduced from baseline in the metoclopramide group only (P < 0.05). No significant intergroup differences were noted with respect to pain or interval morphine usage. We conclude that repeated doses of metoclopramide significantly reduce the duration of induced labor and therefore the total PCA morphine requirements.(ABSTRACT TRUNCATED AT 250 WORDS)