Airway Adjuncts

Anesthesia for Trauma Patients

An improved understanding of the pathophysiology of combat trauma has evolved over the past decade and has helped guide the anesthetic care of the trauma patient requiring surgical intervention. Trauma anesthesia begins before patient arrival with warming of the operating room, preparation of anesthetic medications and routine anesthetic machine checks. Induction of anesthesia must account for potential hemodynamic instability and intubation must consider airway trauma. Maintenance of anesthesia is accomplished with anesthetic gas, intravenous infusions or a combination of both. Resuscitation must precede or be ongoing with the maintenance of anesthesia. Blood product transfusion, antibiotic administration, and use of pharmacologic adjuncts (e.g., tranexamic acid, calcium) all occur simultaneously. Ventilatory strategies to mitigate lung injury can be initiated in the operating room, and resuscitation must be effectively transitioned to the intensive care setting after the case. Good communication is vital to efficient patient movement along the continuum of care. The resuscitation that is undertaken before, during and after operative management must incorporate important changes in care of the trauma patient. This Clinical Practice Guideline hopes to provide a template for care of this patient population. It outlines a method of anesthesia that incorporates the induction and maintenance of anesthesia into an ongoing resuscitation during surgery for a trauma patient in extremis.

Application of process improvement principles to increase the frequency of complete airway management documentation

BACKGROUND

Process improvement in healthcare delivery settings can be difficult, even when there is consensus among clinicians about a clinical practice or desired outcome. Airway management is a medical intervention fundamental to the delivery of anesthesia care. Like other medical interventions, a detailed description of the management methods should be documented. Despite this expectation, airway documentation is often insufficient. The authors hypothesized that formal adoption of process improvement methods could be used to increase the rate of "complete" airway management documentation.

METHODS

The authors defined a set of criteria as a local practice standard of "complete" airway management documentation. The authors then employed selected process improvement methodologies over 13 months in three iterative and escalating phases to increase the percentage of records with complete documentation. The criteria were applied retrospectively to determine the baseline frequency of complete records, and prospectively to measure the impact of process improvements efforts over the three phases of implementation.

RESULTS

Immediately before the initial intervention, a retrospective review of 23,011 general anesthesia cases over 6 months showed that 13.2% of patient records included complete documentation. At the conclusion of the 13-month improvement effort, documentation improved to a completion rate of 91.6% (P<0.0001). During the subsequent 21 months, the completion rate was sustained at an average of 90.7% (SD, 0.9%) across 82,571 general anesthetic records.

CONCLUSION

Systematic application of process improvement methodologies can improve airway documentation and may be similarly effective in improving other areas of anesthesia clinical practice.

Cardiac arrest in special populations

In certain cardiac arrest situations, modifications to current cardiac resuscitation algorithms may improve patient outcome. These situations are often rare, but when they occur they house the potential for severe time and resource use, and in some cases specialized skill sets. The decision to apply these modifications to standard care for the cardiac arrest patient may be obvious in some cases or may be applied due to suspicion from the presenting medical history, history of present illness, or physical examination. However, with rare exception, general care of any cardiac arrest patient should include continuous high-quality chest compressions and appropriate airway and ventillatory management.

Comparing the performance of traditional direct laryngoscope with three indirect laryngoscopes: A prospective manikin study in normal and difficult airway scenarios

OBJECTIVES

The aim of the present study was to evaluate the performance of three indirect laryngoscopes, Truview EVO2 laryngoscope, Clarus Levitan fiberoptic stylet and AirwayScope AWS, in comparison with direct Macintosh laryngoscope (ML) when performed in normal and difficult airway scenarios.

METHODS

This prospective comparative study recruited 30 emergency physicians familiar with direct laryngoscopic intubation. Intubations were performed on manikin and were repeated twice for both scenarios. The primary end points were intubation time and rate of failed intubation. Glottis visualization was graded on Cormack and Lehane score and VAS.

RESULTS

In normal airway scenario: AWS had shortest intubation time (6.0 s) followed by ML (8.7 s); VAS score of ML and AWS was lower (easier to use) than the other two devices; Cormack and Lehane score was similar for all devices. In difficult airway scenario: AWS had shortest intubation time (5.9 s); VAS score of AWS was lower than the other three devices; TVL, FOS, AWS had better Cormack and Lehane score than ML. Intubation time, rate of failed intubation, and Cormack and Lehane score were similar between attempts in both scenarios. Learning effect was significant in FOS in both scenarios and in TVL in normal airway scenario.

CONCLUSIONS

AWS performed best in normal and difficult airways. ML performed better than TVL and FOS in normal airways. Performances of ML, TVL and FOS were similar in difficult airways. Skills with AWS could be mastered rapidly. TVL and FOS required more practice to gain expertise.