Monitoring the monitors--beyond risk management

The use of ETView endotracheal tube for surveillance after tube positioning in patients undergoing lobectomy, randomized trial

The ETView tracheoscopic ventilation tube (TVT) is a tracheal tube (TT) incorporating a video camera and a light source in its tip. The view from the tip appears continuously on a portable monitor in the anesthesia area. We evaluated the effectiveness and usefulness of the single/double ETView TVT in monitoring the tracheal tube position during general anesthesia undergoing video-assisted thoracoscopic lobectomy.Eighty-three patients with pulmonary bullae (American Society of Anesthesiologists (ASA) I-III) undergoing lobectomy, with general anaesthesia, were included. Patients were randomly assigned to 3 groups, based on the tube ETView double-lumen tube (VDT), ETView single-lumen tube (VST), or traditional double lumen tube (DT).All 83 patients' intubations were successful to achieve 1-lung ventilation: 74 patients at the first attempt (22/26 in VDT, 26/28 in VST, 26/29 in DT group) and 9 patients at the second attempt. The time to achieve 1-lung ventilation with the VDT was 58.5 ± 21.5 (mean ± SD) seconds, the VST was 38.2 ± 10.1 (mean ± SD) seconds, and the DT group was 195.5 ± 40.3 (mean ± SD) seconds. During operations, the ETView tubes provided continuous airway visualization in all patients; a good view was obtained in 24/25 patients in VDT/VST, moderate in 4/12 patients in VDT/VST, and poor in 1/1 patients in VDT/VST. When the patient left the postanesthesia care unit, all had sore throat and 26/15/25 patients in VDT/VST/DT group had hoarseness. All had good outcomes of the surgical operations.We found the ETView tube to be helpful in the endotracheal intubation and continuous surveillance of tube position in patients with video-assisted thoracoscopic lobectomy. The ETView single lumen endotracheal tube had fewer associated complications and is superior to the 2 double-lumen tubes.

Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland

This guideline updates and replaces the 4th edition of the AAGBI Standards of Monitoring published in 2007. The aim of this document is to provide guidance on the minimum standards for physiological monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the United Kingdom and Ireland. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and also during transfer of anaesthetised or sedated patients. There are new sections discussing the role of monitoring depth of anaesthesia, neuromuscular blockade and cardiac output. The indications for end-tidal carbon dioxide monitoring have been updated.

Comparison of esCCO and transthoracic echocardiography for non-invasive measurement of cardiac output intensive care

BACKGROUND

The esCCO monitor (ECG- estimated Continuous Cardiac Output, Nihon Kohden(®)) is a new non-invasive tool for estimating cardiac output (CO). It derives CO from the pulse wave transit time (PWTT) estimated by the ECG and the plethysmographic wave. An initial calibration is needed to refine the relation linking pulse pressure (measured by arterial pressure cuff) to PWTT. To assess the accuracy and reliability of the esCCO system, we performed an analysis of agreement of CO values obtained by transthoracic echocardiography (TTE).

METHODS

Thirty-eight intensive care unit patients were prospectively included. CO was determined simultaneously using esCCO (CO(esCCO)) and TTE (CO(TTE)) as our reference method.

RESULTS

A total of 103 paired readings from 38 patients were collected. The correlation coefficient between CO(esCCO) and CO(TTE) was 0.61 (P<0.001). The Bland and Altman analysis corrected for repeated measures showed a bias of -1.6 litre min(-1) and limits of agreement from -4.7 to +1.5 litre min(-1), with a percentage error (2 sd/mean CO) of 49%. The correlation for CO changes was significant (R=0.63, P<0.001), but the concordance rate was poor (73%). Polar plot analysis showed an angular bias of -9° with radial limits of agreement from -54° to +36°. The bias appeared to correlate with systemic vascular resistance (R=-0.45, P<0.001).

CONCLUSIONS

In critically ill patients, the performance of the esCCO monitor was not clinically acceptable, and this monitor cannot be recommended in this setting. Moreover, the esCCO failed to trend CO data reliably.

Model-based assessment of tissue perfusion and temperature in deep hypothermic patients

Deep hypothermic circulatory arrest is necessary for some types of cardiac and aortic surgery. Perfusion of the brain can be maintained using a heart-lung machine and unilateral antegrade cerebral perfusion. Cooling rates during extracorporeal circulation depend on local perfusion. A core temperature of 24 degrees C-25 degrees C is aimed at to extend ischemic tolerance of tissues. Information on cerebral perfusion and temperature is important for the safety of patients, but hardly accessible to measurement. A combined simulation model of hemodynamics and temperature is presented in this paper. The hemodynamics model employs the transmission-line approach and integrates the Circle of Willis (CoW). This allows for parameterization of individual aberrations. Simulation results of cerebral perfusion are shown for two configurations of the CoW. The temperature model provides spatial information on temperature fields. It considers heat transfer in the various tissues retrieving data of local tissue perfusion from the hemodynamics model. The combined model is evaluated by retrospective simulation of two aortic operations.

Rapid sequence induction anaesthesia: a guide for nurses in the emergency department

Emergency rapid sequence induction (RSI) anaesthesia is the cornerstone of emergency airway management performed on patients in the emergency department (ED). The Royal College of Anaesthetists has stated that anaesthesia should not proceed without a skilled, dedicated assistant. It is essential that ED nurses are educated, skilled and competent to assist with RSI in the ED.

Cardiac output measurement in pediatric anesthesia

Maintenance of cardiovascular stability is crucial to safe anesthetic practice, but measurement of cardiac output has been technically challenging, particularly in pediatric patients. Cardiovascular monitoring has therefore generally relied upon pressure-based measurements, as opposed to flow-based measurements. The measurement of cardiac output under anesthesia and in critical care has recently become easier as a result of new techniques of measurement. This article reviews the basic concepts of and rationale for cardiac output monitoring, and then describes the techniques available for monitoring in clinical practice.

Anaesthesia and analgesia: contribution to surgery, present and future

Anaesthetists provide comprehensive perioperative medical care to patients undergoing surgical and diagnostic procedures, including postoperative intensive care when needed. They are involved in the management of perioperative acute pain as well as chronic pain. This manuscript considers some of the recent advances in modern anaesthesia and their contribution to surgery, from the basic mechanisms of action, to the delivery systems for general and regional anaesthesia, to the use of new drugs and new methods of monitoring. It assesses the resulting progress in acute and chronic pain services and looks at patient safety and risk management. It speculates on directions that may shape its future contributions to the management of the patient undergoing surgery.

Anaesthesia services in developing countries: defining the problems

We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.