May 2011 digital edition of Anesthesiology News

Eur Pleas oan e vi s boo aesth it us a th # esia t 03. 20 511 11

The Independent Monthly Newspaper for Anesthesiologists AnesthesiologyNews.com • M a y 2 0 1 1 • Volume 37 Number 5

To Assess Tube Placement, Keep it Simple Depth measurement bests auscultation in new study

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ilateral auscultation, the current gold standard to detect misplacement of an endotracheal tube during intubation, frequently provides inconclusive results. Serious complications, such as hypoxemia, right-sided barotrauma and left-sided atelectasis, can occur from inadvertent placement of the tube in a mainstream bronchus.

After Retractions in Boldt Case, Experts Ponder the Fate Of Hetastarch

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nesthesiologists and other clinicians in Europe and the United States are re-evaluating their use of hydroxyethyl starch for fluid management in surgery as investigators continue to probe the veracity of nearly 90 studies authored by now-disgraced German anesthesiologist Joachim Boldt, MD, PhD. On March 1, the Association of Surgeons of Great Britain and Ireland announced that citations referring to six studies authored by Dr. Boldt, who was forced out of his position at the Klinikum

see ETT page 17

see HES page 24

INside

Electronic Reminders Prompt Improved Ventilation Strategies

10 | technology Running on empty: New alarm signals when vaporizers are low on gas.

21 | Clinical

But even alerts can’t completely overcome bad habits

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n automated alert sent to the pagers of anesthesia providers may increase the use of lung-protective ventilation strategies for patients with suspected acute lung injury, new research has found.

Every year, an estimated 190,600 people in the United States experience critical lung damage. Of those, approximately 40% do not survive.

“Patients with acute lung injury [ALI] have very high mortality, yet there’s very little data supporting

improvements other than the use of lower tidal volume ventilation,” said James Blum, MD, director of critical care research in the Department of Anesthesiology at the University of

Speedy preanesthetic stress assessment pleases patients.

Michigan Medical Center, in Ann Arbor. “We were curious to find out if patients who went into the operating room got this low tidal volume ventilation when they had lung injury,” Dr. Blum added. “The answer is, for the most part, they don’t.”

To see if a reminder might help, Dr. Blum and his colleagues randomly selected 22 providers to receive electronic notifications alerting them of patients with

26 | Policy & Management Firm grasp of technology key to success in anesthesiology.

34 | Pain Medicine Are ex-NFLers prone to opioid abuse?

McMahonMedicalBooks.com Smith’s Anesthesia for Infants and Children: Eighth Edition Peter J. Davis, Franklyn P. Cladis, Etsuro K. Motoyama see page 40

see remind page 11

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4 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

Discuss these and other articles @ AnesthesiologyNews.com.

Heard Here First: It has even been suggested that once the academic anesthesiologist creates a potentially useful

forbidden from further investigations device that they should be

in that area, the logic being that their [conflict of

May 2011

interest] could either consciously or unconsciously

The five most-viewed articles last month on AnesthesiologyNews.com

corrupt future results. This is very

1. How To Navigate the Rising Tide of Aggressive RFPs

disheartening to the committed investigator.

2. As Florida Eyes Mandatory Urine Drug Testing, Experts Weigh in on Ethics, Role

See article on page 14.

3. More Data, but few Answers, For Anesthesia Safety in Peds 4. Ultrasound-guided Central Blocks in Infants, Children, and Adolescents (Educational Review) 5. For Anesthesiologists, Defining Value May Be Key to Future

Register for free @ AnesthesiologyNews.com to read these and other articles.

Robert S. Lagasse, MD, New Haven, CT Alex Macario, MD, MBA, Stanford, CA ALIX MATHIEU, MD, MBA, MS, Cincinnati, OH The Independent monthly Newspaper for Anesthesiologists

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6 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

In Brief

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Senate Bill Addresses Drug Shortages

wo Democratic lawmakers have introduced a bill in the U.S. Senate that aims to improve the FDA’s capability to prevent drug shortages. In the past year, these shortages have become a national crisis, threatening patient safety and disrupting clinical trials.

If the Preserving Access to Life-Saving Medications Act (S. 296) is signed into law, manufacturers would be required to notify the FDA of any discontinuation, interruption or other adjustment in the manufacture of a drug that “would likely result in a drug shortage.” Companies would be required to provide at least six months notice prior to the date of a manufacturing stoppage or other action affecting a drug’s availability. This covers adjustments related to the supply of raw materials, including active pharmaceutical ingredients; adjustments to production capabilities; and business decisions that may affect the manufacture of the drug, such as mergers,

discontinuations and changes in production output. Penalties for failing to notify the FDA will be worked out if or when the bill is enacted, according to the legislative language.

The bill also would require the FDA to take several actions. These include publishing information on existing drug shortages on the agency’s Web site and “to the maximum extent practicable, distribute such information to appropriate health care provider and patient organizations.” The FDA also would be responsible for implementing evidence-based criteria for identifying drugs that may be vulnerable to shortages and collaborating with manufacturers to establish and improve continuity of operations plans with regard to medically necessary drugs.

The American Society of Anesthesiologists, the American Society of Clinical Oncology and other health care organizations have come out in support of the bill.

Sens. Amy Klobuchar (D-Minn.) and Robert P. Casey Jr. (D-Pa.), introduced the bill in February, and at press time, the bill had been referred to the Committee on Health, Education, Labor, & Pensions.

—Kate O’Rourke

T

FDA Launches New UserFriendly Web-Based Search Engine for Recalled Drugs And Other Products

he FDA has made searching for recalls of food, drugs and other products easier and faster.

The Food Safety Modernization Act (FSMA), which was signed into law earlier this year by President Barack Obama, called for the FDA to provide a more consumer-friendly recall search engine within 90 days after the law went into effect. The act also requires the FDA to indicate whether a recall is ongoing or has been completed.

The FDA’s new search engine, launched in early April, displays data from news releases and other recall announcements as a table, which can be organized by several parameters, including date since 2009, product brand name, product description, reason for the recall and the firm involved. If users want more detailed information, the table also provides a link to the news release on each recall.

The new display of the recall results is markedly different from the previous one, which provided links in a scroll-down format. To most effectively and easily communicate recall information to the public, the FDA consulted with stakeholder groups, including the Center for Science in the Public Interest, Consumers Union, Food Marketing Institute, Grocery Manufacturers Association, the Pew Health Group and Safe Tables Our Priority.

Prior to passage of the FSMA, the FDA did not have mandatory recall authority for food products except infant formula. The new status information will be provided for recalls that the FDA either ordered as mandatory or requested as voluntary under the FDA’s FSMA authority.

For more information, visit the FDA’s Web page that provides information on recalls and safety alerts: www.fda.gov/Safety/Recalls/default.htm.

—Based on a press release from the FDA

CORRE SP ONDENCE To the Editor: e are contacting you on behalf of the American Society of Anesthesiologists (ASA) today as the Chair of the Committee on Pediatric Anesthesia and the Executive Director of the Anesthesia Quality Institute (AQI) regarding your article, “More Data, but Few Answers, for Anesthesia Safety in Peds” (­Anesthesiology News, April 2011, page 1).

As sources for the story, we felt the piece drew overly broad conclusions that could mislead your readers (other anesthesiologists) as to the state of knowledge on the issue as well as advice for anesthesiologists and parents, as more

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research is completed. While we recognize that the article incorporated the various perspectives of leading experts in the field of pediatric anesthesiology, there were several points made in the story that were of particular concern to ASA. For instance, the second sentence of the article is misleading: “The panelists agreed that although several studies have indicated that exposure to anesthetic agents during periods of significant brain development in young children can result in neuronal cell death or later cognitive deficits, it’s difficult to generalize the results.” The data found neuronal cell death in animal studies under conditions of much higher and longer exposures than may be even remotely comparable

to typical anesthetic administrations to infants. The article mentions that the data are actually in animals subsequently, but this second sentence seems to infer the evidence was found through human studies in infants.

Of most concern is the statement: “The panel did recommend postponing elective procedures, whenever possible, to age 4 years or older.

They also agreed that anesthesiologists should use the lowest dose possible of anesthetics for the least amount of time …” Although this was a sentiment expressed by the FDA authors in their New England Journal of Medicine article, it is certainly not reflective of sound pediatric care nor anesthesiology

practice. One must ask, “What is an elective procedure for a young child?”

Certainly every therapeutic or diagnostic procedure in this age group has an important medical indication and an optimal time for its performance.

The greatest harm that can predictably occur as a result of our recognition of the possibility of harmful effects of anesthetic drugs, is that fear of what we do not know to be true will prevent treatment of conditions with harmful effects that are known with certainty.

Thank you for coverage on this important topic.

Mark A. Singleton, MD Richard P. Dutton, MD, MBA

8 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

TECHNOLOGY

Technologies Designed To Prevent Errors Can Cause Errors, Too San Diego—The new technologies that are increas- prevent errors. With guided light technology, the ingly being put in place in hospitals around the coun- nurse does not just select any drug from a drawer full try to prevent medication errors can themselves be a of drugs, but would select a drug that she is guided cause of errors, experts said at the 2011 annual meet- to with a light that shows her exactly where it is,” ing of the Society of Critical Care Medicine.

Dr. Cohen said.

“We have a high level of technology in my hospital, Potential Bar-coding Pitfalls and we have reduced many different kinds of errors, but now other types of errors have crept in,” said Bar-code technology for nurse administration Henry Cohen, PharmD, professor of pharmacy prac- of medication is a tremendous advance in preventtice at Long Island University and chief pharmaco- ing medication errors, but it, too, has limitations, Dr. therapy officer at Kingsbrook Jewish Medical Center, Cohen said. both in New York City. “Technology is a tremendous advance, and I wouldn’t have it any other way, but make no mistake, the ‘Unreadable bar codes are technology is not foolproof.”

The ideal technology for prestill a real problem with venting medication errors is the closed-loop medication adminbar‑code technology. istration methodology, which This is an everyday includes computerized physician order entry (CPOE), in which occurrence.’ the prescriber, usually a physician, enters the medication order, —Henry Cohen, PharmD the pharmacist validates the medication order and the nurse charts the medication administration using bar-code technology.

The medication dispensing process also uses technology, primarily robotic dispensing and/or automated dispensing cabinets.

Robotic dispensing to repackage medications using bar-code technology is an almost infallible technology, with an error rate of 0.001%. When the same task is done by a pharmacy technician or a pharmacist, the error rate can be as high as 2% to 3%. “Two percent seems like a One problem is unreadable bar codes. “Unreadsmall number, but in my hospital, where we dispense able bar codes are still a real problem with bar-code about 10,000 medication unit doses a day, that would technology. In one trial, 22% of 1,605 medications be 200 medications that might be going up to the did not have readable bar codes, and 24% of hospitals floor on any given day that are incorrect,” Dr. Cohen reported a bar code that is not readable by the scansaid. ner. This is an everyday occurrence,” he said. “In addiThe primary error that does manage to occur with tion, there are multiple generic brands of the same robotic dispensing is placement of the wrong drug drug, which can complicate bar coding.” into the prepackaging unit of the robot. A prepackFor the entire bar-code system to work, pharmacy aging machine that uses bar-code technology can pre- needs to enter the bar code every time it purchases vent this. “It is more expensive, but it is also a lot safer,” a drug. “All new brands or new lots of a medicahe said. tion must be scanned by pharmacy, but additionAnother useful technology is automated dispens- ally should be scanned by the same scanning device ing cabinets. These must be pharmacy profiled, Dr. that is used at the bedside by the nurse,” Dr. Cohen Cohen emphasized. “The nurse or anyone who suggested. accesses those machines should not be able to get A lack of hospital-wide wireless bar-code contheir hands on medication without pharmacy review- nectivity—where the system fails to work in certain ing, validating and approving the order,” he said. parts of the hospital—failing batteries in the handIn addition, they should be stocked by a pharma- held device, and doorways that do not permit entry cist or pharmacy technician using a scanner aided by of the bar-coding device into the room; remotely guided light technology so that the right drug goes stored medications, such as refrigerated meds; and into the right slot inside the machine. loud noises that prevent the nurse from hearing the “When possible, if you have those automated dis- scanner’s warnings and alarms are some of the compensing machines and you can afford the money and mon obstacles preventing the technology from workthe space, guided light technology is the best way to ing properly.

Unauthorized workarounds that lead to failure of bar-code medication administration (BCMA) include preparing, scanning and transporting medications for more than one patient at a time when administering; giving a partial dose but electronically documenting the administration of a full dose; and scanning bar codes from discarded medication packages.

Currently, only about 7% of hospitals have a CPOE system, and fewer than 20% use bar-code administration checking, Dr. Cohen noted. “We’ve got a long way to go. It’s even worse with closed-loop medication management systems, which is used in less than 5% of hospitals in the United States today.

Very few hospitals are close to where they need to be. Clearly, meaningful use is going to force this to move very quickly in the years to come.”

“Meaningful use” refers to the proposed rule to implement provisions of the American Recovery and Reinvestment Act of 2009 that provide incentive payments for the meaningful use of certified electronic health records technology. Meaningful use will reward eligible professionals and hospitals that are “meaningful users” of the technology and start to penalize those who do not use the technology.

“If, in the next two to three years, hospitals are not well on their way to implementing this technology, they are going to have to pay the federal government. So at a certain point, you’ll have to start using this technology, and if you don’t you’ll pay millions of dollars every year until you do,” Dr. Cohen said.

IV Smart Pumps Sometimes Not So Smart Another advance to increase medication safety in hospitals is IV smart pumps. But there are many problems with these as well, said Katie Burenheide, PharmD, a trauma pharmacist at Stormont-Vail HealthCare in Topeka, Kan. Smart pumps do reduce medication errors, Dr. Burenheide said. However, a big problem with them is the lack of national standards for drug concentrations and administration rates.

“The Institute for Safe Medication Practices has developed guidelines for the use of smart pumps for each institution, but there are no national standards.

Drug concentrations vary all over the place. Nothing is standardized on a national level, and this really needs to be done,” she said.

Another issue is that the premade medications available, such as dopamine and dobutamine, are in dextrose 5% water (D5W) solution. Unfortunately, D5W is not recommended for most disease

May 2 0 1 1

AnesthesiologyNews.com I 9

TECHNOLOGY ‘The data and science around workarounds is better than the data from any studies showing value from BCMA.’ —John Poikonen, PharmD states, including sepsis and trauma resuscitation. Instead, crystalloids, normal saline or lactated Ringer’s are recommended.

“In head trauma, or in people who have hemorrhagic stroke or subarachnoid hemorrhages, D5W is not recommended at all because it can increase swelling in the brain and can further increase neurologic damage,” Dr. Burenheide said.

Cardiovascular infusion rates also differ, sometimes even within the same institution, she said. “Some cardiovascular infusions can be reported in micrograms per kilogram per minute, micrograms per kilogram per hour or micrograms per kilogram per milliliter, and these vary between each institution. Sometimes even within the hospital, different infusion rates may be reported, and this can cause further confusion. When patients transfer from another facility by ambulance, you have to be careful because they may be using different infusion concentrations or administration rates from what your hospital uses. You really have to be careful of transition-of-care issues to make sure everybody is on the same page.”

Another area that needs to be standardized in critically ill patients is what weight to use. The weight to use for medication calculations could be stated weight, estimated weight, scale weight, ideal weight or adjusted body weight, Dr. Burenheide said. “There are no standards regarding what patient weight to utilize, and you really have to be careful to use the most accurate patient weight. This may also be an important issue when you start certain medications, like lipophilic drugs— for example, sedation medications or hydrophilic drugs. However, limited information about this exists.”

An Emerging New Field of Research “A new science in informatics is emerging, termed ‘eIatrogentics,’ or studying errors that are caused by technology,” said John Poikonen, PharmD, clinical informatics director at UMass

Memorial Health Care in Worcester.

He said that more centers are adopting the technology and disagrees with the numbers cited by Dr. Cohen.

“From a recent survey [Pharm Purch Prod 2010;7(8)], it’s more like 35% for CPOE and as high as 53% in hospitals with over 400 beds, with 89% saying they will be implementing the technology in the next five years. And 41% now use BCMA. But it is still just 5% for closed-loop medication management systems,” Dr. Poikonen said.

Nursing workarounds are a very large problem with BCMA, he emphasized.

“They can give a false sense of error prevention—like the nurse who has all of the insulin bar codes on the inside of her uniform and scans them until she gets the right ‘beep,’” he noted. “Then there is reporting of how many errors were averted because of misscans, when all the time the misscans were really workflow issues and not averted errors.”

Dr. Poikonen believes there is a woeful lack of evidence regarding the true

medication error rate and the return on investment with BCMA. “The data and science around workarounds is better than the data from any studies showing value from BCMA,” he said.

Finally, with regard to smart pumps, Dr. Poikonen said that although national standards would be a good thing, individual health systems should not be waiting for them. “They should be working to standardize at their facilities.”

—Fran Lowry

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1 0 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

TECHNOLOGY

New Device Alerts Clinicians to Near-Empty Vaporizers Designers say technology could help prevent intraoperative recall linked to lack of anesthetic

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lthough the reasons for anesthesia awareness are only partly understood, one that does seem clear is the lack of adequate volatile gases during surgery. Unfortunately, vaporizers do not carry alarms to warn clinicians that their patients soon may be breathing oxygen, not anesthetic,

and thus on the verge of regaining consciousness.

That could soon change, thanks to a new invention by researchers at Duke University in Durham, N.C. The device, called the An-Alarm, is a small box that can in theory be mounted to any vaporizer in minutes. It monitors the amount of volatile agents through an optical sensor and issues a warning when the level drops into the danger zone.

The alarm—which uses an infrared detector to gauge gas levels—requires no power supply, running instead on a light-rechargeable battery that must be replaced every two to three years, said Allan Shang, MD, the Duke anesthesiologist who invented the device. “It’s intended to be totally self-sufficient,” said Dr. Shang, who presented a poster about the invention at the 2011 annual meeting of the Society for Technology in Anesthesia (abstract 48).

Dr. Shang said he hopes to start manufacturing the An-Alarm next year and is optimistic about its chances for FDA approval. “One of the nice things is that, since it doesn’t take any measurements directly from a patient, it falls into a much simpler category” of regulatory review, he said.

Although a retail price has not been set, Dr. Shang said he expected the device to cost about $1,000 per unit.

For now, the An-Alarm is designed specifically for use with Tec 7 vaporizers from General Electric. But that simply reflects the reality of the marketplace— the machines make up about 70% of all vaporizers in use in U.S. hospitals—not a limitation of the technology.

Dr. Shang and colleagues have been working on their alarm for several years. And it was with the fretfulness of inventors that they saw a 2008 article from the Anesthesia Patient Safety Foundation questioning why vaporizers did not come equipped with such warning systems.

“We were already working on the [monitor] then, but we had to bite our tongues,” Dr. Shang said. “However, the article was a nice validation of our idea.”

Indeed, Dr. Shang expressed mild surprise that other groups didn’t solve the problem first. “It’s almost high school– level physics,” Dr. Shang said of his invention. “The elegance and reliability of this design lies in it’s simplicity.”

—Adam Marcus

May 2 0 1 1

AnesthesiologyNews.com I 11

TECHNOLOGY Remind continued from page 1 impaired gas exchange, where the PaO2-to-FIO2 ratio was less than 300 within 24 hours of surgery. The message recommended the use of a low tidal volume of 6 mL per kilogram of predicted body weight, and included a link to a Web site with suggested positive end-expiratory pressure (PEEP).

An additional 24 providers caring for similar patients but not sent notifications were evaluated.

The team identified trends toward lower volumes and pressures with use of the alerts, although the differences between the groups with and without

alerts did not reach statistical significance (Figure 1). The median tidal volume in patients of paged physicians was 7.1 mL/kg, compared with 7.8 mL/kg in the other patients (Figure 2; P=0.36). The median PEEP was 6.1 cm H2O with reminders and 6.3 cm H2O without them (P=0.91).

“This suggests that if providers are made aware of the fact that they might be overly ventilating patients, an alert could definitely prompt them to reduce tidal volumes,” Dr. Blum said.

“But we found that they still didn’t reduce it to what we recommended.”

Dr. Blum’s group presented its findings at the 2011 annual meeting of the

14

12

Tidal Volume (mL/kg)

10

8

‘We were curious to find out if patients who went into the operating room got this low tidal volume ventilation when they had lung injury. The answer is, for the most part, they don’t.’

—James Blum, MD Society of Critical Care Medicine, in San Diego (abstract 354).

Jeanine Wiener-Kronish, MD, head of the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital, in Boston, emphasized the importance of educating physicians on proper ventilation strategies for patients with ALI. “Recent studies have suggested that [critically ill] patients ventilated for more than 48 hours should be ventilated with less than 10 mL per kilogram of body weight,” Dr. Wiener-Kronish said. However, she said, more investigations are needed to determine whether low tidal volumes improve outcomes when patients in the intensive care unit are ventilated for shorter periods.

“Now that we have an intervention that can change ventilation settings, we can design an appropriate prospective trial to see if we really can impact mortality,” Dr. Blum said.

For now, if an anesthesiologist is caring for an operating room–bound patient with impaired gas exchange, he advises considering whether or not the patient might have an ALI. “If they do have a low PaO2-to-FiO2 ratio, have bilateral infiltrates on chest x-ray, and you’ve ruled out heart failure and volume overload,” he said, “then you should be providing low tidal volume ventilation, focusing on lower peak inspiratory pressures, and considering an increased level of PEEP.” —Lynne Peeples

6

4

2

 Suggestion  No Suggestion

0 0

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15

20

25

30

Patient Number

the

perfect balance

Figure 1. Distribution of tidal volumes.

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Tidal Volume (mL/kg)

9 8 7

of

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education and travel for 35 years

5 4 3 2 1 0

Suggestion

No Suggestion

Figure 2. Average median tidal volumes between groups with 95% confidence intervals.

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Northwest Anesthesia Seminars

International Continuing Education for the Anesthesia Provider 800-222-6927 www.nwas.com

1 2 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

TECHNOLOGY

Microcatheter Holds Appeal In Continuous Intrathecal Analgesia Device studied in small series of obstetric cases

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microcatheter approved for regional anesthesia also holds promise for intrathecal labor analgesia, according to researchers at the University of Pennsylvania School of Medicine, in Philadelphia. The

findings of the ongoing study, reported at the 2011 annual meeting of the Society for Obstetric Anesthesia and Perinatology, demonstrated successful use of the device in four of six laboring patients (abstract 22).

The intrathecal delivery device (Wiley Spinal, Epimed) comprises a 23-gauge end-orifice, Coude-tipped cannula over a 27-gauge pencil-point needle. After identification of the epidural space by the loss-of-resistance

The Wiley Spinal intrathecal delivery device, from Epimed.

‘I’m pleased that this catheter is stronger and you can aspirate fluid from it. It helps us know we’re in the right place.’

—Valerie A. Arkoosh, MD, MPH

Capnography.

Monitoring every breath your patients take.

As an anesthesiologist, you know capnography has long been the standard for monitoring adequacy of ventilation in the operating room, and for good reason: Capnography provides the earliest, most accurate indication of respiratory distress.

Neither respiratory rate nor pulse oximetry – alone or combined – can tell you if your patient is ventilating properly.

Today, Oridion Microstream® Capnography gives you that same confidence in monitoring your non-intubated patients.

When we set out to develop the safest, most effective non-intubated monitoring, we turned to the experts.We asked anesthesiologists what hadn’t worked in earlier generations and what you need to protect your patients.The result?

Microstream®, non-intubated capnography that works.

• Effective sampling, both oral and nasal, through the patented Uni-junction feature and its specialized patient interfaces • Simplified etCO2 monitoring through the Smart Capnography™ family of superior algorithms: Integrated Pulmonary Index™ (IPI), SARA™ alarm management, and Smart Breath Detection™.

• Clear, crisp waveforms and accurate respiratory rates through our patented Molecular Correlation Spectroscopy™ (MCS™), one technology for all patients in all clinical settings.

When your patients are counting on you, you can count on Oridion Microstream Capnography. Simple. Fast. Accurate.

Learn why capnography is the new standard for monitoring spontaneously breathing patients at www.oridion.com.

160 Gould Street, Suite 205, Needham MA 02494, USA • Toll Free: (888) ORIDION (674-3466) • Tel: (781) 453-0500 • Fax: (781) 453-2722 Hamarpe 7, Jerusalem 97774 Israel • Tel: +972 2 589-9111 • Fax: +972 2 586-6680 © 2010 Oridion Medical 1987 Ltd. All rights reserved.

technique, the device is inserted through a peel-away plastic introducer.

The cannula, inserted into the subarachnoid space similarly to an IV cannula, is connected to infusion tubing at the skin surface via an integrated connector. The device is FDA-approved for intermittent administration of intrathecal medication in regional anesthesia.

The four cases in which the device was used successfully included a patient scheduled for repeat cesarean delivery, a patient undergoing vaginal delivery and induction of labor in two patients—one with gestational hypertension and the other with maternal congenital cardiac disease. The latter two patients eventually had cesarean deliveries. All of these patients reported being “completely satisfied” with their anesthetic and said they would recommend the device, according to the researchers.

In two additional patients, anesthesiologists were unsuccessful in using the device: In one patient, the cannula could not be inserted because of paresthesia; in the second patient, there was no flow of cerebrospinal fluid from the cannula and no anesthetic effect after local injection. Of the total of six patients, none developed postdural puncture headache.

Microcatheters were embraced by the obstetric community in the late 1980s and early 1990s because the amount of anesthetic delivered to patients could be limited and patients could be converted easily from labor delivery to emergency cesarean delivery, according to senior author Valerie

May 2 0 1 1

AnesthesiologyNews.com I 13

TECHNOLOGY

A. Arkoosh, MD, MPH, professor of clinical anesthesiology and critical care, and clinical obstetrics and gynecology at Penn.

But in 1991, four cases of cauda equina syndrome—a serious condition caused by compression of the nerves in the lower spinal canal—associated with continuous intrathecal anesthesia in nonobstetric patients were reported to the FDA. After receiving reports of 11 cases of cauda equina syndrome, the FDA in 1992 required the manufacturers of continuous intrathecal catheters, 27-gauge or smaller, to withdraw their products from the market. The drug used in all 11 cases was 5% hyperbaric lidocaine at more than 100 mg, and investigators later concluded that microcatheters were not to blame. Yet since that time, only largebore epidural catheters have been used to administer continuous intrathecal analgesia.

The FDA recognized that microcatheters would still be helpful for obstetric patients, and Dr. Arkoosh subsequently directed a national study to compare the safety of continuous intrathecal labor analgesia using a 28-gauge catheter with continuous epidural labor analgesia (Anesthesiology 2008;108:286-298). The patients who received continuous intrathecal analgesia had better early analgesia, less motor blockade and higher maternal satisfaction with pain relief at 24 hours postpartum; there were no differences in obstetric outcomes or postdural puncture headache between analgesia strategies.

There were some technical difficulties with the microcatheters used in the earlier study, Dr. Arkoosh said. Fluid could not be aspirated with them, and they had a tendency to break easily because they were so thin. She said the long, IV-like Wiley catheter has a large enough diameter to aspirate fluid and does not break as easily.

Dr. Arkoosh, whose group received the catheters from Epimed but no money from the company for their study, said some patients have

experienced paresthesia in their legs when the needle is inserted: “It’s not dangerous, but it is something we’re very cautious about.” She said the catheter has been particularly effective in patients with severe heart problems, allowing anesthesiologists to use opioid analgesics that have fewer hemodynamic side effects.

Although Dr. Arkoosh said she believes the design of the device needs refining, she is encouraged by the results so far. “I’m pleased that this

catheter is stronger and you can aspirate fluid from it. It helps us know we’re in the right place,” she told Anesthesiology News.

Brendan Carvalho, MBBCh, associate professor of anesthesia at Stanford University School of Medicine in Stanford, Calif., started a clinical trial in 2009 of patients scheduled for cesarean delivery to compare the administration of anesthetics by the Wiley Spinal device with typical spinal catheters. He put the study on hold because he and

his colleagues encountered technical difficulties with the Wiley device.

Dr. Carvalho said he is waiting on a few minor modifications to the design of the device before resuming his trial.

“The appeal with the Wiley is [the] very small gauge—the smaller, the better because of the headache risk,” he told Anesthesiology News. “There is definitely a clinical need for an intrathecal catheter and this device has a lot of potential to fill the need.”

—Karen Blum

C-MAC – ®

The Video Laryngoscope for Daily Routine, Teaching, Training and Difficult Airway

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KARL STORZ Endoscopy-America, Inc., 2151 E. Grand Ave, El Segundo, CA 90245, USA, Phone: (424) 218-8100, Fax: (800) 321-1304, E-Mail: info@ksea.com KARL STORZ GmbH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen/Germany, Phone: + 49 7461 / 70 80, Fax: 07461 / 70 81 05, E-Mail: karlstorz-marketing@karlstorz.de KARL STORZ Endoscopy Canada, Ltd., 2345 Argentia Road, Suite 100, Mississauga, Ontario, Canada L5N 8K4, Phone: (800) 268-4880, Fax: (905) 858-0933 KARL STORZ Endoscopia, Latino-America, 815 NW 57 Ave, Suite #480, Miami, Florida 33126-2042, USA, Telefono: (305) 262-8980, Telefax: (305) 262-8986 A-0810004

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© 2011 KARL STORZ Endoscopy-America, Inc.

1 4 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

TECHNOLOGY

Q&A With STA President Kirk Shelley, MD, PhD Kirk Shelley, MD, PhD, is professor of anesthesiology at Yale University School of Medicine, in New Haven, Conn., and president of the Society for Technology in Anesthesia. Anesthesiology News recently spoke with Dr. Shelley about his view of the current status and future direction of the field.

AN: What are some of the major unresolved technological challenges facing anesthesiologists? Which are most likely to be solved in the near future?

Dr. Shelley: There is an important shift occurring in critical care that is beginning to make its presence felt in the operating room. Known as goal-directed therapy, it has an emphasis on achieving specific physiologic states. At the core is the recognition that medical interventions have to be tailored to the specific needs of a given patient. In effect, we are shifting from a tactical approach to the care of the patient to a strategic one. The best evidence is the growing interest in closed-loop systems, in which the anesthesiologist sets a specific goal for the patient (such as target BIS [bispectral index]) and an automated system makes moment-to-moment adjustments (for example, the propofol infusion rate).

Some have likened this to the change in automobiles from manual to automatic transmission. These closed-loop systems are not only being developed to control propofol infusions but also for fluid management, muscle relaxation, ventilator control, sedation and vasopressor therapy.

AN: What are the technical hurdles to developing these treatments, and do you see any risks for patients?

Dr. Shelley: There needs to be an improvement in understanding of the underlying physiology to better predict, in a reliable manner, how the patient will react to changes in these parameters. For example, is it better to increase the rate of ventilation or to increase the depth of the breath to lower carbon dioxide?

These systems will need redundancy both in the physiologic parameters they follow and to assure the intervention they have made has actually occurred. Is there a way for the syringe pump to ‘know’ that it has been disconnected from the patient?

In the long run, I see these systems as reducing risk.

As the saying goes, though, ‘the devil will be in the details.’ Where and how these systems are introduced will be important. Thorough testing of the devices will be critical.

AN: Many anesthesiologists like to tinker, but do they do enough to spread their better ideas through the clinical community? If not, what should they be doing in this regard?

Dr. Shelley: Anesthesia has a long history of clinical inventors. Like our surgical colleagues, we anesthesiologists like to tinker with our gadgets. The operating room has always been the site for the introduction of new technologies which then spread to the postanesthesia care unit, the intensive care unit, the emergency department, the clinic—and even home (i.e., pulse oximetry). There are world-class anesthesiologists (Severinghaus comes to mind) who gladly identify themselves as ‘gadgeteer,’ but for the modern academic anesthesiologist this is not always an easy path.

One frequently has to straddle multiple worlds requiring engineering, business and academic skill sets. Funding is a constant issue resulting from the tension between industry and government as to who should pay for the development of a clever idea. In addition, conflict of interest (COI) issues quickly arise, threatening the legitimacy of the inventing researcher. It has even been suggested that once the academic anesthesiologist creates a potentially useful device that they should be forbidden from further investigations in that area, the logic being that their COI could either consciously or unconsciously corrupt future results. This is very disheartening to the committed investigator.

Kirk Shelley, MD, PhD

AN: How do you see tablet computers and smartphones affecting clinical care?

Are you wary of these technologies?

Dr. Shelley: Portable information technology is a part of the societal framework. It is a very rare physician who is not pulled in, in some way. On the upside, they have rapid access to a wide variety of information. On the downside, there is a real risk of distraction.

AN: Since your training years, what have been the three most important technological developments in anesthesia, and how have they affected your practice?

Dr. Shelley: Improved monitoring—the pulse oximeter and capnograph; improved medications—propofol, sevoflurane and rocuronium; and improved access to information—electronic access to journals and textbooks, along with simulation and other technologies that promote training.

■

Nonprofit Aims To Foster Health Care Apps

D

o you have the glimmer of a notion for a blockbuster smartphone application to benefit (er, sell to) your fellow physicians, but can’t see a way to develop it? Check out RockHealth, which has been called the first incubator devoted to seeding health care software.

Founded by Apple alumna Halle Tecco, the San Francisco-based nonprofit has begun accepting applications for its first round of grants: $20,000 each, along with mentoring by experts from the worlds of medicine, law and business.

RockHealth is partnering with the Mayo Clinic Center for

Innovation and Cincinnati Children’s Hospital, and has received funding from sources including Microsoft, Nike and Qualcomm.

In addition to capital, winners will receive office space in San Francisco to work on their projects, counseling on marketing and messaging about the product from an in-house expert, and other assistance.

“We’re really trying to … reduce all the barriers and eliminate all the excuses that developers could possibly have, and give them a place where they can take their ideas and turn them into products and businesses,” Ms. Tecco told the San Francisco Chronicle.

The deadline for the first round of funding is May 20, 2011. For more information, visit http://rock​ health.com/program/. ­­—Adam Marcus

WHEN CHOOSING AN IV SEDATIVE

Different situations require different solutions

Precedex : A right fit ®

FOR TODAY’S SEDATION MANAGEMENT PRACTICES

FASTEST GROWING IV SEDATIVE1

DIFFERENT SITUATIONS REQUIRE DIFFERENT SEDATIVE SOLUTIONS The first and only alpha2 agonist indicated for sedation2,3 —Nonintubated patients prior to and during surgical and other procedures2 —Intubated and mechanically ventilated patients during treatment in an intensive care setting2 Can be used alone or in combination with other sedatives or opioid analgesics to provide sedation and added patient comfort.2 Should be administered by continuous infusion not to exceed 24 hours.2 Effective for intubated patients not just before—but also during—and after extubation.2 More than 4.5 million vials administered to millions of patients since launch.4

IMPORTANT PRECEDEX SAFETY INFORMATION Clinically significant episodes of bradycardia, sinus arrest and hypotension have been associated with Precedex infusion and may necessitate medical intervention.

Moderate blood pressure and heart rate reductions should be anticipated when initiating sedation with Precedex.

Prolonged exposure to dexmedetomidine beyond 24 hours may be associated with tolerance and tachyphylaxis and a dose-related increase in adverse events.

Please see the brief summary of Prescribing Information on adjacent page.

The right fit

FASTEST GROWING IV SEDATIVE1

FOR TODAY’S SEDATION MANAGEMENT PRACTICES

For step-by-step instructions on how to start using Precedex and what to expect, please visit us at www.Precedex.com.

Moderate blood pressure and heart rate reductions should be anticipated when initiating sedation with Precedex.2 Clinically significant episodes of bradycardia and sinus arrest have occurred in young, healthy volunteers with high vagal tone or with different routes of administration such as rapid intravenous or bolus administration.2 Transient hypertension has been observed primarily during the administration of the loading dose. Treatment has generally not been necessary, although a reduction in loading dose infusion rate may be desirable.2

Hypotension and bradycardia can occur and may necessitate medical intervention such as —Decreasing or stopping Precedex infusion —Increasing rate of IV fluid administration —Elevating lower extremities —Administering pressor agents such as atropine, ephedrine or glycopyrrolate2 Use with caution in patients with advanced heart block or severe ventricular dysfunction.2 The most common adverse effects (incidence >2%) are hypotension, bradycardia and dry mouth.2

Please see the brief summary of Prescribing Information on adjacent page.

References: 1. Based on increases in weight of active ingredient sold (either mcg or mg). IMS Health National Sales Perspective 2Q 2009. US nonretail market, all channels injectables.

2. Precedex [package insert]. Lake Forest, IL: Hospira, Inc; 2008. 3. Kamibayashi T, Maze M. Clinical uses of α2-adrenergic agonists. Anesthesiology. 2000;93:1345-1349.

4. Data on file. Hospira, Inc. Hospira, Inc. 275 North Field Drive, Lake Forest, IL 60045 P11-3194 Mar., 11. Printed in the USA.

Advancing Wellness™

For more information on Advancing WellnessTM, contact your Hospira representative at 1-877-9HOSPIRA (1-877-946-7747) or visit www.hospira.com.

Reference EN-2680

Precedex®

(dexmedetomidine hydrochloride) injection

For Intravenous Use Rx only

To report SUSPECTED ADVERSE REACTIONS, contact Hospira, Inc. at 1-800-441-4100 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

1 1.1

INDICATIONS AND USAGE Intensive Care Unit Sedation Precedex® is indicated for sedation of initially intubated and mechanically ventilated patients during treatment in an intensive care setting. Precedex should be administered by continuous infusion not to exceed 24 hours.

Precedex has been continuously infused in mechanically ventilated patients prior to extubation, during extubation, and post-extubation. It is not necessary to discontinue Precedex prior to extubation.

1.2 Procedural Sedation Precedex is indicated for sedation of non-intubated patients prior to and/or during surgical and other procedures.

4 CONTRAINDICATIONS None 5 WARNINGS AND PRECAUTIONS 5.1 Drug Administration Precedex should be administered only by persons skilled in the management of patients in the intensive care or operating room setting. Due to the known pharmacological effects of Precedex, patients should be continuously monitored while receiving Precedex.

5.2 Hypotension, Bradycardia, and Sinus Arrest Clinically significant episodes of bradycardia and sinus arrest have been reported with Precedex administration in young, healthy volunteers with high vagal tone or with different routes of administration including rapid intravenous or bolus administration.

Reports of hypotension and bradycardia have been associated with Precedex infusion. If medical intervention is required, treatment may include decreasing or stopping the infusion of Precedex, increasing the rate of intravenous fluid administration, elevation of the lower extremities, and use of pressor agents. Because Precedex has the potential to augment bradycardia induced by vagal stimuli, clinicians should be prepared to intervene.

The intravenous administration of anticholinergic agents (e.g., glycopyrrolate, atropine) should be considered to modify vagal tone. In clinical trials, glycopyrrolate or atropine were effective in the treatment of most episodes of Precedex-induced bradycardia. However, in some patients with significant cardiovascular dysfunction, more advanced resuscitative measures were required.

Caution should be exercised when administering Precedex to patients with advanced heart block and/or severe ventricular dysfunction. Because Precedex decreases sympathetic nervous system activity, hypotension and/or bradycardia may be expected to be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension and in elderly patients.

In clinical trials where other vasodilators or negative chronotropic agents were co-administered with Precedex an additive pharmacodynamic effect was not observed. Nonetheless, caution should be used when such agents are administered concomitantly with Precedex.

5.3 Transient Hypertension Transient hypertension has been observed primarily during the loading dose in association with the initial peripheral vasoconstrictive effects of Precedex.

Treatment of the transient hypertension has generally not been necessary, although reduction of the loading infusion rate may be desirable.

5.4 Arousability Some patients receiving Precedex have been observed to be arousable and alert when stimulated. This alone should not be considered as evidence of lack of efficacy in the absence of other clinical signs and symptoms.

5.5 Withdrawal Intensive Care Unit Sedation With administration up to 7 days, regardless of dose, 12 (5%) Precedex subjects experienced at least 1 event related to withdrawal within the first 24 hours after discontinuing study drug and 7 (3%) Precedex subjects experienced at least 1 event 24 to 48 hours after end of

study drug. The most common events were nausea, vomiting, and agitation.

Tachycardia and hypertension requiring intervention in the 48 hours following study drug discontinuation occurred at frequencies of <5%. If tachycardia and/or hypertension occurs after discontinuation of Precedex supportive therapy is indicated.

Procedural Sedation Withdrawal symptoms were not seen after discontinuation of short term infusions of Precedex (<6 hours).

5.6 Tolerance and Tachyphylaxis Use of dexmedetomidine beyond 24 hours has been associated with tolerance and tachyphylaxis and a dose-related increase in adverse reactions [see Adverse Reactions (6.1)].

5.7 Hepatic Impairment Since Precedex clearance decreases with severity of hepatic impairment, dose reduction should be considered in patients with impaired hepatic function [see Dosage and Administration (2.2)].

6 ADVERSE REACTIONS 6.1 Clinical Studies Experience Because clinical trials are conducted under widely varying conditions, adverse reactions rates observed in the clinical trials of a drug cannot be directly compared to rates in clinical trials of another drug and may not reflect the rates observed in practice.

Use of Precedex has been associated with the following serious adverse reactions: • Hypotension, bradycardia and sinus arrest [see Warnings and Precautions (5.2)] • Transient hypertension [see Warnings and Precautions (5.3)] Most common treatment-emergent adverse reactions, occurring in greater than 2% of patients in both Intensive Care Unit and procedural sedation studies include hypotension, bradycardia and dry mouth.

Intensive Care Unit Sedation Adverse reaction information is derived from the continuous infusion trials of Precedex for sedation in the Intensive Care Unit setting in which 1007 patients received Precedex. The mean total dose was 7.4 mcg/kg (range: 0.8 to 84.1), mean dose per hour was 0.5 mcg/kg/hr (range: 0.1 to 6.0) and the mean duration of infusion of 15.9 hours (range: 0.2 to 157.2). The population was between 17 to 88 years of age, 43% ≥65 years of age, 77% male and 93% Caucasian. Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 2. The most frequent adverse reactions were hypotension, bradycardia and dry mouth [see Warnings and Precautions (5.2)].

Table 2: Adverse Reactions With an Incidence >2%— Intensive Care Unit Sedation Population <24 hours*

Adverse Event Hypotension Hypertension Nausea Bradycardia Atrial fibrillation Pyrexia Dry mouth Vomiting Hypovolemia Atelectasis Pleural effusion Agitation Tachycardia Anemia Hyperthermia Chills Hyperglycemia Hypoxia Post-procedural hemorrhage Pulmonary edema Hypocalcemia Acidosis Urine output decreased Sinus tachycardia Ventricular tachycardia Wheezing Edema peripheral

All Randomized Precedex Precedex Placebo Propofol (N = 1007) (N = 798) (N = 400) (N = 188) (%) (%) (%) (%) 25% 12% 9% 5% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2%

24% 13% 9% 5% 5% 4% 3% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2%

12% 19% 9% 3% 3% 4% 1% 5% 2% 3% 1% 3% 4% 2% 3% 3% 2% 2%

13% 4% 11% 0 7% 4% 1% 3% 5% 6% 6% 1% 1% 2% 0 2% 3% 3%

2% 1% 1% 1%

2% 1% 1% 1%

3% 1% 0 1%

4% 3% 2% 2%

1% 1%

1% 1%

0 1%

2% 2%

<1% <1% <1%

1% 1% 0

1% 0 1%

5% 2% 2%

* 26 subjects in the all Precedex group and 10 subjects in the randomized Precedex group had exposure for greater than 24 hours.

Adverse reaction information was also derived from the placebo-controlled, continuous infusion trials of Precedex for sedation in the surgical intensive care unit setting in which 387 patients received Precedex for less than 24 hours. The most frequently observed treatmentemergent adverse events included hypotension, hypertension, nausea, bradycardia, fever, vomiting, hypoxia, tachycardia and anemia (see Table 3).

Table 3: Treatment-Emergent Adverse Events Occurring in >1% Of All Dexmedetomidine-Treated Patients in the Randomized Placebo-controlled Continuous Infusion <24 Hours ICU Sedation Studies Adverse Event

Randomized Dexmedetomidine (N = 387)

Placebo (N = 379)

28% 16% 11% 7% 5% 4% 4% 4% 3% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 2% 2%

13% 18% 9% 3% 4% 6% 3% 4% 5% 4% 2% 1% 3% 3% 3% 2% 2% 2% 1% <1% <1%

Hypotension Hypertension Nausea Bradycardia Fever Vomiting Atrial Fibrillation Hypoxia Tachycardia Hemorrhage Anemia Dry Mouth Rigors Agitation Hyperpyrexia Pain Hyperglycemia Acidosis Pleural Effusion Oliguria Thirst

In a controlled clinical trial, Precedex was compared to midazolam for ICU sedation exceeding 24 hours duration. Key treatment emergent adverse events occurring in dexmedetomidine or midazolam treated patients in the randomized active comparator continuous infusion long-term intensive care unit sedation study are provided in Table 4. The number (%) of subjects who had a dose-related increase in treatment-emergent adverse events by maintenance adjusted dose rate range in the Precedex group is provided in Table 5.

Table 4: Key Treatment-Emergent Adverse Events Occurring in Dexmedetomidine- or Midazolam-Treated Patients in the Randomized Active Comparator Continuous Infusion Long-Term Intensive Care Unit Sedation Study* Adverse Event Hypotension1 Hypotension requiring intervention Bradycardia2 Bradycardia requiring intervention Systolic Hypertension3 Tachycardia4 Tachycardia requiring intervention Diastolic Hypertension3 Hypertension3 Hypertension requiring intervention† Hypokalemia Pyrexia Agitation Hyperglycemia Constipation Hypoglycemia Respiratory Failure Renal Failure Acute Acute Respiratory Distress Syndrome Generalized edema Hypomagnesemia

Dexmedetomidine (N=244)

Midazolam (N=122)

56%

56%

28% 42%

27% 19%

5% 28% 25%

1% 42% 44%

10% 12% 11%

10% 15% 15%

19% 9% 7% 7% 7% 6% 5% 5% 2%

30% 13% 2% 6% 2% 6% 6% 3% 1%

2% 2% 1%

1% 6% 7%

† Includes any type of hypertension.

1 Hypotension was defined in absolute terms as Systolic blood

pressure of <80 mmHg or Diastolic blood pressure of <50 mmHg or in relative terms as ≤30% lower than pre-study drug infusion value.

2 Bradycardia was defined in absolute terms as <40 bpm or in relative terms as ≤30% lower than pre-study drug infusion value.

3 Hypertension was defined in absolute terms as Systolic blood pressure >180 mmHg or Diastolic blood pressure of >100 mmHg or in relative terms as ≥30% higher than pre-study drug infusion value.

4 Tachycardia was defined in absolute terms as >120 bpm or in relative terms as ≥30% greater than pre-study drug infusion value.

The following adverse events occurred between 2 and 5% for Precedex and Midazolam, respectively: renal failure acute (2.5%, 0.8%), acute respiratory distress syndrome (2.5%, 0.8%), and respiratory failure (4.5%, 3.3%).

Table 5. Number (%) of subjects who had a dose-related increase in Treatment Emergent Adverse Events by maintenance adjusted dose rate range in the Precedex group Precedex mcg/kg/hr Adverse Event

≤ 0.7* N = 95

> 0.7 to ≤ 1.1* N = 78

> 1.1* N = 71

6% 5% 5% 3% 2% 2%

5% 8% 5% 5% 4% 6%

14% 14% 9% 7% 9% 10%

1%

3%

9%

Constipation Agitation Anxiety Oedema peripheral Atrial fibrillation Respiratory failure Acute Respiratory Distress Syndrome

*Average maintenance dose over the entire study drug administration

Procedural Sedation Adverse reaction information is derived from the two trials for procedural sedation in which 318 patients received Precedex. The mean total dose was 1.6 mcg/kg (range: 0.5 to 6.7), mean dose per hour was 1.3 mcg/kg/hr (range: 0.3 to 6.1) and the mean duration of infusion of 1.5 hours (range: 0.1 to 6.2). The population was between 18 to 93 years of age, 30% ≥65 years of age, 52% male and 61% Caucasian.

Treatment-emergent adverse reactions occurring at an incidence of >2% are provided in Table 6. The most frequent adverse reactions were hypotension, bradycardia, and dry mouth [see Warnings and Precautions (5.2)]. Pre-specified criteria for the vital signs to be reported as adverse reactions are footnoted below the table. The decrease in respiratory rate and hypoxia was similar between Precedex and comparator groups in both studies.

Table 6: Adverse Reactions With an Incidence > 2%—Procedural Sedation Population

Adverse Event Hypotension1 Respiratory depression2 Bradycardia3 Hypertension4 Tachycardia5 Nausea Dry mouth Hypoxia6 Bradypnea

Precedex N = 318 (%)

Placebo N = 113 (%)

54% 37% 14% 13% 5% 3% 3% 2% 2%

30% 32% 4% 24% 17% 2% 1% 3% 4%

1

Hypotension was defined in absolute and relative terms as Systolic blood pressure of <80 mmHg or ≤30% lower than pre-study drug infusion value, or Diastolic blood pressure of <50 mmHg.

2

Respiratory depression was defined in absolute and relative terms as respiratory rate (RR) <8 beats per minute or > 25% decrease from baseline.

3

Bradycardia was defined in absolute and relative terms as <40 beats per minute or ≤30% lower than pre-study drug infusion value.

4

Hypertension was defined in absolute and relative terms as Systolic blood pressure >180 mmHg or ≥30% higher than pre-study drug infusion value or Diastolic blood pressure of >100 mmHg.

5

Tachycardia was defined in absolute and relative terms as >120 beats per minute or ≥30% greater than pre-study drug infusion value.

6

Hypoxia was defined in absolute and relative terms as SpO2 <90% or 10% decrease from baseline.

Postmarketing Experience The following adverse reactions have been identified during post approval use of Precedex. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Hypotension and bradycardia were the most common adverse reactions associated with the use of Precedex during post approval use of the drug.

Table 7: Adverse Reactions Experienced During Post-approval Use of Precedex Body System

Preferred Term

Body as a Whole

Fever, hyperpyrexia, hypovolemia, light anesthesia, pain, rigors

Cardiovascular Disorders, General

Blood pressure fluctuation, heart disorder, hypertension, hypotension, myocardial infarction

Central and Peripheral Nervous System Disorders

Dizziness, headache, neuralgia, neuritis, speech disorder, convulsion

Gastrointestinal System Disorders

Abdominal pain, diarrhea, vomiting, nausea

Heart Rate and Rhythm Disorders

Arrhythmia, ventricular arrhythmia, bradycardia, hypoxia, atrioventricular block, cardiac arrest, extrasystoles, atrial fibrillation, heart block, t wave inversion, tachycardia, supraventricular tachycardia, ventricular tachycardia

Liver and Biliary System Disorders

Increased gamma-glutamyl transpepsidase, hepatic function abnormal, hyperbilirubinemia, alanine transaminase, aspartate aminotransferase

Metabolic and Acidosis, respiratory acidosis, Nutritional Disorders hyperkalemia, increased alkaline phosphatase, thirst, hypoglycemia Psychiatric Disorders

Agitation, confusion, delirium, hallucination, illusion

Red Blood Cell Disorders

Anemia

Renal Disorders

Blood urea nitrogen increased, oliguria

Respiratory System Disorders

Apnea, bronchospasm, dyspnea, hypercapnia, hypoventilation, hypoxia, pulmonary congestion

Skin and Appendages Disorders

Increased sweating

Vascular Disorders

Hemorrhage

Vision Disorders

Photopsia, abnormal vision

10

OVERDOSAGE The tolerability of Precedex was studied in one study in which healthy subjects were administered doses at and above the recommended dose of 0.2 to 0.7 mcg/kg/hr. The maximum blood concentration achieved in this study was approximately 13 times the upper boundary of the therapeutic range. The most notable effects observed in two subjects who achieved the highest doses were first degree atrioventricular block and second degree heart block. No hemodynamic compromise was noted with the atrioventricular block and the heart block resolved spontaneously within one minute.

Five patients received an overdose of Precedex in the intensive care unit sedation studies. Two of these patients had no symptoms reported; one patient received a 2 mcg/kg loading dose over 10 minutes (twice the recommended loading dose) and one patient received a maintenance infusion of 0.8 mcg/kg/hr. Two other patients who received a 2 mcg/kg loading dose over 10 minutes, experienced bradycardia and/or hypotension. One patient who received a loading bolus dose of undiluted Precedex (19.4 mcg/kg), had cardiac arrest from which he was successfully resuscitated.

6.2

Manufactured and Distributed by: Hospira, Inc. Lake Forest, IL 60045 USA Licensed from: Orion Corporation Espoo, Finland Printed in USA Hospira, Inc., Lake Forest, IL 60045 USA

May 2 0 1 1

AnesthesiologyNews.com I 17

CLINICAL ANE STHE SIOLOGY ETT continued from page 1 New findings suggest that a three-step test of assessing the placement of an endotracheal tube (ETT) is essentially foolproof, but that as a standalone test, the depth of the tube in the airway is a better measure than auscultation.

The patients were randomly “If [clinicians] hear breath sounds on either side of divided into eight groups, said the chest, they assume the tube is in the right posiDr. Sitzwohl, who presented tion,” said Dan Alfery, MD, associate adjunct prohis findings at the 2011 annual fessor of anesthesiology at Vanderbilt University, meeting of the Society of Critin Nashville, Tenn., who was not part of the study. ical Care Medicine (abstract 341). In “But even an experienced anesthesiologist can be four groups, an ETT was fiber-optically posifooled.” tioned 2.5 to 4.0 cm above the carina; in the other four groups, the tube was positioned in the right ‘Simply using tube insertion depth, mainstem bronchus.

To determine whether the tube was properly positioned in the trachea, first-year residents and experiwhich requires no judgment, better enced anesthesiologists were randomly assigned to perform bilateral auscultation of the chest, observe predicts appropriate tube position and palpate symmetrical chest movements, estimate the position of the tube by the insertion depth or a than the best clinical judgment even combination of all three.

Not surprisingly, the residents performed signifiby experienced anesthesiologists.’ cantly worse with bilateral auscultation than the experienced clinicians (odds ratio, 10.0; 95% confidence interval, 1.4 to 434). In fact, residents correctly diag––Daniel I. Sessler, MD nosed endobronchial intubation by auscultation in only half of the cases.

The new study “suggests that simply using tube 21/23 May Strain Safety Margin insertion depth, which requires no judgment, better predicts appropriate tube position than the best Clinicians estimate the correct depth of the ETT clinical judgment even by experienced anesthesi- by using the “21/23 cm” rule—21 cm for women and ologists,” said Daniel I. Sessler, MD, professor and 23 cm for men, Dr. Sessler said. However, results of chair of the Department of Outcomes Research at this study showed that by inserting the tube to these Cleveland Clinic, in Ohio, who helped conduct the distances, the gap between the carina and the disresearch. tal tip of the tube was less than 2.5 cm—the recomFor decades, physicians have questioned the effi- mended margin of safety—in 20% of women and cacy of tests used to confirm ETT placement. To 18% of men, he said. determine which bedside method of detecting inadIn fact, researchers found that the optimal tube vertent endobronchial intubation has the highest sen- insertion depth is 20 cm in women and 22 cm in sitivity and specificity, Christian Sitzwohl, MD, of men. “Perhaps using a general 20/22 cm rule, with the Medical University of Vienna General Hospital, the possible exception of using 19 cm for smaller in Austria, and colleagues conducted a prospective, women with a higher body mass index, might be randomized blinded study on 160 hospital patients, a safer approach,” Dr. Sessler suggested. Based on aged 19 to 75 years. these results, he said, physicians should rely more on

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insertion depth than on auscultation.

However, combining all three tests—bilateral auscultation of the lungs, observation and palpation of the symmetrical chest movements, and referencing the ETT centimeter scale— provided the most sensitivity, hitting 100%, Dr. Sessler said. Still, tube depth, with a sensitivity of 88%, was significantly more sensitive for detecting endobronchial intubation than either auscultation (65%) or observation (43%) (P<0.001), the researchers found.

Dr. Alfery said the results must be replicated in another study. In addition, the patients used in this study were predominantly healthy and the men tended to be large, he said. “I wonder whether the rule of 20 cm and 22 cm still applies to the physical outliers—very tall or very short men and women—patients with airway complications, or morbidly obese patients,” he said.

Although women in the study outnumbered men by 3-to-1, they are more likely to experience inadvertent endobronchial intubation.

“In anesthesia it’s very easy to get cavalier, or a little sloppy, or to get rushed and use only one tool to detect tube placement,” Dr. Alfery said. “But Dr. Sessler’s research demonstrates that whether you’re an intern or an experienced physician, and whether you are inside or outside the hospital—we really need to use a number of tools to prevent the misplacement of ETTs. ” —Michelle Grey Campion Advertisement

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1 8 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

CLINICAL ANES THE S IOLOGY

Success of CPR in Peds Hindered

By Poor Compression Technique

M

edical professionals providing critical care to pediatric patients in cardiac arrest could be complicating and even crippling resuscitation efforts if they do not allow the patient’s chest to expand after each compression.

Researchers at the Children’s Hospital

Optical Laryngoscope with Video Capabilities

of Philadelphia simulated the residual leaning force that commonly takes place during cardiopulmonary resuscitation and found that the pressure negatively impacted hemodynamics and intrathoracic airway pressures (ITP).

The findings, presented at the 2011 annual meeting of the Society of

Critical Care Medicine (abstract 447), confirm that incomplete chest recoil in CPR, which previously had been shown to negatively affect hemodynamics in adults, also can be an important consideration for children.

In a study that the team described as the first of its kind, researchers applied

sternal wall pressure of between 10% and 20% of body weight on 18 heart transplant recipients, aged 3 to 8 years, who were undergoing routine cardiac catheterization under general anesthesia and mechanical ventilation.

“What we saw was a consistent increase in central venous pressure and a consistent increase in coronary perfusion pressure—both of which would potentially have negative consequences in a cardiac arrest situation where a child already has a compromised circulation,” said Andrew Glatz, MD, a pediatric cardiologist and leader of the study group.

When the greatest sternal pressure of 20% of body weight was applied, central venous pressure increased from an average of 5.8 to 8.2 mm Hg; average coronary perfusion pressure decreased from 42.2 to 39.8 mm Hg. ITP increased from 16.8 to 19.5 cm H2O. “Those numbers are in kids with beating hearts, so it’s hard to translate that into kids in real CPR scenario, but even small changes in millimeters of mercury could be significant,” said Michael Sayre, MD, associate professor of emergency medicine at Ohio State University, in Columbus, and spokesman for the American Heart Association. “If a rescuer leaning on the chest inhibits any kind of flow through coronary arteries, that’s a problem.”

Both Drs. Sayre and Glatz acknowledged that even in a hospital intensive care unit, mistakes like residual leaning could be an issue.

“The American Heart Association emphasizes chest recoil in our training, but making sure that happens during CPR is hard,” Dr. Sayre said. “There are a lot of things the rescuer has to keep track of, like how fast are the compressions and how hard they are. There’s only so much that a person can pay attention to at a time.”

He noted, however, that anesthesiologists in particular have resources on hand that can help. “Invasive monitoring—like an arterial line or central venous pressure monitor—can be a useful tool to check quality of CPR,” he said. “Often their patients have these monitoring lines in place so they can look at central venous pressure, and if it’s getting high that suggests leaning is taking place. It provides that feedback and helps the rescuer to make adjustments.” Capnography, too, can be useful.

May 2 0 1 1

AnesthesiologyNews.com I 19

CLINICAL ANE STHE SIOLOGY

Better CPR in the Palm of a Hand

A

handheld device that provides real-time feedback on CPR could markedly improve the ability of clinicians to administer the lifesaving treatment.

In a study that tested the efficacy of the device, called the Exact Instrument of Resuscitation (EIR), a team of researchers from Boston University assessed its impact on ventilation timing, tidal volume and compression rates among anesthesiology residents practicing on CPR manikins. The researchers found a significant difference in the timing of the breaths, which improved from below target without the EIR to no difference from the target while using the feedback system.

For the study, seven randomly chosen residents performed two sets of one-minute rescue ventilation followed by two cycles of CPR, the first without guidance and the second with the use of the device. The EIR was designed to couple with a bag-valve and displayed real-time tidal volumes and ventilation and chest compression cadence.

Ruben Azocar, MD, anesthesiology residency director and associate professor at Boston School of Medicine, said the timing of ventilation is crucial for successful CPR. “A slow rate may lead to hypoventilation; too fast a rate may lead to a rise in intrathoracic pressure which could be detrimental,” he said.

Although the researchers did not find a significant difference in tidal volumes and compression rates with the device, Dr. Azocar cited the small size of the study and noted the likelihood that the residents who participated may have had strong mastery of CPR skills.

The team continues to collect data from other medical care providers. Dr. Azocar said that anesthesiologists were chosen for the preliminary trial because

they assist in arrest situations in the wards, provide coverage of intensive care units and are involved in the transport of critically ill patients.

Dr. Azocar suggested that the EIR (which was invented by Boston University medical student Matthew Chakan and has a patent pending) could have potential use as a teaching device and might be integrated into

EIR bag-valve devices. If so, he added, everyone would know that CPR is proceeding properly in terms of ventilation and chest compressions.

Resuscitation guidelines from the American Heart Association state that automated CPR feedback devices hold promise as monitors of performance by providing real-time, corrective feedback to the rescuer. Michael

Sayre, MD, a spokesman for the group, sounded a positive but cautious note, saying: “It’s great that researchers are working on better ways to give rescuers ways to deliver higher-quality CPR,” Dr. Sayre said, “but we need more studies in people before reaching any conclusions.”

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“The quality of CPR in a hospital setting is better than bystander CPR in the field, but even when you monitor this in the hospital there’s still room for improvement,” Dr. Glatz noted. “This can be of interest for people who take care of pediatric patients with critical illnesses, including cardiologists, pediatric anesthesiologists, pediatric critical care doctors and anyone who is involved in critical care for pediatric patients.”

a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. To learn more about our medical professional liability program and the benefits that have made us the nation’s leading writer of anesthesiologists, call (800) 352-0320 or visit us at www.thedoctors.com.

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2 0 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

CLINICAL ANES THE S IOLOGY

Novel Route to Sciatic Block Trumps Conventional Method San Diego—A one-size-fits-all ap­ proach to parasacral nerve blocks may work for most anesthesiologists, but a team of French researchers believe that determining where to insert the needle by using anthropometric data from patients may yield more consistent results in the procedure.

The study, which looked at 61 patients undergoing lower limb surgery, found that the novel approach was more likely to produce a successful block following first passage of the needle and required fewer reorientations.

“The parasacral sciatic nerve block is known to be painful for many patients,” said Cécile Rideau, MD, an attending anesthesiologist at Centre Hospitalier Universitaire (CHU), in Nice.

“Our goal was to compare the classic approach to this block with a modified one, which we believe facilitates sciatic block using nerve stimulation.”

Patients were randomized to undergo a nerve stimulator–assisted sciatic block using one of two techniques for locating where to insert the needle. For the conventional technique, clinicians inserted the needle 6 cm away from the postero-superior iliac spine (PSIS) along the line connecting the PSIS and the ischial tuberosity

(IT). With the new technique, the needle was inserted at the point one-third of the way from the PSIS to the IT. One anesthetist marked the location of insertion while a second, unaware of how the site was identified, performed the block.

The blocks succeeded in every patient, Dr. Rideau reported at the 2010 annual meeting of the American Society of Anesthesiologists (abstract A178).

However, clinicians using the conventional approach sometimes took a more circuitous route to get there (Table).

The new technique does not directly consider each patient’s height and weight, Dr. Rideau told Anesthesiology News, but it is still more specific to

body size than the standard approach.

“The conventional technique cannot work as well as the new technique, because the point for needle insertion is the same for all patients, whatever height, weight or musculature,” she said.

“This new technique indirectly considers height and weight, because the landmark is one-third of the distance between the posterior iliac spine and the ischial tuberosity. This distance may differ in all patients because of differences in height and weight.”

Because anesthesiologists at her institution have readily adopted the new technique, Dr. Rideau encouraged her peers to consider it as well. “Locating the posterior iliac spine and ischial

tuberosity can be difficult in obese patients, which makes the new approach even more applicable,” she said.

Ali Shariat, MD, clinical instructor of anesthesiology at St. Luke’s-Roosevelt Hospital in New York City, called this an interesting approach to the sciatic block. “Although contemporary practice is rapidly replacing a landmarksbased technique with ultrasound guidance,” Dr. Shariat said, “such techniques still hold an important place in those situations where ultrasound is unavailable or ultrasound visualization is rendered difficult or impossible by the patient’s anatomy.”

—Michael Vlessides

Table. Using the New Approach to Parasacral Block Improved the Rate of Immediate Success Conventional Approach

Experimental Approach

Number of patients requiring one needle penetration for successful block

26

29

Number of patients requiring more than one needle penetration for successful block

5

1

Number of patients requiring zero needle reorientations (only includes patients requiring one needle penetration for successful block)

13

23

Number of patients requiring at least one needle reorientation (only includes patients requiring one needle penetration for successful block)

13

6

Number of patients with immediate block success

13

23

Number of patients without immediate block success

18

7

ClipChart New York City: Anna Malova, a former Miss Russia, has been charged with using forged prescriptions to steal opioids and anti-anxiety medication from New York pharmacies. According to the Reuters news agency, Ms. Malova faces 44 counts, including forgery and criminal possession of controlled substances in the case. Last year, the former beauty queen was arrested on similar charges, Reuters reported. Ms. Malova’s attorney has said his client trained as a physician in Russia but is not licensed to practice in the United States, where she has been living on a green card.

Anaheim Hills, Calif.: Anesthesiologist Scott Bickman, MD, has been barred from prescribing controlled substances for his role in a scheme to buy and resell pain drugs. Federal officials say Dr. Bickman rented his prescriber registration number to plastic surgeon Harrell Robinson, MD, who used the number to purchase opioids that he then sold to a nearby pain clinic. According to the Associated Press, drug officials revoked Dr. Bickman’s prescribing license. He also may face disciplinary action by the state medical board, the news service reported.

Boston: Ellison “Jeep” C. Pierce Jr., MD, a major figure in the field of anesthesia safety during the 1980s, died Apirl 3 at age 82. Dr. Pierce, a founder of the Anesthesia Patient Safety Foundation, is credited with helping to drive down the incidence of anesthesia-related mortality by urging his colleagues to adopt electronic monitoring, better ventilation practices and other measures.

Washington, D.C.: Medicare patients now will be able to conduct side-by-side assessments of local hospitals for their rates of eight hospital-acquired conditions, from falls and transfusion mismatches to catheter-related bloodstream infections. The Centers for Medicare & Medicaid Services recently added the search feature to its Hospital Compare Web site (healthcare.gov/compare). Medicare does not reimburse hospitals for the extra care incurred in the event of the eight conditions.

May 2 0 1 1

AnesthesiologyNews.com I 21

CLINICAL ANE STHE SIOLOGY

Quick Preanesthetic Interview Increases Patient Satisfaction New York—An interview protocol used in the preanesthesia clinic aimed at addressing psychological stress associated with surgery improved patient satisfaction substantially, according to a new study.

The method is known as BATHE: Background, Affect, Trouble, Handling and Empathy. Samuel DeMaria Jr., MD, an instructor in anesthesiology at Mount Sinai Medical Center in New York City, said that his group came to think of the final part as Explain, as well.

Dr. DeMaria, whose group presented its findings at the 2010 PostGraduate Assembly in Anesthesiology (abstract P-9082), called BATHE “a way of ensuring that the practitioner was meeting the psychological needs of the patient, so that they felt connected to their clinician.”

Dr. DeMaria and colleagues had taught five senior anesthesia residents the method. They interviewed 50 patients using BATHE and 50 without using the protocol. Half of the patients were scheduled for cardiac surgery, the rest for general surgical procedures.

All patients responded to a survey to assess their interactions in Mount Sinai’s preanesthetic clinic. As expected, patients in the BATHE group were more likely to be asked questions about their mood, feelings about the impending surgery and how they had been handling such concerns.

Scores for patient satisfaction, based on survey responses, were somewhat higher in the BATHE group than in patients interviewed without the method (P<0.05). Use of the BATHE method was significantly related to satisfaction (r=0.40; P<0.01).

A hierarchical regression analysis of factors that could predict patient satisfaction showed that age, sex, type of surgery, the interviewing physician and length of visit did not predict satisfaction (P>0.05 for all), but BATHE scores did (P<0.01).

A number of individual satisfaction survey questions also revealed improvements when employing the BATHE method. Patients in the BATHE group rated the friendliness and courtesy of their physician higher, and said their clinician showed greater concern for their worries (P=0.01 for both). Interestingly, BATHE patients also were more satisfied with the amount of time the doctor spent with them, although there were no actual differences in time spent between the two groups.

“As patients met with the anesthesiologist, they had someone there who

was completely on board with them, who wanted them to be informed, who wanted them to be comfortable, who validated their concerns,” Dr. DeMaria said.

Elizabeth Frost, MD, clinical professor of anesthesiology at Mount Sinai, and creator of the PreAnesthetic Assessment continuing medical education series, said that there could be problems

with the use of the BATHE method in the preanesthesia clinic because it was developed primarily for a family practice setting.

“Patients during an anesthetic experience may be unwilling to be questioned and to answer to topics that relate to psychological affect,” said Dr. Frost, who was not involved in the research. “Moreover, the anesthesiologist may be out of

his area of expertise in answering or even posing these queries and those related to surgical techniques and the extent of the planned surgical operation.”

Still, she said, the method might help improve patient satisfaction in this setting. “The most important questions may be, ‘what questions do you have, and how can I help?’”

—Dave Levitan

PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.COM

Current Concepts In the Management Of the Difficult Airway

CARIN A. HAGBERG, MD Joseph C. Gabel Professor and Chairman, Department of Anesthesiology The University of Texas Medical School at Houston Director of Advanced Airway Management Memorial Hermann Hospital Houston, Texas Executive Director 2009-present, Society for Airway Management

Dr. Hagberg has disclosed that she is a member of the speakers’ bureaus for Ambu A/S, Cook Medical, Covidien, and LMA North America; and has received equipment support from Aircraft Medical, Ambu A/S, Cook Medical, Karl Storz Endoscopy, King Systems, LMA North America, Mercury Medical, and Verathon Medical.

T

he practice of airway management has become more advanced in recent years. This advancement is demonstrated by the introduction of many new airway devices, several of which have been included in the American Society

of Anesthesiologists (ASA) Difficult Airway Algorithm (Figure).1

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A N E S T H E S I O L O G Y N E W S • M AY 2 0 1 1

1

exchangers has been introduced by VBM Medizintechnik GmbH. These include the METTS (Muallem ET Tube Stylet) and METTI (Muallem ET Tube Introducer), which are solid in design, and several ventilating catheters.

LIGHTED STYLETS

Figure. The ASA Difficult Airway Algorithm.

(Anesthesiology 2003;98:1269-1277) The algorithm can be viewed at: www.asahq.org/ publicationsAndServices/practiceparam.htm.

In the past several years, several lighted stylets have been developed, including light wands such as the AincA Lighted Stylet (Anesthesia Associates, Inc.) and the air-Vu Plus Fiberoptic Stylet (Mercury Medical), and visual scopes, such as the Shikani Optical Stylet (SOS, Clarus Medical), Flexible Airway Scope Tool (Pocket/ FAST Scope, Clarus Medical), Levitan GLS (Clarus Medical), Clarus Video System (Clarus Medical), Bonfils Retromolar Intubation Fiberscope (Karl Storz Endoscopy), Brambrink Intubation Endoscope (Karl Storz Endoscopy), and the SensaScope (Acutronic Medical Systems AG). Light wands rely on transillumination of the tissues of the anterior neck to demonstrate the location of the tip of the ETâ&#x20AC;&#x201D;a blind technique, unless combined with direct laryngoscopy (Table 2).3,4 The visual scopes, on the other hand, utilize fiber-optic imagery and allow indirect visualization of the airway. They also can be used alone or in conjunction with direct laryngoscopy.

RIGID/VIDEO LARYNGOSCOPES Management of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. Claims involving airway management continue to comprise an important aspect of the ASA Closed Claims Project database, which tracks all anesthesia-related insurance claims.2 This review focuses on several of the alternative airway management devices/techniques and their clinical applications, with particular emphasis on the difficult or failed airway.

Alternative Airway Devices A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of direct laryngoscopy. Many devices and techniques are now available to circumvent the problems typically encountered with a difficult airway using conventional direct laryngoscopy.

ENDOTRACHEAL TUBE GUIDES A number of endotracheal tube (ET) guides (Table 1) have been used to aid in intubation, including the Portex Venn Tracheal Tube Introducer (Smiths Medical) and, more recently, the Single-Use Bougie (Smiths Medical), the Frova Intubating Introducer (Cook Medical), the Aintree Intubation Catheter (Cook Medical), the Arndt Airway Exchange Catheter Set (Cook Medical), the Cook Airway Exchange Catheter EF (Cook Medical), the Cook Airway Exchange Catheter EF Soft Tip (Cook Medical), the RadLyn Stylet (RadLyn LLC), the GlideRite Auto and DLT Stylet (Verathon Medical), and the OptiShape Stylet (Truphatek International Ltd).

Recently, a new range of introducers, stylets, and tube

2

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

Video-assisted techniques have become pervasive in various surgical disciplines, as well as in anesthesiology.

As more video laryngoscopes are introduced into clinical practice, and as airway managers become more skillful with the technique of video-assisted laryngoscopy, it could well become standard procedure for patients with known or suspected difficult airways. It may be longer before video laryngoscopy becomes standard for routine intubations, but as the equipment and usersâ&#x20AC;&#x2122; skills improve, video laryngoscopy may become routine with the potential for important savings in time and decreased morbidity in patients.

It is beyond the scope of this review to discuss all of the laryngoscopes that have been manufactured; thus, only some of the most recently developed blades will be described. Modifications of traditional laryngoscope blades are primarily designed to overcome certain problems associated with difficult airway management, such as limited mouth opening, anterior larynx, sternal space restriction, small intraoral cavity, and immobile or unstable cervical spine (Tables 3 and 4).5-7

INDIRECT RIGID FIBER-OPTIC LARYNGOSCOPES These laryngoscopes were designed to facilitate tracheal intubation in the same population that would be considered for flexible fiber-optic bronchoscopy, such as patients with limited mouth opening or neck movement. Relative to the flexible fiber-optic bronchoscopes (FOBs), they are more rugged in design, control soft tissue better, allow for better management of secretions, are more portable (with the exception of the new portable FOBs), and are not as costly. Intubation can be performed via the nasal or oral route and can

be accomplished in awake or anesthetized patients (Table 5).8-10

SUPRAGLOTTIC VENTILATORY DEVICES The Laryngeal Mask Airway (LMA, LMA North America, Inc.) is the single most important development in airway devices in the past 25 years. Since its introduction into clinical practice, it has been used in more than 200 million patients worldwide with no reported deaths.11 Several new variants of the LMA Classic, or standard LMA, are available, including the LMA Flexible (wire-reinforced flexible), LMA Unique (disposable), LMA Fastrach (intubating, reusable, and disposable), the LMA ProSeal (50% higher seal pressure, reusable with gastric drain tube), and most recently, the LMA Excel (intubating, reusable), and LMA Supreme (disposable with gastric drain tube).

Other supraglottic ventilatory devices (Table 6)12-15 include the Soft-Seal Laryngeal Mask (Smiths Medical), the CobraPLA16 (Pulmodyne), the i-gel (Intersurgical), the King Laryngeal Tube (King Systems), the Esophageal Tracheal Combitube (Covidien), and the Rüsch Easy Tube (Teleflex Medical). Specially designed intubating laryngeal masks include the Air Q laryngeal masks (reusable, disposable), and the latest blocker disposable (Cookgas LLC; distributed by Mercury Medical), as well as the Ambu Aura-i (Ambu).

Special Airway Techniques AWAKE INTUBATION For managing patients in whom a difficult airway is suspected or anticipated, securing the airway before induction of general anesthesia adds to the safety of anesthesia and helps minimize the possibility of major complications, including hypoxic brain damage and death. To perform awake intubation, the patient must be adequately prepared for the procedure. Good topical anesthesia is essential to obtund airway reflexes and can be provided by various topical agents and administrative devices (Table 7). A new device (the JED; Jaw Elevation Device; Hypnoz Therapeutic Devices distributed by LMA North America, Inc.) can be used to maintain an open airway during awake intubation. There are other positioning devices, such as the Chin-UP (Dupaco Inc; distributed by Mercury Medical), the RAMP Rapid Airway Management Positioner (Airpal Patient Transfer Systems, Inc), and the Troop Elevation Pillow (Mercury Medical) that facilitate airway management (Table 8).

Atomizing devices currently available for delivering topical anesthesia to nasal, oral, pharyngeal, laryngeal, and tracheal tissues include the DeVilbiss Model 15 Medical Atomizer (DeVilbiss Healthcare), the Enk Fiberoptic Atomizer Set (Cook Medical), and the LMA MADgic Laryngo-Tracheal Atomizer (LMA North America, Inc.).

Although any technique of tracheal intubation can be performed under topical anesthesia, flexible fiber-optic intubation is most commonly used.

FLEXIBLE FIBER-OPTIC INTUBATION Flexible fiber-optic intubation is a very reliable approach to difficult airway management and assessment. It has a more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited, as well as in patients of any age and in any position. Technological advances—including improved optics, battery-powered light sources, better aspiration capabilities, increased angulation capabilities, and improved reprocessing procedures have been developed. Additionally, a completely disposable system, the aScope (Ambu) has recently been developed. Rescue techniques, such as direct laryngoscopy and placing a retrograde guidewire through the suction channel, may be used if the glottic opening cannot be located with the scope, or if blood or secretions are present.17 Insufflation of oxygen or jet ventilation through the suction channel may provide oxygen throughout the procedure, and allow additional time when difficulty arises in passing the ET into the trachea.18

RETROGRADE INTUBATION Retrograde intubation (Table 7) is an excellent technique for securing a difficult airway either alone or in conjunction with other airway techniques.19 Every anesthesia care provider should be skilled in employing this simple, straightforward technique. It is especially useful in patients with limited neck mobility (that is associated with cervical spine pathology, or in those who have suffered airway trauma). Cook Medical has 2 retrograde intubation sets: a 6.0 Fr for placing tubes of 2.5 mm or greater ID, and a 14.0 Fr for placing tubes of 5.0 mm or greater ID.

TRANSTRACHEAL JET VENTILATION Transtracheal jet ventilation (TTJV) is a well-accepted method for securing ventilation in rigid and interventional bronchoscopy (Table 7).20 There are a number of commercial manual jet ventilation devices currently available, including the Manujet III Jet Ventilator (VBM Medizintechnik GmbH), the Manual Jet Ventilator (Instrumentation Industries), and the AincA Jet Ventilator (Anesthesia Associates, Inc.). The Enk Oxygen Flow Modulator (Cook Medical) is a device recommended for use when jet ventilation is appropriate but a jet ventilator is not available.21 The Wadhwa Emergency Airway Device (Cook Medical), which also can be used for TTJV, is several devices in one (Table 7).22,23 It has an emergency nasopharyngeal airway catheter; a largediameter transtracheal needle for a cricothyrotomy procedure with the option for TTJV; and the main body of the device acts as a blow tube or 15-mm adapter.

CRICOTHYROTOMY Cricothyrotomy (Table 9), a lifesaving procedure, is the final option for “cannot-intubate, cannot-ventilate” text continues on page 6

A N E S T H E S I O L O G Y N E W S • M AY 2 0 1 1

3

Table 1. Endotracheal Tube Guides Name (Manufacturer)

Description

Length, cm

Aintree Intubation Catheter (Cook Medical)

Polyethylene 19 Fr AEC allows passage of an FOB through its lumen. Has 2 distal side holes and is packaged with Rapi-Fit adapters. Color: light blue.

56

Arndt Airway Exchange Catheter Set (Cook Medical)

Polyethylene 8 and 14 Fr AEC with a tapered end, multiple side ports, packaged with a stiff wire guide, bronchoscope port, and Rapi-Fit adapters.

Color: yellow.

50, 65, 78

Cook Airway Exchange Catheter EF (Cook Medical)

Polyethylene 11 and 14 Fr EF AEC that facilitates exchange of DLT of 4.0 mm or larger ID. Also comes in a soft-tip version. Colors: EF, green; soft-tip version, green with purple tip.

100

Frova Intubating Introducer (Cook Medical)

Polyethylene 8 and 14 Fr AEC with angled distal tip with 2 side ports. Has hollow lumen and is packaged with a stiffening cannula and removable Rapi-Fit adapters. 14 Fr also packaged in box of 10.

Colors: 8 Fr, yellow; 14 Fr, blue.

35, 65

GlideRite Auto Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet that conforms to GlideScope blade angulation; adjustable for ETs of various lengths.

Accommodates ETs ≥6.0 mm ID.

GlideRite DLT Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet designed to enable placement of a double-lumen ET.

Designed for use in double-lumen ETs ≥6.0 mm ID.

GlideRite Rigid Stylet (Verathon Medical)

Reusable, sterilizable, semirigid stylet that conforms to GlideScope unique blade angulation; provides improved maneuverability in ET placement.

Accommodates ETs 6.0-10.0 mm ID. Overall length is 32.34 cm (12.73 in).

Muallem ET Tube Introducer Single-use 15 Fr introducer with coudé tip and (VBM Medizintechnik GmbH) hollow for oxygenation. Color: orange.

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Muallem ET Tube Stylet Single-use 8, 12, 14 Fr stylet; malleable, but with (VBM Medizintechnik GmbH) soft and atraumatic coudé tip. Color: green.

40, 65

OptiShape Stylet Reusable, sterilizable, semirigid stylet with optimal (Truphatek International Ltd) shape memory for indirect intubation procedures.

4 sizes; accommodates ETs 2.5-3.5, 4.0-5.5, 5.0-6.5, and 7.0-9.0 mm ID.

Portex Venn Tracheal Tube Introducer (Smiths Medical)

15 Fr ET introducer made from a woven polyester base, with a coudé tip (angled 35 degrees at its distal end). Also known as the gum elastic bougie.

Color: golden brown.

60

RadLyn Stylet R-100 (RadLyn LLC)

Single-use, semirigid dilating stylet employing malleable guide tip and soft, dilating balloon.

Single size only. Accommodates ETs 7.0-10.0 mm ID.

Single-Use Bougie (Smiths Medical)

15 Fr, PVC ET introducer with coudé tip. Has a hollow lumen that discourages reuse and is provided sterile. Color: ivory.

70

VBM Tube Exchanger Single-use 11, 14, and 19 Fr tube exchanger that is (VBM Medizintechnik GmbH) hollow to allow oxygenation. Color: blue.

Abbreviation key for all tables is on page 13.

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Clinical Applications

Special Features

Exchange of SGAs for ETs ≥7.0 mm using an FOB. Its hollow Large lumen (4.7 mm) allows passage of FOB. Rapi-Fit lumen allows insertion of an FOB directly through the cath- adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use. eter so that the airway can be indirectly visualized.

Exchange of LMAs and ETs using an FOB.

Tapered end and multiple side ports. Rapi-Fit adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use.

Exchange of DLTs.

EF with 2 distal side holes. The soft-tip version offers a more flexible tip to help minimize tracheal trauma.

Rapi-Fit adapters as above, but should be used primarily for jet ventilation because of length. Single use.

Facilitates endotracheal intubation and allows simple ET exchange. Can also be used by placing it first in the ET, with its tip protruding, or placing it directly into the glottis and then placing the ET over it.

Can be used in pediatric population for ETs as small as 3.0 mm. Hollow lumen allows oxygenation/ventilation in all sizes. Single use.

Designed to work with GlideScope Cobalt AVL, GVL, Cobalt, and Ranger models to facilitate intubations in OR, ED, and emergency settings.

Reusable, durable stainless steel; easy to clean; adjustable for ETs of various lengths (including cut tubes).

Designed to work with GlideScope video laryngoscopes to facilitate intubation by helping overcome obstructions such as vocal cords, arytenoids, and the cricothyroid membrane depression.

Reusable, durable stainless steel; easy to clean and sterilize in an autoclave.

Designed to work with GlideScope GVL, Cobalt, and Ranger models to facilitate intubations in OR, ED, and emergency settings.

Reusable, durable stainless steel; easy to clean and sterilize in an autoclave.

Difficult intubation with oxygenation possibility.

Supplied with unique removable connector to allow oxygenation with 15-mm connector or jet. Graduation marks for insertion depth.

Difficult intubation.

Malleable stylet with soft coudé tip and graduation marks for insertion depth.

Facilitates smooth passage of ET in both routine and difficult intubations. Especially useful in combination with the variety of video laryngoscopes that employ >42-degree angles. Designed with the ideal curve to closely follow the blade shape and ensure successful passage of ET through vocal cords.

Easily adjustable to a variety of ET sizes. Suitable for use in combination with a variety of video laryngoscopes that employ >42-degree angle of vision.

Proven useful in patients with an anterior larynx (grades 2b, 3, and 4) and those with limited mouth opening. Can be used by slightly protruding through the ET, or placing it directly into the glottis and then placing an ET over it.

Nondisposable and reusable. Size 5 Fr is single use. Has memory properties. Coudé tip effectively detects “tracheal clicks” to confirm correct placement. Part of a range of introducers, stylets, and guides for adults and pediatrics. Can be reused after cold-water disinfection.

Tapered, dilating balloon facilitates mechanical dilation Combines the functionality of a coudé tip bougie with a of the laryngeal anatomy for less traumatic passage of traditional wire stylet into a single, easy-to-use device. the ET. Facilitates smooth passage of ET in routine intubations; when the laryngeal inlet is distorted, edematous, or narrowed; when vocal cords are reactive (ie, nonparalyzed); or when Cormack-Lehane grade III/IV view is encountered.

Single-use product reduces the risk for cross-contamination. Otherwise, same as Portex Venn Tracheal Tube Introducer.

Similar to Portex Venn Tracheal Tube Introducer, but hollow lumen allows oxygenation/ventilation. Single use.

Exchange of tracheal tubes.

Similar to Muallem ET Tube Introducer.

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Table 2. Lighted Stylets Name (Manufacturer)

Description

Size

AincA Lighted Stylet (Anesthesia Associates, Inc.)

Easily malleable, lighted stylet with adjustable ET holder. Shapes and guides ET while forwardly illuminating the passage. Completely reusable device consisting of removable handle with xenon bulb.

Adult and children (ETs ≥5 mm).

Infant (ETs ≥3 mm).

air-Vu Plus Fiber-optic Stylet (distributed by Mercury Medical)

High-resolution, stainless steel, rigid stylet. Incorporates an adjustable tube stop and optional oxygen port for oxygen insufflation.

Adult (ETs ≥5.5 mm).

Bonfils Retromolar Intubation Fiberscope (Karl Storz Endoscopy)

High-resolution rigid fiber-optic stylet with a fixed 40-degree curved shape at the distal end. Available without a working channel for ease of cleaning. Available with a standard eyepiece or with a DCI for video.

3.5- and 5.0-mm OD. ET must be ≥0.5 mm larger to fit.

Brambrink Intubation Endoscope (Karl Storz Endoscopy)

High-resolution semiflexible fiber-optic stylet with a 40-degree curved shape at the distal end, 40× magnification, a fixed eyepiece, a movable ET holder, and an insufflation port.

2.0-mm OD. ET must be ≥0.5 mm larger to fit.

Clarus Video System 30000-V (Clarus Medical)

Removable and articulating monitor, video-malleable (shapeable) stylet; USB for recharging lithium ion battery and connecting to wireless notebook or monitor; red LED for transillumination. Optional detachable flexible scope and laryngoscope blades available.

5-mm OD. ETs ≥5.5 mm.

Levitan GLS (Clarus Medical)

High-resolution optics, malleable (shapeable) stainless steel stylet that protects the illumination optic fibers. Comes in a preformed hockey-stick shape that can be changed, if necessary. Built-in tube stop to hold ET in place with integral oxygen port for oxygen insufflation during intubation.

Adult (ETs ≥5.5 mm ID).

PocketScope (Clarus Medical)

Flexible stylet with a patented, deflected, nondirectable tip.

Adult (ETs ≥4.0 mm ID).

SensaScope (Acutronic Medical Systems AG)

Hybrid S-shaped, semirigid fiber-optic intubation video stylet. Has a 3-cm steerable tip that can be flexed in sagittal plane for 75 degrees in both directions with lever at proximal end of device.

Quality of optics is similar to flexible fiber-optic and rigid endoscopes, but has no working channel.

6.0-mm OD. ET must be >0.5 mm larger to fit.

Shikani Optical Stylet (SOS; Clarus Medical)

High-resolution, stainless steel, malleable (shapeable) fiber-optic stylet that comes in a preformed hockey-stick shape. Has an adjustable tube stop and integral oxygen port for oxygen insufflation.

Adult (ETs ≥5.5 mm ID). Pediatric (ETs 2.5- to 5.0-mm ID).

patients according to all airway algorithms, whether they concern prehospital, emergency department, intensive care unit, or operating room patients.

In adults, needle cricothyrotomy should be performed with catheters at least 4 cm and up to 14 cm in length. A 6 Fr reinforced fluorinated ethylene propylene Emergency Transtracheal Airway Catheter (Cook

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Medical) has been designed as a kink-resistant catheter for this purpose.

Percutaneous cricothyrotomy involves using the Seldinger technique to gain access to the cricothyroid membrane. Subsequent dilation of the tract permits passage of the emergency airway catheter. The Melker Emergency Cricothyrotomy catheters are available in

Clinical Applications

Special Features

Although usable for routine blind intubations or additional illumination during laryngoscopy, it is especially useful when the FOB is unavailable (eg, outside locations or ambulances), or when bronchoscopy is difficult to perform (eg, obscured airway or limited head motion allowed).

Can be used alone or in conjunction with other techniques.

Handle-mounted xenon light source is always on and keeps stylet tip cold. Uses 2 AA batteries. System is completely reusable and sterilizable.

Allows for visualization during intubation through an air-Q laryngeal mask.

A portable, durable rigid stylet that allows for a fiber-optic view during intubation through the air-Q. Light source options include GreenLine laryngoscope handle or fiberoptic light source (4 AA batteries).

Able to elevate a large, floppy epiglottis and navigate through the oropharynx of patients with excessive pharyngeal soft tissue, midline obstruction, limited mouth opening, or fragile veneers on incisors.

Fixed-shape shaft with an adjustable eyepiece that allows ergonomic movement during intubation, in addition to an adapter for fixation of ETs and oxygen insufflation. Portable, rugged, and better maneuverability than the flexible FOB. Used with a battery-powered or fiber-optic light source.

Similar to Bonfils Retromolar Intubation Fiberscope.

Available with a standard eyepiece or a DCI for video cameras.

ET intubation, confirmation, extubation (with video); LMA placement, positioning, and intubation with certain LMAs. Provides access with limited mouth opening; malleable stylet provides shaping to reduce cervical movement.

Red LED provides better illumination than the white LED, and better transillumination when used like a light wand in cases when use of the scope is contraindicated because of blood or vomit.

Originally designed as an adjunct to direct laryngoscopy. Many use it as a stand-alone device similar to the Shikani for intubation, cric/trach tubes, LMAs, and intubation through LMAs or just positioning or checking placement of the same.

GreenLine laryngoscope handle or a Turbo LED can be used for light sources. Very similar to the SOS, but requires the user to cut the ET because it does not have a movable tube stop.

Allows for visualization during intubation through ILMA or quick confirmation of SGA, DLTs, or ET placement/ positioning patency. May also be used for extubation.

This device has been modified with a patented deflected tip that allows it to be used for viewing while performing nasal intubation.

Similar to Brambrink Intubation Endoscope.

Offers an improved view of glottis, simultaneous direct and endoscopic views, full visual control over passage of ET, and confirmation of final position. No need for extreme head extension or forced traction of laryngoscope. Can be rapidly assembled to use immediately. Not currently available in the United States.

Similar to flexible FOB. Can be used alone or as an adjunct to laryngoscopy and is especially useful for those unable to maintain skills with a bronchoscope.4

Has the simple form of a standard stylet, plus the advantage of a fiber-optic view and maneuverability of its tip.

Portable, rugged, and able to lift tissue. Light source options are light cable, Turbo LED or GreenLine laryngoscope handle with adapter.

3.5 mm, 4.0 mm, and 6.0 mm uncuffed tubes, and 5.0 mm cuffed tubes (Cook Medical). A Portex (Smiths Medical) emergency cricothyrotomy kit uses a Veress needle and integral dilator to insert a 6.0 mm cuffed ET. The Quicktrach (VBM Medizintechnik GmbH) is available for children and adults in 2.0 mm and 4.0 mm ID, respectively.

Surgical cricothyrotomy is performed by making incisions through the cricothyroid membrane using a scalpel, followed by the insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and speed is particularly important. text continues on page 10

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Table 3. Video Laryngoscopes Name (Manufacturer)

Description

Size

Berci-Kaplan DCI Video Laryngoscope System (Karl Storz Endoscopy)

Video laryngoscope system with interchangeable laryngoscope blades. Handles allow a DCI camera head to snap onto any standard eyepiece fiberscopes (flexible or semirigid). Required components include a camera control unit, xenon light source, and monitor. MediPack portable combination video/light source/monitor unit is also available for use with this system.

MAC 3 and 4, Dรถrges, and all Miller blade sizes.

C-MAC Video Laryngoscope (Karl Storz Endoscopy)

Instant on, battery-powered video laryngoscope with standard shaped, interchangeable Macintosh blades. Blades house high-resolution CMOS distal chip and LED technology. Real-time viewing on 7-in LCD monitor.

MAC 2, 3, and 4.

Dรถrges D-Blade (Difficult Airway Blade, Karl Storz Endoscopy), has angle of view that is approximately 80 degrees; acute curvature design.

1 adult size only.

CoPilot VL (Magaw Medical)

Next-generation video laryngoscope with an acutely angled blade and C-shaped channel for a bougie. The lithium polymer internal battery provides over 2 hours of continuous use. No buttons or settings.

Adult sizes 3 and 4.

Pediatric sizes available in late 2011.

GlideScope Cobalt AVL (Advanced Video Laryngoscope; Verathon Medical)

Portable video laryngoscope that includes a highresolution camera, antifogging mechanism to resist lens contamination, antiglare color monitor can be used with disposable blades or the new training blades.

Offered with 6 disposable blades ranging in size from 0 through 4.

Direct Intubation Trainer combines the characteristics of a standard Macintosh blade with AVL video technology. Digital video camera near end of blade and digital AVL color monitor. Embedded antifogging mechanism.

Comparable to a 3.5 Macintosh blade.

GlideScope Ranger and Ranger Single Use Video Laryngoscopes (Verathon Medical)

Portable video laryngoscope designed for EMS and Reusable Ranger offers 2 blade military paramedics. Compact and rugged. Opera- sizes, 3 and 4 (patient sizes, 22 lb to morbidly obese). Ranger Sintional in seconds. gle Use is offered with 6 disposable Stats ranging in size from 0 through 4.

GlideScope Video Laryngoscope (GVL) (Verathon Medical)

Video laryngoscope that includes high-resolution camera, antifogging mechanism to resist lens contamination, nonglare color monitor, and unique blade angulation.

GVL reusable offers 2 through 5 blade sizes.

King Vision Video Laryngoscope (King Systems)

Durable, fully portable, and affordable digital video laryngoscope with a high-quality reusable display and disposable blades.

One size, 2 versions, correlating to size 3 laryngoscope. Channeled blade allows use of 6.0 to 8.0 mm ET and min mouth opening of 18 mm. Standard blade requires min mouth opening of 13 mm.

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Clinical Applications

Special Features

Useful for anterior airways, obese patients, and patients with limited mouth opening or neck extension. Additionally useful for teaching purposes, verification of ET position, aiding application of external laryngeal manipulation, or passage of an intubating introducer. Recommend styletted or special ET. May also be used for nasal intubation and ET exchange.

The wide-angle camera allows improved visualization and video documentation of laryngoscopy and intubation.

Extreme positioning of the head is unnecessary. MAC 3 and 4 blades provide 45- and 60-degree angles of view, respectively.

Same as DCI.

Built-in still and video image capture on memory card.

Angled distal lens provides 45- to 60-degree angle of view. Inherent anti-fog design. Unit can be pole-mounted, inserted into waterproof field bag, or freestanding on easelback clamp. No special ETs or stylets needed. Can be used concurrently with battery charging. On-screen toggle brightness control facilitates use in low and bright ambient light conditions.

Designed for intubation of anterior airways that cannot be intubated with a standard or video Macintosh blade.

Has a familiar blade design and 80-degree field of view.

Same as DCI.

Patent-pending Bougie Port was designed to enhance glottic entry. A 14 Fr suction catheter, FOB, reusable rigid stylets, or regular malleable stylets may also be used via this port. A built-in heating mechanism helps prevent fogging.

Same as GVL. Airway views in digital video clarity enable swift intubation for a wide range of patients.

Integrated real-time recording, onboard video tutorial, and multiple configurations.

Real-time recording, onboard video tutorial, antifog mechanism to resist lens contamination, advanced resolution output to an external monitor, intuitive user controls and status icons, lightweight and easily transportable, impactresistant, durable polycarbonate-coated video screen. Disposable blades allow quick turnaround and help limit the possibility of cross-contamination.

Same as GVL. Ideal for teaching. A digital video camera near the end of the blade and the digital AVL color monitor allow instructors to watch and guide a direct laryngoscopic intubation as it happens.

Glidescope Direct intubation trainer facilitates teaching of direct laryngoscopy. Compatible with the Cobalt AVL video laryngoscope.

Ideal for EMS (ground and air), military, ED, ICU, and crash cart settings. Offers same benefits as the GVL and Cobalt systems.

Ranger models are compact, rugged, portable, and built to military and EMS specifications. Powered by rechargeable lithium polymer battery; 1.5 lb. Awarded US Army Airworthiness and US Air Force Safeâ&#x20AC;&#x201C;to-Fly certifications.

Reusable and disposable.

Useful for adult and pediatric airways, including preterm/neonatal and obese patients, bloody or anterior airways, and patients with limited neck mobility. Can be used for teaching purposes. Optimized for demanding applications in the OR, ED, ICU, and NICU.

Offers improved visualization and allows video documentation of laryngoscopy and intubation. The GlideRite Rigid Stylet is designed to complement the angle of the GlideScope GVL to help facilitate placement of an ET.

Facilitates both routine and difficult intubations.

Display is in-line with blade, ergonomic handle is integrated into blade, the disposable blades incorporate the camera and light source with each disposable, antifog coating on distal lens. Channel is soft, allowing easy ET detachment.

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Table 3. Video Laryngoscopes

(continued)

Name (Manufacturer)

Description

Size

McGrath MAC Video Laryngoscope (Aircraft Medical Ltd)

Blade sizes 2, 3, and 4.

New video laryngoscope designed for everyday use. The monitor is located on the handle to remain in a more natural line of sight with the patient.

McGrath Series 5 Video Laryngoscope (Aircraft Medical Ltd; distributed by LMA North America, Inc.)

Portable video laryngoscope with adjustablelength single-use disposable blade that can be disarticulated from the handle to further assist with difficult airways. The flatscreen monitor is located on the handle to remain in a more natural line of sight with the patient.

Adjusts to fit many adult and pediatric sizes.

The McGrath Series 5 HLDi is the new â&#x20AC;&#x153;High Level Disinfection Immersibleâ&#x20AC;? system that is entirely waterproof.

Pentax Airway Scope (Pentax Medical; distributed

by Ambu Inc.)

Wireless video laryngoscope with disposable transparent blade (Pblade) that has a suction port.

Has a 12-cm cable with CCD camera and 2.4-in LCD color monitor.

Fully portable, lightweight and compact system Truview PCD Video and with interchangeable laryngoscope blades. New Optical Laryngoscope (Truphatek International Ltd) 5-in LCD color monitor with picture capture device.

Video output for remote display and recording.

Rechargeable battery pack.

Venner AP Advance Video Laryngoscope (Venner Capital S.A.)

Fully portable video laryngoscope with 3.5-in monitor that attaches to a reusable handle.

Self-containing LED light source. Built-in antifogging mechanism.

TRACHEOSTOMY Tracheostomy (Table 10) establishes transcutaneous access to the trachea below the level of the cricoid cartilage.24 Emergency tracheostomy may be necessary when acute airway loss occurs in children under 10 years of age or children whose cricothyroid space is considered too small for cannulation, as well as in individuals whose laryngeal anatomy has been distorted by the presence of pathologic lesions or infection.25 Percutaneous dilatational tracheostomy is the most commonly performed tracheostomy technique, yet it is still considered invasive and can cause trauma to the

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One size only.

5 blade sizes: pediatric 0, 1, and 2; regular adult 3; large adult 4.

Mac 3 and 4, and Difficult Airway Blade.

tracheal wall. The Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical) incorporates a unique introducer to aid smooth insertion of the tracheostomy tube over a Seldinger wire. In addition, the Ciaglia Blue Rhino Percutaneous Introducer Set (Cook Medical) has a flexible tip dilator for less traumatic insertion. The slippery hydrophilic coating and tapered profile eliminate the need for multiple passes with increasingly larger dilators. The Ciaglia Blue Dolphin Balloon Percutaneous Tracheostomy Introducer has a unique balloon-tipped design that combines balloon dilatation and tracheal tube insertion into one step (Cook Medical).

Clinical Applications

Special Features

Its dual capability combines the benefits of a video-supported anterior view as well as a direct visualization to support a wide range of airways from routine to more difficult cases.

Does not require additional training. Supports direct and indirect visualization due to video support. Blade is very slimline for improved agility. Blade shape requires less tube curvature than other video laryngoscopes for easier insertion and a stylet is not always required. Highly portable and lightweight. Does not require an electrical outlet and thus is ideal for settings outside the OR. Uses disposable blades for quick turnaround between uses and for limiting crosscontamination. The monitor is located on the handle to remain in a more natural line. Entirely waterproof.

Useful in patients with limited mouth opening or head and neck movement, anterior airways; obese patients; in patients in whom an increased hemodynamic response is a concern; and for teaching purposes.

Highly portable and lightweight. Uses disposable blades for quick turnaround between uses and for limiting crosscontamination. An adjustable blade allows use of different blade lengths on the spot. Low-profile blade and disarticulating handle can accommodate patients with very limited mouth opening and severely limited movement of the head and neck. The monitor is located on the handle to remain in a more natural line of sight with the patient.

Similar to McGrath Video Laryngoscope. Useful for patients with limited neck mobility. Does not require alignment of the oral, pharyngeal, and laryngeal axis.

Ideal for prehospital use. Monitor permits viewing from various positions to facilitate all methods of intubation.

Additionally useful for teaching purposes.

Green target symbol on monitor display indicates direction of the tracheal tube tip. The Pblade comes with 2 channels: one allows safe placement and insertion of ET, and the other has a suction port through which a suction catheter can be passed. ET is attached to right side of the blade. The device, powered by 2 AA alkaline batteries, is portable with a 1-hour run time and 5-minute low-battery warning.

With a 42- to 47-degree blade angle, used in difficult pediatric and adult intubations of all grades, including patients with limited neck extension or mouth opening. Provides improved visualization of airway and tube placement. Delivers oxygen to prevent fogging and manages secretions. The image can be exported via USB or RCA output as a teaching tool.

Preformed memory stylets with ideal shape for indirect intubation technique provided in each set. Reusable.

Versatile and rugged system can be used with unaided vision through eyepiece, or with customized camera attachment and monitor.

Similar to CMAC video laryngoscope.

Can be used as traditional laryngoscope and converted to video laryngoscope by attachment of monitor.

Translaryngeal tracheostomy, a newer tracheostomy technique, is considered to be safe and cost-effective, and it can be performed at the bedside.26 It may be beneficial in patients who are coagulopathic.

Surgical tracheostomy is more invasive, and should be performed on an elective basis and in a sterile environment.

Conclusion Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. As

with any intubation technique, practice and routine use will improve performance and may reduce the likelihood of complications. Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.

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Table 4. Rigid Laryngoscope Blades Clinical Applications

Name (Manufacturer)

Description

Size

Special Features

Dörges Emergency Laryngoscope Blade (Karl Storz Endoscopy)

Developed in Europe as a universal blade that combines features of both the MAC and Miller laryngoscope blades.

One size only for patients >10 kg.

Blade is inserted into the oropharynx to the appropriate depth, which correlates with the patient’s size.

Has 10-kg and 20-kg markings on the blade.

Flexible tip or levering fiber-optic MAC laryngoscope blades are designed with a hinged tip controlled by a lever at the proximal end.

Designed to fit standard handles.

Adult sizes 3 and 4.

Pediatric size 2.

Controlled manipulation of large or floppy epiglottis. Also useful in patients with a recessed mandible and decreased mouth opening.

A lever controls the tip angle through 70 degrees during intubation to lift the epiglottis, if necessary, to improve laryngeal visualization.5

Adult sizes only.

Useful in patients with a recessed mandible and decreased mouth opening.

Modified MAC Blades AincA Flex-Tip FiberOptic Laryngoscope Blade (Anesthesia Associates, Inc.)

Flipper (Teleflex Medical) Heine Flex Tip Fiber-Optic Laryngoscope Blade (Heine USA, Ltd.) AincA Macintosh Viewing Prisms (Anesthesia Associates, Inc.)

An optically polished viewing prism for attachment to most Macintosh laryngoscope blades (conventional OR fiberoptic). Effectively repositions the practitioner’s viewpoint to the forward portion of the Mac curve via a 30-degree refraction without inverting the image. Clips to the vertical flange of the Mac to “look around the curve of the blade.”

Sizes 2, 3, and 4 for use on Macintosh laryngoscope blades of sizes 2, 3, and 4.

Allows viewing of the vocal cords even in a patient with an anterior airway position. Also useful during nasal intubation (with impaired view) and for postoperative examination of the larynx.

A built-in clip on each prism allows attachment to any Macintosh-type laryngoscope blade that has a standard thickness vertical flange.

Usable on both conventional and fiberoptic type Mac blades. Reusable and sterilizable.

Rüsch Truview EVO (Truphatek International Ltd; distributed by Teleflex Medical)

Indirect rigid laryngoscope with specially designed 42-degree blade curvature; fits onto all standard endoscopic camera heads. Provides clear, unmagnified view of the glottis. Oxygen channel for demisting, clearing secretions, and insufflation.

Adult, smalladult, and infant sizes.

Useful for difficult adult and infant airways, including patients with an anterior airway and limited neck extension.

Rugged, portable, easy to maintain.

Depth lines on the blade to guide insertion. Can be used with all fiber-optic laryngoscope handles. Designed to provide indirect laryngoscopy with continuous oxygen insufflation. Infant size features an LED light and rechargeable battery.

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Table 5. Indirect Rigid Fiber-Optic/Optical Laryngoscopes Name (Manufacturer)

Description

Size

Clinical Applications

Airtraq (Prodol Meditec SA, Spain; distributed by Airtraq LLC in the United States)

Disposable optical laryngoscope that provides a magnified angular view of the glottis without alignment of oral, pharyngeal, and tracheal axes. Includes a guiding channel to hold ET and direct it toward the vocal cords. Optional snap-on camera can be attached for viewing on external wireless monitor. Sizes are colorcoded to cover the full patient range for 2.5 mm to 8.5 mm ET.

7 versions available: regular adult for ET 7.0-8.5 mm; small adult for ET 6.0-7.5 mm; pediatric for ET 4.05.5 mm; infant for ET 2.5-3.5 mm; nasotracheal (adult and infant); and double-lumen endobronchial tubes.

Intended to facilitate intubation in both routine and difficult airway situations. Useful in all cases where ET tube intubation is desired.

Also appropriate for emergency settings, cervical spine immobilization, fiberscope guidance, tube exchange, and foreign body removal.

Totally self-contained disposable advanced airway device with built-in antifog system, and low-temperature light source. Can be used with standard ETs. Integral tracking channel allows ET to be directed without a stylet or bougie.

Bullard Elite Laryngoscope (Gyrus ACMI)

Most recent version of the Bullard laryngoscope and the only indirect fiber-optic laryngoscope that incorporates attachable metal stylets.

Adult and pediatric sizes (newborn/ infant and child).

Six methods of intubation have been described.8,9 Useful for anterior airways and patients with limited neck extension.

Has a working channel for oxygen insufflation, suction, and instillation of local anesthetics. Can be used with a conventional laryngoscope handle or fiberoptic light source.

Special Features

Abbreviation Key AEC AHA ASA CCD CMOS CPR DCI DISS DLT ED EF EMS ENT ET FOB Fr ICU ID ILMA

airway exchange catheter American Heart Association American Society of Anesthesiologists charge-coupled device complementary metal oxide semiconductor cardiopulmonary resuscitation direct coupled interface diameter index safety system double-lumen tube emergency department extra firm emergency medical services ear nose and throat endotracheal tube fiber-optic bronchoscope French intensive care unit internal diameter intubating laryngeal mask airway

ISO LCD LED LMA LT MAC NICU NTSC OD OR PPV PVC PVP SGA Stat TFE TTJV USB

International Organization for Standardization liquid crystal display light-emitting diode laryngeal mask airway laryngeal tube Macintosh neonatal intensive care unit National Television System Committee outer diameter operating room positive pressure ventilation polyvinyl chloride polyvinylpyrrolidone supraglottic airway sterile single-use blade tetrafluoroethylene transtracheal jet ventilation universal serial bus

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Table 6. Selected Supraglottic Ventilatory Devices Name (Manufacturer)

Description

Size

AES The Guardian CPV (AES, Inc)

All silicone laryngeal mask with a vented gastric tube and CPV that constantly monitors cuff pressure.

Adult sizes 3, 4, 5.

AES Ultra (AES, Inc)

All-silicone laryngeal mask with standard cuff valve.

Adult sizes 3, 4, 5, 6.

AES Ultra Clear (AES, Inc)

Silicone cuff and PVC tube, laryngeal mask with standard cuff valve.

Adult sizes 3, 4, 5, 6.

AES Ultra Clear CPV (AES, Inc)

Silicone cuff and PVC tube, laryngeal mask with cuff pilot valve (CPV) which constantly monitors cuff pressures.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra CPV (AES, Inc)

All-silicone laryngeal mask with CPV that constantly monitors cuff pressures.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra EX (AES, Inc)

All-silicone, multiple-use laryngeal mask (40 uses).

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra Flex CPV (AES, Inc)

Wire-reinforced, silicone cuff and tube with CPV which constantly monitors pressure changes in the cuff.

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

AES Ultra Flex EX (AES, Inc)

All-silicone, wire-reinforced, multiple-use laryngeal mask (40 uses).

Pediatric to adult sizes 1, 1½, 2, 2½, 3, 4, 5, 6.

air-Q Blocker Disposable Laryngeal Mask (Cookgas LLC; distributed

by Mercury Medical)

Combines the features of air-Q Disposable Laryngeal Mask, with an additional soft flexible guide tube located to the right of the breathing tube.

Sizes (2.5, 3.5, and 4.5) that can accommodate standard ETs up to 8.5 mm. Also available in kits with syringe and lubricant packet.

air-Q Disposable Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical)

Same features as air-Q Reusable Laryngeal Mask, except disposable.

Sizes (1.0, 1.5, 2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs up to 8.5 mm.

air-Q Reusable Laryngeal Mask (Cookgas LLC; distributed by Mercury Medical)

Hypercurved intubating laryngeal airway that resists kinking, and removable airway connector.

Anterior portion of mask is recessed; a larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet.

Sizes (2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs 5.5–8.5 mm.

Ambu AuraFlex (Ambu Inc.)

Disposable wire-reinforced flexible laryngeal mask airway.

Adult and pediatric sizes 2-6.

Ambu Aura-i (Ambu Inc.)

Laryngeal mask with built-in bite blocker designed as a conduit for endotracheal intubation.

Adult and pediatric sizes 1-6.

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Clinical Applications

Special Features

Similar to LMA Supreme, but with built-in CPV to minimize postoperative sore throat. Color indicator bands provide instant feedback regarding pressure changes.

The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.

Standard all-silicone SGA.

All silicone. Single use.

Combines all-silicone cuff with PVC tube for cost savings.

All-silicone cuff with PVC tube. Single use.

Similar to AES Ultra CPV.

Similar to AES Ultra CPV.

Similar to LMA Classic, but with built-in CPV to minimize postoperative sore throat. Color-indicator bands provide instant feedback regarding pressure changes.

The CPV detects changes caused by temperature, nitrous oxide levels, and movement within the airway, enabling clinician to maintain a recommended cuff pressure of 60 cm H2O. Single use.

Reusable, standard SGA.

40 uses.

Wire-reinforced SGA that accommodates repositioning of the head and neck. Color-indicator bands provide instant feedback regarding pressure changes.

Single use. The cuff pressure indicator detects changes caused by temperature, nitrous oxide levels, and movement within the airway. The CPV enables the clinician to maintain a recommended cuff pressure of 60 cm H2O.

Reusable, wire-reinforced SGA, designed to accommodate repositioning of the head and neck during surgery.

40 uses.

Enhanced version of the standard air-Q. It is indicated as a primary airway device when an oral endotracheal tube is not necessary or as an aid to intubation in difficult situations.

The soft guide tube allows access to the posterior pharynx and esophagus by supporting and directing medical instruments beneath the air-Q mask and into the pharynx and esophagus. Medical instruments especially suited are suction catheters, nasal gastric tubes up to size 18.0 Fr, and the newly designed air-Q Blocker tubes. The Blocker tubes are designed to suction the pharynx, or suction, vent and block the upper esophagus during use of the air-Q Blocker airway.

Removable color-coded connector allows intubation with standard ETs up to 8.5 mm.

Same as air-Q Reusable Laryngeal Mask.

Removable color-coded connector allows intubation with standard ETs up to 8.5 mm.

Similar to both LMA Classic and LMA Fastrach. Allows easy access for flexible fiber-optic devices. Use as routine masked laryngeal airway. Removable connector allows intubation with standard ETs up to 8.5 mm.

Designed to minimize folding of the cuff tip on insertion.

Same use and benefits as LMA Classic and LMA Fastrach.

Integrated bite block reinforces the tube while diminishing the need for a separate bite block. Color-coded removable connectors are tethered to the airway tube avoiding episodes of misplaced connectors.

Designed for use in ENT, ophthalmic, dental, and torso surgeries.

Integrated pilot tube, and high flexibility enables positioning away from the surgical field, without a loss of seal. Single use. EasyGlide texture and extra-soft cuff ease insertion and removal. Convenient depth marks for monitoring correct position of the mask.

Combines everyday routine use of supraglottic airway with direct intubation capability in case of difficult airway situations.

Anatomically correct curve designed as Ambu Aura once and Ambu Aura 40 but specially designed as a conduit for intubation. Compatible with standard ETs. table continues on next page

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Table 6. Selected Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

Ambu AuraOnce (Ambu Inc.)

A laryngeal mask with a special built-in curve that replicates natural human anatomy. It is molded in 1 piece with an integrated inflation line and no epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

Ambu AuraStraight (Ambu Inc.)

Similar to the LMA Unique but without epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

Ambu Aura40 (Ambu Inc.)

Same design as the Ambu AuraOnce, but reusable.

Adult and pediatric sizes 1-6.

Ambu Aura40 Straight (Ambu Inc.)

Similar to the LMA Classic. No epiglottic bars on the anterior surface of the cuff.

Adult and pediatric sizes 1-6.

Cobra Perilaryngeal Airway (Pulmodyne)

Large ID laryngeal tube, which is soft and flexible with a tapered, striated tip. Now has an improved distal curve, softer tube, and softer head. It has a high-volume, low-pressure oropharyngeal cuff.

Adult and pediatric sizes 1⁄2-6.

CobraPLUS (Pulmodyne)

Similar to the CobraPLA. Includes temperature monitor (all sizes) and distal gas sampling (pediatric sizes only: 1⁄2, 1, and 11⁄2).

Adult and pediatric sizes 1⁄2-6.

Esophageal Tracheal Combitube (Covidien)

A disposable DLT that combines the features of a conventional ET with those of an esophageal obturator airway. Has a large proximal latex oropharyngeal balloon and a distal esophageal low-pressure cuff with 8 ventilatory holes in between.

Two adult sizes.

41 Fr: height >5 ft.

37 Fr: height 4-6 ft.

Intersurgical i-gel (Intersurgical Inc)

Supraglottic airway with a noninflating cuff, designed to mirror the anatomy over the laryngeal inlet, with an integral bite block, buccal cavity stabilizer and a gastric channel. It also incorporates a wide-bore airway channel that can be used as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5).

Adult sizes (3-5) and pediatric sizes (1-2.5).

Adult sizes accommodate ET sizes 6.0-8.0 mm.

KING LAD (King Systems)

Family of disposable silicone and flexible laryngeal masks.

Adult and pediatric sizes 1-5 in silicone and 2-5 in flexible.

KING LT (King Systems)

Multiuse, latex-free, single-lumen silicone tube with oropharyngeal and esophageal low-pressure cuffs, 2 ventilation outlets, insertion marks, and a blind distal tip (almost like a single-lumen, shortened Combitube).16 Color-coded connectors for each size.

Sizes 3-5 available worldwide; sizes 0-2 currently available only outside the United States and Canada.

KING LT-D (King Systems)

Same design as the KING LT, except disposable.

Adult sizes 3-5 and pediatric sizes 2, 2.5.

KING LTS (King Systems)

Double-lumen laryngeal tube that incorporates a second (esophageal) lumen posterior to the ventilation lumen.

Adult sizes (3-5) and pediatric sizes (0, 1, 2, 2.5) currently available only outside the United States and Canada.

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Clinical Applications

Special Features

Allows easy access for flexible fiber-optic devices. For use in both anesthesia and emergency medicine.

Anatomically correct curve facilitates placement. One-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask.

MRI safe. Extra-soft cuff. If intubation becomes necessary or desired, recommend intubation over Aintree AEC. Single use.

For use in both anesthesia and emergency medicine.

Single-use, one-piece mold. EasyGlide texture for ease of insertion. Convenient depth marks for monitoring correct position of the mask. MRI safe. Extra-soft cuff.

Same as LMA Classic.

Same as LMA Classic, but reusable.

Same as LMA Classic.

Reusable. Available only in the United States.

Same as LMA Classic.

Disposable. If intubation becomes necessary or desired, will accommodate ET up to 8.0 mm. Single use.

Same as LMA Classic. An added benefit is the ability to measure core temperature. In addition, distal CO2 can be monitored in pediatric patients.

Similar to CobraPLA, but CobraPLUS allows monitoring of the patientâ&#x20AC;&#x2122;s core temperature. In neonatal and infant patients, CobraPLUS has the ability to increase the accuracy of end-tidal CO2 and volatile gas analysis. If intubation becomes necessary or desired, will accommodate ET up to 8.0 mm. Single use.

Same as LMA Classic but not contraindicated in nonfasting patients. Appropriate for prehospital, intraoperative, and emergency use. Especially useful for patients in whom direct visualization of the vocal cords is not possible, patients with massive airway bleeding or regurgitation, limited access to the airway, and patients in whom neck movement is contraindicated.

Ventilation is possible with either tracheal or esophageal intubation. Distal cuff seals off the esophagus to prevent aspiration of gastric contents. Allows passage of an orogastric tube when placed in the esophagus. Single use.

Indicated for use in routine and emergency anesthesia and resuscitation in adult patients. I-gel is not indicated for use in resuscitation in children. Can be used as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5). The gastric channel provides an early warning of regurgitation, allows for the passing of a nasogastric tube to empty the stomach contents and can facilitate venting of gas from the stomach (except size 1).

The non-inflating cuff allows easy and rapid insertion, provides high seal pressures and minimizes the risk for tissue compression. Gastric channel provides an early warning of regurgitation if it occurs. Buccal cavity stabilizer reduces the risk for rotation or displacement and the integral bite block prevents occlusion of the airway channel. The widebore airway channel also allows for use as a conduit for intubation with fiber-optic guidance (sizes 3, 4, and 5).

Similar to LMA Classic but disposable.

All silicone.

Same as LMA Classic, but with ventilatory seal characteristics like those of LMA ProSeal.

Easily inserted, possible aspiration protection, and allows both PPV and spontaneous breathing. Reusable (up to 50 times).

Same as KING LT.

Also available in a kit. Single use.

Same as KING LT, except that it has a second lumen for gastric access, similar to LMA ProSeal.

Allows easy passage of a gastric tube to evacuate stomach contents. Distal tip reduced in size to facilitate insertion.

Reusable. table continues on next page

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Table 6. Selected Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

KING LTS-D (King Systems)

Same as KING LTS, except disposable.

Adult sizes (3-5).

LMA Classic (LMA North America, Inc.)

Supraglottic ventilatory device that consists of an oval inflatable silicone cuff in continuity with a wide-bore tube that can be connected to an Ambu bag or anesthesia circuit. Designed to fit the pharynx of patients of various weights.

Adult and pediatric sizes 1-6, accommodating ET 3.5-7.0 mm.

LMA Classic Excel (LMA North America, Inc.)

The Classic Excel has the benefits of LMA Classic and an improved design to facilitate intubation.

Adult and pediatric sizes 3-5.

LMA Fastrach (LMA North America, Inc.)

Adult sizes 3-5 that can accomConsists of a mask attached to a rigid stainless steel tube curved to align the barrel aperture to the modate special ETs 6.0-8.0 mm. glottic vestibule. The set includes an LMA with a stainless steel shaft covered with silicone (reusable version) and a single movable epiglottic elevating bar, ET stabilizer, and silicone wire-reinforced ET. The single-use Fastrach is made from PVC and includes a disposable wire-reinforced ET.

LMA Flexible (LMA North America, Inc.)

Original LMA cuff design attached to smaller diameter, flexible armored tube that allows repositioning of the tube without cuff displacement. New single-use version is easier to insert.

Adult and pediatric sizes 2-6.

LMA ProSeal (LMA North America, Inc.)

Designed with a modified cuff and dual tubes to separate the respiratory and alimentary tracts. Has a built-in bite block.

Adult and pediatric sizes 1-5.

LMA Supreme (LMA North America, Inc.)

Adult and pediatric sizes 1-5.

Has a gastric drain tube designed to suction the stomach, channel gases and fluids away from the airway, and confirm placement of the tip of mask at upper esophageal sphincter. The airway tube has a gentle curve and oblong shape to allow easier insertion and more stable placement.

LMA Unique (LMA North America, Inc.)

Original, disposable LMA design. Sterile, latex-free, available with or without syringe and lubricant.

Soft cuff and airway tube allow for conformity to patients’ natural anatomy.

Rüsch Easy Tube (Teleflex Medical)

Disposable LT that combines the features of a con- Small 28 Fr; large 41 Fr. ventional ET with those of an esophageal obturator airway similar in design to the combitube.

Soft-Seal Laryngeal Mask (Smiths Medical)

Adult and pediatric sizes 1-5.

Similar in shape to the LMA Unique, but differs in its 1-piece design, in which the cuff is softer and there is no “step” between the tube and the cuff, an integrated inflation line, no epiglottic bars on the anterior surface of the cuff, and a wider ventilation orifice.

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Adult and pediatric sizes 1-5.

Clinical Applications

Special Features

Same as KING LTS.

Allows passage of 18 Fr gastric tube. Also available in a kit.

Although originally developed for airway management Reusable. of routine cases with spontaneous ventilation, it is now listed in the ASA Difficult Airway Algorithm as an airway ventilatory device or a conduit for endotracheal intubation.1,13 Can be used in both pediatric and adult patients in whom ventilation with a face mask or intubation is difficult or impossible. Can also be used as a bridge to extubation14 and with pressure support or PPV.15 Same as LMA Classic.

Removable connector and epiglottic elevating bar to facilitate intubation. Works with ET up to 7.5 mm. Reusable up to 60 times.

Useful for ventilation and intubation. Designed for blind orotracheal intubation but can be used in conjunction with lighted stylets, FOB, or Flexible Airway Scope Tool.

FOB recommended when using PVC ET.

Both reusable and disposable versions now available. Can be utilized as a blind or visually guided technique. Benefits include ability to intubate with larger ET and remove the device easily over the ET.

Particularly useful in ENT/head and neck procedures.

Both reusable and disposable versions now available. Airway tube resists kinking and cuff dislodgment, and thus may be positioned away from the surgical field without loss of seal.

Same as LMA Classic except drain tube also allows for evacuation of stomach contents.

Second cuff allows tighter seal for PPV. Reusable.

Same as LMA ProSeal.

A single-use LMA with a redesigned mask that achieves a 50% higher seal pressure than the Classic or Unique. Similar to all LMAs, the Supreme is designed to protect the airway from epiglottic obstructionâ&#x20AC;&#x201D;in this model with molded fins in the bowl of the mask.

Same as LMA Classic. Included in AHA 2000 Guidelines for CPR and Emergency Medicine Cardiovascular Care.

Single use.

Same as Esophageal Tracheal Combitube.

Similar to Combitube with following differences: single lumen at distal tip, soft latex-free cuff, open proximal second lumen allows use of fiber-optic device or passage of a suction catheter or tube exchanger. Single use.

Same as LMA Classic. Allows easy access for flexible fiber-optic devices.

If intubation becomes necessary or desired, will accommodate ET up to 7.5 mm. Single use.

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Table 7. Devices for Special Airway Techniques Name (Manufacturer)

Description

Size

DeVilbiss Model 15 Medical Atomizer (DeVilbiss Healthcare)

Metal atomizer; includes glass receptacle (for liquid), pair of metal outlet tubes extending from metal atomizing nozzle, and adjustable tip for directing spray to inaccessible areas of the throat.

Can be used with or without RhinoGuard tip cover.

Length: 10.5 in.

Enk Fiberoptic Atomizer Set (Cook Medical)

Atomizer set consists of a pressure-resistant oxygen tube and a connecting tube attached by a 3-way side-arm fitting with a small flow control opening. The set also contains an introducer catheter and 2 syringes (1-mL).

EZ-Spray (Alcove Medical)

Disposable atomizer device which comprises a plastic receptacle, atomizer nozzle, and gas inlet tube. Tubing is connected from an air or oxygen flowmeter nipple to the gas inlet tube on the device.

LMA MADdy Pediatric Mucosal Atomization Device (LMA North America, Inc.)

Pediatric Mucosal Atomization Device delivers intranasal/intraoral medications in a fine mist that enhances absorption and improves bioavailability for fast and effective drug delivery.

Typical particle size: 30 microns.

System dead space: 0.12 mL (with syringe), 0.07 mL (device only).

Tip diameter: 0.19 in (4.8 mm).

Applicator length: 4.5 in (11.4 cm).

LMA MADgic Laryngo-Tracheal Atomizer (LMA North America, Inc.)

Mucosal atomization device that incorporates a small flexible, malleable tube with an internal stiffening stylet that connects to a 3-mL syringe.

Typical particle size: 30-100 microns. System dead space: 0.25 mL and 0.13 mL. Tip diameter: 0.18 in (4.6 mm). Applicator length: 8.5 in (21.6 cm) and 4.5 in (11.4 cm).

LMA MADgicWand Pharyngeal Tissue Retractor/Atomizer (LMA North America, Inc.)

Disposable pharyngeal tissue retractor/atomizer that connects to a 5-mL syringe.

Typical particle size: 30-100 microns.

System dead space: 0.25 mL.

LMA MAD Nasal-Intranasal Mucosal Atomization Device (LMA North America, Inc.)

Disposable, compact atomizer for delivery of medi- Typical particle size: 30-100 cations to the nose and throat in a fine, gentle mist. microns.

System dead space: 0.13 mL and 0.07 mL. Tip diameter: 0.17 in (4.3 mm).

Applicator length: 1.65 in (4.2 cm).

Awake Intubation

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Clinical Applications

Special Features

Intended for the application of topical anesthetics to the nose, oropharynx, and upper airway of patients, at the direction/discretion of a clinician.

Includes glass receptacle for dispensing the liquid; adjustable swivel top and vented nasal guard attached to a hand bulb. Can be used with all types of oil or water solutions that are compatible with rhodium metal plating. The allmetal top can be autoclaved. Reusable.

To apply topical anesthetics to laryngotracheal area through the working channel of a bronchoscope using oxygen flow. Designed and intended to be used by those trained and experienced in techniques of flexible fiber-optic intubation.

Device is an accessory to a bronchoscope. Delivery form is a fine spray mist using oxygen flow through the working channel bronchoscope. Sterile. Single use.

Application of topical anesthetic to the nose, oropharynx, and upper airway of patients, at the direction/ discretion of a clinician.

Trigger-valve system provides controlled release of compressed gas to an atomizing nozzle, creating a liquid spray.

Gas flow is adjusted to the desired setting. Use with either oil- or water-based solutions. Nonsterile. Single use.

Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity.

Child-friendly and no sharps (bright colors in a toy-like presentation make the procedure less scary for young patients). Flexible (internal stylet provides support, malleability and memory). Disposable (single patient use, eliminates risk for cross-contamination). Practitioner-controlled (patient needs targeted specially by medication, concentration, position, and location).

Application of topical anesthetics to oropharynx and upper airway region. Fits through vocal cords, down LMA, or into nasal cavity.

Malleable applicator retains memory to adapt to individual patientâ&#x20AC;&#x2122;s anatomy. Delivery of a fine spray mist is generated by a piston syringe. Luer connection adapts to any luer lock syringe. Nonsterile. Single use.

Allows retraction of soft tissue while applying topical anesthesia in a fine, gentle mist. Used to apply topical anesthetic to the airway before awake intubation.

Device blade positioned along floor of the mouth can be directed immediately in front of laryngeal inlet to generate a fine mist by a piston syringe. Nonsterile. Single use.

Intranasal medication delivery offers a rapidly effective method to deliver selected medications to a patient without the need for a painful shot and without the delays in onset seen with oral medications.

Rapidly effective (atomized nasal medications absorb directly into blood stream, avoiding first-pass metabolism, atomized nasal medications absorb directly into the brain and CSF via olfactory mucosa to nose-brain pathway, achieves medication levels comparable to injections).

Controlled administration (exact dosing, exact volume, titratable to effect [repeat if needed], atomizes in any position, atomized particles are optimal size for deposition across broad area of mucosa). table continues on next page

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Table 7. Devices for Special Airway Techniques Name (Manufacturer)

(continued)

Description

Size

Reusable, contoured, good sealing facemasks with special capped port containing flexible silicone diaphragm that allows for endoscopy without interruption of ventilation.

Child, small adult, and large adult.

Face Mask Ventilation AincA Patil-Syracuse Mask (Anesthesia Associates, Inc.)

Endoscopy Mask Face mask with diaphragm to allow simultaneous (VBM Medizintechnik GmbH) ventilation and endoscopy.

Newborn, infant, child, and adult.

ErgoMask (King Systems)

Face mask with contoured finger/thumb grip.

Medium adult size.

Available as a complete set in 6.0 Fr or 14.0 Fr and includes Arndt Airway Exchange Catheter with Rapi-Fit adapter.

6.0 Fr=50 cm; 14.0 Fr=60 cm.

AincA Manual Jet Ventilator (Anesthesia Associates, Inc.)

Portable jet ventilation device with thumb depression mechanism which initiates a controlled burst of oxygen flow. Customizable assembly includes DISS inlet connection, 5 ft of inlet tubing, flow control knob, on/off thumb control, internal filter, back pressure gauge, and 2 ft of outlet hose ending in a Luer-Lok male fitting. Connects to any tool or port that has a Luer-Lok female connection (ie, malleable stylets, various adapters, etc).

Jet ventilation catheters of malleable copper with Luer fittings accommodate adults, children, and infants. Adapters allow direct connection to bronchoscope or ET.

AincA MRI Conditional 3.0 Tesla Manual Jet Ventilator (Anesthesia Associates, Inc.)

Similar to AincA Manual Jet Ventilator but MRI compatible.

Jet ventilation catheters of malleable copper with Luer fittings accommodate adults, children, and infants.

Enk Oxygen Flow Modulator Set (Cook Medical)

Complete set including 15-gauge needle with reinforced fluorinated ethylene propylene catheter, syringe (5 cc), connecting tubing, and Enk oxygen flow modulator with tracheal catheter connector.

7.5 cm (2.0 mm ID).

Manual Jet Ventilator (Instrumentation Industries)

Complete set includes an on/off valve, 6 ft of highpressure tubing, and 4 ft of small-bore tubing.

Jet ventilation catheter size 13G can accommodate adults, and 14G children.

Retrograde Intubation Cook Retrograde Intubation Set (Cook Medical)

Transtracheal Jet Ventilation

Manujet III Complete set including 4-m pressure hose, Luer(VBM Medizintechnik GmbH) Lok connecting tubing, bronchoscope adapter, Endojet adapter with Endojet catheter, and jet ventilation catheter.

Jet ventilation catheters can accommodate adults, children, and infants.

All in One Wadhwa Emergency Airway Device (Cook Medical)

22

Single device that looks similar to a pen. At one end of the â&#x20AC;&#x153;penâ&#x20AC;? is a needle with a 9 Fr cricothyrotomy catheter; on the other end is a nasopharyngeal airway catheter.

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

Cricothyrotomy catheter: 6.0 cm.

Nasopharyngeal catheter: 9.5 cm (7.0 mm ID).

Clinical Applications

Special Features

Simple technique that allows leak-free endoscopy while maintaining minimal interference with mask ventilation.

Useful for identifying anatomic landmarks, obstructions, conditions and growths. Often used in conjunction with an oral airway (Patil-Syracuse, Williams, or other) to aid endoscopy.

Choice of 3 durable materials (latex, neoprene, and silicone), available in various sizes and seal types. Silicone seal of the special port is extremely durable, but replaceable if damaged. When capped, functions like a normal mask.

Reusable and sterilizable.

• • • •

Available in different sizes and with different sized diaphragms for a perfect seal during endoscopy. Special Bronchoscope Airway available to protect equipment and aid endoscopy.

Fiber-optic intubation Airway endoscopy Gastroenterology Transesophageal echocardiography

Intended to facilitate 1-handed mask ventilation.

Encourages proper chin lift to open airway. Allows improved control of mask seal.

Ergonomically designed for better hand placement. Ventilation port off-center facilitates use with small hands and improves mask seal.

Technique used for securing a difficult airway, either alone or in conjunction with other alternative airway techniques. Especially useful in patients with limited neck mobility or patients who have suffered airway trauma. 6.0 Fr places tubes ≥2.5 mm ID; 14.0 Fr places tubes ≥5.0 mm ID.

Packaged as a complete kit with everything needed to perform a retrograde intubation. The recently added Arndt Airway Exchange Catheter allows for patient oxygenation and facilitates placement of an ET. Disposable.

Manual Jet Ventilation for oxygen saturation maintenance and usable for emergency direct TTJV and for laser throat surgery (elimination of plastic ET in laser path).

Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quickdisconnect types) as well as optional pressure regulator (with gauge) and standard or custom regulator-to-source connection hoses. Adapters, fittings, and connectors available. Completely reusable and sterilizable.

Similar to the AincA Manual Jet Ventilator, but fully certified for use in MRI suites with coil strength to 3.0 Tesla. Allows emergency oxygen saturation maintenance while determining how to solve airway issues.

Easy factory customization available for hose lengths and oxygen source connection type (DISS vs various quickdisconnect types). Adapters, fittings, and connectors available. Completely reusable and sterilizable.

Similar to the AincA Manual Jet Ventilator. Recommended for use when jet ventilation is appropriate but a jet ventilator is unavailable.

Packaged as a complete set with everything needed to perform TTJV. Disposable.

Same as Manujet III. Can also be used in unobstructed difficult airway management.

Offered with and without an adjustable pressure regulator to accommodate use on various-sized patients. Reusable.

Well-accepted method for securing ventilation in rigid and interventional bronchoscopy. Because airflow is generally unidirectional, it is important that air has a route to escape (unobstructed airway).

Packaged as a complete kit with everything needed to perform TTJV. The Endojet adapter allows jet ventilation on an ET, LMA, or face mask. The catheter can be pushed forward through the ET or LMA as far as required, and can be fastened with a screw. Includes a pressure regulator. Reusable.

Can be used for a needle cricothyrotomy, for TTJV, or as a nasal catheter.

The components require some preassembly. Once assembled, it is easy to transport to offsite locations and is intended for use in emergencies. The main body of the device acts as a blow tube or 15-mm adapter. Disposable.

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Table 8. Positioning Devices Name (Manufacturer)

Description

Chin-UP (Dupaco Inc.; distributed by Mercury Medical)

Hands-free airway support device used to lift up the patientâ&#x20AC;&#x2122;s chin and hold it in position to keep the airway open.

JED Jaw Elevation Device (Hypnoz Therapeutic Devices; distributed by LMA North America, Inc.)

New hands-free, noninvasive device that helps clinicians maintain an open airway during any procedure in which a patient is sedated and the airway may be compromised.

RAMP Rapid Airway Management Positioner (Airpal Patient Transfer Systems, Inc.)

Air-assisted medical device that can be inflated to transfer and position patients for various procedures.

Troop Elevation Pillow (Mercury Medical)

Foam positioning device that quickly achieves the headelevated laryngoscopy position (HELP). Includes many accessories (head cradle, arm board pads, addition pillow).

Table 9. Cricothyrotomy Devices Name (Manufacturer)

Description

Size

6 Fr reinforced fluorinated ethylene propylene catheter.

5.0 and 7.5 cm.

Melker Cuffed Emergency Cricothyrotomy Catheter Set (Cook Medical)

Same as Melker Emergency Cricothyrotomy Catheter Set.

9.0 cm (5.0 mm ID).

Melker Emergency Cricothyrotomy Catheter Set (Cook Medical)

Complete set including syringe (10 cc), 2- to 18-gauge introducer needles with TFE catheter (short and long), 0.038-in diameter Amplatz extrastiff guidewire with flexible tip, scalpel, curved dilator with radiopaque stripe, and PVC airway catheter. Also available in a Special Operations kit, which includes all of the above in a slip peel-pouch and 2 airway catheters.

Standard kit: 3.8 cm (3.5-mm ID), 4.2 cm (4.0-mm ID), and 7.5 cm (6.0-mm ID). Special kit: 4.2 and 7.5 cm.

Pertrach Emergency Cricothyrotomy Kit (Pulmodyne)

Contents include 2 splitting needles, cuffed or uncuffed Trach tube, dilator with flexible leader, twill tape, syringe, extension tube, and scalpel (optional).

Adult: 6.8 cm (5.6 mm ID).

Child: 3.9 cm (3.0 mm ID), 4.0 cm (3.5 mm ID), 4.1 cm (4.0 mm ID), and 4.4 cm (5.0-mm ID).

Needle Cricothyrotomy Emergency Transtracheal Airway Catheter (Cook Medical) Percutaneous Cricothyrotomy

Complete kit includes airway catheter, stopper, Quicktrach Emergency needle, and syringes that come preassembled.

Cricothyrotomy Device (VBM Medizintechnik GmbH)

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Adult (4.0 mm ID) and child (2.0 mm ID).

Clinical Applications

Special Features

Aids during monitored anesthesia care and total intravenous anesthesia sedation procedures.

Disposable polyurethane foam cushions.

OR procedures, MRI, recovery, FOB intubation, and interventional radiology, oral surgery, and endoscopy procedures.

Assists provider in maintaining an open airway in sedated or anesthetized patients without the need for additional instrumentation. Frees medical personnel from the need to hold the jaw manually in sedated patients. When left in place after a procedure, reduces postoperative airway complications. Noninvasive and easy to use. Reusable device with disposable pads.

Allows for the positioning of a patient for direct laryngoscopy, extubation, and central venous access. Enhances the safe apnea period, bag valve mask ventilation, and chest wall excursion.

Base of the RAMP is integrated with an Airpal platform (air-assisted lateral patient transfer and positioning device). Inflates and deflates, thus can remain in place during surgery and reinflate for extubation. Reusable.

Aids airway management for obese patients by aligning upper airway axes, and facilitating mask ventilation, laryngoscopy, direct laryngoscopy, and central venous access. Allows patients to breathe more comfortably during preoxygenation and regional anesthesia.

Available in disposable and reusable formats. Troop Elevation Pillow Addition may be added for super morbidly obese patients.

Clinical Applications

Special Features

A lifesaving procedure that is the final option for “cannot-ventilate, cannot-intubate” patients in all airway algorithms.

Designed to be kink-resistant specifically for the purpose of needle cricothyrotomy.

Same as Melker Emergency Cricothyrotomy Catheter Set.

Same as Melker Emergency Cricothyrotomy Catheter Set.

Same as Emergency Transtracheal Airway Catheter.

Intended to be used with the Seldinger technique via the cricothyroid membrane; however, it has the capability to be used as a surgical cricothyrotomy.

Packaged as a complete kit with everything needed to perform a percutaneous cricothyrotomy. The Special Operations kit comes in a slip peel-pouch for easy transport to offsite locations. Also can be used in the OR. It comes with 2 differently sized airway catheters to reduce the number of kits needed in the field. Disposable.

Use in failed orotracheal or nasotracheal intubation and/ Serves as an emergency cricothyrotomy or tracheostomy device that uses a patented splitting needle and dilator to or fiber-optic bronchoscopy. Immediate airway control in patients with maxillofacial, cervical spine, head, neck, perform a rapid and simple procedure. and multiple trauma. Also used when endotracheal intubation is impossible and/or contraindicated. Immediate relief of upper airway block.

Same as Melker Emergency Cricothyrotomy Catheter Set.

Packaged as a complete kit with everything needed to perform a percutaneous cricothyrotomy—even the neck tape and connecting tube. The removable stopper is used to prevent a “too-deep” insertion and avoid the possibility of perforating the rear tracheal wall. The conical needle tip allows for the smallest necessary stoma and reduces the risk for bleeding. Easily transported to offsite locations. Disposable. table continues on next page

A N E S T H E S I O L O G Y N E W S • M AY 2 0 1 1

25

Table 9. Cricothyrotomy Devices Name (Manufacturer)

(continued)

Description

Size

Surgical Cricothyrotomy There is no special kit for a surgical cricothyrotomy. It is performed by making an incision through the cricothyroid membrane using a scalpel, followed by the caudad insertion of an ET. This is the most rapid technique and should be used when equipment for the less invasive techniques is unavailable and when speed is particularly important.

Combination Percutaneous and Surgical Cricothyrotomy Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Medical)

Same as Melker Cuffed Emergency Cricothyrotomy 9.0 cm (5.0-mm ID).

Catheter Set for percutaneous technique. Also includes for surgical technique: tracheal hook, safety scalpel, Trousseau dilator, and blunt curved dilator.

Table 10. Tracheostomy Devices Name (Manufacturer)

Description

Size

Percutaneous Dilatational Tracheostomy Ciaglia Blue Dolphin Balloon Percutaneous Tracheostomy Introducer (Cook Medical)

Complete kit with size-specific Blue Dolphin balloon dilator. Available with or without Shiley 6 or 8 PERC tracheostomy tubes. A tray version is available that includes lidocaine/ epinephrine, 15-mm swivel connector, chlorhexidine skin prep, drape, and suture.

21, 24, 26, 27, 28, 30 Fr introducers.

Ciaglia Blue Rhino Percutaneous Introducer Set (Cook Medical)

Complete kit includes 24.0, 26.0, and 28.0 Fr loading dilators and Shiley 6 or 8 PERC disposable dual-cannula tracheostomy tube. A tray version is available that includes lidocaine/ epinephrine, connector, chlorhexidine skin prep, drape, needle driver, and suture.

74 mm (6.4-mm ID); 79 mm (7.6-mm ID).

Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical)

Complete set with or without a tracheostomy tube.

70.0 mm (7.0-mm ID); 75.5 mm (8.0-mm ID); 81.0 mm (9.0-mm ID).

Shiley TracheoSoft XLT Extended-Length Tracheostomy Tubes (Covidien)

Available in 4 ISO sizes (5.0-, 6.0-, 7.0-, and 8.0-mm ID). Each size offers the choice of cuffed or uncuffed stylets, and proximal or distal extensions. Disposable inner cannula; replacements sold in packages of 10.

90 mm (5.0-mm ID); 95 mm (6.0-mm ID); 100 mm (7.0-mm ID); 105 mm (8.0-mm ID).

Surgical Tracheostomy Surgical tracheostomies are performed by making a curvilinear skin incision along relaxed skin tension lines between sternal notch and cricoid cartilage. A midline vertical incision is then made dividing strap muscles, and division of thyroid isthmus between ligatures is performed. Next, a cricoid hook is used to elevate the cricoid. An inferior-based flap or Bjork flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall. Finally, the tracheostomy tube is inserted, the cuff is inflated, and it is secured with tape around the neck or stay sutures.

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I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G

Clinical Applications

Special Features

Same as Melker Emergency Cricothyrotomy Catheter Set.

One-half of the tray is the same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for the percutaneous technique. The other half of the tray includes all items necessary to perform a surgical emergency cricothyrotomy.

Clinical Applications

Special Features

One-step dilation and tracheal tube insertion. Establishes transcutaneous access to the trachea below the level of the cricoid cartilage by Seldinger technique.

Unique balloon-tipped design combines balloon dilatation and tracheal tube insertion into one step. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy.

Same as Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit.

Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The single dilator with a hydrophilic coating and flexible tip results in a simpler, less traumatic insertion. The wire guide has a SafeT-J tip to reduce trauma. Disposable.

Establishes transcutaneous access to the trachea below the level of cricoid cartilage. Allows for smooth insertion of the tracheostomy tube over a Seldinger wire.

Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy. The dilator is single-staged and prelubricated with an ergonomic handle to facilitate insertion. Disposable.

Flexible dual cannula tube for patients with unusual anatomy. Proximal length extension for thick necks; distal length extension for long necks, tracheal stenosis, or malacia.

The only fixed-flange extended-length tube with disposable inner cannula. Flexible inner cannula conforms to the shape of the outer cannula. Sixteen configurations to fit a wide variety of patients. Disposable.

A N E S T H E S I O L O G Y N E W S â&#x20AC;˘ M AY 2 0 1 1

27

References 1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology.

2003;98(5):1269-1277.

2. Miller CG. Management of the difficult intubation in closed malpractice claims. ASA Newsletter. 2000;64(6):13-19.

3. Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg. 2000;90(3):745-756.

4. Frass M, Kofler J, Thalhammer F, et al. Clinical evaluation of a new visualized endotracheal tube (VETT). Anesthesiology.

1997;87(5):1262-1263.

5. Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the levering laryngoscope. Anaesthesia. 1996;51(1):71-73.

6. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anesth.

2003;50(6):611-613.

7. Agro F, Barzoi G, Montecchia F. Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization (letter). Br J Anaesth.

2003;90(5):705-706.

8. Gorback MS. Management of the challenging airway with the Bullard laryngoscope. J Clin Anesth. 1991;3(6):473-477.

9. Bjoraker DG. The Bullard intubating laryngoscopes.

Anesthesiol Rev. 1990;17(5):64-70.

10. Wu TL, Chou HC. A new laryngoscope: the combination intubating device. Anesthesiology. 1994;81(4):1085-1087.

11. Verghese C. Airway management. Curr Opin Anaesthesiol.

1999;12(6):667-674.

12. Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology. 1996;84(3):686-699.

13. Patel P, Verghese C. Delayed extubation facilitated with the use of a laryngeal mask airway in the intensive care unit.

Anaesthesia. 2000;55(4):396.

14. Brimacombe J, Keller C, Hörmann C. Pressure support ventilation versus continuous positive airway pressure with the

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laryngeal mask airway: a randomised, crossover study of anesthetized adult patients. Anesthesiology. 2000;92(6):1621-1623.

15. Dörges V, Ocker H, Wenzel V, Schmucker P. The laryngeal tube: a new simple airway device. Anesth Analg. 2000;90(5): 1220-1222.

16. Gaitini LA, Vaida SJ, Somri M, Tome R, Yanovski B. A comparison of the Cobra, Perilaryngeal Airway, and Laryngeal Mask Airway Unique in spontaneously breathing adult patients.

Anesthesiology. 2004;101:A518.

17. Gupta B, McDonald JS, Brooks JH, Mendenhall J. Oral fiberoptic intubation over a retrograde guidewire. Anesth Analg. 1989; 68(4):517-519.

18. Sivarajan M, Stoler E, Kil HK, Bishop MJ. Jet ventilation using fiberoptic bronchoscopes. Anesth Analg. 1995;80(2):384-387.

19. Audenaert SM, Montgomery CL, Stone B, Akins RE, Lock RL. Retrograde-assisted fiberoptic tracheal intubation in children with difficult airways. Anesth Analg. 1991;73(5):660-664.

20. Klain M, Smith RB. High-frequency percutaneous transtracheal jet ventilation. Crit Care Med. 1977;5(6):280-287.

21. Enk D, Busse H, Meissner A, Van Aken H. A new device for oxygenation and drug administration by transtracheal jet ventilation. Anesth Analg. 1998;86:S203.

22. Safar P, Penninckx J. Cricothyroid membrane puncture with special cannula. Anesthesiology. 1967;28(5):943-948.

23. Safar P, Bircher NG. Cardiopulmonary Cerebral Resuscitation.

3rd ed. London, England: WB Saunders; 1988.

24. Wong EK, Bradrick JP. Surgical approaches to airway management for anesthesia practitioners. In: Hagberg CA, ed.

Handbook of Difficult Airway Management. Philadelphia, PA: Churchill Livingstone; 2000;209-210.

25. Gibbs M, Walls R. Surgical airway. In: Hagberg CA, ed.

Benumof’s Airway Management. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2007:678-696.

26. Sarpellon M, Marson F, Nani R, Chiarini L, Bradariolo S, Fonzari C. Translaryngeal tracheostomy (TLT): a variant technique for use in hypoxemic conditions and in the difficult airway [in Italian]. Minerva Anestesiol. 1998;64(9):393-397.

May 2 0 1 1

AnesthesiologyNews.com I 23

CLINICAL ANE STHE SIOLOGY

Blood Transfusion Speeds Recurrence of Ovarian Cancer New York City—A new retrospective study suggests that women who receive a blood transfusion during surgery for advanced ovarian cancer experience a shorter time to recurrence of tumors. Similar associations have been found in other malignancies, but the new work is the first to indicate such a connection with ovarian cancer.

“This is the most lethal cancer in women, so it might have big implications,” said the study’s lead investigator Gildasio S. De Oliveira Jr., MD, instructor in anesthesiology at Northwestern University Feinberg School of Medicine, in Chicago. “Even if you gain four months in those women, it is a big deal.”

Dr. De Oliveira said that previous work in malignancies such as colon cancer has indicated that blood transfusion could shorten times to recurrence (N Engl J Med 1993;328:1372-1376). In this study, he and his colleagues reviewed chart data for 143 patients who underwent cytoreduction surgery for stage III ovarian cancer.

Of the total cohort, 71 patients received perioperative blood transfusion and 72 did not. There were no differences between the two groups with regard to both patient and procedural characteristics. The median time to tumor recurrence was 13 months in the transfusion group and 24 months in the women who did not receive blood (P=0.01).

Transfusion was significantly associated with a decreased time to tumor recurrence, with a hazard ratio of 1.59 (95% confidence interval [CI], 1.082.34). Adjusting for other factors did not change the outcome, with a hazard ratio of 1.51 (95% CI, 1.01-2.23) for decreased recurrence time with transfusion.

“I think we need to examine this in more detail in the future in prospective studies to get a final answer,” said Dr. De Oliveira, whose group presented the findings at the 2010 PostGraduate Assembly in Anesthesiology (abstract P-9084). The researchers intend to launch larger studies in the near future.

Mark H. Ereth, MD, professor of anesthesiology at Mayo Clinic in Rochester, Minn., said the results with ovarian cancer are not surprising and join a growing body of literature suggesting the deleterious effects of blood transfusion. “Blood transfusion is actually a tissue of transplant, and as such it carries a lot of

immunologic implications for the recipient,” Dr. Ereth said.

Dr. Ereth said the mechanisms underlying the immune response to transfusion are not fully understood, but that transfusion of leukocytes contributes to immune suppression that induces a state in which the growth of cancer cells is not fully challenged.

This reason is one of many that have

prompted institutions, including Mayo, to move toward transfusion of leukoreduced red blood cells, he added.

“There are now dozens of studies that demonstrate superior patient outcomes with restrictive transfusion practices,” Dr. Ereth said. “In general, the less blood you transfuse, the better your patient outcomes. In the future we will hopefully be able to further define the

mechanisms of immune modulation with transfusion and then when transfusion is absolutely necessary, be able to design interventions to limit those effects.”

Until then, however, he stressed that efforts should be made in all clinical settings to minimize blood transfusion as much as possible.

—Dave Levitan

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1

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2 4 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

CLINICAL ANES THE S IOLOGY HES continued from page 1 Ludwigshafen late last year, had been withdrawn from the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.

“The references by Boldt should not now be regarded as valid evidence pending their review,” a statement posted on the association’s Web site read. “We shall undertake a thorough review of the recommendations of the guidelines to determine whether any

adjustments to them are needed.”

In Europe, changes in practice are evolving, said Jukka Takala, MD, PhD, director of intensive care medicine at University Hospital Bern, Switzerland.

But “it’s clearly too early to evaluate this in any objective manner,” he told Anesthesiology News.

Dr. Boldt, who has published nearly 350 articles, was a leading proponent of hetastarch (HES) as a volume expander for surgical and trauma patients. Many of his studies formed the basis of

clinical guidelines for HES therapy worldwide. But other studies have documented adverse effects from HES, including increased risk for bleeding, heart and kidney failure and anaphylactic shock (Anesth Analg 2011:112:635645). As a result, the debate over the efficacy and safety of colloid, crystalloid and even albumin solutions has been intense and long-standing.

Dr. Boldt was thrust into the research and publishing scandal in October 2010, when the journal

M7

‘You have to look at the published studies and ask what in them is good and what isn’t.

The parts that have been replicated by others and found to be true are probably true. The ones that seem too good to be true probably are not.’

—Howard Nearman, MD, MBA

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Anesthesia & Analgesia retracted a 2009 article of his over concerns of data manipulation and ethical lapses. Since then, investigators have been reviewing his research results. In March, a German medical board released a list of 88 articles for which it could not find evidence that Dr. Boldt had obtained proper approval from an institutional review board.

An international group of 16 anesthesiology journals subsequently announced that it was retracting those papers (Anesthesiology News, March 2011, page 1). Dr. Boldt faces criminal charges for allegedly fabricating research results and forging the signatures of other scientists on submitted papers. Dr. Boldt has not responded to the allegations.

Broader Use in Europe HES is a synthetic colloid that has been used for fluid resuscitation since the 1960s. Practitioners in Europe and other countries have used HES more often and for a wider range of conditions than have practitioners in the United States.

Several large clinical trials and other studies have found that HES does not improve clinical outcomes and impairs renal function and coagulation. Nevertheless, recent surveys of anesthesia and intensive care departments in Germany and Switzerland found that 70% to 80% of respondents believe that HES does improve outcomes (Eur J Anaesthesiol 2006;23:206).

“In Europe, there is a discrepancy between the narrow indication for which the [HES] products are labeled

May 2 0 1 1

AnesthesiologyNews.com I 25

CLINICAL ANE STHE SIOLOGY Dr. Shafer said he doubted the Boldt controversy would affect current clinical practice among U.S. anesthesiologists because newer colloidal solutions are used more sparingly here than they are in Europe and other countries. “However, the scandal may make it more difficult to broaden the label of existing colloidal solutions or bring new colloidal solutions into the U.S. market,” Dr. Shafer said.

“Because of the scrutiny from this scandal, I think the FDA may require

a very broad demonstration of safety across the full spectrum of indications, not just acute volume replacement, before permitting broadening of existing labels or introducing new volume expanders into the U.S. market,” he told Anesthesiology News.

Howard Nearman, MD, MBA, chair of anesthesiology and perioperative medicine at Case Western Reserve School of Medicine, in Cleveland, recommended keeping an open mind on HES. “You have to look at

the published studies and ask what in them is good and what isn’t. The parts that have been replicated by others and found to be true are probably true. The ones that seem too good to be true probably are not,” he said.

“If we are concerned about bleeding and coagulation,” Dr. Nearman said, “we probably ought not to use hetastarch solutions in those patients until we can verify the integrity of the data.”

—Ted Agres

FACE EVERY DIFFICULT INTUBATION WITH CONFIDENCE

and where safety has been demonstrated, and the much broader clinical use, much of which has been supported by investigator trials, such as the now discredited work of Joachim Boldt,” said Steven L. Shafer, MD, professor of anesthesiology at Columbia University and editor-in-chief of Anesthesia & Analgesia.

Still, many European practitioners have shied away from HES over safety concerns. “We discontinued the use of HES completely three years ago,” said Michael Bauer, MD, anesthesiologist and chief executive director of the Integrated Research and Treatment Center at the Center for Sepsis Control and Care, at Jena University Hospital in Germany.

In this country, the FDA approved Voluven in 2007 as a plasma volume expander for use during high–blood loss surgeries. Manufactured by German drugmaker Fresenius Kabi AG and marketed in the United States by Hospira Inc., Voluven is a “third-generation” HES solution. It is considered to be an improved and safer version because of its lower molecular weight and lower degree of substitution compared with earlier HES solutions.

“We have had some customer inquiries based on the current situation,” said Dan Rosenberg, a Hospira spokesman. “However, it’s important to note that the discredited scientist [Dr. Boldt] was not involved in the pivotal U.S. clinical trial that secured approval of Voluven in the United States.” Mr. Rosenberg declined to provide information about sales of the product before or after the controversy erupted.

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2 6 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

P OLICY & M ANAGE MENT Further on down the road …

Successful Anesthesiologists Must Embrace Innovation

M

aking predictions is dangerous. Nevertheless, it is possible to examine the pressures and trends that will influence the practice of anesthesiology. Like it or not, it boils down to business—or more basically, money. In this commentary, I have attempted to integrate certain business concepts into a discussion of the future of anesthesia.

I have highlighted the universal driver called money, discussed the so-called disruptive innovation effect and included a simple “SWOT” analysis. Horizontal and vertical integration, as well as demographics and anesthesiologist assistants (AAs), also are discussed.

A dedicated profession tries to eliminate—or at least keep reinventing—itself by solving the problems that created the need for its existence. Dentists, for example, pushed for fluoride in water to reduce caries.

Anesthesiologists have made anesthesia fairly safe over the past 20 to 30 years. Contributing factors have been standardization and safety lists. A pulse oximeter, capnograph, airway rescue devices and commonly needed drugs should always be at our fingertips or we are not ready. But, have we been too successful?

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Technology Marches On

T

he U.S. Postal Service lost almost 57,000 mail sorter jobs between 2004 and 2009; an additional 30% will likely be eliminated by 2018. More communication is being conducted by telephone, email and cloud computing, and less by “snail mail.”

Mail sorting also has become automated with robots replacing people.

Approximately 300,000 administrative jobs disappeared between 2005 and 2009. Technologies like voice mail have enabled professionals to do their own clerical work. Clerical positions likely will decline 23% in the next few years.1 (Who needs a file clerk when records are on a computer?)

In my experience, voice-recognition software is constantly improving and this will further affect how work gets done.

The legal profession is undergoing changes as a result of advanced software coupled with faster computers, leading to a slashing of costs involved in the lawsuit discovery process.2 So-called e-discovery software used by companies such as BlackStone Discovery (Palo Alto, Calif.) can analyze millions of documents at a fraction of the cost and time that it used to take an army of lawyers and paralegals to do.

Another software example is that used by the information-processing company Cataphora, based in Silicon Valley, which mines documents for activities and interactions between people. Using this software for example, one can search for anomalous behaviors of white-collar criminals that may have been used to hide activities.2 Let us also not forget that recently a computer called “Watson” defeated humans on the television game show “Jeopardy.”3 Technological advances extend beyond the realm of computers and software. What about the possibility of cold fusion?4 Two Italian scientists, Andrea Rossi and Sergio Focardi at the University of Bologna, recently announced that they had developed a cold-fusion device, although their claim is still being investigated. Another example is the reported completion of the first quantum machine.5 Theoretically,

the door now may have opened a crack toward achieving the capability of walking through walls or transporting objects—just like on “Star Trek.”

Speaking of “Star Trek,” the doctor characters were able to induce anesthesia with a delta-wave inducer, a small device placed over the forehead of a patient. Imagine the changes in anesthesia practice if such a device existed. The future of anesthesiology will likely bring changes even more surprising than those described here. As anesthesiologists, we should be open to disruptive innovations that can abruptly change our lives.

—Lowell Feinstein, DO, MBA

References 1. http://finance.yahoo.com/career-work/article/111881/careersheaded-for-the-trash-pile. Accessed April 4, 2011.

2. http://www.nytimes.com/2011/03/05/science/05legal.html.

Accessed April 4, 2011.

3. http://www.wired.com/epicenter/2011/01/ibm-watson-jeopardy/.

Accessed April 4, 2011.

4. http://www.physorg.com/news/2011-01-italian-scientists-coldfusion-video.html. Accessed April 4, 2011.

5. Cho A. The first quantum machine. Science. 2010;330:1604. http:// www.sciencemag.org/content/330/6011/1604.summary. Accessed April 4, 2011.

Reimbursement changes also can affect how anesIs this the reason that certified registered nurse anesthetists (CRNAs) and anesthesia technicians are pro- thesia is delivered. Do we need to be present in the viding care, and doing so quite adequately in many room the whole time for each case? Telemetry and streaming video allow us to “see” what is going on in instances? an operating room (OR). When managing patients Money the Driver classified as American Society of Anesthesiologists Money is a potent driver of the system. Take psy- (ASA) physical status I or II, could we be in charge of chiatry, for instance. Many psychiatrists no longer several rooms from a control desk with such devices? treat as many patients with “talk therapy.” Instead, Is our time actually being spent productively when we they prescribe medicine and send the patients to sit at the anesthesia machine for an extended period cheaper therapists. Part of the reason for doing this with a good regional block on a healthy patient? I susmay be insurance company reimbursement rates and pect our current system for anesthesia delivery and policies that discourage talk therapy in favor of drug supervision has as much to do with reimbursement see future page 28 therapy (which is likely to be cheaper).1

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2 8 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

P OLICY & M ANAGE MENT Future continued from page 26

sorters to nuclear scientists, including anesthesia providers (sidebar, page 26). rules as it does quality of care. If the Will the time come when a comrules for reimbursement change to puter is advising—or telling—anesallow more flexibility in the system, thesiologists what to do in the OR for I have no doubt that we will indeed every scenario encountered? Systems change how we deliver anesthetics and already have been developed in which supervise our cases. a device titrates propofol for anesthesia induction and maintenance is guided Technology and by the Bispectral Index monitor (BIS Disruptive Innovation monitor, Covidien).2 Another examTechnological advances are affect- ple is the FloTrac sensor–Vigileo moning virtually all disciplines from mail itoring system (Edwards Lifesciences),

which displays continuous cardiac output, stroke volume, stroke volume variation and systemic vascular resistance through an existing arterial line— replacing the Swan-Ganz catheter, in most circumstances.

The new pulse oximeters deliver information on hemoglobin, total arterial oxygen content, perfusion index, carboxyhemoglobin and methemoglobin, in addition to oxygen saturation and fluid responsiveness. Ultrasound devices can generate three-dimensional

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According to a meta-analysis that evaluated strategies to avoid epidural vein cannulation, “the effect size is so large that other techniques for reducing the risk of intravascular cannulation may be irrelevant if a wire-embedded polyurethane catheter is used.”1

Trust the evidence: Catheter design matters. Teleflex’s Arrow ® FlexTip Plus Epidural Catheter with its unique wire-embedded polyurethane design has been clinically proven to virtually eliminate the incidence of intravascular cannulation1,2,3 and effectively reduce transient paresthesia.2,4 The FlexTip Plus Difference: A wire-embedded polyurethane design. Other springwound catheters are made of nylon. When compared to nylon catheters, this unique design was associated with: 3,4

images of such good quality that almost anyone with virtually no special training will be able to administer a nerve block.

Another new technology is photoacoustic imaging, which combines optical imaging with ultrasound,3 making it possible to see the oxygen saturation of various tissues in real time.4 Anesthesiology SWOT Analysis Many companies have evaluated their businesses and environments using a SWOT analysis that breaks things down into four categories: strengths, opportunities, weaknesses and threats. A SWOT analysis of the practice of anesthesia is shown in Table 1. Some items fall into more than one category; however, if the diagram helps pinpoint the issues, it has served its purpose. Such an analysis is important when we think about positioning ourselves for the future. The following discussion only touches the surface and is admittedly arbitrary, but is a useful starting point.

Strengths Anesthesiologists are usually good at critical care—even those who have not trained specifically in a critical care fellowship. It is part of what we do. Similarly, we are routinely deeply involved in patient resuscitations. Anesthesiology often is cited as the model for safety improvement. We have succeeded at decreasing morbidity and mortality by using better monitoring techniques and standardizing the techniques we employ.

Although it is not always the case, we are generally present in the hospital for long hours at a time, unlike some of the other specialists—for example, surgeons who may be on-site for particular cases and internists and surgeons who conduct patient rounds and leave.

3,4

Table 1. A SWOT Analysis of the Practice Of Anesthesia

1,2,3,4 4 3,4

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1. Mhyre, Jill M., et al. A Systematic Review of Randomized Controlled Trials That Evaluate Strategies to Avoid Epidural Vein Cannulation During Obstetric Epidural Catheter Placement. Anesthesia & Analgesia 2009; 108 (4): 1232-1242.

2. Banwell B.R., et al. Decreased incidence of complications in parturients with the Arrow (FlexTip Plus™) epidural catheter. Canadian Journal of Anaesthesia 1998; 45 (4): 370-372.

3. Cohen S., et al. Sutured Epidural Catheter for Epidural Block in obstetric Patients:“Arrow” versus “B. Braun”. Anesthesiology 2006;105: A904.

4. Cohen S., et al. Arrow versus B. Braun Epidural Catheter for Epidural Block in Obstetric Patients. Anesthesiology 2004; 101: A1199.

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Strengths Critical care Resuscitation Demonstrated safety Full-time presence?

Opportunities Teaching Print media, television, radio ICU OR management Demographics AAs AAs, anesthesiologist assistants; CRNAs, certified registered nurse anesthetists; ICU, intensive care unit; OR, operating room

May 2 0 1 1

AnesthesiologyNews.com I 29

POLICY & M ANAGEMENT Anesthesiologists need to capitalize on these areas of strength.

Opportunities As involved and proficient as anesthesiologists are in critical care and resuscitation, shouldn’t we be getting more attention in the hospital— even in the media—by teaching in the community and making appearances on television or radio? In smaller or medium hospitals without dedicated critical care staff, shouldn’t we be more involved? Another opportunity for anesthesiologists is in OR management. Given the importance of the OR as a revenue-generating area, we need to be better versed in its management. Why aren’t anesthesiologists regularly consulted on decreasing the length of hospital stays? Our techniques for patient-controlled analgesia, epidurals and newer blocks can make a major impact. We should be training our residents better in these areas, and perhaps even including some cost-accounting training. Our expertise and input can be valuable to hospital management.

Demographics are extremely important for predicting the need for services; these data can be used to capitalize on opportunities. The U.S. population comprises an increasing percentage of older individuals5 who are obese,6 diabetic7 and hypertensive.

Many of them will develop kidney failure.8 Less than 50% of adults get regular exercise.9 Unfortunately, the current medical system only reinforces the irresponsibility that contributes to these conditions (except aging) in the population. Is there a place for anesthesiologists to get involved with these issues?

A more controversial topic is the employment of AAs. Unlike CRNAs in some states, AAs require supervision, but can be used as “physician extenders.”

Weaknesses Unknown reputation or entity High cost Low expertise Poor attendance

Threats Legislative Economic CRNAs Technology “Ourselves”

Weaknesses In my experience, anesthesiologists do not always have the best reputation among the population at large. Typically, it is not really a negative view of us as much as a perception that we are “unknown soldiers.” I have seen surgeons blame the anesthesiologist for many of their own (iatrogenic) problems. Sometimes this has even been communicated to the patient. But, a larger problem is that patients are unaware of our contributions because

we are not the primary service and may not have had a lot of interaction with the patient.

Ironically, this is why some of us went into the field. Many of us are not called “gas passers” for nothing. There are anesthesiologists who have become technicians, having forgotten much of the knowledge that was needed to pass the boards. The money driver has pushed some of us in the direction of “do many cases, interact little with the patient, make money and go home.” We have

allowed ourselves to follow the laws of thermodynamics; we have found the lowest energy level and stayed there. Politics, however, is a fact of life. It is important that anesthesiologists be involved in hospital committees. It needs to be seen that our expertise is valuable to the hospital administration.

Threats It is no secret that many anesthesiologists feel their livelihood is threatened. see future page 31

3 0 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

P OLICY & M ANAGE MENT

Can Gainsharing Impact Cost Savings in the ICU? Hospital-wide analysis hints at impressive rewards

I

n 2006, Beth Israel Medical relative to their own historical baseCenter in New York City impleline or if they reach a certain benchmented a pay-for-performance mark, such as performing in the top system that provides financial incenquartile compared with their peers at tives to attending physicians in an Beth Israel. effort to reduce hospital costs while “In the beginning, we were a little maintaining quality of care. bit lax about what we paid the docThe gainsharing program, which tors. We were just interested in gethas saved the hospital millions ting them to buy into the program,” of dollars and generated substanhe said. “However, we’ve slowly been tial dividends for doctors, initially making the criteria for payment included physicians and surgeons more stringent. We’re pushing to get but not intensivists, said David Berpatients’ length of stay down even nard, MD, Beth Israel’s chief medical more, and we’re trying to get all of officer. But administrators wondered the physicians to reach the 25th perwhether extending it to clinicians in centile benchmark.” the intensive care unit (ICU) would Although Dr. Bernard said he reap similar rewards. is confident that he and his team “We hope that by adding intensivhave incorporated safeguards, quesists to the gainsharing program, we tions remain regarding whether it can help to bring down ICU costs,” can effectively reduce costs withDr. Bernard explained. Intensivists out harming quality of care. “Not joined the program in late 2010. every physician has agreed to be part To examine the impact of gainof the program, with some citing sharing on cost, Dr. Bernard and colpotential legal ramifications as the leagues conducted a retrospective primary inhibitor,” he noted. Others analysis of 9,034 adults admitted to are uncomfortable with telling their the medical and surgical ICUs, as well patients that they’re part of a proas the coronary care unit, between gram that offers financial incentives July 2006 and December 2009. to physicians who discharge their “We found that total hospital patients early, as each hospital run‘Traditionally, we took the view that the discharging costs—mostly related to shorter ning the project is required to prooverall hospital stay—decreased by vide patients with a notice of their doctor owned the patient and was responsible for millions for these admissions,” said participation. Despite these contheir care—both on the quality side and the efficiency Dr. Bernard, who presented his findcerns, Dr. Bernard said almost all of ings at the 2011 annual meeting of the hospital’s physicians have signed side. However, we predict that intensivists can the Society of Critical Care Medon. icine, in San Diego (abstract 109).

“Physician interest and participacontribute to a patient’s overall length of stay.’

Dr. Bernard said he could provide a tion has also been high in The New more precise number for the savings.

Jersey Care Integration Consortium’s —David Bernard, MD However, the benefits of gainshar[which is made up of NJHA and 12 ing in other areas of the hospital did hospitals] gainsharing demonstranot trickle down to the ICU, Dr. Bernard said. In fact, Dr. Bernard said intensivists were not previ- tion project,” said Sean Hopkins, senior vice president average ICU costs rose by $0.9 million, or 32%, dur- ously part of the program because they don’t dis- of the New Jersey Hospital Association, in Princeing the study period. charge patients from the hospital. “Traditionally, we ton. Almost across the board, hospitals are reporting The researchers assumed that patients who had took the view that the discharging doctor owned a more cohesive interaction with their participating received a tracheostomy and were undergoing pro- the patient and was responsible for their care—both physicians and improvements are being achieved, he longed ventilation were the most significant cost cen- on the quality side and the efficiency side,” he said. said. And physicians are reacting positively to the ter, and thus presented the greatest opportunity for “However, we predict that intensivists can contribute early incentive payments. savings, estimated at up to $1.7 million. This group to a patient’s overall length of stay.”

A common obstacle to improving hospital quality averaged $67,000 in ICU costs per patient, said Dr. and controlling costs is this misalignment of hospiAn Eye on Early Discharges Bernard, but accounted for only 0.8% of the total tals and their medical staffs, Mr. Hopkins said. This number of admissions. Patients with septicemia repA critical part of the program is to run a quality dissonance is best exemplified by disparate attitudes resented another source of potential savings as did profile on all doctors before they are paid their share, regarding the discharge of patients, he said. Physithose recovering from bowel surgery, each $0.4 Dr. Bernard said. “In order to ensure physicians aren’t cians want to keep patients in the hospital for as long million. discharging patients too early, only to have them be as possible, so they can continue to charge for visits.

“Just as we have done with other physicians and sur- readmitted, we developed a profile of quality met- Hospitals want to discharge the patients as quickly geons in the program, we plan to take costs of care in rics—if we run a physician through and there’s evi- as possible. “Gainsharing aims to bridge the gap the ICU in one quarter and compare it to the next,” dence that the quality of care has decreased, he between these two very different philosophies,” he Dr. Bernard explained. “It’s going to be fascinating doesn’t get paid,” he said. said. to see what happens. We should know within a year Physicians are paid in one of two ways: if they demwhether or not it has been effective,” he said. onstrate a reduction in costs based on performance —Michelle Grey Campion

May 2 0 1 1

AnesthesiologyNews.com I 31

POLICY & M ANAGEMENT Future continued from page 29

employees that does billing for other patient activities).12 Legislative changes have allowed states Increased market power translates to to opt out of requiring supervision of leverage in setting prices and negotiating CRNAs. The economic implications with the hospital, insurance firms and of this and the fact that we almost got so on. Customer perceptions of linkhit with nearly a 27% Medicare cut last ages between services can add perceived January has sent tremors through the value to your services overall.12 An excellent pain service with its renowned repprofession.10 I have already mentioned technol- utation, for example, enhances the ogy as a threat; “ourselves” is listed as perception of the rest of the anesthesia a threat for a reason. The insurance group in the minds of both patients and companies probably love the infight- hospital administrators. ing among various anesthesia providers. It is too easy to blame everyone and everything for our problems. I once played trumpet in a school band with a boy who would hit his trumpet when he played a wrong note, as if it was the trumpet’s fault. But change must not be viewed only as a threat.

Anesthesiologists need to take advantage of change. Successful companies are good at this. For instance, some manufacturers are continually innovating their products and cannibalizing their current ones. They stay ahead of the curve and simultaneously keep their competitors at bay. Companies that hang on to old products or ways get swept away fast.

Defining your product or service too narrowly also is a mistake. The buggy whip is the often-cited example: If buggy-whip manufacturers had viewed their business as one of leather goods accessories for transportation and not just as a product for horses, some of the companies would still be around today, making products for the automobile industry instead.11 Horizontal and Vertical Integration Horizontal Horizontal integration is the branching out of business activities at the same level. It need not be limited to internal expansion; external activities also are possible. Whereas a business may feel safer expanding into related areas, unrelated areas that bring diversification fit the definition. Examples are BP acquiring other refineries or a magazine firm buying a television station.

There are several benefits from horizontal integration. First, it makes economies of scale possible. For instance, if someone purchased a license for anesthesia charting software, the addition of a second station may be free or low cost compared with the initial expenditure.

Economies of scope—a similar benefit—apply to more diverse activities.

They often are referred to as synergies (e.g., the same group of billing

or downstream (acquiring users).13 A recent example was the purchase of Kinko’s by FedEx in order to have more locations for FedEx services. A hypothetical example would be an oil refinery purchasing a chain of gas stations.

Stark laws (pertaining to physician self-referrals) limit many applications of vertical integration in anesthesia practices. Another considVertical eration involves so-called transaction Vertical integration refers to expan- costs (i.e., will the expected income see future page 32 sion upstream (acquiring suppliers)

Anesthesiologists might consider some of the following horizontal moves. Can we run more rooms, more locations or use technology like telemetry to expand our coverage? Should we cover the intensive care unit (ICU) or expand our pain service to hospices?

Be aware that anticipated economic gains do not happen overnight.

3 2 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

P OLICY & M ANAGE MENT managing. As mentioned, we are in a Table 2. AAs Currently Work in 17 States and Washington, D.C. good position to run the OR, and anes- Alabama New Mexico from owning the supplier or user be thesiologists are doing it now at some Colorado North Carolina enough to offset the additional trans- facilities. After all, we may be in-house 13 District of Columbia Ohio action costs of running it?). It may be all the time, compared with part-time cheaper just to purchase the product or surgeons who may have conflicting Florida Oklahoma service. (I do not know of many den- interests. Because anesthesiologists can Georgia South Carolina tists who own their own dental labo- be employed by the hospital without Kentucky Texas ratory.) Essentially, if we acquire a new any outside interests, we can be the business in the same industry, do we dedicated team needed.

Michigan Vermont have the expertise to run it?

Other hospital areas to consider man- Missouri West Virginia Still, there are areas in the hospital aging (if it’s not being done already) are New Hampshire Wisconsin that anesthesiologists might consider the pre-op clinic, recovery room, pain

Future continued from page 31

AAs, anesthesiologist assistants

control and ICU. Of course, the issue is whether we can get paid for these services. There is evidence to support the involvement of anesthesiologists in the ICU. Mortality rates have been shown to be significantly lower in those hospitals where patients in the ICU are cared for by physicians who are either boardcertified intensivists or have completed training in anesthesia.14 Anesthesiologist Assistants The subject of nonphysician anesthesia providers continues to be raised as an issue, given that not all clinicians agree on the value and service they provide. States being allowed to opt out of requiring supervision of CRNAs has been in the news, although the topic is hardly new: Take a look at the following excerpt from a letter to the editor in 1933: “The future of anesthesiology as a medical specialty in our country depends entirely upon whether or not the American medical profession is sufficiently ethical to keep the practice of medicine in the hands of physicians.

This truth applies with particular force to the medical anesthetists who have yielded to pressure and are teaching or supervising technicians. Anesthetists must not only be physicians, they must be ethical physicians.”15 AAs are not to be confused with CRNAs. AAs function as specialty physician assistants under the direction of a licensed anesthesiologist only.

As such, they can function in the hospital setting like a CRNA. AAs complete prerequisite coursework in biology, inorganic and organic chemistry, biochemistry, physics and calculus. They must obtain a baccalaureate degree (preferably in science) and then train for approximately 27 months to earn a master’s degree in science. Finally, they must pass a certifying examination to become an AA. According to the ASA Web site, AAs are “qualified members of the anesthesia care team” and

May 2 0 1 1

AnesthesiologyNews.com I 33

POLICY & M ANAGEMENT “highly qualified non-physician anesthesia providers who assist anesthesiologists in implementing an anesthesia care plan developed for the patient.”

AAs are recognized by the Centers for Medicare & Medicaid Services, the Department of Veterans Affairs (VA), and the military health care program TriCare. Currently there are approximately 1,800 AAs practicing in 17 states and the District of Columbia (Table 2).16 On the Web site of the American Academy of Anesthesiologist Assistants,17results from a four-year study at University Hospitals in Cleveland are quoted, in which more than 46,000 cases involving AAs and CRNAs (23,000 cases each) were compared. No difference in complication rates was found between the two groups. Professional liability insurance carriers treat AAs and CRNAs similarly. Several years ago, the job of AA was ranked as 15th best in America by CNN. Over the next decade, the number of such physician extenders is expected to increase.

Conclusion Anesthesiologists must acknowledge the pressures and adapt to changes rather than hanging on to old patterns of practice. We must take an active part in changing the way we practice and not be too restrictive in how we define ourselves and our roles (keeping in mind the fate of the buggy-whip makers). In this regard, we need to fully immerse ourselves in the perioperative management of patients, from pre-op through post-op care. Preoperatively, the anesthesiologist should be able to perform thoracic echocardiography on patients if needed, instead of waiting for the cardiologist to do it. Similarly, we need to be adept at administering blocks needed to reduce postoperative pain and hospital length of stay. Anesthesiologist training programs need to address these issues and perhaps even reduce the number of graduates if necessary. If we are not active in this transition, we risk being a victim of it.

—Lowell Feinstein, DO, MBA Dr. Feinstein is director of post-anesthesia recovery at Stroger Hospital of Cook County, in Chicago.

References 1. http://www.nytimes.com/2011/03/06/health/ policy/06doctors.html. Accessed March 31, 2011.

2. Liu N, Chazot T, Genty A. Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual

control: a prospective, randomized, multicenter study. Anesthesiology. 2006;104:686-695.

3. http://arstechnica.com/science/news/2011/01/photoacoustic-imaging-beyond-my-wildest-dreams.ars.

Accessed March 31, 2011.

4. http://www.visualsonics.com/photoacoustics.

Accessed March 31, 2011.

5. Interim state projections of population for five-year age groups and selected age groups by sex: July 1, 2004 to 2030. U.S. Census Bureau, Population Division, Interim State Population Projections, 2005. www.census.gov/population/www/projections/ files/filelayout.doc. Accessed March 31, 2011.

6. http://www.cdc.gov/vitalsigns/AdultObesity/ StateInfo-large.html#AdultObesity. Accessed March 31, 2011.

7. http://www.cdc.gov/brfss. Accessed March 31, 2011.

8. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm5942a2.htm?s_cid=mm5942a2_w. Accessed March 31, 2011.

9. http://www.cdc.gov/datastatistics/dsphysical Activity/. Accessed March 31, 2011.

10. http://www.beckersasc.com/anesthesia/congressacts-at-last-no-cuts-in-medicare-payments-to-anesthesiologists-in-2011.html. Accessed March 31, 2011.

11. http://open.salon.com/blog/lyle_bateman/​2009/​ 10/​07/magazine_death_the_modern_buggy_whip.

Accessed March 31, 2011.

12. http://www.quickmba.com/strategy/horizontal-­ integration. Accessed March 31, 2011.

13. http://www.quickmba.com/strategy/vertical-­ integration. Accessed March 31, 2011.

14. http://www.leapfroggroup.org/for_hospitals/­ leapfrog_hospital_survey_copy/leapfrog_safety_ practices/icu_physician_staffing. Accessed March 31, 2011.

15. Palmer CB. The future of anesthesiology as a medical specialty. Cal West Med. 1933;39:148-150.

16. http://www.anesthesiologistassistant.com/articles/.

Accessed March 31, 2011.

17. http://www.anesthetist.org/factsaboutaas/patientsafety.iphtml. Accessed March 31, 2011.

3 4 I A n e s t h e s i o l o g y N e w s . c o m May 2 0 1 1

P AIN M EDICINE

Opioid Abuse Common Among Former NFL Players Experts say professional sports culture cultivates opioid misuse and abuse; league doctor challenges findings

N

early three-fourths of NFL players who used opioids for pain relief during their careers misused them, according to a study of former professional football players.

The study also found that 7% of former players currently use opioid painkillers—three times the rate of the

general population—and that of the players who misused or abused opioids during their career, 15% still do so in retirement.

The study’s findings—which cover pain, opioid use and current health status of former professional football players—describe a “cycle of injury, pain

Closed.

and re-injury [that] could lead to subsequent pain pill use” and “result in later life disability, continued pain and misuse of prescription pain pills,” the study’s authors, led by Linda Cottler, PhD, MPH, professor of epidemiology in psychiatry at Washington University in St. Louis, wrote.

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A recent spike in interest in concussions among NFL players has led to several studies in that area; however, this is the first to look at opioid abuse among former NFL players.

“The concussion issue is the tip of the iceberg,” said Thomas L. Schwenk, MD, professor and chair of family medicine at the University of Michigan in Ann Arbor and associate director of the university’s multidisciplinary Depression Center, where he has conducted studies of former professional football players.

“And that has to do with the broader view of the retired football player’s health—the loss of fitness and physical vitality and the depression that goes with that. It’s far less sexy than the concussion issue and less dramatic, but it has more to do with players’ day-to-day life. And it’s more important, on an epidemiologic basis.”

Approximately five years ago, Dr. Schwenk worked with the NFL Players Association (NFLPA) to develop a series of studies to look at the spectrum of issues affecting retired players and their mental health; the organization later shifted its focus to concussionrelated studies.

The current study, published in the journal Drug and Alcohol Dependence, also worked with the NFLPA, conducting a telephone survey of 644 retired NFL players from the 2009 NFLPA directory, with a 53.4% completion rate. The largest group of surveyed players was offensive linemen (28%), a group known to have poorer health than those in other positions.

Players had an average 7.6-year active career and were retired for an average length of 17.7 years.

Injury rates were extremely high in this population. Forty-nine percent of players had diagnosed concussions and 81% reported suffering an undiagnosed concussion during their active career.

More than half (55%) had career-ending injuries. Just 13% reported “excellent health” within the 30 days prior to being contacted by University of Washington investigators.

“These are players who were elite athletes and a day later they could barely walk the dog [because] they had so much musculoskeletal pain,” said Dr. Schwenk, who began studying professional athletes after the issue was highlighted by a former Detroit Lions quarterback who had suffered from major depression.

May 2 0 1 1

AnesthesiologyNews.com I 35

Pa in M e d icin e ‘These are players who were elite athletes and a day later they could barely walk the dog [because] they had so much musculoskeletal pain.’

—Thomas L. Schwenk, MD

Fifty-two percent of players used opioids during their active career, and of those, 71% reported misuse, which was defined as using more than prescribed, misleading physicians to obtain opioids or acquiring them from a nonphysician source. Players who abused opioids tended to have three or more injuries (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.152.97), and used opioids for a longer period during their career (3.7 vs. 5.9 seasons). More than half of players who took opioids during their career reported getting them at some point from an illicit source.

In retirement, the overwhelming majority of patients (82.9%) had not taken any opioids in the 30 days prior to the study. But of those who had (n=110), 41% misused or abused them.

Former players were significantly more likely to use opioids in the past 30 days if they had higher levels of pain during their NFL career, suffered moderate to severe mental impairment or drank heavily within the past week, defined as consuming more than 14 drinks in a seven-day period.

Among former players who had taken opioids within the past 30 days, either prescribed or misused, several factors made them more likely to abuse these agents, including younger age, fewer years of retirement, three or more injuries, knee or shoulder injuries, heavy drinking behavior and undiagnosed concussions. However, after multivariate analysis, only one factor— undiagnosed concussions—predicted misuse within the past 30 days.

Data on reported versus unreported concussions are difficult to assess and probably unreliable, said Dr. Schwenk.

All of the data are self-recall; perhaps more significantly, during their active career, players have every motivation to hide concussions, and as soon as they retire, they have every motivation to report all of them.

The NFL’s medical advisor, Lawrence S. Brown Jr., MD, MPH, executive senior vice president of Addiction Research and Treatment Corporation and a clinical professor at both Columbia University and Weill Cornell Medical College in New York City, cited a number of other concerns with the study, which he formally lodged in a commentary posted on the National Football League Physicians Society Web site.

Dr. Brown’s main concerns include comparing the opioid use and misuse

of NFL players with the general population and inferring that the misuse and abuse of NFL retirees correlates to current behaviors of players. “I still contend that it is misleading to compare former NFL players with the general public,” Dr. Brown wrote, adding that the databases used for comparisons in the study do not include high-risk subpopulations. It is exactly these patients—other former athletes, or patients at high risk for abuse of see NFL page 36

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P AIN M EDICINE NFL continued from page 35 harmful substances—with whom NFL players should be compared, Dr. Brown argued.

Regarding opioid use by current players, “Today’s NFL is a much different landscape than that existing five or more years ago,” Dr. Brown wrote, adding that the NFL’s approach to substance abuse is “the most comprehensive approach within and outside of sports.”

But it is precisely the culture of professional sports that encourages opioid abuse, says Louis Baxter, MD, president of the American Society of Addiction Medicine and medical director of the Professional Athlete Substance Abuse Treatment Program at Behavioral Health of the Palm Beaches, a substance abuse and pain management clinic in Florida.

“A major contributor to this problem is this culture in professional athletes, and to a lesser degree collegiate

athletes aspiring to turn pro, that you have to be present, you’ve got to play,” Dr. Baxter said.

“The professional athletes with whom I’ve talked tell you clearly they don’t want to miss time from the playing field or court because someone else is there ready to step into their starting position,” he said. “That is a tremendous motivation for these athletes to seek out meds that manage their pain and to continue to use these medications, accepting the risk that they may become dependent.

In their minds, the most important thing is that they are able to continue to perform at high levels.”

The athletes drive much of this behavior; it typically does not come from team management or physicians, but is simply part of highly competitive professional sports. “These professionals don’t want the management to note that they are injured, that they may not play, and so sometimes, especially when we talk about concussions, these players will actually conceal or seek to conceal their injuries,” Dr. Baxter said, which leads to “getting medications outside of the knowledge of their organization.”

The problems can be compounded when players’ careers end. “They’ve had this very difficult adjustment from this very high-powered, high-energy, structured life where somebody does everything for them and they don’t have to do anything except show up and play.

Someone provides for their whole life.

And when they get dumped, some of them start to get physical issues, functional deterioration, financial issues and poor career counseling, then sometimes [they get] drugs, alcohol and depression,” Dr. Schwenk said. Many former players go on to successful careers, but “there is this reservoir of patients who have a lot of misery and we need to start teasing them out.”

‘The concussion issue is the tip of the iceberg.’

—Thomas L. Schwenk, MD Former Miami Dolphins tight end Dan Johnson’s experience may not be typical, but it is not uncommon. After two back surgeries because of injuries as a player, Johnson was taking 1,000 Vicodin pills a month, he told ESPN.com.

After years of giving everything to a physically demanding and violent career, many professional athletes feel abandoned by their organizations.

“That’s the impression that the athletes with whom I’ve talked have—they feel that they are in many cases abandoned,” Dr. Baxter said.

He added that it’s incumbent on sports programs to take care of their athletes long after their playing days are over. “It is important that professional sports, and even collegiate programs, provide an exit strategy when they know that they have players with these issues,” Dr. Baxter said.

—Gabriel Miller

May 2 0 1 1

AnesthesiologyNews.com I 37

Pa in M e d icin e

Study Validates Chiropractic Spinal Manipulation For Chronic Low Back Pain

C

hiropractic manipulation of the spine appears to be as effective as other commonly used approaches for treating chronic lower back pain, according to a new meta-analysis (Cochrane Database Syst Rev 2011;2:CD008112).

“All of the modalities studied, including spinal manipulation, are effective in about two-thirds of patients with chronic low back pain,” said lead author Sidney Rubinstein, DC, PhD, a chiropractor and postdoctoral researcher at VU University Medical Center in Amsterdam, The Netherlands. “Spinal manipulation appears to be no better or no worse than other existing therapies for chronic low back pain. Thus, spinal manipulation should be considered a valid choice for patients who suffer from this condition.”

Low back pain is the fifth most common reason people seek medical treatment, according to a 2006 report from the Centers for Disease Control and Prevention. Many people seek back pain relief by using painkillers, which are expensive, often have side effects and can become addictive. But chiropractic spinal manipulation, an alternative, has been a controversial treatment for LBP for many years.

Dr. Rubinstein’s team combed through the literature and identified 26 studies (with 6,070 participants), that evaluated chronic low back pain; nine of these studies met criteria for high quality. The authors compared trials evaluating chiropractic spinal manipulation with those assessing other common treatment options, including yoga, exercise, acupuncture, massage, cognitive-behavioral therapy and analgesic medications.

They found generally high-quality evidence that “spinal manipulation therapy has a small, statistically significant but not clinically relevant, short-term effect on pain relief and functional status compared with other interventions.” Spinal manipulation therapy helped approximately 66% of patients with back pain, about the same success rate as was reported for other treatments. The authors found some evidence that spinal manipulation, when added to another intervention, has a statistically significant short-term effect on pain relief and functional status.

The authors also concluded that spinal manipulation may benefit some patients more than others. For example, the review suggests that chiropractic spinal manipulation may be particularly helpful for patients with restricted back movement; patients free of

psychological problems/disorders, such as anxiety and depression; and patients who have back pain with no involvement of the sciatic nerve (i.e., no pain below the knee).

The results of the review were limited, however, because spinal manipulation

was not compared with a “sham” procedure (i.e., placebo). The studies included in the review also had little or no data on recovery time, return to work after treatment, quality of life during and after treatment and costs.

—Alice Goodman

2 * Doctor pictured is fictitious, does not represent Ambu and is used for advertising purposes only. Website layout subject to change.

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Celebrating Another Successful Year As 2010 came to a close, the McMahon Group took time out to recognize the best of an outstanding group of employees. During 2010, McMahon’s readership scores solidified the best-read status of many of its medical newsmagazines, and sales revenues increased despite a challenging economy. All of which proves yet again that a company powered by talented people will necessarily generate success. In 2010, McMahon’s publishing success was on display in the pages and on the Web sites of its publications and medical education platforms.

2010

Here then is a look at the winners of the 2010 employee awards.

SUPPORT/PRODUCTION/IT/FINANCE PERSONS OF THE YEAR:

GRAPHIC DESIGNER OF THE YEAR:

Employees were asked to pick the two most outstanding members from these four departments. The winners were MARTIN BARBIERI, production manager, for his dedication to his publications; and MARIELLA SINDONI, financial accounts receivable, for her ability to round up stray dollars.

GABRIEL BERLIN won the award in recognition for his creative approach as art director for Gastroenterology & Endoscopy News, as well as his design work on several medical education and custom media projects.

ACE PERSON OF THE YEAR: There is a strict firewall separating those who work in our CME division, Applied Clinical Education—but not for voting. The 2010 winner was GEORGE OCHOA, whose ability to research, write and edit sometimes dense medical information, and do it by tomorrow, is legendary.

NEWSMAGAZINE/ COPY EDITOR OF THE YEAR: The 2010 winner was ADAM MARCUS, managing editor of Anesthesiology News.

Adam’s pursuit of important stories led him to break several well before the competition, including a few of national importance.

PERSON OF THE YEAR

MOST IMPROVED SALESPERSON OF THE YEAR:

SPECIAL PROJECTS EDITOR OF THE YEAR:

In a crowded field of sales excellence, it can be difficult to stand out, but MATT SPOTO managed to do just that, honing his skills while working as account manager on Gastroenterology & Endoscopy News.

Despite first-rate competition, MEGAN BLOCK, managing editor, won the award for her superb work creating custom media of various kinds, including custom newsletters and podcasts.

SALES ACHIEVEMENT AWARD:

SALESPERSON OF THE YEAR:

JULIANNA DAWSON, publication director of Clinical Oncology News, was the 2010 winner in this category.

Julianna sets herself up for success by working long hours for her clients.

Whereas their peers vote for the other award winners, this award is never subject to a vote. It’s a fact, not an opinion: The salesperson who brings in the most revenue receives this award. For a record-breaking fifth year in a row, the winner was RICHARD TUORTO, senior group publication director for Anesthesiology News and Pain Medicine News.

PARTNERS AWARD

PERSON OF THE YEAR 2010:

PARTNERS SPECIAL RECOGNITION AWARD 2010:

Representing the very best of the best, the 2010 Person of the Year was KEVIN HORTY, editor of General Surgery News. With Kevin at the helm of GSN, readership scores have enjoyed a steady climb skyward, and with these advancing numbers has inevitably come increased revenue. Kevin has concentrated on making the editorial he oversees fully relevant to the complicated world of today’s general surgeon, and the reward has been a publication that is, by far, better than ever.

The partners of McMahon Publishing occasionally present an award to someone who has contributed to the success of the company over many years of service. This year’s winner was GARY SMITH, CEO of Fairfield (Conn.) County Bank (FCB), for his decades-long financial service. FCB financed all of the company’s expansions over the years. “Gary has been a great partner in helping the family and staff grow this company from a start-up to a major medical publisher,” said Ray McMahon, CEO. “Gary will retire from FCB in June; we wish him the best and have appreciated his wise counsel over many years.”

May 2 0 1 1

AnesthesiologyNews.com I 39

Pa i n Medi ci ne

Pain Location Predicts Outcomes After Spine Surgery

P

eople with predominant leg pain have better surgical outcomes for degenerative spondylolisthesis and spinal stenosis than do those with predominant low back pain, a recent study has confirmed.

Philadelphia researchers performed a post-hoc analysis of patients from the large, prospective Spine Patient Outcomes Research Trial (SPORT). The researchers examined the outcomes of 591 patients with degenerative spondylolithosis (DS), 364 of whom had surgery, and another 615 patients with spinal stenosis (SpS), 374 of whom had surgery (Spine 2011;36:219-229).

The researchers found that SpS and DS patients with predominant leg pain who underwent surgery had significantly better outcomes on most measures at one and two years following surgery than did those with predominant low back pain (LBP).

“These data allow me to inform patients with predominant LBP that they will likely improve more with surgery than with nonoperative treatment, but they might not improve as much as patients who have predominant leg pain,” said study leader Adam Pearson, MD, MS, a spine surgery fellow at Thomas Jefferson University. “This is an important point, since prior to this study there was no data to demonstrate that there was a significant treatment effect of surgery for predominant LBP patients compared to predominant leg pain patients.”

Y. Raja Rampersaud, MD, associate professor of orthopaedics and neurosurgery at the University of Toronto, said these results match the prevailing understanding among spine surgeons.

“We believe their results are generalizable across North America,” said Dr. Rampersaud, whose study of 400 Canadian patients with DS and SpS ­— which he presented at the 2010 annual meeting of the North American Spine Society (abstract 209)—­revealed similar findings. “But what I would caution people is not to misinterpret the results by saying, ‘You shouldn’t consider surgery on DS and SpS patients with predominant back pain.’ Because it works, only it works better on those with predominant leg pain.”

Overall results from SPORT, led by James Weinstein, DO, MS, at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., showed that spine

patients improve more with surgery than with nonoperative treatment, and that patients with DS improve more than do those with SpS (N Engl J Med 2007;356:2257-2270). To follow up on these findings, Dr. Pearson, Dr. Weinstein and several others analyzed the outcomes based on the patients’ baseline pain-location characteristics.

Among the 591 DS patients in SPORT, 199 (34%) were leg pain–predominant, 154 (26%) were LBP-predominant and 238 (40%) had equal distribution of pain. Similarly, among the SpS patients, 196 (32%) were leg pain–predominant, 159 (26%) were LBP-predominant and 260 (42%) had equal pain in both locations. Furthermore, the DS and SpS patients with equal pain in both locations had the worst baseline symptoms.

“We were somewhat surprised to find that the distribution of predominant back and leg pain patients was nearly identical for spinal stenosis and degenerative spondylolisthesis, since traditional teaching suggested the degenerative spondylolisthesis patients would more commonly have back pain due to their listhesis,” Dr. Pearson said.

After surgery, the leg pain–predominant DS patients had significantly greater improvements in bodily pain and physical function at one year, although these differences were no longer significant at two years, with patients in all three groups having improved significantly from baseline. However, the relative gap in leg pain–predominant DS patients’ outcomes on the Oswestry Disability Index and the Stenosis Bothersome Index persisted at two years.

Among SpS patients treated surgically, predominant pain location was significantly associated with improvement in all outcomes except LBP Bothersome Index score at one year and Leg Pain Bothersome Index score at one and two years, with the leg pain–predominant patients improving the most and the LBP-predominant patients experiencing the least improvement.

“Conventional wisdom suggested that patients with predominant leg pain would improve more with surgery than patients with predominant back pain,” said Dr. Pearson. “So, we were not surprised to find that this was true in SPORT.” —Rosemary Frei, MSc

e-Newsletters and e-Alerts Get the latest news from the best-read anesthesiology publication in the country delivered directly to your computer or mobile device for free!

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Case Files Anesthesiology Lydia Conlay; Julia Pollock; Mary Ann Vann; Sheela Pai; Eugene Toy

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Case Files: Anesthesiology contains 53 high-yield cases with openended questions. Each case includes an extended discussion, definitions, clinical Pearls, USMLE-style comprehension questions and references to the most current literature for further reading.

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essentials of Pain Management Nalini Vadivelu; Richard D. Urman; Roberta L. Hines

This concise, evidence-based text contains essential topics important for every pain management student, trainee, and practitioner. Both acute and chronic pain management principles and techniques are discussed, while numerous case vignettes help reinforce basic concepts and improve clinical decision making. A multidisciplinary approach to pain is stressed. Behavioral and physical therapies, plus ethical considerations, also are discussed.

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Christopher R. Jarvis; David B. Mandell; Jason M. O’Dell This volume helps physicians move beyond theory and into practice by outlining how to find quality advisors and construct a collaborative, multidisciplinary planning team.

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Quality of Anesthesia Care, An issue of Anesthesiology Clinics

Mark Neuman, MD; Elizabeth Martinez, MD Ongoing improvement in the quality of patient care is essential to all anesthesia practices. This issue of Anesthesiology Clinics provides solid foundation and guidance in how to improve outcomes, as it covers the following topics. An overview of QI structures and initiatives is presented, focusing on the relevance to anesthesiology. A practical guide on how to implement a QI program is provided.

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P RN Should physicians be banned from wearing neckties in medical venues?

Neckties for Physicians: Rethinking the Practice With resistant infections on the rise, a professional tradition should cede to caution [Editor’s Note: The following article was originally published in Missouri Medicine: The Journal of the Missouri State Medical Association; November/December 2010;Vol. 107(6). Minor changes have been made to the original.]

N

osocomial infections are a major problem for hospitals, both nationally and internationally.1,2 Additionally, there is growing concern about the increasing rates of infection with resistant organisms, particularly methicillin-resistant Staphylococcus aureus (MRSA).1,2 Given the gravity of the problem and its cost to the health care system, all reasonable measures should be taken to halt the spread of nosocomial infections.

Health care providers play an important role in transmitting these infections. For instance, fastidious hand hygiene remains an important and effective prophylactic measure.3 Additionally, the white coats and neckties physicians and hospital staff wear represent a major culprit—both pathogenic and nonpathogenic bacteria commonly colonize neckties. Thus, avoiding neckties is a simple measure that can help prevent the spread of nosocomial infections.

Several small studies have suggested that doctors’ ties frequently are colonized with bacteria.4-6 In a study from the United Kingdom, 20% of physician neckties tested (n=40) were contaminated with S. aureus.4 Isolates from one of the eight contaminated ties were methicillin-resistant.4 In an older study from the gynecology and obstetrics literature, bacterial contamination of physicians’ bow ties and neckties was tested in a randomized crossover fashion.6 Contamination of new neckties and bow ties was tested at the end of workdays 1 and 3. A trend toward higher contamination was noted with neckties compared with bow ties after day 1. However, at the end of day 3, the levels were the same between both types of ties. Bacteria detected included Alcaligenes species, coagulase-negative staphylococci (CNS), and Enterococcus faecalis.

Microorganisms such as MRSA, vancomycin-resistant enterococci, Escherichia coli, and Pseudomonas aeruginosa can persist in the inanimate

environment for months.7,8 In a study investigating survival of microorganisms on fabrics commonly used in hospitals, staphylococci species survived for one to 28 days on fabrics made of a 60% cotton/40% polyester blend.8 Importantly, enterococci survived for two weeks to more than three months on blend fabrics. Staphylococci and enterococci survived for even longer periods on polyester fabrics. Pathogenic bacteria can persist for months on fabrics. Because neckties are rarely laundered, it is suggested that they may be one of the many potential vectors for transmitting infections in hospitals.4,8,9 Several studies have focused on other potential sources of contamination, such as white coats and identification badges. A 1991 study that examined 100 physicians’ white coats found a higher level of contamination on the cuffs and the pockets than on the backs.10 Additionally, although CNS and diphtheroid species were the most commonly isolated organisms, S. aureus was isolated from the coats of 29 individuals. In this study, none of the isolated S. aureus was methicillin-resistant.

In a more recent study, the white coats of 23% (34 of 149) of medical and surgical Grand Round attendees at a teaching hospital were contaminated with S. aureus, 18% (6 coats) of which were MRSA.11 Contamination was more frequent among resident physicians and those in the inpatient setting. Another study isolated methicillin-sensitive S. aureus, MRSA and Enterococcus species in swabs taken from lanyards and badges worn by health care workers.9 A higher bacterial load was noted on lanyards compared with badges.

Although it is important to convey a professional appearance,12 this should not occur at the risk for spreading infection. The Department of Health in England has already adopted wideranging infection-control practices mandating that physicians involved in patient care cannot wear neckties.13,14 Formal proscription against neckties for individuals involved directly in patient care has not been adopted yet in the United States.

President Kennedy broke with tradition when he chose not to wear a hat for his inauguration.15 American culture followed his lead and hats for men

subsequently fell out of fashion. President Obama often is seen without a tie in situations where prior presidents have typically worn one.

In 2009, a necktie was deemed optional for professionals; indeed ties are now considered optional for business casual attire.

A recent blinded study evaluated the effect of physicians’ attire on overall patient satisfaction with their medical encounter. The 1,116 patients in the study perceived similar levels of prof ess iona l ism and overall satisfaction whether the physician was wearing traditional business attire (including a tie and white coat), business casual (without a tie) or scrubs.16 Perhaps physicians should seize this opportunity to transition away from wearing a tie at work. Abandoning neckties soon might be considered, like good hand washing, to be among the best practices in the fight to keep patients safe.17 —Mohammad Abuannadi, MD, James H. O’Keefe, MD, and Joseph Brewer, MD References 1. National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.

2. Rosenthal VD, Maki DG, Mehta A, et al. International Nosocomial Infection Control Consortium Members. International Nosocomial Infection Control Consortium report, data summary for 20022007, issued January 2008. Am J Infect Control.

2008;36:627-637.

3. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821-826.

4. Ditchburn I. Should doctors wear ties? (Letter to the Editor) J Hosp Infect. 2006;63:227-228.

5. Dixon M. Neck ties as vectors for nosocomial infection. Intensive Care Med. 2000;26:250.

6. Biljan MM, Hart CA, Sunderland D, Manasse PR, Kingsland CR. Multicentre randomised double blind crossover trial on contamination of conventional

ties and bow ties in routine obstetric and gynaecological practice. BMJ. 1993;307:1582-1584.

7. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;6:130.

8. Neely AN. A survey of gram-negative bacteria survival on hospital fabrics and plastics. J Burn Care Rehabil. 2000;21:523-527.

9. Kotsanas D, Scott C, Gillespie EE, Korman TM, Stuart RL. What’s hanging around your neck? Pathogenic bacteria on identity badges and lanyards.

Med J Aust. 2008;188:5-8.

10. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ. 1991;303:1602-1604.

11. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers’ white coats. Am J Infect Control. 2009;37:101-105.

12. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118:1279-1286.

13. Day M. Doctors are told to ditch “disease spreading” neckties. BMJ. 2006;332:442.

14. Jacob G, Department of Health. Uniforms and workwear: An evidence base for developing local policy.

England, Department of Health (Crown copyright); Sep. 2007:10. http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/documents/digitalasset/dh_078435.pdf.

15. Steinberg N. Hatless Jack: The President, the Fedora, and the History of American Style. New York, NY: Plume; 2004:368.

16. Fischer RL, Hansen CE, Hunter RL, Veloski JJ. Does physician attire influence patient satisfaction in an outpatient obstetrics and gynecology setting? Am J Obstet Gynecol. 2007;196:186.e1-e5.

17. Collignon PJ. Methicillin-resistant Staphylococcus aureus (MRSA): “missing the wood for the trees.”

Med J Aust. 2008;188:3-4.

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1

Drover DR et al. Anesthesiology 2002, 97:82–89 White PF et al. Anesth Analg 2004, 99:1429-1435

2