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A Commentary:

MOCA Must Change Thomas Gallen, MD, MPH and Oren Bernstein, MD

cross all medical specialties, Maintenance of Certification (MOC) programs have become increasingly criticized for being too costly, overly burdensome and lacking evidence of benefit to physicians and patients. The American Board off Anesthesiology’s (ABA) Maintenance of Certification in Anesthesiology (MOCA) program requires its diplomates to participate in numerous exercises at great cost, none of which have any unbiased support. Although the American Board of Medical Specialties

Neuromuscular Blockade Helps Intubation in ICU Patients Phoenix—Despite the apparent risks, using a neuromuscular blocking agent (NMBA) before tracheal intubation improves the odds of first-attempt intubation success in critically ill ICU patients, a study has found. “The question of whether to paralyze or not to paralyze is clearly answered in the operating room and emergency department: Using a paralytic is the way to go if you want to increase your first-attempt success at intubation,” said Jarrod M. Mosier, MD, an assistant professor of medicine and emergency medicine at the University of Arizona, Tucson. “However,

see MOCA page 22

see ICU page 19

The Storm Abroad: Anesthesiology During Wartime Preparing for battle: anesthesia training for combat missions

6 10

Lt. Cmdr. Jesse M. Ehrenfeld, Medical Corps, U.S. Navy

gleaned occasional insights into military medicine during the past seven years while serving as a medKandahar, Afghanistan—When most anesthe- ical reserve officer in the U.S. Navy. Since Septemsia providers think about keeping their skills up, they ber 2014, however, those insights have become much picture continuing medical education courses, brows- more profound as I have been deployed in Kandaing through the latest specialty journals, or perhaps har, Afghanistan at one of the world’s busiest military attending a national meeting. For military physi- combat trauma hospitals. I knew I would bring a world of relevant expericians, however, training for a day on the job takes on a whole different meaning. As an anesthesiologist who ence to my current mobilization from my civilian job, practices primarily at Vanderbilt University, I have see storm page 36

PAIN MEDICINE

Liposomal-encased bupivacaine is a good, costeffective choice for pain after breast surgery.

CLINICAL ANESTHESIOLOGY

Presenting a new, modified technique for US-guided penile nerve block for circumcision.

PRN

Interview with Kelly McQueen, MD, on ASA’s committee on Global Humanitarian Outreach.

8 Perioperative Goal-Directed Therapy: Optimizing Fluid Management and Reducing Postoperative Complications

EDUCATIONAL REVIEW Current Concepts in the Management of the Difficult Airway, see insert at page 24.

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DEA Issues Warning on Dangers of Fentanyl

Propofol for Colonoscopy: Are Some Patients Being Oversedated?

Perioperative Anesthesia Care For Obese Patients

Closed Claims Airway Injury Analysis Spotlights Problems

Postop Cognition in Elderly Improved With Dexamethasone

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Tweets of Interest #anesthesianews (From the Annual Meeting of the Society of Cardiovascular Anesthesiologists) Anesthesiology News @anesthesianews Audience survey at #SCA2015: 25% of respondents say they have briefing while patient is on table but still awake. Is that good for patients?

Gavin Doolan @anaestricks @ Check it out,, a BIS on an orang-utan @MelbourneZoo with human anaestheetist Dr Kevin Moriarty y http://bit.ly/1yzCQF0

Anesthesiology News @anesthesianews Learned from the military: if someone asks for something to be done in the OR, do it AND confirm verbally it’s been done #SCA2015 Anesthesiology News @anesthesianews Grade of aortic atheroma increases risk of long-term mortality, BWH study shows. #SCA2015 #anesthesianews

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Liposomal-Encased Bupivacaine Offers Advantages in Breast Surgical Procedures Miami—Liposomal-encased bupiva- College of Medicine, Rochester, Minn., caine (LEB) is a good, cost-effective medical choice for pain control after breast surgery. Valerie Lemaine, MD, MPH, an assistant professor of plastic surgery and the vice chair for research at Mayo Clinic

reviewed her experience at the 32nd Annual Miami Breast Cancer Conference. She noted that the drug has proved safe, decreased opioid requirements and reduced costs for patients having breast surgery at Mayo Clinic.

LEB is a recently approved formulation of bupivacaine loaded in multivesicular liposomes, which allows slow release from the liposome and increases the duration of local anesthetic action (Figure). LEB is FDAapproved for postoperative analgesia

when given as a single-dose surgical site injection. In breast surgery, LEB has been used in patients after mastectomy, lumpectomy, and autologous and implant-based reconstruction. As background, Dr. Lemaine emphasized the frequency at which postsurgical pain and chronic pain are inadequately managed. Among almost 500,000 breast surgical procedures performed annually in the United States, as many as half may result in chronic postoperative pain of the scar, breast, chest wall, shoulder or arm as a result of nerve injury, inflammation or inadequate management of acute pain, she said. “In my opinion, this is a significant problem for these women, especially with breast cancer treatments available today that positively impact survival. Now that women live longer after diagnosis, quality of life becomes more important and living pain-free is a key component,” she said. Pharmacokinetics Plasma levels of LEB can persist up to 96 hours, although in Dr. Lemaine’s experience, 72 hours is more likely. The pain relief provided by LEB has best been observed in patients who undergo microsurgical breast reconstruction and are typically hospitalized for three to four days. “You can really see a difference around day 3, when patients start taking more oral medications for pain control because the liposomal bupivacaine is starting to wear off,” she said. Dr. Lemaine said she dilutes the drug with preservative-free normal saline, up to a total of 260 cc, but also occasionally injects it undiluted, depending on the situation. LEB must be injected within four hours of preparation, a characteristic she makes sure to communicate to the surgical team. Showing a video of how she uses LEB in tissue expander breast reconstruction, she noted, “I perform a field block and inject the entire surgical site following the mastectomy. The injection is intramuscular and sometimes also subcutaneous. I adjust the dilution and, for example, in very large-breasted women, I may increase my dilution. I make these decisions intraoperatively, on a case-by-case basis, based on body habitus and size of the surgical site.” When mastectomy skin flaps are sufficiently thick, she may inject subcutaneously, addressing the subclavicular area and lateral subcutaneous tissue before inserting tissue expanders. Although reports suggest that other anesthetic agents can be used safely in conjunction with liposomal

MAY 2015

AnesthesiologyNews.com I 7

PAIN MEDICINE Liposomal encased bupivacaine (LEB) Outer lipid membrane

Chambers w/drug

Inner lipid membranes Released drug 15-50 μm

10 cm

interview. He noted that LEB is used in various other procedures, such as hemorrhoidectomy, bunionectomy, colectomy and total knee arthroplasty. It has proved beneficial in placebocontrolled studies; however, a statistically significant advantage has not been shown when compared with bupivacaine with epinephrine, he said. “The nature of release and later metabolism might give LEB a safety advantage. A reduction in the total dose of bupivacaine needed to achieve

a clinical benefit is another reported benefit,” Dr. Goudraa said. In research settings, LEB is used both as epidural and perineural injections, which can produce prolonged sensory blockade, an important feature. Currently, however, it is not approved by the FDA for routes other than wound infiltration, he added. —Caroline Helwick There were no relevant financial disclosures.

The bupivacaine is located within multivesicular liposomes, akin to the structure of a pomegranite, which increases the duration of anesthetic action. bupivacaine, Dr. Lemaine has not personally done so. LEB Versus Paravertebral Block Dr. Lemaine and her colleagues recently compared patients who had LEB or paravertebral block in conjunction with mastectomy and immediate breast reconstruction using tissue expanders. “Regional block is our standard of care postmastectomy but, having a good experience with LEB in microsurgical breast reconstruction, we thought LEB could be useful when we used tissue expanders.” In this retrospective (and unpublished) evaluation, LEB offered a number of advantages, she said. Patients receiving LEB required less opioids in the recovery room, had a longer timeto-first opioid use, required fewer postoperative antiemetics on day 1 and had lower mean pain scores on postoperative day 0. LEB was also less time consuming, she added. “Paravertebral blocks take time—adding about 45 minutes to a procedure at my institution—and this has been a source of frustration for our plastic surgeons.” Paravertebral blocks also carry a small risk for pneumothorax, she added. “In my two years of experience with LEB,” Dr. Lemaine concluded, “I have found this to be safe, to make a difference to my patients and to be cost saving. I do think there’s a learning curve, so surgeons should not get discouraged. Good communication with anesthesiology and with postoperative nursing is key to providing the best analgesia, and to improving outcomes overall.” Basavana Goudra, MD, of the University of Pennsylvania, Philadelphia, commented on the presentation in an

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THE SCIENCE BEHIND POSITIVE PATIENT OUTCOMES

Perioperative Goal-Directed Therapy: Optimizing Fluid Management and Reducing Postoperative Complications Faculty Timothy E. Miller, MB, ChB, FRCA

Michael (Monty) G. Mythen, MBBS, MD, FRCA, FFICM

Associate Professor of Anesthesiology Department of Anesthesiology Duke University Medical Center Durham, North Carolina

Smiths Medical Professor of Anaesthesia and Critical Care Director Centre for Anaesthesia University College London Hospitals London, United Kingdom

Introduction Perioperative goal-directed therapy (PGDT) is a cliniciandirected protocol that uses measurements of advanced hemodynamic parameters during surgery to guide fluid management.1 The accurate assessment of hemodynamic parameters—stroke volume (SV), stroke volume variation (SVV), and cardiac output (CO)—allows for individualized volume management and decreases variability among clinicians because fluids are given only when there is demonstrable fluid responsiveness.1 Implementation of PGDT has been shown to improve patient outcomes and can be applied alone or as part of larger protocol initiatives, such as enhanced recovery after surgery (ERAS) and perioperative surgical home programs.1,2 The goal of ERAS is for patients to achieve earlier recovery after surgery. Minimally invasive surgery with appropriate fluid and pain management are central elements of ERAS.1,2 Noninvasive and minimally-invasive monitoring systems, which provide these continuous measurements of CO, SV, and SVV, expand the benefits of PGDT and ERAS to more patients.1

Fluid Management Optimal fluid management is a multidisciplinary process that requires a continuum of care through the preoperative, intraoperative, and postoperative phases.2 In the preoperative phase, routine mechanical bowel preparation should be avoided, and overnight fasting is no longer recommended.2,3 Patients may consume a clear carbohydrate beverage 2 to 3 hours before surgery.3,4 The goals of these methods are to have a euvolemic patient who feels fed before surgery.2 Intraoperative fluid management involves maintaining central euvolemia while minimizing excess salt and water.2 Achieving these goals requires maintaining background fluid therapy and using volume therapy to restore fluid as necessary.2 Maintenance fluid replacement replenishes fluid lost by urinary output as well as perspiration.2 Despite these clear physiologic goals, intraoperative fluid management remains challenging.2,5 Blood loss and fluid

ANESTHESIOLOGY NEWS • MAY 2015

Anthony Senagore, MD General and Colon & Rectal Surgeon University Hospitals Parma Medical Center Parma, Ohio

shifts during surgery may lead to hypovolemia, hypoperfusion, and adverse events (Figure).1,2 Conversely, the administration of excess fluid may result in tissue edema.2 Administering excess fluid causes increased intravascular pressure and possible damage to the endothelial glycocalyx.2 Excess fluid may be administered under conditions that are incorrectly interpreted as fluid deficit, and until recently, belief in a “third space” (ie, a concept by which fluid was stored within an extravascular, extracellular space) often resulted in liberal administration of fluid during surgery.1 The existence of the “third space” is not supported by current evidence.6

Determining Fluid Needs During surgery, patients with fluid deficits benefit from fluid administration. The decision to provide fluid to a patient is based on a fluid challenge that identifies fluid responsiveness.2 When there is evidence of intravascular hypovolemia, a fluid challenge is administered rapidly over 5 to 10 minutes.2,7 Measurement of hemodynamic parameters will indicate when patients are replete and fluid administration should halt.2,5 However, traditional methods used to guide fluid management, such as heart rate, urine output, mean arterial pressure, and central venous pressure, are unreliable measures of intravascular volume status.2 PGDT uses a non- or minimally invasive measurement of SV or SVV to monitor the response to a fluid challenge.2 Patients who respond to a fluid challenge with an increase in SV of more than 10% are considered fluidresponsive and may benefit from additional fluid challenges. Euvolemic patients will not exhibit a change in SV greater than 10% and are not likely to benefit.2 SVV is an assessment of the expiratory and inspiratory decreases of the arterial pulse pressures caused by intrathoracic pressure as compared with negative pressure ventilation.8 Therefore, accurate hemodynamic monitoring of CO, SV, and SVV allows physicians to provide fluid as needed, in appropriate amounts, and with optimal timing.2,5 Modern monitoring systems reliably measure

hemodynamic variables that are the best predictors of fluid responsiveness, such as SV, SVV, pulse pressure variation (PPV), and systolic pressure variation.2 These advanced hemodynamic parameters may indicate hypovolemia before a change in heart rate or blood pressure.9,10 In the postsurgical period, many patients are in positive sodium and fluid balance and also have altered excretion of sodium and chloride. The focus of postoperative fluid management should therefore be to administer lowsodium volume fluids to enable patients to return to fluid and electrolyte homeostasis postoperatively.2 Continued PGDT management in the immediate postoperative period may be useful for maintaining patients in the optimal volume range and/or resuscitating as needed.

Benefit of Perioperative Goal-Directed Therapy Recent research has demonstrated the clinical benefit of PGDT on patient recovery, including reduced postsurgical complications and reduced hospital length of stay (LOS).11-13 A stratified meta-analysis of 5,021 patients from 34 randomized controlled trials compared a restrictive fluid therapy approach with either a liberal fluid therapy without hemodynamic goals (11 studies, 1,160 patients) or PGDT (23 studies, 3,861 patients).11 The outcomes for patients receiving liberal use of fluid without hemodynamic goals was not equivalent to those for patients receiving PGDT, although patients in the PGDT and liberal therapy groups received more fluid than patients in the restrictive groups, but with very different effects. Patients in the liberal fluid group had a higher risk for pneumonia and an increased time to first bowel movement.11 Patients in the PGDT group had a lower risk for pneumonia, fewer renal complications, and shorter LOS. Liberal use of fluids during surgery produced inferior patient outcomes relative to PGDT.11 Other studies of PGDT demonstrated reduced gastrointestinal complications12 and reduced infections relative to control conditions.13 The recently completed OPTIMISE trial evaluated 734 high-risk patients who underwent major gastrointestinal surgery with or without PGDT.14 After adjusting for risk factors, compliance with the protocol, and excluding the 10 patients per center who discontinued the trial, the decrease in postsurgical complications was significant.14 The primary outcome, a composite measure of complications at 30 days postsurgery, trended toward lower values in the PGDT group relative to usual care (36.6% vs 43.4%; P=0.07).14 Similarly, 180-day mortality was reduced in patients in the PGDT group (7.7% vs 11.6%, respectively; P=0.08).14 These results suggest that PGDT could positively

Current Practices Assessment of current practices in high-risk surgery demonstrated low adoption of hemodynamic monitoring practices in the United States and Europe.22 Although written guidelines concerning hemodynamic management were more common in Europe, only 34% of anesthesiologists in Europe and the United States monitored CO in patients undergoing high-risk surgery.22 Of American Society of Anesthesiologists members surveyed, nearly 87% believed that their hemodynamic management could be improved.22 Furthermore, respondents revealed that they associated CO monitoring with the use of a pulmonary artery catheter, indicating that the availability of less invasive monitors is widely known or used in the United States.22 Additionally, the study found that many clinicians monitor central venous pressure despite consistent evidence that filling pressures are unreliable predictors of fluid responsiveness.22,23 Variability among institutions and clinicians may be affected by implementation of clinical guidelines in the United States or application of standardized protocols at individual institutions.

The Economic Opportunity of Reducing Postsurgical Complications ERAS and PGDT have the potential to reduce hospital LOS and medical costs.17,18 Indeed, reductions in hospital

LOS is a consistent finding in studies that used PGDT.11 Consequently, the reduction of LOS may result in considerable cost savings.24 Analysis of data from 75,140 patients who had major non-cardiac surgery in 2011 revealed that 8,421 developed at least one postsurgical complication (morbidity rate, 11.2%).24 The in-hospital mortality of patients with complications was 12.4% compared with 1.4% in patients with no complications (P<0.001).24 Patients with complications had a mean LOS of 20.5 days, whereas the mean LOS for patients without complications was 8.1 days, a difference of 12.4 days (P<0.001).24 The cost of treating postsurgical complications in the study population equaled $252 million in 2011.24 Investigators estimated decreased morbidity as result of implementing PGDT by applying risk ratios from a recent meta-analysis and projected gross savings of $569 to $970 per patient or $43 million to $73 million for the entire study population.24 Postsurgical complications increased costs by 172%.24

Overcoming Barriers to Implementation Implementation of a PGDT protocol involves up-front investment in hemodynamic monitoring systems and thus requires a recognition of value by clinicians and hospital administration.2 However, unfamiliarity with the evidence supporting PGDT is likely to preclude investment of time and resources for systems and training. Furthermore, a lack of understanding of PGDT methods and benefits and related monitoring systems remains a barrier to clinicians, who may have a “good enough” view of existing methods.22 In some cases, clinical practice may be strongly influenced by local conditions rather than published evidence.22 Survey and audit of consultant surgeons found that the least experienced member of a team was often made responsible for postoperative fluid prescription and that fewer than one-half of these clinicians knew the sodium content of normal saline.19,25,26 Leadership efforts may serve to effect change within the multidisciplinary surgical team and involve hospital management.2 A leader in the anesthesia department can draw attention to gaps in knowledge and training and provide education regarding the evidence base for PGDT. In this manner, it may be possible to align clinical and financial objectives and overcome a tendency to silo budgeting. Experience in existing quality programs has demonstrated that data collection and continuing feedback to clinicians are important in maintaining program standards, sustained compliance, and therefore effectiveness.22

Edema Organ dysfunction Adverse outcome

Hypoperfusion Organ dysfunction Adverse outcome

OPTIMAL Bowel ischemia

Bowel wall edema

Hypovolemic

Overloaded

Volume Load

Figure. Fluid volume load versus clinical complications. Based on reference 1.

support the individualization of fluid therapy through PGDT. Maintaining fluid balance has profound effects on patient physiology and may prevent adverse events that occur under conditions of either hypo- or hypervolemia. Accordingly, evidence and clinical care guidelines support optimal fluid management through all 3 phases of surgery.

References 1.

Miller TE, et al. Best Pract Res Clin Anaesthesiol. 2014;28(3): 261-273.

Miller TE, et al. Can J Anaesth. 2014 Nov 13. [Epub ahead of print]

Mythen MG, et al. Periop Med d (Lond). 2012;1:2-4.

American Society of Anesthesiologists Committee On Standards. Anesthesiology. 2011;114(3):495-511.

Edwards ME, et al. Extrem Physiol Med. 2014;3:16-24.

Jacob M, et al. Best Pract Res Clin Anaesthesiol. 2009;23: 145-157.

Cecconi M, et al. Curr Opin Crit Care. 2011;17:290-295.

Michard F. Anesthesiology. 2005;130(2):419-428.

Kungys G, et al. Anesth Analg. 2009;109(6):1823-1830.

10.

Grocott MP, et al. Anesth Analg. 2005;100(4):1093-1106.

11.

Corcoran T, et al. Anesth Analg. 2012;114(3):640-651.

12.

Giglio MT, et al. Br J Anaesth. 2009;103(5):637-646.

13.

Dalfino L, et al. Crit Care. 2011;15(3):R154.

14.

Pearse RM, et al. JAMA. 2014;311(21):2181-2190.

15.

Rhodes A, et al. Intensive Care Med. 2010;36(8):1327-1332.

16.

Grocott MPW, et al. Br J Anaesth. 2013;111(4):535-548.

17.

Miller TE, et al. Anesth Analg. 2014;118(5):1052-1061.

18.

Enhanced Recovery Partnership, National Health Service. http://www.enhancedrecovery.uk. Accessed March 11, 2015.

19.

Powell-Tuck J, et al. http://www.bapen.org.uk/pdfs/bapen_ pubs/giftasup.pdf. Accessed March 11, 2015.

20.

Vallet B, et al. Ann Fr Anesth Reanim. 2013;32(10):e151-e158.

Conclusion

21.

European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35:2383-2431.

PGDT alone or embedded in a larger protocol such as an ERAS or perioperative surgical home has the potential to improve patient outcomes and reduce hospital costs. Modern non- and minimally invasive systems allow for accurate monitoring of fluid needs during surgery and

22.

Cannesson M, et al. Crit Care. 2011;15(4):R197.

23.

Marik PE, et al. Chest. 2008;134(1):172-178.

24.

Manecke GR, et al. Crit Care. 2014;18(5):556-574.

25.

Walsh SR, et al. Ann R Coll Surg Engl. 2005;87(2):126-130.

26.

Lobo DN, et al. Clin Nutr. 2001;20(2):125-130.

Disclosures: Dr. Miller reported that he has received honoraria from Edwards Lifesciences and research support from Covidien. Dr. Mythen reported that he has received grant/research support from Deltex Medical and Smiths Medical and honoraria from Baxter Pharmaceuticals, Fresenius Kabi, and BevMD. He also is a consultant for Deltex Medical and Edwards Lifesciences, and is on the speaker’s bureau for BevMD, Deltex Medical, and Edwards Lifesciences. Dr. Senagore reported that he is a consultant for Cubist Pharmaceuticals, Edwards Lifesciences, and Ethicon Endo-Surgery.

ANESTHESIOLOGY NEWS • MAY 2015

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affect recovery and long-term survival after surgery. Other studies also have indicated PGDT benefits long-term outcomes. Data from a 15-year follow-up evaluation of PGDT in high-risk surgical patients revealed that randomization to PGDT was an independent factor in long-term survival.15 In clinical studies, PGDT alone11,16 or in the context of an ERAS program17 has demonstrated decreased LOS of 1 to 2 days.11 One study comparing traditional care with an ERAS protocol in patients undergoing colorectal surgery revealed positive effects of ERAS on several parameters, including LOS.17 A significant difference was observed in LOS between the 2 groups; the median LOS in the ERAS and traditional groups was 5 and 7 days, respectively (P<0.001).17 Hospital LOS reductions were similarly observed during the implementation of the Enhanced Recovery Care Pathway in Britain between 2009 and 2013 and saved an estimated 170,000 bed-days annually.18 Based on the growing evidence supporting PGDT and the need for professional guidance and education, clinical societies have published guidelines for operative fluid management in the United Kingdom,19 France,20 and Europe.21 The European Society of Cardiology/ European Society of Anaesthesiology enhanced recovery guideline cites the utility of specific hemodynamic variables (eg, SVV, PPV, and CO) and the importance of PGDT in reducing postoperative mortality.21

Complications

Supported by Edwards Lifesciences

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CLINICAL ANESTHESIOLOGY

Ultrasound-Guided Penile Nerve Block for Circumcision: A New, Modified Technique M-Irfan Suleman, MD

standard method to block the dorsal penile nerve. Ultrasound scanning verifies the distribution of Assistant Professor of Anesthesiology the anesthetic in real time.15 In addition, ultrasound Director of Pediatric Regional Anesthesia has lowered postoperative pain scores14,18 and shortDepartment of Anesthesiology 18 Arkansas Children’s Hospital and University of Arkansas ened recovery time. Identification of better techniques could make ultrasound-guided regional for Medical Sciences anesthesia a standard of care for this application. Little Rock, Arkansas With this technology, patient discomfort is relieved describe here a new, modified, ultrasound- and better pain control is achieved as part of periopguided penile block for male pediatric patients erative care for circumcision. undergoing circumcision. The technique uses Methods portable ultrasound with a linear probe and realI describe a new, modified, ultrasound-guided time scan at the base of the penis to identify vessels and fascia layers, which allows safe advancement penile block for male children undergoing circumof the needle and injection of local anesthesia bilat- cision. After administering general anesthesia to the erally. The technique allows the practitioner to see local anesthetic distribution under the deep fascia of the penis. The procedure produces a subcutaneous DA DV DA DPNBF DPN wheal along the anterior side of the base of the penis or penoscrotal junction to achieve a complete penile block (Figure 1). Circumcision is one of the most frequent surgiCC CC cal procedures for pediatric males.1,2 In an effort to relieve postoperative pain, several anesthetic approaches, all with varying efficacies, have been CS used, including topical analgesics such as lidocaine and lidocaine-prilocaine,3-6 ring block,7-9 and caudal block.5,8,10 A study by Weksler et al found that children treated with caudal block had an increased incidence of tachycardia, motor block, and vomiting compared with those treated with penile block, with- Figure 3. Ultrasound-guided landmarks for dorsal out a significant difference in pain severity between penile nerve block via the Suleman approach. the groups.11 The ring block procedure includes an BF, Buck’s fascia; CC, corpus cavernosum; CS, corpus spongiosum; DA, dorsal artery; 8% failure rate,8 bleeding,12 and edema,13 although DPN, dorsal penile nerve; DV, dorsal vein complications have not been reported with this technique.2 Recently, interest has focused on using ultrasound to direct bilateral injections into the subpubic space,14 thus allowing clearer identification of both the subpubic space and penile structure,15 although some researchers remain unconvinced of this procedure’s benefits.16 Blind landmark-based needle placement, described by Maxwell et al,17 has been a

Dorsal artery

Ultrasound probe

patient, the penis and surrounding area, including the scrotum, are prepared with 0.5% chlorhexidine in 70% alcohol. Sterilized gel was used at the site and the ultrasound probe was covered to ensure sterility. We used a 4-inch sterile occlusive dressing, which is easier to apply and less costly than commercial probe covers (Figure 2). Holding the ultrasound probe while positioning the needle against the probe can be problematic, but I found that the 27-gauge, 1.5-inch regular needle is comfortable to use and easily visible on the ultrasound monitor because the nerve is close to the skin. Sandeman and Dilley15 recognized that observing the tissue movement as the needle advances and see block page 12

DV DA LA DPN BF

Figure 4. Ultrasound-guided in-plane needle placement for dorsal penile nerve block. BF, Buck’s fascia; CC, corpus cavernosum; CS, corpus spongiosum; DA, dorsal artery; DPN, dorsal penile nerve; DV, dorsal vein

Superficial and Deep dorsal vein

Skin

Areolar tissue Deep fascia (Buck’s fascia)

Superficial fascia

Corpus cavernosum

Urethra Corpus spongiosum

Figure 1. Schematic of the Suleman approach.

Figure 2. Suleman approach: ultrasound-guided (in-plane technique) penile block.

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CLINICAL ANESTHESIOLOGY BLOCK

monitor, the musculoskeletal setting was used. The probe was placed transchecking for the black hypoechoic versely along the base of the penis, for region on the ultrasound monitor indi- which gentle traction was used. The cate both the needle tip position and corpora cavernosa, dorsal arteries, dorplacement of the anesthetic; I found sal veins, and superficial and deep this to be accurate as well, but prefer penile Buckâ&#x20AC;&#x2122;s fascia were identified. an in-plane technique to see needle The needle was moved forward using advancement to avoid any surrounding the in-plane technique under real-time structures. ultrasound guidance and continued A linear ultrasound probe with to advance until the practitioner felt a a frequency range of 5 to 10 MHz loss of resistance as the needle passed was used; for optimal viewing on the through the hyperechoic superficial

lining of Buckâ&#x20AC;&#x2122;s fascia. Immediately after passing through this superficial layer, the needle tip, located lateral to the dorsal artery, was advanced deep into Buckâ&#x20AC;&#x2122;s fascia. After negative aspiration, I injected 1 to 2 mL of local anesthetic under direct vision,19 while being careful to prevent neurovascular injury or intravascular injection20 (Figures 3 and 4). Plain 0.25% bupivacaine was used, and the maximum dose was 3 mL. The local anesthetic was evident on

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ultrasound as a black hypoechoic area, and the same procedure was performed on the other side. Finally, I placed a small ventral bleb with local anesthetic at the penoscrotal junction to block the scrotal branches of the pudendal nerve, as recommended by Sandeman and Dilley.15 Discussion Dorsal penile nerve block (DPNB), a procedure first described in the mid1970s,21 requires a local anesthetic injection close to the dorsal nerve of the penis. The American Academy of Pediatrics approves the use of DPNB.2 Reports of minor complications include swelling,22 hematoma or edema,23 and bruising at the injection site.24 Other safe approaches using DPNB in infants and children have been described.13,25 Ultrasound imaging in regional anesthesia is a leading advancement in pediatric regional anesthesia.26 The technology allows the practitioner to visualize the target nerve directly, maneuver the needle under real-time observation, precisely navigate away from complex or sensitive anatomy, and manage and administer the distribution of local analgesics. For those who believe that DPNB is an uncomplicated procedure that does not require routine ultrasound,16 I argue that ultrasound allows the twodimensional anatomy of the subpubic space and penile structures to be clearly recognized, allowing needle placement directly into the subpubic space, thus avoiding the penile structures and problems that could occur. Several studies have concluded that when needles are placed close to the nerves, the frequency of adverse events declines.15,18,27 In-plane needle placement technique seems to be reliable and minimizes adverse events, its use is supported by existing studies and it is not complicated to learn. I recommend this ultrasound technique to improve clinical care for patients undergoing circumcision. References 1. Al-Ghazo MA, Banihani KE. Circumcision revision in male children. Int Braz J Urol. 2006;32:454-458. 2. American Academy of Pediatrics, Technical report: Male circumcision. Pediatrics. 2012;130:e756-e785. 3. Benini F, Johnston CC, Faucher D, et al. Topical anesthesia during circumcision in newborn infants. JAMA. 1993;270:850-853. 4. Choi WY, Irwin MG, Hui TW, et al. EMLA cream versus dorsal penile nerve block for postcircumcision analgesia in children. Anesth Analg. 2003;96:396-399. 5. Tree-Trakarn T, Pirayavaraporn S. Postoperative pain relief for circumcision in children: comparison

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CLINICAL ANESTHESIOLOGY among morphine, nerve block, and topical analgesia. Anesthesiology. 1985;62:519-522. 6. Woodman PJ. Topical lidocaine-prilocaine versus lidocaine for neonatal circumcision: a randomized controlled trial. Obstet Gynecol. 1999;93:775-779. 7. Broadman LM, Hannallah RS, Belman AB, et al. Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis. Anesthesiology. 1987;67:399-402. 8. Irwin MG, Cheng W. Comparison of subcutaneous ring block of the penis with caudal epidural block for post-circumcision analgesia in children. Anaesth Intensive Care. 1996;24:365-367.

The author has no relevant financial disclosures.

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Corresponding author: M-Irfan Suleman, M.D.; msuleman@uams.edu Acknowledgment: For assistance and support, I acknowledge Ashay Patel, DO, Assistant Professor, Department of Urology, Section of Pediatric Urology; Director of Outpatient Urologic Services; Director of Robotic Urologic Surgery; University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, Arkansas.

Education

11. Weksler N, Atias I, Klein M, et al. Is penile block better than caudal epidural block for postcircumcision analgesia? J Anesth. 2005;19:36-39. 12. Kaplan GW. Complications of circumcision. Urol Clin North Am. 1983;10:543-549. 13. Holder KJ, Peutrell JM, Weir PM. Regional anaesthesia for circumcision. Subcutaneous ring block of the penis and subpubic penile block compared. Eur J Anaesthesiol. 1997;14:495-498. 14. Faraoni D, Gilbeau A, Lingier P, et al. Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children? Paediatr Anaesth. 2010;20:931-936. 15. Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve block in children. Anaesth Intensive Care. 2007;35:266-269. 16. O’Sullivan MJ, Mislovic B, Alexander E. Dorsal penile nerve block for male pediatric circumcision— randomized comparison of ultrasound-guided vs anatomical landmark technique. Paediatr Anaesth. 2011;21:1214-1218. 17. Maxwell LG, Yaster M, Wetzel RC, et al. Penile nerve block for newborn circumcision. Obstet Gynecol. 1987;70:415-419. 18. Sandeman DJ, Reiner D, Dilley AV, et al. A retrospective audit of three different regional anaesthetic techniques for circumcision in children. Anaesth Intensive Care. 2010;38:519-524. 19. Brown TC, Weidner NJ, Bouwmeester J. Dorsal nerve of penis block—anatomical and radiological studies. Anaesth Intensive Care. 1989;17:34-38. 20. Soh CR, Ng SB, Lim SL. Dorsal penile nerve block. Paediatr Anaesth. 2003;13:329-333. 21. Bateman DV. An alternative block for the relief of pain of circumcision. Anaesthesia. 1975;30:101-102. 22. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block—a painless procedure. J Pediatr. 1978;92:998-1000. 23. Serour F, Cohen A, Mandelberg A, et al. Dorsal penile nerve block in children undergoing circumcision in a day-care surgery. Can J Anaesth. 1996;43:954-958. 24. Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics. 1995;95:705-708. 25. Dalens B, Vanneuville G, Dechelotte P. Penile block via the subpubic space in 100 children. Anesth Analg. 1989;69:41-45. 26. Griffin J, Nicholls B. Ultrasound in regional anaesthesia. Anaesthesia. 2010;65 Suppl 1:1-12. 27. Rubin K, Sullivan D, Sadhasivam S. Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children? Paediatr Anaesth. 2009;19:92-96.

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9. Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA. 1997;278:2157-2162. 10. Bengisun AK, Ekmekci P, Halilo lu AH. Levobupivacaine for postoperative pain management in circumcision: caudal blocks or dorsal penile nerve block. A ri. 2012;24:180-186.

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PERSPECTIVES IN ANESTHESIOLOGY For postsurgical pain control

Is regional analgesia being used to its full potential? Regional analgesia allows for pain to be targeted at its source while signiﬁcantly reducing pharmacologic load, including the use of opioids. It’s also been shown to offer an advantage in reducing postsurgical pain compared with general anesthesia.1,2 As part of the commitment to improving postsurgical patient care, we must remain focused on what can be done to help ensure that regional analgesia is being used to its full potential to manage postsurgical pain.

Broadening the value of regional analgesia So what’s preventing greater use of regional block? Current regional analgesia options continue to have limitations when it comes to postsurgical pain management. As a result, physicians are forced to weigh the pros and cons of single-shot and continuous infusion blocks for each patient.3,4 Single-shot blocks meet the anesthesiologists’ goals of being simple, quick, and reliable, providing assurance that the right dose was administered to the right site and that it will last for the intended amount of time.5 However, even when single-shot blocks are chosen, it is often necessary to supplement with opioids or continuous infusion catheters and pumps to compensate for the limited duration of current short-acting, local analgesics. As a result, associated side effects of these additional agents and modalities may undermine patient recovery.4,6-8

Continuous infusion blocks: longer duration, bigger challenges? While continuous infusion blocks can extend the duration of blocks well into the postsurgical period, they can be burdensome on several fronts. For patients: continuous infusion blocks require the use of catheters, which can impede patient mobility due to cumbersome bags and tubing, and can increase the risk of myotoxicity, infection, and overdosing/underdosing due to device malfunction. Catheters can also migrate, dislodge, or clog, further complicating patient care.3,6-9

For treating physicians: the use of catheters may introduce unintended variability by requiring dose adjustments while necessitating management of transient adverse events, which can contribute to insufficient pain control and interfere with postsurgical recovery.8,10 Significant financial consideration: an associated financial burden exists for the equipment required for administration of continuous infusion blocks and postadministration monitoring, which can amount to more than $600 per patient. One must consider these costs compared with those for single-shot blocks.7,11

What is the next level of postsurgical patient care? Despite numerous advancements in postsurgical pain management, patients have seen little or no improvement in postsurgical pain control over the past 20 years.12 Moving forward, an ideal solution would effectively incorporate the strengths of both single-shot and continuous block options in a single therapy while minimizing their inherent risks and shortcomings: • Maintaining the simplicity of single-shot technique without opioid supplementation • Avoiding use of devices and their inherent limitations • Achieving longer-lasting effects to rival those provided by catheters and infusion devices

Dragan Gastevski, MD Anesthesiology, Pain Medicine Chicago, IL

References: 1. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101(6):1634-1642. 2. What is regional anesthesia? Hospital for Special Surgery. http://www.hss.edu/anesthesiology-anesthetic-techniques. asp#.VNk3GC42dVc. Accessed February 9, 2015. 3. Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. 2010;105(suppl 1):i86-i96. 4. Brummett CM, Williams BA. Additives to local anesthetics for peripheral nerve blockade. Int Anesthesiol Clin. 2011;49(4):104-116. 5. Buckenmaier III C, Bleckner L. Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: Broden Institute; 2008. 6. Golf M, Daniels SE, Onel E. A phase 3, randomized, placebocontrolled trial of DepoFoam® bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Adv Ther. 2011;28(9):776-788. 7. Bingham AE, Fu R, Horn J-L, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systemic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37(6):583-594. 8. Medtronic. Important safety information for drug delivery systems. http://www.medtronic.com/patients/cancer/important-safetyinformation/. Updated June 4, 2014. Accessed February 11, 2015. 9. Marhofer D, Marhofer P, Triffterer L, Leonhardt M, Weber M, Zeitlinger M. Dislocation rates of perineural catheters: a volunteer study. Br J Anaesth. 2013;111(5):800-806. 10. Subramaniam R, Sathappan SS. The effects of single shot versus continuous femoral nerve block on postoperative pain and rehabilitation following total knee arthroplasty. Malays Orthop J. 2010;4(1):19-25. 11. Knight KH, Brand FM, Mchaourab AS, Veneziano G. Implantable intrathecal pumps for chronic pain: highlights and updates. Croat Med J. 2007;48:22-34. 12. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey [published online November 15, 2013]. Curr Med Res Opin. 2014;30(1):149-160. doi:10.1185/03007995.2013.860019.

02/15

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CLINICAL ANESTHESIOLOGY

Preoperative Fasting in Children Unnecessarily Prolonged Long Beach, Calif.—Children routinely face prolonged periods without eating or drinking before surgery, often extending hours beyond recommended guidelines, a new study has found. More than three-fourths of children who had surgery went more than 12 hours without solids before their operations, researchers at Boston Children’s Hospital reported. The

study, which examined the records of more than 22,806 children who underwent elective surgery at the hospital between November 2012 and May 2014, found that 10% had gone more than 18 hours without eating. The results, presented at Clinical Nutrition Week 2015, showed that 36% of children who had surgery at the hospital during the study period

went more than six hours without liquids (abstract 2079392). The American Society of Anesthesiologists (ASA) recommends that patients stop drinking liquids two hours and stop eating six hours before an operation. “Despite these reports, many children undergo prolonged preoperative fasting, far exceeding the current ASA recommendations,” the study found.

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The time of day that surgery was performed, and to a lesser extent the age of the child, affected the length of preoperative fasting, the researchers noted. Even though there has been increasing research highlighting the potential health benefits for children of shorter preoperative fasting periods, the study found that the recommendations have yet to be put into clinical practice. The study was led by J. William Sparks, MD, associate clinical director of operating rooms at Boston Children’s Hospital, in Waltham, Mass., and a member of the Department of Anesthesiology, Perioperative and Pain Medicine. His co-investigators were Nilesh M. Mehta, MD, Departments of Anesthesiology and Critical Care Medicine; Daniela Anderson, MD, the Center for Nutrition; and Craig D. Smallwood, a respiratory therapist. The children had a median age of nearly 9 years; 57% were boys. Binary logistic regression was used to isolate the factors determining prolonged preoperative fasting times. Reviewing the hospital’s electronic health records, the team collected data on several variables: gender, fasting duration for liquids and solids, the surgical service performing the operation, the time of the surgery and hospital length of stay. The median duration of preoperative fasting was four hours for liquids and 14 hours for solids (Table). In addition to the 76% of children who went 12 hours or more without eating, another 20% went eight to 12 hours without solids. The deviation from the ASA guidelines on preoperative fasting was the most extreme for solids. Preoperative fasting duration was lower for liquids. Still, a full 20% of children had nothing to drink for more than 12 hours before their surgeries, and another 16% went without clear liquids for six to 12 hours. Why Prolong Fasting? After analysis of several potential factors behind the prolonged preoperative fasting times, the strongest correlation was found with the time of surgery. Fasting duration increased steadily throughout the day, practically doubling from around 10 hours at 8 a.m., to 20 hours or more by late afternoon, the study found. Preoperative fasting also increased

MAY 2015

AnesthesiologyNews.com I 15

CLINICAL ANESTHESIOLOGY Table. Preoperative Fasting Times in Children steadily, although less dramatically, the way to further research. Dr. Sparks Fasting Time Clears Fasting Time Solids with advancing age of the child. said the next step will be to examine the metabolic effects of prolonged Infants less than 1 year old went, on % of % of Category Range, h N Cohort Range, h N Cohort average, without liquids for 3.6 hours fasting before surgery in children and whether there is an effect on patient and without solids for 9.6 hours. <2 329 1.7 <6 181 0.8 Those figures rose to 4.4 hours for liq- Short fast outcomes. uids and 13.6 hours for solids among “Obviously, the big picture is whether Appropriate fast 2-6 12,231 62.4 6-12 5,263 23.2 a prolonged fast affects patient outchildren aged 1 to 5 years. Whereas Prolonged fast >6 7,033 35.9 >12 17,207 76 preoperative fasting times for liquids comes,” he said. generally stayed the same among older children, fasting time for solids rose The Boston Children’s Hospital been a reduction in duration of pre—Scott Van Voorhis to 14.8 hours among patients aged 5 researchers will review patient records operative fasting, he noted. to 12 years, leveling off to 14.5 hours after six months to see if there has The study is also expected to open There were no relevant financial disclosures. among children aged 12 years and older. Preoperative fasting duration also varied slightly depending on the surgical service performing the operation, ESA BOOTH with patients undergoing oral, orthopedic or genitourinary surgery more likely to go longer without drinking or eating, albeit mostly for less than an hour. The phenomenon of prolonged preoperative fasting occurs even as research in the medical and scientific community increasingly highlights the benefits of shorter periods of abstention from food and drink before surgery, the study noted. Recent studies have shown an increase in feelings of general malaise, anxiety, weakness, hunger and thirst among patients who have undergone prolonged fasting before surgery. During fasting, metabolic changes occur as well, including “reduced hepatic glycogen stores, increased gluconeogenesis and increased insulin resistance,” Dr. Sparks said. By contrast, reduced fasting has been shown to improve patient comCASMED has taken tissue oximetry to the next level and fort, with no change or reduction is making it easier than ever to get the kind of accurate in gastric volume or pH, while also and actionable readings you can trust. Building upon reducing insulin resistance, reducing the proven accuracy of the FORE-SIGHT® algorithm, ELITE hyperglycemia/stress response and is the first and only FDA cleared tissue oximeter featuring increasing protein metabolism. five wavelengths of near-infrared light for greater accuracy Several factors may be driving the and enhanced tissue recognition. ELITE is next generation phenomenon, Dr. Sparks said. Parentechnology designed to deliver a level of confidence that tal or patient anxiety over the potenother conventional parameters cannot match. tial for aspiration during surgery is Visit CASMED at ESA Booth 87 A. certainly one reason, he pointed out. But there is also a need to look at whether parents are getting the right information when it comes to the number of hours their children need to go without eating or drinking before surgery, Dr. Sparks said. To that end, Boston Children’s Hospital has created a pamphlet on preoperative fasting that is given to parents at its Boston campus, he said. At its satellite campus in suburban Boston, the hospital’s nurses are making phone calls to parents to ascertain that they understand the correct fasting times, Dr. Sparks said.

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here’s a Hydra-like world. In its collaboration quality to public with Lifebox, which started in 2012, the GHO focuses health in the developing world—dispatch one on Latin America. problem and two more Pulse oximeters are cruemerge. The good news in cial to the safe practice of recent years is the dramatic anesthesia. When pulse decrease in the incidence oximetry was introduced in the United States in of malaria, HIV/AIDS and tuberculosis in the world’s the 1980s, the incidence poorest countries. The bad Kelly McQueen, MD of death during surgery news is that surgical disdropped 100-fold. But Lifeease, largely neglected, is box estimates that 31.5 milnow reaching what many call epidemic lion operations still take place annually levels. By 2020, noncommunicable dis- in the world’s poorest countries witheases are expected to surpass infectious out the device. diseases as the leading cause of global Dr. McQueen has seen how this mortality. plays out. Surgeons monitor physical signs such as breathing, the pulse and the color of the lips and blood. But it By 2020, is a risky business, especially when they noncommunicable are using suboptimal anesthetic medication such as ketamine (widely used diseases are expected in poorer countries) and have no rescue medicine on hand in the event to surpass infectious of an overdose. It’s estimated that in diseases as the leading Africa, one of every 150 patients will cause of global mortality. die on the operating table due to problems associated with the anesthesia; the figure for North America is about Kelly McQueen, MD, chair of the one of every 180,000. American Society for Anesthesiolo“They do the best they can,” said gists’ (ASA) committee on Global Dr. McQueen on the phone from Humanitarian Outreach (GHO), is Vanderbilt’s Surgery Center “They’re determined that surgery and anes- not intending to hurt anyone.” thesia become top priorities in global The Lifebox Program public health. Having spent 20 years Anesthesiologists are in short supply working overseas as an anesthesiologist, service provider and teacher, in these countries and those who are Dr. McQueen has seen firsthand the there lack training, a side effect of the impact that inadequate surgical facili- concentration of resources on infecties have across Africa, South and Cen- tious diseases. Dr. McQueen cites as an tral America, southeast Asia and the example Rwanda, where one sole anesMiddle East. Dr. McQueen now holds thesiologist remained at the conclusion a faculty position at Vanderbilt University Medical Center in Nashville, Tenn., and is also the president of both the Alliance for Surgery and Anesthesia Presence and the Global Surgical Consortium. GHO started in 1991 with a teaching program in Rwanda and has since expanded to include residencies and scholarships in several countries as well as partnerships with other organizations. The most significant of these is with Lifebox, a U.K.-based charity that provides pulse oximeters and related training to surgical clinics around the

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AnesthesiologyNews.com I 17

PRN of that country’s 1994 genocide. Today, she believes there are 44 anesthesiologists for a population of 12 million people. Women form a disproportionate number of the victims. It is estimated that up to 80% of emergency operations conducted in poor countries are obstetric. A ruptured uterus, obstetric fistula or uncontrolled bleeding can cost a mother her life or her continence. For Dr. McQueen, these are among the most tragic situations— when a mother, exhausted from unproductive labor with an obstructed baby, faces a choice of losing her baby or undergoing a cesarean delivery with inadequate or unmonitored anesthesia. Although a standard pulse oximeter costs between $2,000 and $4,000, Lifebox is able to obtain them from a Taiwanese manufacturer for a unit price of $250 by buying in bulk and not insisting they be medical grade or have FDA approval. The technology is developing quickly with versions now entering the market that plug into iPhones. This gives Dr. McQueen reason for hope, as does a growing awareness of the problem. She said that 2015 may turn out to be a breakthrough year for global surgery, with several international bodies honing in on the issue. This year marks the end of term for the “Millennium Development Goals,” set by the United Nations in 2000, which focused on HIV/AIDS, malaria and other diseases and made no mention of surgical disease. Determined to reverse this omission, the World Federation of Societies of Anesthesiologists will present a resolution to make surgery and anesthesia priority areas in the future at the May World Health Assembly annual meeting. In April, the 25-member Lancet Commission on Global Surgery, established in January 2014 to investigate the “alarming lack of global focus on widespread provision of quality surgical services,” as stated on its website, will deliver its final report. Estimating that the poorest one-third of the world’s population has access to only 3.5% of the world’s surgical operations and that roughly 15% of the world’s disability is caused by surgically treatable conditions, the report is expected to steer governments and policymakers toward more equitable delivery of surgical services. Also due for publication this year is the third edition of the World Bank’s “Disease Control Priorities.” Its first volume, “Essential Surgery,” which came out in February, points out that 1.5 million deaths annually in low- and

middle-income countries could be avoided with essential surgical services, and calls these among the most costeffective health interventions. For Dr. McQueen, decades of what felt like advocacy work are starting to pay off. But identifying the problem is just the beginning. Now, resources have to be put into solutions. She is hopeful that, as was the case with retrovirals, public pressure will force the removal of patents from anesthetic medications, making them more

Today in Rwanda there are 44 anesthesiologists for a population of 12 million people.

currently allocates 0.01% of its budget to its global outreach arm. Acknowledging that there are many competing interests within the organization and that not everyone feels as passionately about outreach as she does, Dr. McQueen said this figure could do with a boost. “One percent would be nice.”

affordable. And she is encouraged by the effect Lifebox is having around the world. —Naomi Buck As chair of the GHO committee, Dr. McQueen can’t help but wish The website for the ASA’s Global Humanitarian for a little more funding. The ASA Outreach is www.asahq.org/gho.

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CLINICAL ANESTHESIOLOGY

Serious Adverse Events Unlikely From Pediatric Dexmedetomidine Use

was administered by anesthesiologists (35%), intensivists (34%), emergency medicine physicians (12.7%), hospitalists (1.1%) and other clinicians (17%), which included But type of practitioner affects complications… CRNAs. “We found that there were Phoenix—Analysis of the Pediatric Sedation Dr. Sulton explained. “The PSRC has pros and cons, only about 45 reported seri- Carmen Sulton, MD Research Consortium (PSRC) database has revealed but the beauty of it is that it’s blinded and gets its ous adverse events (0.34%),” that pediatric procedural sedation with dexmedeto- data from multiple children’s hospitals. The other Dr. Sulton said in an interview midine is unlikely to yield serious adverse events good thing about the PSRC is that it keeps track of with Anesthesiology News (Table 6). “Then we broke (SAEs), regardless of the type of practitioner admin- serious adverse events.” The PSRC was established the data down by provider [Tables 7 and 8], and the istering the drug. The multicenter research team at with 35 participating institutions and has grown numbers got so small—because the overall rate was the helm of the analysis concluded however that rates since its inception in 2003. so low—that it didn’t really make a difference. We of minor complications varied significantly from proDemographic (Table 1) and clinical data (Tables 2 converted the data to a rate per 10,000 cases, and vider to provider. and 3), provider subspecialty (Table 4) and sedation- found that the SAE rates between specialties were “We use dexmedetomidine quite a bit in our ICU,” related complications (Table 5) were abstracted from very comparable.” Indeed, the SAE rate was approxsaid Carmen Sulton, MD, a fellow in emergency the database. SAEs were defined as cardiac arrest, air- imately 34 per 10,000 cases for anesthesiologists, 38 medicine at Emory University in Atlanta. “I found way obstruction, death, laryngospasm, emergent airsee ped SAEs page 43 that it’s a great drug for intubated children because way intervention, unplanned hospital admission/ you can give a little bit of sedation, it’s easy to titrate increased level of care, aspiration or need for an Table 5. Overall AE Rate (n=466) and we can get children very sedated or wake them emergency anesthesia consult. up very quickly if need be. As Dr. Sulton reported at the 44th Critical Care AE Frequency (%) 95% CI, % “These qualities piqued my curiosity about its use, Congress of the Society of Critical Care Medicine Overall AE rate 466 (3.6) 3.26-3.90 however,” she continued. “I wanted to be able to see (abstract 123), 13,072 children (73% ASA Class who was using the drug, how they were using it and I-II) were sedated using dexmedetomidine. The drug Unexpected change in 122 (0.93) 0.78-1.11 HR or BP >30% the complication rates associated with the various Table 3. Primary Location of Sedation Using subspecialists.” Other 76 (0.58) 0.46-0.73 To that end, the researchers reviewed data from Dexmedetomidine Agitation/Delirium 60 (0.46) 0.36-0.59 the PSRC database to identify children who received Frequency (%) Desaturation 57 (0.44) 0.33-0.56 dexmedetomidine as their primary sedation agent Location IV-related complication 55 (0.42) 0.32-0.55 for elective pediatric procedural sedation. “I wanted Radiology 11,880 (90.9) a snapshot of how the drug was being used across Clinic/floor 676 (5.2) AE,, ad adverse e se eevent; e t; BP,, bblood ood ppressure; essu e; HR,, heart ea t rate ate multiple children’s hospitals, not just our institution,” Table 1. Demographic Data (N=13,072)

Pediatric ICU

319 (2.4)

Other

147 (1.1)

Emergency room

43 (0.3)

Age, mo (25%-75%)

36 (19-60)

Cardiac catheterization suite

5 (0.04)

Weight, kg (25%-75%)

15.4 (11.1-22.0)

Dental

2 (0.02)

Male (%)

7,575 (58)

ASA class (%)

Table 6. Overall SAE Rate (n=45)

Table 4. Primary Sedation Provider

•I

2,160 (16.6)

• II

7,369 (56.6)

• III

SAE

Frequency (%) 95% CI, %

Overall SAE rate

45 (0.34)

0.19-0.37

Airway obstruction

35 (0.27)

0.19-0.27

Emergent airway intervention

7 (0.05)

0.03-0.11

Laryngospasm

3 (0.03)

0.01-0.07

Increased level of care

5 (0.04)

0.02-0.09

Aspiration

0-0.02

Provider

Frequency (%)

3,447 (26.5)

Anesthesiologist

4,585 (35.1)

• IV

44 (0.3)

Intensivist

4,461 (34.1)

0-0.02

4 (0.03)

Emergency physician

1,662 (12.7)

Emergency anesthesia consult

• V+

Othera

2,223 (17)

Cardiac arrest

0-0.02

Hospitalist

141 (1.1)

Death

0-0.02

ASA S , American e ca Society Soc etyy of o Anesthesiologists est es o ogg stts

Table 2. Dexmedetomidine Routes of Administration Route

Frequency (%)

Bolus only

4,302 (32.9)

Infusion only

2,937 (22.5)

Bolus and infusion

3,961 (30.3)

Intranasal only

1,250 (9.6)

Intramuscular only

229 (1.8)

Sublingual only

211 (1.6)

PO only

44 (0.3)

Other

44 (0.3)

PO O, oorally a y

Defined as certified nurse anesthetists,, reg registered gistered nurses,, fellows and residents.

SAE, serious adverse event

Table 7. AE Rates by Provider Provider (n)

AE Frequency

AE Rate/ 10,000

Unadjusted OR

Adjusteda OR

Adjusted P Value

Anesthesiologist (4,585)

130.8

Reference

Hospitalist (141)

354.6

4.24

3.71

0.007

Otherb (2,223)

413.9

4.68

4.64

<0.001

Intensivist (4,461)

260

582.8

5.98

5.33

<0.001

Emergency physician (1,662)

130

782.2

7.69

8.48

<0.001

AE, adverse event; ASA, American Society of Anesthesiologists; NPO, nothing by mouth a

OR adjusted for weight <5 kg, prematurity, primary diagnosis as upper or lower respiratory infection, location of sedation, ASA class >II and NPO time.

Defined as certified nurse anesthetists,, registered g nurses,, fellows and residents. residentts.

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AnesthesiologyNews.com I 19

CLINICAL ANESTHESIOLOGY ICU

because why would you “With that in mind, I would recomAdministering neuromuscular blockade to ICU mend that if you’re in the ICU with need a paralytic to improve we don’t know if this is true in the your view if the view is propatients is not without its a critically ill patient who needs to be ICU as well. risks, however, which makes intubated and you think that you can vided by the camera?” “We also know that ICU patients The investigators also patient selection and pro- mask ventilate them in the event of a are very different from those in the looked into a subgroup vider technique all the failure, then a neuromuscular blocker other two arenas. They’re sicker, and of patients intubated via more important. “If you will increase your odds of first-attempt often times the people intubating them video laryngoscopy, and can’t get an airway, you’ve success.” are not as experienced as in the other found that the propensity- Jarrod M. Mosier, MD taken away somebody’s two venues when it comes to tracheal adjusted odds ratio of spontaneous breathing ,” —Michael Vlessides intubation.” first-attempt success with the use of Dr. Mosier said. “If you can’t intubate, To help get a handle on the potential neuromuscular blockade was 2.50 that’s a situation that could quickly spi- The researchers reported no relevant financial relationships. risks and rewards associated with intu- (95% CI, 1.43-4.37; P<0.001). ral out of control. bating ICU patients, Dr. Mosier and his colleagues enrolled 664 consecutive patients into the observational study. Intubation-related data were collected prospectively on all patients intubated in the ICU over the study period, and then analyzed. The researchers also performed a propensity adjustment for factors predetermined to affect the decision to use an NMBA. Adjusted multivariate regression analysis was used to evaluate the effect of neuromuscular blockade on first-attempt success. Although the two groups were found to be demographically similar, Since 1987, Preferred Physicians Medical (PPM) has exclusivelly insured those who did not receive neuromusanesthesiologists and their practices. Our policyholders also own PPM, so helping cular blockade had a greater number our physician owners manage their risk is a cornerstone of wh hat makes us unique. of median difficult airway predictors One emerging risk for anesthesiologists is the rise in unauth horized disclosure (DAPs) than their counterparts (2.4 of personal health information (PHI) from high tech data breaches and security vs. 1.8; P<0.001). Significant differlapses in dealing with patient records, both electronic and paper. As of 1/1/2015, ences also were found between groups all PPM policyholders receive standard Cyber Liability Covverage at no with respect to the sedative used additional charge, with no underwriting required or deducctibles applied.* and the operator’s level of training. Additional coverage tailored to your practice is also availab ble. Indeed, more paralyzed patients were sedated with etomidate (83% vs. 35%; PPM also maintains a substantial database of more than 122,500 adverse anesthesia events and uses this information to identify areas of risk, monitor P<0.0001), whereas more patients in developing loss trends, and provide cutting-edge, timely an nd practical anesthesiathe non-NMBA group received ketspecific risk management advice and strategies like: amine (39% vs. 9%; P<0.001). The researchers reported their findings at On-site risk management seminars for policyholderrs and staff the 44th Critical Care Congress of presented by PPM in-house in house claims attorneys. attorneys the Society of Critical Care Medicine Immediate email notification via Anesthesia Alertss of important, (abstract 729). time-sensitive issues such as widespread drug contamination and Dr. Mosier noted that first-attempt significant changes to ASA Standards. intubation success was greater among 24/7/365 telephone access to our experienced attorn neys and claims patients who were first paralyzed than specialists for the expert risk management advice you need. those who were not (81% vs. 70%; Exclusive access to anesthesia specific practice and risk management P=0.003). After controlling for total resources. Examples include white papers, sample in nformed consent DAPs, device used, sedative and operdocuments, current and archived issues of Anesthesiia & the Law, w ator level of training, the propensityand other useful information for your practice. adjusted odds ratio for first-attempt success with neuromuscular blockade was 2.17 (95% confidence interval [CI], 1.29-3.66; P<0.001). There were no differences in procedure-related complications between groups. These findings proved surprising to the researchers, particularly in an age where video laryngoscopy has gained such a strong foothold. “I thought that with the advent of video laryngoscopy, *In partnership with NAS Insurance, the leading provider of Cyber Liability Coverage to health care professionals in the United States. you probably wouldn’t need a paralytic,” he explained. “Personally, I was only Add your good name to our growing list of ASA “standard of care” clinicians. 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CLINICAL ANESTHESIOLOGY

Q: Can Mechanically Ventilated Patients Self-Administer Sedatives? A: Yes Phoenix—Despite obvious challenges in identifying appropriate candidates, mechanically ventilated patients can safely selff administer sedative medications using widely available infusion pumps, a research team has concluded. Although the researchers’

primary focus was not the efficacy of the patient-controlled sedation (PCS) system, they hope to delve deeper into outcomes in future studies. “For many years, the paradigm has been that ICU patients are helpless and have no decision-makingg capacity, so

clinicians decided what was best for the patient,” said Craig R. Weinert, MD, MPH, an associate professor of medicine at the University of Minnesota, in Minneapolis. “However, that’s probably not true. There are many ICU patients who can make care decisions.

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There are inherent risks in all medical devices. Please refer to the product labeling for Indications, Cautions, Warnings, and Contraindications. Failure to follow the product labeling could directly impact patient safety. Physician is responsible for prescribing and administering medications per instructions provided by the drug manufacturer. Refer to www.halyardhealth.com for product safety Technical Bulletins. 1. Sherwinter DA, et al. Continuous infusion of interperitoneal bupivacaine after laparoscopic Surgery: A randomized controlled trial. Obes Surg. 2008: 18 (12): 1581-6. 2. Klein et al. Interscalene brachial plexus block with continuous catheter insertion system and a disposable infusion pump. Anesth Analg. 2000; 91:1473-8. 3. Data on File. ON-Q* Pain Relief System. *Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2015 HYH. All rights reserved. RX Only. MK-00754 03/2015.

‘Our goal is to improve the experience of mechanical ventilation, not to decrease sepsis, ICU mortality or length of stay. We’re here to make the experience as tolerable as possible.’ —Craig R. Weinert, MD, MPH

“And with the push over the last five to seven years to have patients more alert, we tried to look at alternative types of sedative therapy, where patients may end up getting less drug. The idea here is that if we let patients give themselves their drug, the feeling that they’re managing themselves might mean they get less medication than if a nurse or physician is looking at them and interpreting their behavior. So we’re trying to change the paradigm from the doctor or nurse knowing best to maybe the patient knows best.” To that end, Dr. Weinert, his coinvestigator Linda Chlan, RN, PhD (now at Ohio State University), and their colleagues enrolled 37 informed and consenting patients into the trial. PCS dexmedetomidine was administered with a basal infusion ranging from 0.1 to 0.7 mcg/kg per hour, titrated up or down every two hours by staff nurses based on patient-triggered bolus doses (0.25 mcg/kg per dose, maximum three doses per hour). Dexmedetomidine was delivered through a standard PCS infusion pump for up to five days. The trial’s primary safety goals were to maintain heart rate above 40 beats per minute (bpm), systolic blood pressure greater than 80 mm Hg and diastolic blood pressure greater than 50 mm Hg. Feasibility was assessed by the ability to enroll eligible patients, days on PCS protocol and adherence to the titration protocol by the institution’s ICU nurses. “This is actually the second study we’ve done,” Dr. Weinert told Anesthesiology News. “We published a smaller,

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AnesthesiologyNews.com I 21

CLINICAL ANESTHESIOLOGY nonrandomized trial several years ago (Chestt 2010;138[5]:1045-1053) where we showed that patient-controlled sedation is possible in these individuals. The current study was to see if we can do this in a randomized fashion, and for a longer time.” The researchers reported at the 44th Critical Care Congress of the Society of Critical Care Medicine (abstract 684) that patients (60% male; mean age 52 years) were randomly assigned to receive either PCS dexmedetomidine (n=17) or usual sedation care (n=20). No patient’s heart rate fell below 40 bpm, although three PCS patients had mild hypotension necessitating rate reduction, fluid bolus or transient drug cessation. Almost half of the PCS patients (n=7) required no supplemental sedatives. Seven others received between one and three sedative doses, while the remaining three patients received more than three doses while on the protocol. PCS patients were also satisfied and/or very satisfied with their ability to selff administer medication (92%), control anxiety (69%) or feel relaxed (62%). “Most importantly, staff nurses— these were not research nurses—could follow the protocol for titrating the dexmedetomidine up or down based on the study algorithm,” Dr. Weinert added. “They didn’t do it perfectly, but they did it well enough that there weren’t any adverse effects from the titration protocol.” Nursing adherence was found to be 79%; safety parameter adherence was 100%. Finally, no PCS patient became delirious (as measured by the Confusion Assessment Method for the Intensive Care Unit) while on protocol; four of their counterparts undergoing usual care did. Enrolling mechanically ventilated ICU patients into a randomized controlled trial may seem daunting, but as Dr. Weinert explained, it is feasible under the right circumstances. “There were many patients in the ICU on a ventilator who were not even eligible for the study,” he said. “They had to know what they were doing in order to press the button. So one of our feasibility questions was: ‘Are there patients awake enough to understand the study and participate in it? And we showed there are, indeed, patients who can do this.” Given the success of the National Institutes of Health–funded trial, the researchers are submitting a grant for a follow-up study looking more specifically at patient anxiety, drug consumption and ventilator duration as outcomes. “Our goal is to improve the

experience of mechanical ventilation, not to decrease sepsis, ICU mortality or length of stay. We’re here to make the experience as tolerable as possible. We want patients to be more awake, less anxious and receive less total sedative drug.”

questions comments story ideas

—Michael Vlessides The study was supported by Hospira, which provided dexmedetomidine and support for laboratory testing required by the FDA, but was not involved in study design.

Contact the editor, James Prudden, at

jprudden@mcmahonmed.com

DELIVERING INSIGHT.

CAN YOU HELP REDUCE POSTOPERATIVE DELIRIUM RISK? Earlier research concluded that univariate factors associated with delirium include age, preexisting cognitive impairment, greater preoperative functional limitations and a history of prior delirium.1 However, in a more recent randomized controlled trial of 1155 patients, it was shown that episodes of deep anesthesia (bispectral index score <20) were independently predictive for postoperative delirium.2 Numerous additional studies have shown an increased risk of institutionalization, dementia and death in patients with delirium2 as well as increases in hospital length of stay by up to six days3. Moreover, total cost estimates attributable to delirium ranged from $16,303 to $64,421 per patient.4 The good news is, you can reduce the likelihood of delirium occurrence. Guiding anesthetic dosing with brain function monitoring may decrease the rate of postoperative delirium in certain patients.2,3,5,6 Brain function monitoring with Bispectral Index™ (BIS™) technology during surgical procedures gives anesthesia providers the ability to

It’s everybody’s BIS 1. Litaker D1, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry. 2001 Mar-Apr;23(2):84-9. 2. Radtke, FM et al. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. British Journal of Anaesthesia. Published ahead of print Mar 2013. 3. Whitlock, EL et al. Postoperative delirium in a substudy of cardiothoracic surgical patients in the BAG-RECALL clinical trial. Anesth Analg. 2014 Apr;118(4):809-17 4. Leslie DL et al. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008 Jan 14;168(1):27-32. 5. Chan MT, Cheng BC, Lee TM, Gin T; CODA Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013 Jan;25(1):33-42. 6. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal

directly monitor the anesthetic effect on a patient’s brain to optimize the anesthetic dosing for the individual. Peer-reviewed literature has shown BIS-guided anesthetic titration may aid in a reduction in the incidence of delirium in elderly and other patient populations at increased risk. In turn, reducing delirium can positively impact health care economics by lowering total cost of care.4

“The anesthesia practitioner may use processed electroencephalographic monitors of anesthetic depth during IV sedation or general anesthesia of older patients to reduce postoperative delirium.”7 - Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society.

BIS brain function monitoring has also been clinically shown to reduce primary anesthetic delivery (as much as 50%) and promote faster wake-up, recovery and discharge from the PACU.8,9,10

Learn more at: www.everybodysBIS.com anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010 Jan;85(1):18-26. 7. Inouye, Sharon K. et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. Intraoperative Measures to Prevent Delirium. J Am Coll Surg. 2014; 220; 2, 136 - 148.e1. 8. Gan TJ, Glass PS, Windsor A, et al. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia. BIS Utility Study Group. Anesthesiology. 1997;87(4):808-815. 9. Song D, White PF. Titration of volatile anesthestics using bispectral index facilities recovery after ambulatory anesthesia. Anesthesiology. 1997;87:842-848. 10. Luginbühl M, Wüthrich S, Petersen-Felix S, Zbinden AM, Schnider TW. Different beneﬁt of bispectal index (BIS) in desﬂurane and propofol anesthesia. Acta Anaesthesiol Scand. 2003;47(2).

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COMMENTARY MOCA

system, in which board certification was a badge of honor for completing resi(ABMS) and the ABA maintain that dency and passing rigorous exams of participation is voluntary, many phy- knowledge and judgment. Diplomates sicians are compelled to participate were free to choose the CME that was in MOCA or face the loss of practice relevant to them—“grandfathers” are still free to do so. By our calculation, privileges at their institutions. We believe that MOCA was a solu- only 7.2% of grandfathered anesthesition to a problem that did not exist. ologists1,2 have voluntarily participated Patients do not demand MOC—no in the MOC system, so clearly they feel patient has ever asked either of us the previous system was adequate too. about our MOC participation. There No data suggest the previous system was was nothing wrong with the pre-MOC inadequate. Although we decry the fact CONTINUED FROM PAGE 1

that the ABA must now hew to MOC guidelines set forth by the ABMS, we acknowledge that this is the present (but perhaps not permanent3) reality we face. But if MOCA is to exist, it must be radically altered and scaled back. The ABA must therefore demonstrate that it is serious in its pledges to reduce the burdens of the program by working to “improve and enhance the MOCA process to address areas of concern raised by… diplomates.”4 In its 2015 newsletter, the ABA announced

One number could help you improve patient safety.

The Integrated Pulmonary Index.

etCO2

Designed to help clinicians more easily monitor a

Resp Rate

patient’s complete respiratory status, the Integrated Pulmonary Index (IPI) is an algorithm that incorporates four respiratory measurements into a single number. Helpful in busy clinical environments, IPI provides clinicians with a simple and comprehensive indication of respiratory status and trend, promoting early awareness of changes to a patient’s breathing. Only available on Microstream™ capnography monitors.

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Four monitoring parameters in one number.

IPI

some future changes. Dubbed “MOCA 2.0,” it involves a new online module that may consolidate some of the current components.4 We believe the ABA must go further—that a simple, inexpensive online module should supplant the entirety of the current MOCA system. We lay out here a minimally burdensome MOCA program that most participants would find acceptable, although we reiterate that even this new system should be voluntary. Now that a credible alternative certification entity exists, we and others like us will opt out of the MOCA process if these changes are not realized. In the recently released ABA newsletter, 33% of diplomates suggested in an open-ended question that removing or changing the simulation requirement would enhance MOCA.4 Two-thirds of diplomates said they want to be able to skip exam questions not pertinent to their specialty. Barely one-third of diplomates thought the exam reflects their level of knowledge accurately. Half of the respondents cited cost and time commitments as significant obstacles to participation. These are dismal numbers, reflecting an overwhelming dislike of the MOCA program, and they support the idea of radically altering or abolishing it altogether. Receipts from all certification programs (primary and MOCA) increased from $3.06 million in 20011 to $15.1 million in 2013.2 As the number of primary certifications granted per year has been roughly level over that time, the average 33% annual increase and 393% overall increase in revenue necessarily reflects income from an increasing pool of MOCA participants—many of whom complete the process only because they must do so for hospital credentialing. Clearly, the ABA has a financial incentive to continue to increase the cost and scope of these programs. However, MOCA should exist to benefit anesthesiologists and the patients they care for, rather than provide a reliable revenue stream for the ABA. Let’s consider the relevant components of the current MOC program (see Table for a conservative cost estimation): • Presently we pay $2,100 for a closedbook, secure examination. It is obvious to anyone in practice that these examinations do not reflect the way physicians obtain, reinforce or use information. In 2015, when faced with a clinical challenge or rarely encountered medical condition, detailed and up-to-date information regarding the disease and its

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AnesthesiologyNews.com I 23

COMMENTARY anesthetic implications can be readily obtained via digital databases. The consultant anesthesiologist can then formulate an appropriate anesthetic plan based on the researched condition and the patient’s other comorbidities. Current examinees are not provided information detailing the areas in which their knowledge is deficient—the results of the test are simply pass/fail. Any notion that this exercise might therefore be used to improve physicians’ practices is highly suspect. • The simulator requirement is perhaps the most flawed component. Only 25 states have simulation centers endorsed by the American Society of Anesthesiologists, thus mandating that many physicians travel long distances to attend. This cost is rivaled only by the registration price tag of around $2,000. Many, if not most, practicing anesthesiologists frequently care for critically ill patients with multiple comorbidities, and given the extraordinary costs of enrollment, travel and lost opportunity (totaling more than $5,000 for one of us, who must fly from Hawaii to the U.S. mainland, and more than $4,000 for

the other, who practices several hours south of Chicago), the value of this requirement will almost invariably be low. This component should therefore be removed. Anesthesiologists who feel that live critical event simulation may be of particular benefit to them can elect to enroll in such a course, but this should not be mandatory to maintain board certification status. Physicians in every hospital in the country engage in practice improvement endeavors without

being prompted to do so by an expensive simulator experience. • Practice Performance Assessment and Improvement (PPAI) modules are often considered the most burdensome components of the process, despite being one of the cheapest (“only” a few hundred dollars). Most physicians find these requirements to consist of cumbersome busy work, and they often seek to choose the activities that least intrude on their busy practices. Given the

multiple layers of oversight and regulation over physicians and hospitals that already exists, a single PPAI activity is unlikely to substantially improve a diplomate’s perioperative care. Regrettably, voluntary practice improvement endeavors undertaken by an individual or group do not qualify for MOCA credit, although these are far more relevant—they address their own specific situations and selff identifiedd deficiencies.

Table. Estimated MOCA Costs Component Part

Cost

Simulator

Travel: roundtrip driving (time valued at $150/h, assuming 2 h per leg)

$600

Simulator

Travel: driving/parking/ gas

$150

Simulator

Travel:flight

$500

Simulator

Travel: airport parking

$50

Simulator

Simulator cost

$1,800$2,000

Simulator

Hotel

$250/ night

Simulator

Food

$50/d

Simulator

Lost wages/ expended vacation

$1,200/d

Secure exam

Test cost

$2,100

Secure exam

Lost wages/ expended vacation

$1,200/d

PPAI

Time $1,200 expended (estimated 8 h @ 150/h)

PPAI Total

Module cost

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MOCA, Maintenance ooff Certification in Anesthesiology Anestheesiology gy

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see MOCA page 24

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MAY 2015

COMMENTARY MOCA

With the American Board of Internal Medicine (ABIM) recently Furthermore, the ethics of these announcing a moratorium on its own modules have been questioned within Practice Assessment, Patient Voice and anesthesiology and other medical Patient Safety MOC components,7 fields.5,6 Some feel they constitute each ABMS member board should human research without patient or carefully examine whether its requireinstitutional review board consent, and ments truly result in demonstrable because the researcher reaps the pri- benefits to practicing physicians and mary gain of these modules (by main- the patients they care for. In the current economic climate, taining board certification), they may be perversely incentivized to undertake there is increasing emphasis on valuee in meaningless or selff servingg projects. health care delivery. When evaluating CONTINUED FROM PAGE 23

a medical intervention, a drug or procedure that confers significant benefit at low cost has excellent value, whereas one that only minimally improves health at great expense does not. Physicians are frequently reminded to choose those interventions with appropriate value, and to reject those that are costly and with trivial benefit. Importantly, these choices are expected to be based on robust, unbiased evidence. Applying this principle to MOCA, we find the cost is high (estimated costs would

likely be greater than $9,500, plus any additional CME costs), the evidence for improvement in quality is poor and riddled with conflicts of interest, and so the value is objectively low. An Online MOCA 2.0 Although some weak evidence might exist in support of a benefit of primary board certification, there is no independent, peer-reviewed evidence that MOC or MOCA programs confer a benefit to either physicians or patients. Specifically, there is no evidence to suggest that participation in a MOCA program improves the quality of anesthetic delivery or the outcomes of the perioperative care rendered.8 What, then, should MOCA look like, if the secure examination, simulator and PPAI are abandoned? If there must be a MOCA program, it should be a mechanism to ensure that boardcertified anesthesiologists have been exposed to recent landmark literature that has the potential to change perioperative practice. That is, if emerging research demonstrates that a particular intervention represents best practice, MOCA should expose ABA diplomates to this literature. Next, MOCA activities should not be burdensome to busy physicians. The time and costs necessary to participate should be minimized, and no travel should be required. We submit that an online MOCA 2.0 should entirely replace the current MOCA requirements. It should be interactive, open-book and available to be incrementally worked on at the convenience of the participant. This online module could incorporate didactic components as well as critical event vignettes, or a â&#x20AC;&#x153;simulated simulator.â&#x20AC;? It would not be a burdensome imposition of time, as it could be completed gradually at the participantâ&#x20AC;&#x2122;s convenience. And because it should be inexpensive, such a module would be more likely to be considered valuable by diplomates. Here we come to the age-old and challenging question: How do we actually force change? The answer may be competition. Dr. Paul Teirstein, an outspoken critic of MOC,9,10 along with a board of top-notch academic physicians from highly regarded institutions, have founded an alternative board for those dissatisfied with the MOC process. The National Board of Physicians and Surgeons (NBPAS; nbpas.org ) exists to certify physicians across most medical specialties who embrace the necessity of lifelong see MOCA page 42

MAY 2015

AnesthesiologyNews.com I 25

CLINICAL ANESTHESIOLOGY

Perioperative Surgical Home Builds Anesthesiology Support Atlanta—As physicians, patients and politicians all continue to investigate how to control health care costs and reduce waste, anesthesiologists have an opportunity to step up. The concept of the Perioperative Surgical Home (PSH) is one option that is gaining momentum and support. Nationally, health care expenditures totaled nearly $2.8 trillion in 2012, according to the Centers for Medicare & Medicaid Services, and 29% of all health care dollars were spent on surgical procedures. Unplanned hospital readmissions cost Medicare about $17 billion annually, and higher Medicare payments are going to hospitals with higher complication rates. “Patients are not being managed optimally,” said Shubjeet Kaur, MD, professor and executive vice chair of anesthesiology at the University of Massachusetts Medical School. She is the anesthesiology director for perioperative services at the University of Massachusetts Memorial Medical Center, and serves on the American Society of Anesthesiologists’ Committee on Future Models of Anesthesia Practice. Dr. Kaur spoke about the possibilities of the PSH to a group of residents at the American Society of Anesthesiologists’ 2015 Practice Management conference. “All of us here in this room can help achieve the triple aim: better care, better health and lower costs,” Dr. Kaur said. “Under the health care changes, we have an opportunity to reduce waste and deliver quality, and the PSH is one way to do that.” Dr. Kaur cited several recent studies and landmark reports by the Institute of Medicine that explore preventable medical errors, patient-centered care and improved patient experiences. About one-third of health care expenses is waste, she noted, related to high pricing, unnecessary tests and services, administrative expenses and missed prevention opportunities. “There’s no glory in prevention, and no one knows that better than anesthesiologists,” she said. “When a procedure goes as planned, we may not hear anything. The PSH gives anesthesiologists an opportunity to bring value to the care of the patient.” Roots of PSH Anesthesiologists began discussing the future paradigms of anesthesia practice in 2005. The ASA formed the Committee on Future Models for

Anesthesia Practice in 2012 to explore several options. The committee produced a white paper in 2013 about how the surgical home would work and gained endorsement from the ASA’s executive council. The committee asked the ASA for funding to run a Multicenter National Learning Collaborative to test the PSH as a model of health care delivery. The collaborative

55 50 45 40 35

launched in July 2014, with more than 40 centers participating across the country. In parallel with the patient-centered medical home, in which primary care providers lead a team that manages patient health, the PSH is a patientcentered, physician-led, team-based multidisciplinary system of care designed for the surgical patient. It

spans the entire surgical experience from the decision to seek surgery to postdischarge. Under this model, patients begin in a patient-centered medical home and transition into a PSH when they pursue a surgical procedure. The physician team leader coordinates care, including postoperative pain control, discharge planning see PSH page 41

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MAY 2015

CLINICAL ANESTHESIOLOGY

Comments From Readers on Advent Of the Perioperative Surgical Home Anesthesiology News recently published a series of articles highlighting potential benefits of the perioperative surgical home (PSH), in which anesthesiologists are charged with the oversight of care throughout a patient’s hospital stay. Whereas some feel this is a logical step to improving clinical care, others disagree with the concept of the “perioperativist.” We have compiled below some of the comments we received on anesthesiologynews.com and via email (with some comments slightly edited for clarity). Where do you stand on this topic? We encourage you to join the conversation.

The PSH Saves Money The American Society of Anesthesiologists (ASA) launched the PSH model to address increasing concerns about costs and outcomes associated with surgery. This patient-focused, multidisciplinary approach has anesthesiologists

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guiding the perioperative clinical process and overseeing patient care from the moment a procedure is booked to as many as 30 days postoperatively. Researchers cited a study showing that the PSH model can reduce total per-diem costs for total knee arthroplasty (TKA) and total hip arthroplasty (THA); specifically, from literaturereported benchmarks of $17,588 for TKA and $16,267 for THA down to $10,042 and $9,952, respectively. (See “Perioperative Surgical Home Promotes Perioperativists”; February 2015, page 8.) C. Lund, MD, from Denmark, wrote: “Thank you for an interesting and supporting point of view. We are already practicing this way of planning acute high-risk abdominal surgery patients in our hospital with great results over the past 2 years. Probably a significant decrease in post-op mortality and morbidity just by letting the anesthesiologists plan, optimize and follow the patients through standardized best evidence, anesthesia and goal-directed fluid therapy.” R.macnet wrote: “They have been doing it this way in Austria for the last 30 years. Surgeons love it. Anesthesiologists do everything but the operation and post-op wound care. The anesthesiologist is contacted by the surgeon and given the particulars about the patient. The patient then sees the anesthesiologist in his office, does the preoperative history and physical exam and lab work. The anesthesiologist admits the patient to the appropriate operating facility, does the anesthesia, runs cell-saverr prn, manages all collateral medical prognoses pre-op, intra-op, and post-op. Surgeon visits daily and checks the wound/bandage. The anesthesiologist then discharges the patient, writes appropriate prescriptions and sends the patient home.” Anesthesiologists Support the PSH A recent survey conducted at the 68th New York State Society of Anesthesiologists’ PostGraduate Assembly found that most respondents agreed that anesthesiologists had the leadership skills, ability to gather data and knowledge of necessary interventions needed to serve as “operating room (OR) directors.” The investigators said the OR can be a major source of income or financial loss for a hospital, and anesthesiologists are “best suited to take on a leadership role” to help maximize revenues and improve quality and efficiency. Steven Boggs, MD, the lead investigator, said he had seen dramatic improvements in all major OR productivity metrics in his medical centers ever

MAY 2015

AnesthesiologyNews.com I 27

CLINICAL ANESTHESIOLOGY since anesthesiologists assumed this role. However, some experts said other specialists working in the OR (e.g., doctors and nurses) may not be willing to let anesthesiologists be in charge, and there are other ways for them to boost productivity without being assigned this role. (See “Survey: Anesthesiologists Think They Should Be in Charge”; March 2015, page 1.) Preop… wrote: “I agree that the anesthesiologist is the logical manager. I think we have shown by example, time and time again, that surgeons need to bring patients to the OR and operate. Anesthesiologists are in the hospital on a daily basis, working with all specialties and have the best physician perspective to manage OR resources…. In addition, many of us have sought special management skills by studying business and public health. We have taken the time to learn to manage, and, with our nursing colleagues, we do an excellent job!” Dr.no… wrote: “The operating surgeon has not been the captain of the ship in my lifetime, with them having (gladly) abdicated the role in preference to being captain of the operative field. There are economic reasons for this (the surgeon is paid the same, even if someone else provides perioperative care) as well as practical ones (seriously, how much does the current surgeon know about all of the co-morbidities that a patient may have?). Will and Charlie Mayo recognized the limitations of a surgeon’s provision of global perioperative care when they hired Henry Plummer to care for the medical aspects of surgical patients over 100 years ago (1901). Rather than marginalizing the surgeon the current reality recognizes the importance of having the surgeon pay attention nearly exclusively to what s/he does best—surgery. The surgeon’s place is in the OR, preferably operating. Let the rest of us do what we do, and care for the nonsurgical needs of the patient…. Although not potentially optimally trained in resource and personnel allocation, anesthesiologists as a group are no less qualified than surgeons and nurses, and due to team based behavior and required training in preoperative, intraoperative, postoperative, and intensive care are innately better qualified than surgeons and nurses for administrative OR roles.” Martt… wrote: “In France it is usual to have a specially trained ‘Chef du Bloc’ allocating the resources. He/she is normally a nurse who has been trained in surgery and who also has special training for the purpose. I have lived under the circumstance where an anesthetist tried to do his clinical patient work on the side [while] running the OR and of

course it did not work. Also, when surgeons interfere with planning without adequate knowledge of the facts, things go to hell. Running the unit properly takes the effort of all professionals. Only the surgeon knows exactly what he is going to need for the operation, eg, if there is going to be bleeding or other special things to be considered. The anesthetist works out the ideal approach with the surgeon. The ‘Chef du Bloc’ takes care that the material and the staff will be available.”

Not So Fast Seeking an opinion from the other side of the spectrum, Frederick L. Greene, MD, clinical professor of surgery, UNC School of Medicine, in Chapel Hill, N.C., wrote a commentary discussing the PSH. Although Dr. Greene agreed that some aspects of the PSH model are beneficial to patients, he was concerned that the concept will marginalize the surgeon while the anesthesiologist assumes the role of the perioperativist. Dr. Greene said patient care

“must not transition to nonsurgical specialists because of the presumption that [surgeons] have undervalued or abdicated our responsibility for coordinating the care of the surgical patient. The operating surgeon should and must remain the captain of the entire ship!” (See “The ‘Perioperativists’ Are Coming!”; March 2015, page 14.) Michael J Peck, MD, emailed: “First of all, surgeons have not been ‘captains’ of the ship for years. They gave that up see comments page 41

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MAY 2015

TECHNOLOGY

Electronic Health Records Present Unin Atlanta—Electronic health records (EHRs) can be seen as either friend or foe for the improvement of documentation and the optimization of clinical care. For anesthesiologists, the anesthesia information management system (AIMS) can more accurately reflect patient physiology and clinical status and facilitate continuity of care. However, the transition to electronic

anesthesia records can serve as a distraction to anesthesia providers, pose challenges for data accuracy and raise some liability concerns. “All of you who have practiced for any period of time know the challenges of practicing with paper records,” said Neal Cohen, MD, vice dean at the University of California, San Francisco School of Medicine. Dr. Cohen

discussed the transition, benefits and unintended consequences of EHRs at the Americcan Society of Anesthesiologists’ 2015 Practice Management Conference. “I like to teell the story of a formeer clerk who fell behind on filing and caught up on his records by

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t h r o w i n g th them m int into a dumpster at the airport. When a 747 took off, so did the records.” It’s clear that anesthesiologists need to transition to EHRs. Along with the economic implications tied to the Affordable Care Act and “meaningful use,” future health care advances will require large data sets for analysis, personalized care and patient privacy. Anesthesiologists must participate in the decision-makingg process to select and implement these systems to ensure that platforms incorporate the requirements of the perioperative period. Data Accuracy Anesthesia practices are keeping an eye on the challenges and unintended consequences of the transition to EHRs, such as data accuracy, documentation templates, copyy and-paste functions and the audit trail. Data accuracy requires intervention and edits by the provider, Dr. Cohen said. Electronic systems automatically download information from physiologic monitors, such as the electrocardiogram (ECG) and blood pressure, but that is not necessarily a correct reflection of the patient’s status. For example, if a patient moves or the ECG leads fall off, the record will include inaccurate patient data. If the information is not validated, the incorrect information becomes a permanent part of the patient’s record, which creates both clinical and legal risks. Similarly, data can be lost or inadvertently not recorded as part of the permanent record. Providers should ensure that data are being documented, and if missing, have a mechanism to manually enter the information. “We need to intervene appropriately and accurately reflect what has happened to the patient,” Dr. Cohen said. see EHR page 46

MAY 2015

AnesthesiologyNews.com I 29

TECHNOLOGY

Communication and Transparency Keys to Risk Management Atlanta—In the health care industry, communication and transparency both play a large role in maintaining patient safety and ensuring management of clinical risk. In fact, about 70% of adverse events (AEs) can be traced back to gaps in communication. “Many times we blame adverse events on an ill-definedd process, the environment of care, lack of education, lack of training or equipment malfunction, but typically they stem from human error or lack of communication,” said Brian M. Parker, MD, an anesthesiologist at Cleveland Clinic in Ohio, and chairman of the Cleveland Clinic’s Medical Legal and Clinical Risk Management Committee. Dr. Parkerr discussed strategies for effective communication here at the American Society of Anesthesiologists’ Practice Management 2015 conference.

‘This is your opportunity to go in with a unified front alongside the surgeon or physician. Don’t let someone else represent the care you rendered. It’s better to know what’s being said about you and how the family was told.’ —Brian M. Parker, MD

Before an AE occurs, physicians should avoid potential legal hiccups by maintaining accurate documentation. With electronic medical records, everything typed and saved in the record becomes the legal interpretation of the event. Providers must be accurate and detailed and state what was known at the time of the event. They should not speculate in the electronic record, and should not be part of the “blame game” in the chart, Dr. Parkerr said. Everything in the medical record can be used as potential evidence in a trial and for punitive damages, so disputable facts or sideline stories that can be turned into dramatic narratives should be avoided. If providers create a “late entry” in the medical record, they should clearly include the purpose of the entry and not alter or delete previous entries in the record. All of these small actions can change the way lawyers interpret the record of a patient’s care. “Attorneys may look for audit trails and want to see what you looked at and

when,” Dr. Parkerr said. “Everything has an electronic signature, so they can see if you actually looked at the EKG screen and for how long you looked at it.” When a medical error or unanticipated outcome occurs, the next steps are the most vital. How the event is handled can determine the course of what happens—and whether that means litigation. About 80% of claims arise from

poor communication, Dr. Parker said, and 70% of individuals who sue feel their questions about an AE were devalued or ignored. Apologies and disclosures are viable alternatives to the “deny and defend” tactic used for so long. But apologies and disclosures should be done in the context of the institution, the medical malpractice insurer and as part of a medical team.

N W

The care team must create a communication plan—and do it together. They must prepare for the conversation with the family and patient; learn who will be present for the conversation; and determine what the family dynamics are. Team members must practice what they will say and how they will answer any questions. Anesthesiologists often see risk page 46

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MAY 2015

TECHNOLOGY

Anesthesia Management System: Smart and Saves Money Phoenix—A cutting-edge anesthesia management system developed at the University of Washington (UW) Medical Center, in Seattle, has generated an estimated return of $1 million annually for the hospital while providing a major boost to patient care. Bala Nair, PhD, associate professor of anesthesiology and pain medicine at UW, detailed the development of the

new system and its impact on patient care and hospital revenue, during a presentation at the Society for Technology in Anesthesia’s annual meeting. For example, the new Smart Anesthesia Manager (SAM) has resulted in a far more efficient use of expensive inhalation agents, Dr. Nair said. Developed over the past five years by Dr. Nair with assistance from other

medical center colleagues, SAM has also boosted clinical care. The use of SAM has significantly improved blood pressure, glucose and antibiotic management, resulting in greater compliance to institutional guidelines, Dr. Nair said. Other benefits include barcode verification of drugs at the time of administration and a “handoff tool,” particularly helpful for the

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transfer of care from anesthesia to nursing at the end of a procedure. In addition to the UW Medical Center, SAM also has been installed at Harborview Medical Center, also in Seattle, and at Ochsner Medical Center, in New Orleans. “Timing of notification is as critical as the decision rule itself. The strategy is to get the provider’s attention in a very optimal fashion without bombarding them with a lot of messages,” Dr. Nair said. “You have to balance that.” Dr. Nair began developing SAM in 2009 as a way of building on existing technology that had proved to be limited in its utility. His idea was to build a support module for the Anesthesia Information Management System (AIMS), a documentation system that turned out to have limited ability to improve quality of care and revenue. The new SAM system conveys a real-time stream of prompts and information, a major upgrade over AIMS, Dr. Nair said. That capability, in turn, has boosted revenue while enabling tighter monitoring on the clinical care side and improved quality of care. “Real-time notification is effective in changing and sustaining provider behavior,” Dr. Nair said. “Data latency is a severe disadvantage.” SAM’s Savings SAM’s biggest bottom line impact has been in the use of gas. The system has resulted in far more efficient use of expensive inhalant agents, leading to reduction in use of sevoflurane, desflurane and isoflurane (28%, 33% and 12%, respectively). That change alone has saved the UW Medical Center an estimated $120,000 a year, Dr. Nair said. More efficient billing has been another important benefit, he said. SAM captures charges for procedures that were previously missed through lack of supporting documentation, including some invasive line special procedures and physician attestations, Dr. Nair said. There also has been a significant improvement in billing accuracy and documentation compliance as well. Meanwhile, patient care and safety also has improved. SAM has more than halved extended gaps in blood pressure monitoring at the UW Medical Center, from 15.7 instances per 1,000 cases to 6.7 instances, Dr. Nair said. Before SAM, the maximum gap in blood

MAY 2015

AnesthesiologyNews.com I 31

TECHNOLOGY pressure monitoring was 64 minutes, but after the new system was installed, it dropped to 28 minutes. The tighter monitoring had a big effect on patient care, with concurrent hypotensive–high anesthetic agent episodes dropping to 2.3 per 1,000 after SAM, whereas hypertensive episodes with concurrent phenylephrine infusions dropped from 30.3 to 21.1 per 1,000. The maximum hypotensive episode dropped from 44 to 15 minutes, whereas hypertensive episodes fell from 30 to 21 minutes after use of the new system. The UW Medical Center also saw a major improvement in the rate of initial antibiotic dosing, with compliance rising to 99% from percentages in the 80s and low 90s previously, Dr. Nair said. Compliance rates on antibiotic redosing also climbed, from 62% before SAM to 95% after. Since using SAM, the hospital met the β-blocker Surgical Care Improvement Project measure 97% of the time compared with 62% before, he said. Glucose management improved as well. The new system sends out prompts to “initiate glucose management,” perform “a preincision glucose measurement” and check glucose measurements hourly, Dr. Nair said. Glucose compliance—as measured by hourly glucose measurements and correct insulin adjustments—also rose significantly. Compliance with hourly glucose measurements rose to 81% with SAM notification from 53% without, Dr. Nair said. Additionally, SAM also has proved helpful to clinicians dealing with unusually complex or rare cases. A prime example is pediatric traumatic brain injury cases, with SAM helping clinicians at the Harborview Medical Center stay on top of complicated care protocols. Dr. Nair has also developed a “handoff tool” through SAM that can be used when transferring patient care from one provider to another. SAM will page the ICU or postanesthesia care unit nurse coordinator when a patient is in transport and print a transfer summary report to supplement a handoff checklist. Another feature is barcode confirmation of syringe drugs, ensuring accuracy of medication administration in an area where incomplete or incorrect syringe labeling can be a significant problem, he said. As an added safeguard, SAM also speaks the name of the medication when the clinician scans the barcode. However, it is also important to

prevent “alert fatigue” for anesthesiologists and other hospital staff. That means carefully examining the data and behavioral patterns while listening closely to feedback from clinicians, Dr. Nair said. New features and functions are still being added to SAM, with Dr. Nair and the UW exploring the possibility of licensing the module to AIMS vendors. Under development is a preanesthetic induction patient safety checklist (PIPS), as part of a project initiated

by T. Andrew Bowdle, MD, PhD, an anesthesiologist and professor at UW. Planned checklist items include whether suction is working; if backup devices are immediately available; or whether drug allergies or potential drug interactions have been noted, Dr. Nair said. According to Dr. Nair, other future SAM enhancements will include: • A framework for building checklists, as well as decision trees with navigation and guidance functions;

• Integration with UW’s electronic medical records system; • Enhancing voice prompts, while expanding model- and protocolbased decision support; • Integrating a fading memory algorithm for glucose management and a continuous glucose monitor; and • Barcode verification of infusions and blood products to enhance medication and transfusion safety. —Scott Van Voorhis

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The History and Art of Anesthesia Patents A.J. Wright, MLS Librarian, Anesthesiology Department University of Alabama at Birmingham

few years ago, I gave a talk on some untapped sources for anesthesia history: newspapers, equipment and pharmaceutical company catalogs; journal advertisements; and so forth. Another source of this type is patents. Both Google and the European Patent Office have made U.S. patents easy to search, and doing so for “anesthesia” and related words will uncover items that are fascinating as basic elements of history, as well as the often-artistic drawings filed as part of the applications. Here are a few of the patents from the first half of the 20th century. Patent applications in that period would typically contain several pages of illustrations, followed by detailed descriptions of the device and then specific claims of originality. Some important names in anesthesia history can be found in the patent files. Elmer I. McKesson (1881-1935; Figure 1) was a physician and inventor who became interested in anesthesia as an intern after finishing Rush Medical School in Chicago. During

his career, he created various gas-oxygen machines, valves, oxygen tents and so on. These were all manufactured by the Toledo Technical Appliance Company. Some of his inventions were used into the 1950s. The McKesson patent illustrated here (Figure 2) is one he filed in 1921 for a “gas-administeringg apparatus.” His application notes, “This invention has utility when incorporated in apparatus for administering gas for anaesthesia, analgesia, pain allaying cases and resuscitation.” Detailed descriptions are included for numbered parts of the machine. Dr. McKesson made eight claims about the novel characteristics of his invention. Jay A. Heidbrink (1875-1957; Figure 3) was a dentist whose company, Heidbrink Machines, developed equipment for dental anesthesia. Ohio Chemical & Manufacturing Company bought the firm in the 1930s. The 1935 patent shown here (Figure 4) was designed to provide “particularly that low form of anaesthesia known as analgesia,” and “to provide means to permit the patient himself to control the flow and delivery of anesthetizing fluid to himself.” Dr. Heidbrinkk made 11 claims about his equipment

Figure 1. Elmer I. McKesson, MD. Photo source: Wood Library-Museum of Anesthesiology.

Figure 2. The McKesson patent of 1921 for a “gas-administering apparatus.”

Figure 4. A 1935 Heidbrink patent designed to provide analgesia.

Figure 3. Jay A. Heidbrink, DDS, whose company, Heidbrink Machines, developed equipment for dental anesthesia. Photo source: American Society of Dental Anesthesia, at http://www.adsahome.org/ hawards.html

in the patent application. His many other patents included a mask, a mask leak tester, a method to humidify oxygen, a portable oxygen unit for aviation, and in 1930 a “football game apparatus” to simulate college and professional play. Sydney Ormond Goldan was one of the earliest physician anesthetists in New York City and wrote an article in 1900 that included the first published anesthesia record. In his 48 years of practice he also founded The Terraces, a retreat for doctors and nurses on Long Island Sound. Between 1899 and 1908, Goldan published more than two dozen articles on topics ranging from general anesthesia with nitrous oxide, ether and chloroform to spinal anesthesia with cocaine; patient awareness during surgery; anesthesiology as a profession; and the relationships among the anesthetist, patient and surgeon. In 1903, Goldan patented an inhaler (Figure 5), which was later cited in a 2006 U.S. patent. Myrtle B. George filed an anesthesia-related patent in 1937 (Figure 6), at a time when a woman filing a medical patent was much more of a rarity. In her application, George noted that her inhaler related particularly “to inhalers such as are used by dentists and doctors for the inhalation of nitrous oxide gas.” She made six specific claims about the device. Apparently, this patent is the only one George was awarded. I have yet to find any biographical information about her, much less the motivation for her anesthesia interests. Anesthesia-related U.S. patents can come from anywhere, not just centers of medical or technical research. In July 1916, Archelus H. Mitchell (1892-1986) of Selma, Alabama, submitted an application for

Figure 5. Sydney Ormond Goldan, MD, presented this patent for an inhaler.

see patents page 46

Figure 6. Myrtle B. George filed a patent for a “rhythmic inhaler” in 1937.

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34 I AnesthesiologyNews.com

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TECHNOLOGY

Data Reporting Through AIMS Automated Reporting Systems Can Improve Care Phoenix—Physician practices no longer have the luxury of ignoring federal reporting requirements, with Medicare and Medicaid now penalizing medical groups that fail to file quality-off care data. Practices that are not yet filing data

with the Physician Quality Reporting System (PQRS) now face significant consequences, with tough new financial penalties that took effect at the start of this year, explained Jonathan Wanderer, MD, at the Society for Technology in Anesthesia 2015

annual meeting. Dr. Wanderer is an assistant professor in the Department of Anesthesiology at Vanderbilt University, Nashville, Tenn. However, the technolog y used to gather the required data also has the potential not just to measure the

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TOPICAL ANESTHETIC SPRAY Brief Summary of the Prescribing Information Active Ingredients Benzocaine ......................................................................14.0% Butamben..........................................................................2.0% Tetracaine Hydrochloride ..................................................2.0% Contains Benzalkonium Chloride .....................................................0.5% Cetyl Dimethyl Ethyl Ammonium Bromide .....................................................0.005% In a bland water-soluble base. Action The onset of Cetacaine-produced anesthesia is rapid (approximately 30 seconds) and the duration of anesthesia is typically 30-60 minutes, when used as directed. Indications Cetacaine is a topical anesthetic indicated for the production of anesthesia of all accessible mucous membrane except the eyes. Cetacaine is indicated to control pain and for use for surgical or endoscopic or other procedures in the ear, nose, mouth, pharynx, larynx, trachea, bronchi, and esophagus. Dosage and Administration Cetacaine Spray should be applied for approximately one second or less for normal anesthesia. Only a limited quantity of Cetacaine is required for anesthesia. Spray in excess of two seconds is contraindicted. Average expulsion rate of residue from spray, at normal temperatures, is 200 mg per second.

Adverse Reactions Hypersensitivity Reactions: Unpredictable adverse reactions (i.e. hypersensitivity, including anaphylaxis) are extremely rare. Localized allergic reactions may occur after prolonged or repeated use of any aminobenzoate anesthetic. The most common adverse reaction caused by local anesthetics is contact dermatitis characterized by erythema and pruritus that may progress to vesiculation and oozing. This occurs most commonly in patients following prolonged self-medication, which is contraindicated. If rash, urticaria, edema, or other manifestations of allergy develop during use, the drug should be discontinued. To minimize the possibility of a serious allergic reaction, Cetacaine preparations should not be applied for prolonged periods except under continual supervision. Dehydration of the epithelium or an escharotic effect may also result from prolonged contact. Precaution: On rare occasions, methemoglobinemia has been reported in connection with the use of benzocaine-containing products. Care should be used not to exceed the maximum recommended dosage (see Dosage and Administration). If a patient becomes cyanotic, treat appropriately to counteract (such as with methylene blue, if medically indicated). Use in Pregnancy: Safe use of Cetacaine has not been established with respect to possible adverse effects upon fetal development. Therefore, Cetacaine should not be used during early pregnancy, unless in the judgement of a physician, the potential benefits outweigh the unknown hazards. Routine precaution for the use of any topical anesthetic should be observed when Cetacaine is used. Contraindications Cetacaine is not suitable and should never be used for injection. Do not use on the eyes. To avoid excessive systemic absorption, Cetacaine should not be applied to large areas of denuded or inflamed tissue. Cetacaine should not be administered to patients who are hypersensitive to any of its ingredients or to patients known to have cholinesterase deficiencies. Tolerance may vary with the status of the patient. Cetacaine should not be used under dentures or cotton rolls, as retention of the active ingredients under a denture or cotton roll could possibly cause an escharotic effect. Routine precaution for the use of any topical anesthetic should be observed when using Cetacaine.

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Tissue need not be dried prior to application of Cetacaine. Cetacaine Cetacaine should be applied directly to the site where pain control is required. Anesthesia is produced within one minute with an approximate duration of thirty minutes. Each 200 mg dose of Cetacaine Spray residue contains 28 mg of benzocaine, 4 mg of butamben and 4 mg of tetracaine HCl.

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quality of care but to improve it as well through timely monitoring of antibiotic dosing and glucose management, among other clinical variables, Dr. Wanderer noted. Still, careful thought is needed to determine which metrics make the most sense to track, with the answers varying from institution to institution. These metrics, in turn, may need to undergo rigorous statistical analysis to account for variability stemming from patient and clinician factors, he said.

The technology used to gather the required data also has the potential not just to measure the quality of care but to improve it as well. “We have definitely gone from the carrot phase into the stick phase,” Dr. Wanderer warned. Practices that don’t report data to the PQRS could wind up with penalties ranging from $37,000 to $225,000, based on their size, Dr. Wanderer said. That’s based on $1,500 per eligible provider (EP), with the penalty equaling $37,500 for a practice with 25 EPs, rising to $75,000 for 50, $150,000 for 100 and $225,000 for 150. It is a shift from the first few years of PQRS, with physicians or other providers previously being paid bonuses of 1.5%, later rising to 2%, for reporting on 80% of cases in three metrics. Data Reporting Options Dr. Wanderer said there are four major ways of reporting data. One option is through the Qualified Clinical Data Registry, which for anesthesiologists means the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry. There are 19 metrics to choose from for this reporting option, as opposed to three available through other reporting mechanisms. Other options include group practice reporting; claims-based reporting; and certified electronic health reporting technology, which sends data directly to the Centers for Medicare & Medicaid Services or through a

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TECHNOLOGY Tracking and reporting data through anesthesia information management systems (AIMS) and converting them for realtime use can also boost the quality of care. data submission vendor, Dr. Wanderer said. However, tracking and reporting data through anesthesia information management systems (AIMS) and converting them for real-time use can also boost the quality of care as well. Dr. Wanderer cited a case from the University of Michigan Health System in which antibiotic dosage prompts were set up within AIMS. Biweekly emails delivered feedback on performance and the results were posted in the operating room, with inperson reminders as well. The compliance rate for the administration of prophylactic antibiotics rose from 69% to 92%. In another case, prescriptions for prophylaxis of postoperative nausea and vomiting for high-risk patients rose from 38% to 73% at Onze Lieve Vrouwe Gasthuis, an Amsterdam hospital. Prompts were sent out to clinical staff through the MetaVision Clinical Information System (iMDsoft) for patients who exhibited three or more risk factors. However, there also can be pitfalls to intensive data use as well, Dr. Wanderer warned. There can be errors with instruments, measurements can be manipulated and “results can be recorded that don’t reflect measurements,” he said. He pointed to the example of getting an inaccurate temperature reading in a patient with perioperative hypothermia. The accurate measurement of pain in patients also can be difficult. However, statistical analyses of metrics can help iron out inconsistencies between how various doctors and nurses ascertain the severity of pain in individual patients. A proportional odds, mixed-effect model can help provide a more accurate reading, with the ability to calculate the odds that a patient from one attending physician “will have a higher level of pain compared to [patients from] the median anesthesiologist,” he said.

After Dr. Wanderer’s presentation, the audience broke into small groups for further discussion on current anesthesia metrics and to consider new metrics for automated reporting. A number of potential metrics to track emerged from the discussions, including unexpected difficult airways; same-day cancellations; inappropriate transfusions; respiratory arrest and postoperative pain in the postanesthesia care unit (PACU); intraoperative hypertension; time

spent in PACU phase 1; sleep apnea screening in higher-risk patients; postoperative cognitive dysfunction; nerve injury and patient positioning; total time in PACU; pain scores; and total narcotic usage. One larger lesson that came out of the group discussions was the widely varying experiences of anesthesiologists at different hospitals around the country in terms of collecting and reporting the data needed for the various metrics.

In some hospitals, anesthesiologists are unable to gain direct access to the data, and instead must rely on a programmer to write a report. “It was interesting to hear from some folks the trials and tribulations they have gone through in getting access for purposes of reporting,” Dr. Wanderer said. “In some institutions, this has been pretty straightforward, whereas at other places it has been pretty difficult.” —Scott Van Voorhis

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working and taking calls at a busy Level 1 trauma center (Vanderbilt University Medical Center admits roughly 4,000 trauma patients every year). After all, resuscitative care of critically ill patients is what we are used to doing day in and day out. In fact, somewhat paradoxically, reservists often have exposure to higher trauma patient volumes than their active duty counterparts because of the relatively low volume of acute trauma cases at most military treatment facilities. For example, Walter Reed National Military Medical Center is currently designated as a Level II trauma center, and many of its staff trauma surgeons work at other nearby facilities to maintain their skills. However, despite the clinical experience I knew I would bring with me to Afghanistan, there are still a number of unique aspects of working in a combat setting that require both training and a bit of an adjustment in thinking. As a way to adapt my skills and prepare myself to work in a multinational

environment with both colleagues and patients from across the globe, I embarked on a monthlong journey to prepare for my deployment. Tactical Combat Casualty Care The heart of my premobilization training began at the Naval Expeditionary Medical Training Institute (NEMTI) housed at Camp Pendleton in California. In place of the well-appointed hotel room I had booked but could not use for the fall American Society of Anesthesiologists meeting, I was greeted with a Southeast Asia Hut, an open-bay, y non–climatecontrolled, wooden structure that was in desperate need of a paint job. NEMTI was indeed a field training location, and instead of a wall thermostat, I found myself provided with a sleep system that included a sleeping bag, a liner, a mat and a rickety cot that alerted my bunkmates with the screech of worn metal springs every time I moved. The cuisine made my usual hospital cafeteria look gourmet by comparison to the Meals Ready to Eat or selff containedd individual

field rations we subsisted on, along with interspersed trips to a Marine mess hall a few miles down the road. But it was here in this rustic venue set along the gorgeous California coastline that our newly formed hospital team—including surgeons, nurses, technicians and administrative staff—all underwent a rigorous series of courses and training exercises designed to enable us to work together under the most strenuous conditions. The training included requirements mandated by the Navy Bureau of Medicine and Surgery, Congress and the U.S. Central Command, and consisted of a set of didactic, hands-on and field training exercises. The focus of our experience at NEMTI was undergoing the Tactical Combat Casualty Care course—the military counterpart to the Prehospital Trauma Life Support Course. Although primarily designed for military medics and corpsmen who are preparing to deploy in support of combat operations, it was a chance for our group to learn, practice skills and grow together as a team. see storm page 38

Although I had gone through skills stations before on how to perform an emergent needle chest decompression for a tension pneumothorax, or how to apply a junctional tourniquet to stop inguinal hemorrhage, I had never done it against a background of explosions, gallons of fake blood being poured on top of me, or a senior instructor screaming “squirt, squirt, squirt” at the top of his lungs.

Welcome to Kandahar: Dr. Ehrenfeld with a medical copter aloft.

Gear issue day was long and tedious. The end result was 60 pounds of gear that the physician-soldiers would have to wear daily.

Dr. Ehrenfeld attended weapons training, military tactics and marksmanship classes at McCrady Training Center.

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The following advertorial has been provided by Tri-anim and is designed to support the advertisement presented below.

ANEclear™ Anesthesia Recovery Device, by Curaplex Q. What is ANEclear™? A. ANEclear™ by Curaplex is a user-friendly device that actively and rapidly removes residual volatile anesthetics following surgical procedures, significantly improving the safety and quality of the anesthetic experience for both patients and clinicians.

Q. How does ANEclear™ work? A. ANEclear™ uses a threefold mechanism to actively clear volatile anesthetics from the patient’s brain and lungs as follows: • Captures the patient’s exhaled breath and allows them to re-breathe their CO2 This increases the cerebral blood flow to rapidly clear anesthetic from the brain, while simultaneously increasing the patient’s drive to breathe • Allows increased ventilation without lowering the patient’s CO2 Increased ventilation rapidly clears anesthetic from the blood via the lungs • Absorber captures the exhaled anesthetic The built-in absorber prevents the patient from re-breathing exhaled anesthetic

Additionally, during cases when tapering of the volatile anesthetic is not possible (abruptly ending case) or it is not safe (patient should not move until completely finished), ANEclear™ increases the respiratory drive, reduces variability and time to extubation.

Q. What are the benefits of ANEclear™? A. ANEclear™ provides the following OR and PACU benefits: • Restores patient’s protective airway reflexes faster

• Shortens time to consciousness and extubation • Patients are more awake and alert in recovery, in control of their own airway and less likely to experience respiratory complications • Reduces the risk of PONV related to volatile anesthetics • Improves pain assessment and management • Reduces time to readiness for discharge improving PACU throughput and patient satisfaction • Reduces caregiver exposure to waste anesthetic gas (WAG) in the PACU

Are you treating more obese surgical patients at risk of OSA?

1. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806814. doi:10.1001/jama.2014.732. 2. United States Department of Health and Human Services /Administration on Aging. 3. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Aff (Millwood). d 2009;28(5):w822-w831. doi: 10.1377/hlthaff.28.5.w822. Epub 2009 Jul 27.

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Q. What types of patients and surgical procedures are recommended? A. Patients and surgical procedures for ANEclear™ use include: 1) obese and elderly at risk of obstructive sleep apnea (OSA); 2) patients at high risk of experiencing postoperative nausea and vomiting (PONV); 3) surgeries where patients must remain motionless to the end of the surgery; and, 4) surgeries where early post-op assessments are required.

more conscious the patient "...the is on arrival at the recovery room, the lower the incidence of respiratory complications.*

Q. Why are today’s surgical patients more challenging? A. With rising obesity rates and an aging population, clinicians are performing routine procedures on more patients with high risk factors for OSA. These patients are at greater risk of respiratory complications following surgery under volatile anesthetics and have a higher cost of care. And, in spite of the use of prophylactic anti-emetics, PONV continues to affect patient safety and satisfaction. Not only do these complications negatively impact patient recovery, they can also cost your facility valuable time and resources. • More than one-third of U.S. adults (34.9%) are obese.1 • By 2030, there will be about 72.1 million older persons (more than 25% of the population), more than twice their number in 2000.2 • Medical costs for people who are obese were $1,429 higher than those of normal weight.3

Q: Why do I need this device? I can already titrate my anesthetic and predict when the surgeon is going to be done. A. Volatile agents suppress upper airway muscle activity and inhibit the arousal mechanism in OSA patients. Titrating discontinues delivery of the volatile anesthetic, where ANEclear™ actively clears these agents from the brain and lungs and increases the spontaneous drive to breathe to help these patients control their airway.

Patients are more alert on PACU arrival and ready for discharge up to 25% sooner. As obesity rates rise and the population ages, surgical patients are frequently at risk for respiratory complications such as OSA. ANEclear keeps these patients awake, alert and more in control of their airway in the OR and PACU.

ANEclear actively removes volatile anesthetics at the end of surgery •

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Improves pain assessment and management

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*T. Asai, K. Koga, R.S. Vaughan, “Respiratory complications associated with tracheal intubation and extubation,” British Journal of Anaesthesia, 1998; 80: 767-775

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Conceptually, casualty care on the battlefield is designed to be the best possible combination of evidence-based medicine and good small-unit tactics. However, on the battlefield, casualty care is only one part of the mission, whereas in the civilian hospital setting the patient is the only mission. That was the message that came across loud and clear, especially when we performed “care under fire” exercises designed to simulate our response to treating a battlefield casualty while taking incoming fire. Although I had gone through skills stations before on how to perform an emergent needle chest decompression for a tension pneumothorax, or how to apply a junctional tourniquet to stop inguinal hemorrhage, I had never done it against a background of explosions, gallons of fake blood being poured on top of me, or a senior instructor screaming “squirt, squirt, squirt” at the top of his lungs—indicating that the bleeding was not being controlled effectively. But these exercises enabled me to refresh my skills, develop a new tolerance for distraction and begin to prepare for a set of scenarios that I very well may encounter while deployed. Although the resuscitative principles and interventions presented to us were not novel, a number of topics had newfound relevance given our upcoming duty station. Disposition of human remains, the ethics of working with detainees and evacuation of injured personnel in particular were topics I had not given much thought to previously. Additionally, the Department of Defense has developed a series of 27 clinical practice guidelines based on the best available evidence and lessons learned through the Joint Theater Trauma System and Joint Theater Trauma Registry. The effect of these guidelines has been profound. Notably, the damage control resuscitation guideline was associated with a decrease in mortality in massively transfused patients from 32% to 21% after guideline implementation. It seemed as though the importance of standardization could not be overemphasized, especially given that we would be working on interchangeable teams, with colleagues from other coalition nations, under challenging circumstances. In summary, I arrived at NEMTI as a part of a diverse group of first-time deployees and seasoned individuals drawn from both active duty and the reserve component. The experience enabled us to integrate ourselves into a cohesive team in preparation for our deployment. Throughout my Navy career, a pillar of Navy medicine training has always been training as a team—and after eating, sleeping, training and working together, although we may have arrived at Camp Pendleton as individuals, we certainly left as part of a newfound family, excited and eager for the challenges we knew we would face together in the coming months.

Dr. Ehrenfeld in full “battle-rattle” at McCrady Training Center in Fort Jackson, S.C.

mobilization. Weapons training, military tactics and marksmanship were important parts of the training provided to enable us to work with our cross-service counterparts. Although many arrived never having fired a weapon before, all left fully qualified on either the M9 service pistol, the M4 semiautomatic rifle or both, because even in the operating room, it would be essential for all of us to be armed at all times. Learning how to operate, calibrate and maintain these weapons systems was certainly a far cry from the most recent hospital in-service I had undergone on the use of transesophageal echocardiogram probes. Gear issue day was a long and tedious process during which we had to ensure that our body armor, tactical vests and Kevlar helmets all fit and were able to be used properly. The blazing sun and southern humidity were vicious and unrelenting as we each struggled to become one with the 60 pounds of gear we would be wearing daily. This was followed by counter-improvised explosive device training, which served as an indicator of not only the dangers we would shortly face but also the cause of many of the injuries we were likely to see. Core classes included basic survival training, and a condensed version of search, evasion, resistance and escape training. We also were trained on how to use the PRC-117F communication system and the basics of Army radio communication, including how to do a nine-line brief, which is a standardized method of reporting unexploded ordnance or calling for close air support or a medical evacuation. Additional training sessions provided an introduction to Afghan culture, language and some of the customs we were likely to encounter. These sessions were interspersed with basic combat skills training around convoy force protecCombat Training for an tion, military operations in an urban terrain, detainee Austere Environment search and handling, nonlethal weapons familiarizaAs a group of Navy individual augmentees brought tion, management of direct and indirect fire and familtogether from various commands across the world, our iarization with military vehicles, including Humvee next stop was the McCrady Training Center in Fort and Mine-Resistant Ambush Protected (MRAP) vehiJackson, S.C. Here we underwent an intense three- cles. At the end of the second week, I found myself weekk combat training course designed to enable each strapped into an MRAP egress trainer, in which the of us to work seamlessly with the soldiers, sailors, air- large armored vehicle was turned upside down and men and marines we would encounter during our we were then left to figure out how to safely unstrap

ourselves, exit the vehicle and establish a secure perimeter. Adding to the realism of being turned on our heads was a series of items placed in the vehicle, specifically designed to simulate equipment that would likely bounce around and either injure or disorient us. Fortunately for us, to prevent actual injuries during the simulation, these items were all made of Styrofoam. Most of our days started at 5 a.m.; after morning physical training, we donned our full “battle-rattle” for the day’s activities. Under the watchful eyes of a group of dedicated Army drill sergeants, I shot nearly 1,000 rounds on the firing range; learned how to properly disassemble and reassemble my weapons; and became facile at thoroughly cleaning and lubricating each component. Realizing that there would be no anesthesia technicians where I was heading, this was a useful introduction to becoming selff sufficient and planning in advance for the tasks ahead of me. Unlike most of our usual workplaces, we would be on our own with limited support and no one to call if we had forgotten to bring or set something up. At the end of the three weeks as we boarded our bus onward, when asked if I was ready, I meant it when I shouted back “Yes, Drill Sergeant!” Afghanistan Bound As one of hundreds of physician reservists who have been called to active duty, I have been privileged with the opportunity to bring the best of civilian medicine to the battlefield. The opportunity to bridge these two worlds is a unique one, and one of the many reasons I am proud to be a part of the Navy medicine team. Having been gone from home and my practice for just over a month, I was finally cleared to fly into Afghanistan. As I said goodbye to my partner, Judd, and boarded my flight to the Middle East, my confidence as a skilled physician anesthesiologist was now augmented with a new set of combat skills that I knew would enable me to provide the best care possible to some of the most challenging and important patients I would likely see in my career. Note: The views expressed in this article do not represent the views of the Department of Defense or the U.S. Navy. They are the personal opinions of Lt. Cmdr. Ehrenfeld.

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TECHNOLOGY

Statistical Approach Able To Pinpoint Real From Artifact Alerts The forest for the trees… Phoenix—Using a statistical approach known as Random Forest modeling, real and artifact vital sign events from continuous monitoring data have been distinguished. The approach is an important step toward reducing the alarm fatigue that plagues so many health care practitioners. “We’ve had a long history of using machine learning to assess the instability of patients in the hospital,” said Michael R. Pinsky, MD, professor of Critical Care Medicine, Bioengineering, Anesthesiology, Cardiovascular Diseases, and Clinical/Translational Services at the University of Pittsburgh School of Medicine. “In one such study, we analyzed noninvasive vital signs such that alerts would go off if the monitor value was outside the normal range,” he said. “And using an artificial neural net, we were able to identify stable from unstable, good from bad. This current study is an extension of that work.”

As part of the study, noninvasive monitoring data were recorded for patients in the institution’s 24-bed step-down unit over a period of eight weeks. The data included heart rate (HR), respiratory rate (RR), blood pressure (BP) and peripheral oximetry. Deviations of vital signs beyond stability thresholds that persisted for 80% of a five-minute moving window comprised important events. These stability thresholds were defined as HR 40 to 140 beats per minute; RR eight to 36 breaths per minute; systolic BP 80 to 200 mm Hg; diastolic BP less than 110 mm Hg; peripheral oxygen saturation (SpO2) greater than 85%. The researchers, reporting at the 44th Critical Care Congress of the Society of Critical Care Medicine (abstract 42), found that of 1,582 events, 631 were labeled by consensus of four expert clinicians as either real alerts, artifacts or “unable to classify”;

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‘This is where you need a marriage of clinicians and machine learning science. Neither one on its own would be able to come up with anything of relevance; it has to be a union.’ —Michael R. Pinsky, MD

another 795 were labeled as “unseen.” Random Forest models, which use an ensemble of algorithms that together provide increasing predictive accuracy, were then applied to the 631 labeled events; the models were trained to differentiate real events from artifacts, and then were cross-validated to mitigate overfitting. The resulting model was then applied to the 795 unseen events, which were reviewed by the experts for external validation of Random Forest events. “We found that in this specific example, Random Forest was the most predictive of all the machine learning approaches,” Dr. Pinskyy said in an interview with Anesthesiology News. “This is where you need a marriage of clinicians and machine learning science. Neither one on its own would be able to come up with anything of relevance; it has to be a union.” Experts labeled 418 alerts as real alerts (SpO2 44%, RR 32%, BP 11%, HR 14%), 158 as artifacts (SpO2 59%, RR 16%, BP 25%, HR 0%) and 55 as unable to classify. Of 510 unseen RR events, experts agreed with 100% of the Random Forest artifact predictions and 99% of the real alert predictions. Of the 55 unseen BP events, the agreement was 80% and 76%, respectively. Of 230 SpO2 events, there was 55% artifact agreement and 92% real alert agreement. “So our new approach allows us,

with a high degree of certainty, to identify almost all alerts that are real or artifact,” Dr. Pinsky said. “This turned out to be the real excitement at the meeting, for which we won the award as best abstract. Clearly, this is really important for the bedside practitioners.” Yet what proved most exciting for Dr. Pinsky was the model’s ability to look forward. “We’re now going to be using that prospectively to identify instability beforehand, in the operating room and in the intensive care unit,” he noted. Doing this, he explained, requires only a few minutes of vital sign data. “Once you’ve calculated the best algorithms,” he explained, “then the actual data needed to apply these algorithms is phenomenally sparse. You need very little because you’ve already identified the leading indicators needed to make a diagnosis. “And what becomes interesting is that you immediately appreciate the potentiality of the monitors we already have,” he added. “You actually end up needing fewer new monitors, just more intelligent use of existing ones. And this had the distinct advantage for hospitals in that they don’t have to buy new hardware, just better software.” —Michael Vlessides There were no relevant financial disclosures.

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CLINICAL ANESTHESIOLOGY COMMENTS

CONTINUED FROM PAGE 27

when willingly or unwillingly we anesthesiologists had to step up. As initiatives from the ASA, such as the PSH and ERAS [early recovery after surgery] protocols, begin to take hold in the US it will once again be the anesthesia that takes charge. The days of the quiet unsung heroes of the operating room are over. We anesthesiologists are once again stepping up to do what must be done to better care for our patients as our surgical colleagues do what they do best. And together, through teamwork and mutual respect, we will improve the outcomes for our patients.” Preop… wrote: “It seems to be ok to marginalize the anesthesiologist to OR functions while glorifying the leadership of the surgeon. Sometimes this is inappropriate, especially when the preoperative initiative was ignored by surgery until the ACA [Affordable Care Act]. Anesthesiologists must continue to demonstrate their management skills.” Dr.no… wrote: “Dr. Greene’s antediluvian approach is supported by neither facts nor history.” Epret… wrote: “This concept of ‘Captain of the OR Ship’ has long ago become a historical curiosity. The vast majority of medical decisions during surgery are made by anesthesiologists. It is time surgeons stopped believing they are omnipotent and omnipresent and can perform surgery while at the same time keep track of the surgical patient’s medical condition to ensure patient safety. The issue here is not abdication of the role, but who is best suited to ensure patient safety during the perioperative process at reduced costs. Today, health care costs are linked with outcomes. Outcomes depend on early identification of problems in the immediate postoperative period before they evolve into complications, thereby improving efficiency of patient care and safety. Therefore, we are being compelled to find new mechanisms to prevent complications in the immediate postoperative period before they become severe so as to require rehospitalization and increased costs. Anesthesiologists have the time, knowledge, training and, most importantly, the organizational structure to carry out this mission and to improve efficiency while reducing costs. We are always present in the operating room and the postoperative care unit (PACU)…. For the above reasons, our role as perioperativists is well suited and long overdue.” We appreciate your comments and encourage readers to keep the conversation going. —AN Staff

PSH

CONTINUED FROM PAGE 25

and chronic disease management. The PSH aligns with accountable care organizations and can fit the future financial model of bundled payments. “We all know change is hard, but change is upon us,” Dr. Kaur said. “A leader in anesthesia can move a patient to a better outcome, minimize readmissions and provide evidence-based care.”

Several anesthesiology departments pioneered the PSH model, particularly those at the University of California at Irvine and the University of Alabama, Dr. Kaur noted. Her affiliated institutions—UMass Memorial Medical Center and the anesthesiology and urology departments at the University of Massachusetts Medical School, both in Worcester—are starting a pilot PSH project as well. She highlighted the evolution of critical care as a subspecialty of anesthesiology and drew a parallel

between critical care fellowships and a potential future fellowship in perioperative medicine for surgeons, internists or anesthesiologists. Professional societies and advocates will be the key to moving the conversation forward among hesitant anesthesiologists in the coming years, Dr. Kaurr said. “It’s time for us to innovate, adapt and make our specialty indispensable,” she said. “One possibility is a shared vision and common direction with the PSH.” —Carolyn Crist

IMPORTANT CORRECTION OF DRUG INFORMATION ABOUT EXPAREL® (BUPIVACAINE LIPOSOME INJECTABLE SUSPENSION)

from the US Food and Drug Administration (FDA) Office of Prescription Drug Promotion (OPDP) on September 22, 2014 concerning an advertisement for EXPAREL, which you may have seen published in several professional journals. This publication provides important corrective information about the false and misleading claim. The FDA stated that the advertisement was false or misleading because it overstates the efficacy of EXPAREL. The FDA objected to the claims that EXPAREL provides pain control that lasts for up to 72 hours because the claims suggest that EXPAREL has been shown to provide pain control beyond 24 hours. According to the Prescribing Information, “The primary outcome measure was the AUC [area under the curve] of the NRS [numeric rating scale] pain score (cumulative pain scores) collected over the first 72 hour period.…In this clinical study, EXPAREL demonstrated a significant reduction in pain intensity compared to placebo for up to 24 hours. The difference in mean pain intensity between treatment groups occurred only during the first 24 hours following study drug administration. Between 24 and 72 hours after study drug administration, there was minimal to no difference between EXPAREL and placebo treatments on mean pain intensity.” Excerpts from the applicable sections of the FDAapproved package insert for EXPAREL follow. The FDA has reviewed and approved this communication. Indication for EXPAREL EXPAREL is a liposome injection of bupivacaine, an amide-type local anesthetic, indicated for administration into the surgical site to produce postsurgical analgesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Clinical Studies Hemorrhoidectomy The primary outcome measure was the AUC of the NRS pain intensity scores (cumulative pain scores) collected over the first 72 hour period. There was a significant treatment effect for EXPAREL compared to placebo. ©2015 Pacira Pharmaceuticals, Inc. Parsippany, NJ 07054 PP-EX-US-0623

2/15

In this clinical study, EXPAREL demonstrated a significant reduction in pain intensity compared to placebo for up to 24 hours. The difference in mean pain intensity between treatment groups occurred only during the first 24 hours following study drug administration. Between 24 and 72 hours after study drug administration, there was minimal to no difference between EXPAREL and placebo treatments on mean pain intensity; however, there was an attendant decrease in opioid consumption, the clinical benefit of which was not demonstrated. Important Safety Information EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL. Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at greater risk of developing toxic plasma concentrations. In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting. Reporting Adverse Events Heath care providers and patients are encouraged to report adverse events in patients taking EXPAREL to Pacira at 1-855-793-9727. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Please see accompanying brief summary of Prescribing Information.

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COMMENTARY MOCA

chosen by the participants to benefit their own unique practice situations learning, but who have concluded that should be a sufficient demonstration the MOC process is of no value to of their ongoing commitment to lifethem. To qualify for NBPAS certifi- long learning. The cost of this certification, physicians must have achieved cation is far lower than participating primary board certification in their in the MOCA process—at $169 for specialty and must demonstrate com- two years (and a promise to provide pletion of a minimum of 50 hours of service at a cost commensurate with CME over each 24-month period. their expenses), it would cost $845 for NBPAS therefore recognizes the a 10-year period without any travel or value of primary board certification, opportunity costs. This is in stark conbut its members believe that CME trast to the current high cost of the CONTINUED FROM PAGE 24

MOCA program—$9,500 for the same time period, and perhaps substantially more. We believe that the ABA has a clear choice to make. If it continues to offer a MOCA program that is viewed as too expensive, too great a burden and too lacking in value, then physicians like us will be obligated to consider opting out of the process entirely, choosing either to certify with an alternative entity like NBPAS, or simply choosing to relinquish the title

of “board certified,” and lobbying our hospitals and insurers to allow this. Notably, it is the recently stated position of the American Medical Association (AMA) that “The MOC program should not be a mandated requirement for licensure, credentialing, payment, network participation or employment.”11 Those of us who opt out of MOCA will continue to strive to be excellent physicians. We will continue to participate in educational activities and embrace selff directed lifelong learning. But we will do so because we are competent, motivated, caring physicians, not because we are otherwise compelled to do so over the threat of loss of certification and revocation of our hospital privileges. We have authored an online petition that asks the ABA to enact these changes. This petition is available for signature at www.petitionbuzz.com/ petitions/changemoca. This is a grassroots effort; signing is not enough, vocal public discourse and frank discussions with colleagues are crucial. To that end, like and share us on Facebook at www.facebook.com/ChangeMOCA. Perhaps most importantly, we encourage you to give your feedback to the ABA at its website (http://www. theaba.org). If a significant portion of those subjected to the current MOCA components voice their dissatisfaction via this petition, we believe that the ABA should reform the process accordingly. If it does so, the ABA will have regained our trust that it acts in our best interests and is accountable to its membership. If it does not, its incentives must be strongly questioned, and we, and many others, will seek alternatives to MOCA and to the ABA. Thomas Gallen, MD, MPH, is at Indiana University Health, Arnett Hospital, Lafayette, Ind. Oren Bernstein, MD, is a private practice anesthesiologist in Honolulu, Hawaii. The authors are ABA-certified anesthesiologists, both having also passed the National Board of Echocardiography’s Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. The authors report no financial or other relevant association with NBPAS other than certification status.

References 1. Department of the Treasury, Internal Revenue Service. Form 990. http://pdfs.citizenaudit. org/2002_06_EO/06-0646523_990_200112.pdf. Accessed March 22, 2015. 2. Department of the Treasury, Internal Revenue Service. Form 990. http://pdfs.citizenaudit. org/2014_12_EO/06-0646523_990_201312.pdf. Accessed March 22, 2015.

EXP-AP-0020-201301

MAY 2015

AnesthesiologyNews.com I 4 3

CLINICAL ANESTHESIOLOGY PED SAEs

CONTINUED FROM PAGE 18

Perhaps intensivists and anesthesiologists are much more comfortable with certain events during sedation and don’t report them, whereas [emergency medicine] physicians consider it something that’s reportable. “Also, when compared with all these groups, I certainly think that many emergency physicians are experienced with this medication,” she added. “But more research is needed to explain the findings.” Either way, Dr. Sulton acknowledged that dexmedetomidine is a very good drug in any clinician’s hands for pediatric procedural sedation. “I think dexmedetomidine has a wellestablished place in the ICU and the [operating room]. And I don’t see any reason why we shouldn’t use it in the emergency room as well. “Propofol has become the darling drug of the sedation world, but not everyone is comfortable using it. So here’s a drug where the serious complication rates are low and where there are very few respiratory side effects. So if you’re not comfortable using propofol, here’s another option.”

for intensivists, 48 for emergency medicine physicians and 70 for hospitalists. Non-SAEs occurred in 3.6% of patients (n=466; 95% confidence interval [CI], 3.3%-3.9%). However, when the investigators examined rates per 10,000 cases, a different picture emerged. In this part of the analysis, the non-SAE rate was greatest for emergency medicine physicians (782), followed by intensivists (583), other providers (414), hospitalists (355) and anesthesiologists (131). After adjusting for weight, prematurity, upper respiratory infection, location, and ASA class, the adjusted odds ratio for having an AE (compared with anesthesiologists) was 8.5 times greater for emergency physicians (P<0.001); 5.3 times greater for intensivists (P<0.001); 4.6 times greater for other providers (P<0.001); and 3.7 times greater for hospitalists (P=0.007). These differences, Dr. Sulton explained, may be partly explained by the nature of the PSRC data. “Although serious adverse events are strictly defined,” she said, “adverse events are —Michael Vlessides a little less clear. The PSRC doesn’t define it. It could be that emergency Dr. Sulton reported no relevant financial physicians report more adverse events. disclosures.

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Table 8. SAE Rates by Provider Provider (n)

SAE Frequency

SAE Rate/ 10,000

Adjusted ORa

Adjusted P Value

Anesthesiologist (4,585)

34.9

Reference

Other (2,223)

36.0

1.58

0.227

Intensivist (4,461)

38.1

1.56

0.271

Emergency physician (1,662)

48.1

1.83

0.335

Hospitalist (141)

70.9

3.92

0.335

ASA, American Society of Anesthesiologists; NPO, nothing by mouth; SAE, serious adverse event a

OR adjusted for weight <5 kg, prematurity, primary diagnosis as upper or lower respiratory infection, location of sedation, ASA class >II and NPO time b

Defined e ed as certified ce t ed nurse u se anesthetists, a est et sts,, registered egg ste edd nurses, u ses,, fellows e o s and a d residents. es de ts

3. AAPS Takes MOC to Court. http://www.aapsonline.org/index.php/site/article/aaps_takes_moc_to_ court/. Accessed March 22, 2015. 4. The American Board of Anesthesiology. Letter to diplomates, dated 02/23/2015. 5. Kempen PM. Maintenance of certification and licensure: regulatory capture of medicine. Anesth Analg. 2014;118:1378-1386. 6. Independent Physicians for Patient independence. Pediatrics journal rejects ethical questions about MOC. https://ip4pi.wordpress.com/2014/06/23/ pediatrics-rejects-ethical-questions-about-moc/. Accessed March 22, 2015. 7. The American Board of Anesthesiology. http://www. abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx. Accessed March 22, 2015.

8. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. y 2002;96:1044-1052.

9. Teirstein P. Boarded to death—why maintenance of certification is bad for doctors and patients. N Engl J Med. 2015;372:106-108.

10. Medscape.com. An interview with maintenance of certification dissenter: Paul Teirstein. January 7, 2015. http://www.medscape.com/viewarticle/837012. Accessed March 22, 2015.

11. Medscape.com. AMA sings same tune as MOC critics. December 9, 2014. http://www.medscape.com/ viewarticle/836215. Accessed March 22, 2015.

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The University of Florida College of Medicine, part of the UF Health system, which is headquartered in Gainesville, is searching for the best and brightest full-time assistant/associate/full professors on tenure and non-tenure tracks in the following anesthesiology subspecialties: Ì Pediatric anesthesia Ì Critical care medicine Ì Neurosurgical anesthesia Ì Congenital heart surgical anesthesia Ì Obstetric anesthesia Ì Non-operating room anesthesia Ì Multispecialty anesthesia

UF Health UF Health is the Southeast’s most comprehensive academic health center. With its main campus located in Gainesville and more than 22,000 faculty and staﬀ, UF Health includes six health colleges, nine research institutes and centers, two teaching hospitals, four specialty hospitals, dozens of physician medical practices and outpatient services throughout north central and northeast Florida, and two veterinary hospitals. We are dedicated to providing high-quality education, research, patient care and public service.

UF Department of Anesthesiology The department of anesthesiology at the UF College of Medicine includes 69 clinical faculty members, 20 active research faculty members, 79 residents, 16 fellows and a support and administrative staff of 38 people. It is a world-renowned academic department that typically publishes at least 26 books and book chapters and more than 55 manuscripts and is granted at least five U.S. patents each year. Multiple fellowship-trained faculty cover each clinical subspecialty discipline, including: critical care medicine, pediatric, congenital cardiac, adult cardiac, neurosurgical and obstetric anesthesia, as well as regional and acute pain medicine and chronic pain. Research interests of the faculty span clinical, basic science, nanotechnology, simulation training and interactive Web projects. The Center for Safety, Simulation & Advanced Learning Technologies, or CSSALT, within the UF department of anesthesiology provides education, training and services to professionals around the world. CSSALT is endorsed to deliver Maintenance of Certification in Anesthesiology simulation sessions.

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PRN PATENTS

CONTINUED FROM PAGE 32

an “anesthetizing and resuscitation apparatus.” (Figure 7.) He made five specific claims of uniqueness for his machine, which included mixing chamber, wash bottles, control valves and a mercury manometer. In 1933, Mitchell filed an additional patent application for a “motor vehicle.” Why he had an interest in anesthesia equipment and what he did in Selma for the rest of his long life are currently unknown. If you search Google Patents for “anesthesia pillow” you’ll be blessed with a variety of results. One of them, filed in April 1939 by J.T. Cappel, is of interest because it may be the first patent for such a thing (Figure 8). The application declares that “the invention is to provide a pillow designed particularly for assisting the anesthetist, making it possible for him to be relieved of the duty of using one of his hands in holding the patient’s head in the correct position during the administration of an anesthetic.” Cappel made only two claims about his pillow, but his patent has been cited by numerous others from 1949 to 2010. Text and all the illustrations for the patents discussed here can be found in two places: Google Patents at http://www.google.com/patents and the European Patent Office at http://www.epo.org/ searching/free/espacenet.html. The latter site offers access to more than 80 million worldwide patents since 1830, including U.S. patents, which can all be printed as PDF files. Happy hunting!

EHR

CONTINUED FROM PAGE 28

“There is much noise in physiologic data, and we should ensure the accuracy and completeness of it.” Additionally, templates can pose a challenge for data accuracy. Although they provide a structure for documentation, templates can force somewhat predictable assessments, particularly when drop-down fields limit what is documented and how it is explained. “Lawyers will question why you didn’t use the correct template,” Dr. Cohen said. “You must choose one that’s relevant to the patient, or you may not have documentation of a significant finding or medical problem that impacts clinical care.” Electronic records also create risk with the use of the copyy and-paste function. Providers often use this to take advantage of previous notes, particularly in a teaching hospital environment, but the copied information may not reflect the current clinical situation. Anesthesiologists should record their personal assessments and clinical plans and avoid using older data or entries. If copied and pasted, incorrect entries become the “reality” of the patient record, which can influence clinical decisions and create

Figure 7. Archelus H. Mitchell, of Selma, Ala., submitted a patent application for an “anesthetizing and resuscitation apparatus.” He later filed a patent for a motor vehicle.

liability problems. For example, if a patient receives 50 mcg of a medication but the initial documentation states the dose as 500 mcg, the incorrect entry could pose a problem for clinical management and litigation. The situation is magnified if the entry is copied and pasted across the record. Ultimately, providers must understand the “audit trail” used to monitor medical record use. The audit trail allows others to see what, when and how each provider accessed records— and whether entries were modified. Any “late” modifications should include a note to explain why the record was edited, and communications between the patient and provider (such as email or phone calls) should be added to the record as well. As a result of the audit trail, EHRs can be a “smoking gun or salvation,” particularly during litigation, Dr. Cohen said. “The transition to electronic records is valuable and beneficial, but we’re still in the learning stage,” Dr. Cohen said. “This will change how we do business, and we must adapt our practices but also understand the associated and often unintended risks.” —Carolyn Crist

RISK

Figure 8. J.T. Cappel filed a patent application for an “anesthesia pillow” in 1939, likely the first for such a device.

CONTINUED FROM PAGE 29

are still dealing with critical situations when other physicians communicate with family members, but if possible, they should be there for that first discussion. “This is your opportunity to go in with a unified front alongside the surgeon or physician,” Dr. Parker said. “Don’t let someone else represent the care you rendered. It’s better to know what’s being said about you and how the family was told.” In Ohio and 35 other states, physicians can say “I’m sorry” when disclosing events with patients. Evidence shows that multiple institutions have been successful at using an “I’m sorry” approach, Dr. Parker said, but only in the context of rigorous risk management programs. Disclosures can lead to reduced costs per claim, fair settlement negotiations and emotional benefits for patients and caregivers. At the Cleveland Clinic, risk managers use a “just in time” coaching approach to prepare physicians for a disclosure conversation. “What makes a good disclosure? Planning. I can’t say it enough,”

Dr. Parkerr said. “Identify the best time, setting and people to participate.” During a disclosure conversation, patients need accurate information, emotional support and a specific followup. They want to know how providers will prevent the medical error from happening again. A study in Colorado from 2007 to 2009 tracked responses to 837 AE disclosures through 445 patient surveys and 705 physician surveys. Overall, the doctors rated themselves well, but patient ratings of physicians were scattered. Patients gave high marks to the physicians for being truthful, explaining the AE with clear terminology and offering an apology. However, patients felt the physicians did not tell them as much as they wanted to know about the event, why the event happened and whether the event was preventable. The top concern? The patients did not think the doctor assured them that steps would be taken to prevent similar events from happening in the future. “For many patients, the main concern really is about the institution sorting out the error and making sure it doesn’t happen to someone else,” Dr. Parkerr said. “How you handle an event often determines the course of what happens next.” —Carolyn Crist

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Current Concepts In the Management of The Difficult Airway Volume 12, Number 1

CARIN A. HAGBERG, MD Joseph C. Gabel Professor and Chair Department of Anesthesiology The University of Texas Medical School at Houston Director of Advanced Airway Management Memorial Hermann Hospital–Texas Medical Center Houston, Texas Executive Director 2009-Present, Society for Airway Management Dr. Hagberg has received grant support from Ambu, Karl Storz Endoscopy, Mallinckrodt, and MedcomFlow, and is also an unpaid consultant for Ambu, Covidien, and SonarMed.

Editor’s note: All acronyms are listed on page 28.

anagement of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. 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. It includes descriptions of many new airway devices, several of which have been included in the ASA Difficult Airway Algorithm.1

A N E S T H E S I O L O G Y N E W S • M AY 2 0 1 5

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

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 4).

SUPRAGLOTTIC VENTILATORY DEVICES ENDOTRACHEAL TUBE GUIDES Several ET guides have been used to aid in intubation or extubation, including both reusable/disposable and solid/hollow introducers, stylets, and tube exchangers (Table 1).

LIGHTED STYLETS In the past decade, many lighted stylets have been developed, including light wands, which rely on transillumination of the tissues of the anterior neck to demonstrate the location of the tip of the ET—a blind technique, unless combined with DL, and visual scopes, which use fiber-optic imagery and allow indirect visualization of the airway. They also can be used alone or in conjunction with DL (Table 2).

VIEWING STYLETS Viewing stylets provide a view from the tip of the ET. Whereas the view from a VL is at the end of the laryngoscope, viewing stylets provide a view from the tip of the ET for steering the ET through the cords. The stylet size for this device allows it to be placed within an ET as an independent instrument, or as an adjunct to VL or DL. Additionally, some can be used to place an ET through intubating supraglottic ventilatory devices for visualization of ET placement through the SGA (Table 2).

VIDEO LARYNGOSCOPES Video-assisted techniques have become pervasive in various surgical disciplines, as well as in anesthesiology. As more VLs 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 also may become the standard for routine intubations as the equipment and users’ skills improve and the cost of the devices decreases, 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 (Table 3).

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 FOBs, they are more

A N E ST H E S I O LO GY N E WS .CO M

The Laryngeal Mask Airway (Teleflex) 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 300 million patients worldwide. Other supraglottic ventilatory devices are available for routine or rescue situations. The most recently developed supraglottic ventilatory devices have a gastric channel or are intended to be used as a conduit for fiber-optic–guided intubation (Table 5).

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 6). Other relatively new devices can be used to best position patients and maintain an open airway during awake intubation (Table 7). 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), the LMA MADgic Laryngo-Tracheal Atomizer (Teleflex), and the LMA MADgic Airway (Teleflex). 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. The Airway Mobilescope (MAF; Olympus) is a portable, flexible endoscope with expanded viewing and recording capability, incorporating a monitor, LED light source, battery, and recording device in a

single unit. A completely disposable system, the aScope (Ambu) also is available. Rescue techniques, such as DL and placing a retrograde guidewire through the suction channel, may be performed if the glottic opening cannot be located with the scope, or if blood or secretions are present. 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.

Seldinger technique to gain access to the cricothyroid membrane. Subsequent dilation of the tract permits passage of the emergency airway catheter. 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.

RETROGRADE INTUBATION

TRACHEOSTOMY

Retrograde intubation (Table 6) is an excellent technique for securing a difficult airway either alone or in conjunction with other airway techniques. 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 ID, and a 14.0 Fr for placing tubes of ≥5.0 mm ID.

Tracheostomy (Table 9) establishes transcutaneous access to the trachea below the level of the cricoid cartilage. Emergency tracheostomy may be necessary when acute airway loss occurs in children under the age of 10 or those 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. Percutaneous dilatational tracheostomy is the most commonly performed tracheostomy technique, yet it is still considered invasive and can cause trauma to the tracheal wall. Translaryngeal tracheostomy, a newer tracheostomy technique, is considered safe and costeffective, and can be performed at the bedside. 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.

TRANSTRACHEAL JET VENTILATION TTJV is a well-accepted method for securing ventilation in rigid and interventional bronchoscopy, and there are several commercial manual jet ventilation devices available (Table 6). The Enk Oxygen Flow Modulator (Cook Medical) is recommended for use when jet ventilation is appropriate but not available. An MRI Conditional 3.0 Tesla manual jet ventilator (Anesthesia Associates, AincA) is also now available to enable TTJV in the MRI suite for both planned and emergency procedures (Table 6).

CRICOTHYROTOMY Cricothyrotomy (Table 8), a lifesaving procedure, is the final option for “cannot-intubate, cannot-ventilate” patients according to all airway algorithms, whether they concern prehospital, ED, ICU, or surgical patients. In adults, needle cricothyrotomy should be performed with catheters at ≥4 cm and ≤14 cm in length. A 6.0 Fr reinforced fluorinated ethylene propylene Emergency Transtracheal Airway Catheter (Cook Medical) has been designed as a kink-resistant catheter for this purpose. Percutaneous cricothyrotomy involves using the

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.

Reference 1.

ASA Difficult Airway Algorithm. Anesthesiology. 2013;118[2]:251-270

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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.

Arndt Airway Exchange Catheter Set (Cook Medical)

Polyethylene 8.0 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 Catheters (Cook Medical)

8.0, 11, 14, and 19 Fr polyethylene designs facilitate exchange of SLT or DLT of ≥4.0 mm ID. The DLT versions are EF with soft tips. Colors: yellow, green; soft-tip is purple.

43, 83, 100

Cook Staged Extubation Set (Cook Medical) (Available outside of US only)

Soft-tipped marked extubation wire to maintain continuous airway access, wire holder and Tegaderm for securement, soft-tipped Reintubation Catheter, Rapi-Fit adapters to assist in oxygen delivery, if necessary.

Accommodates ETs >5.0 mm ID.

CoPilot VL Single-Use Bougie (Magaw Medical)

14 Fr polyethylene single-use ET introducer with coudé tip. Color: orange

60. Accommodates ETs ≥6.0 mm ID.

CoPilot VL Rigid Stylet (Magaw Medical)

Reusable CoPilot VL intubation stylet.

Accommodates ETs ≥6.0 mm ID.

Frova Intubating Introducer (Cook Medical)

Polyethylene 8.0 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 Rigid Stylet (Verathon)

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

26.6. Accommodates ETs ≥6.0 mm ID.

Introes Pocket Bougie (BOMImed)

Single-use 14 Fr (4.7 mm) malleable ET introducer made from special blend of Teflon. Packaged in box of 10.

60. Accommodates ETs ≥5.0 mm ID.

Muallem ET Tube Stylet (VBM Medizintechnik)

Single-use 8.0, 12, 14 Fr stylet; malleable, but with soft and atraumatic coudé tip. Color: green.

40, 65

OptiShape Stylet (Truphatek International)

Reusable, sterilizable, semirigid stylet with optimal shape memory for indirect intubation procedures.

4 sizes. Accommodates ETs 2.5-3.5, 4.0-5.5, 5.06.5, and 7.0-9.0 mm ID.

Pocket Introducer (VBM Medizintechnik)

Single-use 15 Fr Introducer with coudé tip. Color: blue.

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.

Rapid Positioning intubation Stylet (RPiS) (Airway Management Enterprises)

Single-use flexible stylet with tip that allows 180-degree flexion and retroflexion. Tip protrudes 5 cm from the end of ET. Color: blue

38, ETs ≥6.0 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.

S-Guide (VBM Medizintechnik)

Single-use 15 Fr stylet, malleable, with atraumatic coudé tip and hollow for oxygenation.

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Clinical Applications

Special Features

Exchange of SGAs for ETs ≥7.0 mm using an FOB. Its hollow lumen allows insertion of an FOB directly through the catheter so that the airway can be indirectly visualized.

Large lumen (4.7 mm) allows passage of FOB. Rapi-Fit adapters allow both jet ventilation and ventilation with 15-mm adapter (anesthesia circuit or Ambu bag). Single use.

Exchange of LMAs and ETs using a 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.

The Cook AEC is intended for uncomplicated, atraumatic, ET exchange for both SLTs and 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.

Provides a tool for a more complete extubation strategy, which should be in place for every patient.

Uses an atraumatic wire to maintain continuous airway access and a soft-tipped reintubation catheter to facilitate a successful reintubation if required and delivery of oxygen when desired.

Facilitate endotracheal intubation. May also be used for tube exchange.

Single use.

Reusable CoPilot VL intubation stylet for use with VL to facilitate ET placement.

Reusable, easy to high level disinfect or sterilize.

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 AVL, GVL, Cobalt, and Ranger VLs to facilitate intubations in OR, ED, and emergency settings.

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

Designed to facilitate endotracheal intubation for both DL and VL. Unique curvature designed to follow natural path of airway. Flexibility allows for manipulation of distal tip for anterior airways. Customizable coudé tip angles.

Self-lubricated bougie, Tactiglide technology for tactile sensation, optimal curve with shape memory, balanced rigidity with soft-tissue protection, nonremovable depth markings, packaged sterile.

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 VLs 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 VLs that employ >42-degree angle of vision.

Facilitates endotracheal intubation.

Folded to only 20 cm, unfolds to 65 cm within seconds, ideal space solution for emergency bags.

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 directly into the glottis and then placing an ET over it.

Nondisposable and reusable. Size 5.0 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.

Provides greater visibility and control of tip similar to a FOB (with 1 provider) in difficult and routine intubations with VL.

Single-use stylet with atraumatic soft tip.

Single-use product reduces 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.

Difficult intubation. Ideal for nonchanneled VL.

Malleable stylet with soft tip and oxygenation possibility (3 in 1). Unique oxygen connector included. table continues on next page

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Table 1. Endotracheal Tube Guides

(continued)

Name (Manufacturer)

Description

Length, cm

Truflex Flexible Stylet (Truphatek International)

Reusable, stainless steel stylet. Has flexible tip with upward lift action of 30-60 degrees, depending on size of ET.

Suitable for use with ETs 6.5-8.5 mm ID.

VBM Introducer (VBM Medizintechnik)

Single-use 15 Fr introducer with coudé tip and hollow for oxygenation. Color: orange.

VBM Tube Exchanger (VBM Medizintechnik)

Single-use 11, 14, and 19 Fr tube exchanger that is hollow to allow oxygenation. Color: blue.

Description

Size

Aaron Surch-Lite (Bovie Medical Industries)

10-in sterile, single-use, flexible stylet.

Adult

AincA Lighted Stylet (Anesthesia Associates)

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

Adult and children (ETs ≥5.0 mm). Infant (ETs ≥3.0 mm).

Tube-Stat Lighted Intubation Stylet (Medtronic)

Similar to AincA lighted stylet.

Nasotracheal: 33 cm shaft. Orotracheal: 25 cm shaft.

Vital Signs Light Wand Illuminating Stylet (GE Healthcare)

Similar to AincA lighted stylet.

Adult

AincA VideoStylet (Anesthesia Associates)

Easily malleable, video imaging stylet with built-in ET holder. Shapes and guides ET while forwardly illuminating the passage and providing full-color image. Completely reusable device consisting of removable VideoStylet and attached rechargeable LCD monitor.

Adult and children (ETs ≥6.0 mm)

air-Vu Plus Fiber-optic Stylet (Cookgas; 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)

Ambu aScope 3 (Ambu)

Single-use flexible videoscope. OD: 5.0 mm; working channel ID: 2.2 mm.

60 cm long

Ambu aScope 3 Slim (Ambu)

Single-use flexible videoscope. OD: 5.0 mm; working channel ID: 2.2 mm.

60 cm long

Table 2. Stylets Name (Manufacturer) Lighted Stylets

Viewing Stylets

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Clinical Applications

Special Features

Using a dynamic intubation stylet eases clinical coordination difficulties associated with use of VLs by providing greater control of the ET tip direction. Also offers easy and improved laryngeal entry of ET in difficult or routine intubations.

Adjustable stopper allows use of ET tubes of differing lengths. Can be used in both direct and indirect intubations.

Difficult intubation with oxygenation possibility.

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

Exchange of ETs.

Similar to Muallem ET Introducer.

Clinical Applications

Special Features

Usable for routine blind intubations or additional illumination during laryngoscopy, but especially useful when FOB 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 with other techniques. Completely disposable. Intended for single use. Individually packaged in boxes of 3.

Same as Aaron Surch-Lite.

Can be used alone or 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.

Ideal for difficult intubations, teaching.

Minimizes neck flexion and head hyperextension in trauma cases.

Flexible lighted stylet for use with or without a laryngoscope. Especially useful in soiled or bloody airways.

Bright light provides excellent verification of ET positioning, even during difficult intubations. ET temperature will not rise above 42°C (108°F).

Usable for routine intubations or video imaging during laryngoscopy, but especially useful when FOB unavailable (eg, outside locations or ambulances), or when bronchoscopy is difficult to perform (eg, obscured airway or limited head motion allowed).

Provides rapid learning curve due to similarity to standard ET advancement techniques, but with added benefit of an attached, clear video image of all landmarks forward of ET tip. Allows for single-handed use with imaging or used in conjunction with a laryngoscope, as desired for physical alignment. Reusable system. Sterilized by Glutaraldehyde or Sterrad.

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

Portable, durable rigid stylet that allows for a fiber-optic view during intubation through the airQ light source. Options include GreenLine laryngoscope handle or fiber-optic light source (4 AA batteries).

Alternative to standard reusable flexible bronchoscopes. Useful for visualization during intubation through SGAs.

Fully disposable flexible scope avoids cleaning/disinfecting issues. Attaches to high-quality aView Monitor with on-board recording of video images.

Equivalent to standard reusable pediatric flexible bronchoscopes. Especially useful for positioning double-lumen endobronchial tubes or bronchial blockers.

Fully disposable flexible scope avoids cleaning/disinfecting issues. Attaches to high-quality aView Monitor with on-board recording of video images. table continues on next page

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Table 2. Stylets

(continued)

Name (Manufacturer)

Description

Size

Bonfils Retromolar Intubation Endoscope (KARL STORZ Endoscopy)

High-resolution rigid fiber-optic stylet with a fixed 40-degree curved shape at the distal end. Available with standard eyepiece or DCI to endoscopic camera system. Can be used within C-MAC system while using the portable monitor of the C-MAC VL with C-CAM camera head.

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

Brambrink Intubation Endoscope (KARL STORZ Endoscopy)

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

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

Clarus Video System 30000V (Clarus Medical)

Malleable (shapeable) rigid stylet scope with attached LCD screen and adjustable curve shape provides view from end of stylet; USB for recharging lithium ion battery and option to connect to notebook or monitor; red LED for transillumination. Assist with DL/VL or used as independent device. Also malleable for use through intubating supraglottic ventilatory devices.

5 mm OD. ETs ≥5.5 mm.

Levitan GLS (Clarus Medical)

Portable high-resolution optics from end of stylet, malleable (shapeable) rigid stainless steel stylet that protects the illumination optic fibers. Comes in 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. Assist with DL/VL like regular stylet or used as independent device. Also malleable to be used through intubating supraglottic ventilatory devices. Optional adapter uses smartphones to transform optics to video.

Adult (ETs ≥5.5 mm ID).

PocketScope (Clarus Medical)

Conveniently sized, easy-to-clean, and cost-effective (reusable) flexible stylet that has a patented, deflected, nondirectable tip. Optional adapter uses smartphones to transform optics to video. Often used to confirm placement and patency of airways.

Adult (ETs ≥4.0 mm ID).

SensaScope (Acutronic Medical Systems)

Hybrid S-shaped, semi-rigid fiber-optic intubation video stylet. Has a 3-cm steerable tip with video chip that can be flexed in sagittal plane 75 degrees in both directions with lever at proximal end of device. Has no working channel.

Adult (ETs ≥6.5 mm ID).

Shikani Optical Stylet (SOS; Clarus Medical)

Viewing stylet: high-resolution, stainless steel, malleable (shapeable) fiberoptic stylet that comes in preformed hockey-stick shape. Has adjustable tube stop and integral oxygen port for oxygen insufflation. Use to assist with DL/VL like regular stylet or used as independent device. Also malleable for use through intubating supraglottic ventilatory devices. Optional adapter uses smartphones to transform optics to video.

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

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Clinical Applications

Special Features

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

Similar to Bonfils Retromolar Intubation Fiberscope.

Available for DCI 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 when use of the scope is contraindicated because of blood or vomit.

Originally designed as adjunct to DL. Many use it as a standalone 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 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.

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 for immediate use.

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

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.

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Table 3. Video Laryngoscopes

(continued)

Name (Manufacturer)

Description

Size

Airtraq Avant (Prodol Meditec; distributed by Teleflex)

Disposable VL that provides a magnified angular view of the glottis without alignment of oral, pharyngeal, and tracheal axes. Includes a guiding channel to both hold and direct ET toward the vocal cords. Reusable optic piece (up to 50 intubations) and antifog heater resists lens clouding. Disposable blade and eye-cup. MRI conditional use. Also optional: A-360 camera and smartphone adapter.

Regular adult for ET 7.08.5 mm ID. Small adult for ET 6.0-7.5 mm ID.

Airtraq SP (Prodol Meditec; distributed by Teleflex)

The SP model is single use with all the features of the Avant but fully disposable. Both Airtraq models have an optional snap-on camera, with integrated 2.8-in touch screen that flips and rotates on 2 axes and can be attached to all Airtraq models. It records and can Wi-Fi connect to smartphone/iPad/iPhone/PC.

6 color-coded sizes available: regular adult for ET 7.08.5 mm ID; small adult for ET 6.0-7.5 mm ID; pediatric for ET 4.0-5.5 mm ID; infant for ET 2.5-3.5 mm ID; nonchanneled blade; and double-lumen ETs.

Berci-Kaplan DCI Video Laryngoscope System (KARL STORZ Endoscopy)

VL system with interchangeable laryngoscope blades. Platform system enables DCI camera head to snap onto any standard eyepiece fiberscopes (flexible or semi-rigid). Required components include camera control unit, xenon light source, and monitor. Telepack portable combination video/light source/ monitor unit is also available for use with this system.

MAC 2-4, Miller 0, 1, 4, Dรถrges universal blade and D-Blade for difficult, very anterior airways.

C-MAC Video Laryngoscope (KARL STORZ Endoscopy)

Instant on, battery-powered VL with standard shaped interchangeable Macintosh and Miller blades for obese adults through neonates as well as a difficult airway blade (D-Blade) for very anterior airways. Blades house high-resolution CMOS distal chip and LED technology. Real-time viewing on 7-in LCD monitor. Dรถrges D-Blade has angle of view with approximately 80-degree acute curvature design.

MAC 2-4, Miller 0 and 1, MAC 3 and 4 with channel for suction, D-Blade, and S-Blade (singleuse). Single-use blade.

C-MAC Pocket Monitor (KARL STORZ Endoscopy)

Highly portable rescue device, 2.4-in monitor fits directly on all C-MAC blades. LCD 4.3 ratio high-resolution screen works in direct sunlight; rechargeable battery lasts 1 h; ergonomic screen can be moved in several directions and folded away for transportation; fully immersible.

Same as C-MAC.

CoPilot VL (Magaw Medical)

Portable VL with an acutely angled blade and C-shaped channel for a bougie. Rechargeable lithium polymer internal battery provides >2 h of continuous use. Built-in anti-fog mechanism.

Adult sizes 3 and 4.

GlideScope Titanium Video Laryngoscope (Verathon)

GlideScope Titanium systems are available in reusable options and feature streamlined, low-profile blade designs and durable, lightweight titanium construction. Built-in anti-fog mechanism. With new snapshot and on-screen playback features.

4 reusable blade designs. LoPro 3 and 4 angled blades, and Mac-style 3 and 4 blades. Compatible with full line of GlideScope AVL pediatric blades.

GlideScope AVL (Advanced Video Laryngoscope; Verathon)

Portable advanced VL features a digital color monitor and digital camera for DVD clarity. Also includes integrated real-time recording and onboard video tutorial. Anti-fog feature to resist lens fogging. Reusable and single-use options available. With new snapshot and on-screen playback features.

6 disposable blades, sizes 0-4. Reusable blades in 4 sizes: GVL 2-5.

GlideScope Ranger and Ranger Single Use Video Laryngoscopes (Verathon)

Portable VL designed for EMS and military paramedics. Compact and rugged. Operational in seconds.

Reusable Ranger offers 2 blade sizes: 3 and 4. Ranger Single Use is offered with 6 disposable sizes: 0-4.

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Clinical Applications

Special Features

Intended to facilitate intubation in both routine and difficult airway situations. Useful in all cases where ET intubation is desired. Also appropriate for emergency settings, cervical spine immobilization, fiberscope guidance, tube exchange, and foreign body removal.

Optics fully isolated from patient, preventing crosscontamination. Advanced airway device with built-in anti-fog 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. May be used in MRI suite as MRI compatible.

Same as Airtraq Avant.

Same as Airtraq Avant but totally disposable and self-contained. 3-y shelf-life.

Useful for anterior airways, obese patients, and patients with limited mouth opening or neck extension. Variety of blade sizes and designs accommodates patients ranging from morbidly obese to neonate (500 g). Additionally useful for teaching purposes, verification of ET position, aiding application of external laryngeal manipulation, or passage of an intubating introducer. 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. Blades provide 80-degree field of view.

Same as DCI. Highly portable system for use in all hospital settings.

Unique platform design is compatible with multiple intubation devices, including video laryngoscopes, the F.I.V.E. distal chip flexible video scopes, and standard eyepiece scopes (fiberoptic and semi-rigid) via C-CAM camera head. Built-in still and video image capture on memory card, with real-time playback on monitor. Angled distal lens provides 80-degree field of view. Inherent anti-fog design. Unit can be pole mounted or inserted into waterproof field bag. No special ETs or stylets needed. Can be used while battery is charging.

Ideal for ICU, crash carts, ED and all prehospital environments including EMS, ambulatory services, air transport, and military. Has familiar blade design and 80-degree field of view.

Lightweight, handheld, and battery-operated device well suited for areas outside the OR. Waterproof.

Same as DCI.

Patented bougie port is designed to facilitate ET placement. Single use.

More VL options for routine and difficult airways—including new MAC-style blades—provide clinicians with a choice of airway tools for a wide range of patients, clinical settings, and teaching purposes.

Reusable blades and video cable, as well as the single-use Smart Cable, can be completely immersed in the recommended cleaning solution (IPX8 compliant). Includes anti-fog capability, plus real-time recording, display, and playback features on 6.4-in digital, color GlideScope Video Monitor.

DVD-quality airway view enables intubation in a wide range of adult and pediatric patients, including preterm/small child and morbidly obese, bloody or anterior airways, and patients with limited neck mobility. Optimized for demanding applications in the OR, ED, ICU, and NICU. Can be used for teaching.

Real-time recording, onboard video tutorial, anti-fog feature to resist lens fogging, advanced resolution output to an external monitor, intuitive user controls and status icons, lightweight and easily transportable, impact-resistant, durable polycarbonatecoated video screen. Disposable blades allow quick turnaround and help limit the possibility of cross-contamination.

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

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 Safe-to-Fly certifications. Reusable and disposable. table continues on next page

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Table 3. Video Laryngoscopes

(continued)

Name (Manufacturer)

Description

Size

King Vision Video Laryngoscope (Ambu)

Durable, fully portable digital VL with a high-quality reusable display and disposable blades. Display aligned with blade, ergonomic handle integrated into blade, the disposable blades incorporate the camera and light source, anti-fog coating on distal lens. Channel is soft, allowing for easy ET detachment.

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

King Vision Video Laryngoscope aBlade System (Ambu)

Reusable video adapter attaches to the existing King Vision display to allow use of lower-cost aBlades.

Same as original offering: size 3 with channeled and standard (nonchanneled) aBlade versions.

McGrath MAC (Aircraft Medical; distributed by Covidien)

Portable VL designed for everyday use in the OR, ICU, and ED. Uses disposable MAC-shaped blades as well as acutely curved X3 Blade. Durable (drop tested up to 2 m). Screen displays minuteby-minute battery life countdown.

Blade sizes 2, 3, and 4 and X3.

McGrath Series 5 Video Laryngoscope (Aircraft Medical; distributed by Teleflex)

Portable VL with adjustable-length, single-use disposable blade that can be disarticulated from the handle to further assist with difficult airways. Flat-screen monitor located on the handle to remain in a more natural line of sight with patient. McGrath Series 5 HLDi is the new “High Level Disinfection Immersible” system that is entirely waterproof.

Adjusts to fit many adult and pediatric sizes.

Venner AP Advance Video Laryngoscope (Venner Capital)

Fully portable VL with 3.5-in monitor that attaches to a reusable handle. Self-contained LED light source. Built-in anti-fogging mechanism.

MAC 3 and 4, and Difficult Airway Blade.

VividTrac (MercuryMedical/FujiFilm/ SonoSite)

Video intubation device that works on many computer systems equipped with USB II port as a standard USB camera, using available video camera applications on Windows, Mac, and Linux systems. Alternatively, automated video display software (VividVision) can be downloaded.

ET 6.0-8.5 mm.

Table 4. Indirect Rigid Fiber-Optic Laryngoscopes Name (Manufacturer)

Description

Size

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 to adult.

AincA Flex-Tip Fiber-Optic Laryngoscope Blade (Anesthesia Associates)

Flexible tip or levering fiber-optic MAC laryngoscope blades 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.

AincA Macintosh Viewing Prisms (Anesthesia Associates)

An optically polished viewing prism for attachment to most MAC laryngoscope blades (conventional OR fiber-optic). 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 MAC laryngoscope blades of sizes 2, 3, and 4.

Modified MAC Blades

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Clinical Applications

Special Features

Facilitates both routine and difficult intubations.

Can be used alone or with other techniques. Powered by 3 AAA batteries. Organic LED screen allows wide-angle viewing in various lighting conditions. Video out available for connection to external display or video-capture device.

Facilitates both routine and difficult intubations.

Can be used alone or with other techniques. Powered by 3 AAA batteries; high fidelity 2.4-in screen allows wide-angle viewing. Video out available for connection to external display or videocapture device.

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 extreme cases.

No additional training required. Supports direct and indirect visualization due to video support. Slimline blade for improved agility. Blade shape requires less tube curvature than other VLs for easier insertion and a stylet is not always required. Highly portable and lightweight. No electrical outlet required, thus ideal for settings outside the OR. Uses disposable blades for quick turnaround between uses and for limiting cross-contamination. Monitor located on the handle to remain in a more natural line. Waterproof.

Useful in patients with limited mouth opening or head and neck Highly portable and lightweight. Uses disposable blades for quick movement, anterior airways; obese patients; patients in whom an turnaround between uses and for limiting cross-contamination. increased hemodynamic response is a concern; and for teaching. 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. Monitor is located on the handle to remain in a more natural line of sight with the patient. Similar to C-MAC VL.

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

Intended to facilitate intubation in both routine and difficult airway situations.

VividTrac is inserted more like an oral airway device (or LMA) than a laryngoscope blade. The ET can be preloaded or inserted once visualization is achieved in the VividTrac tube channel.

Clinical Applications

Special Features

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

10- and 20-kg markings on the blade.

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

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.

Built-in clip on each prism allows attachment to any MAC-type laryngoscope blade that has a standard thickness vertical flange. Usable on both conventional and fiber-optic–type MAC blades. Reusable and sterilizable.

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Table 5. Supraglottic Ventilatory Devices Name (Manufacturer)

Description

Size

AES The Guardian CPV (AES)

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

Adult sizes 3, 4, 5.

AES Ultra (AES)

All-silicone laryngeal mask with standard cuff valve.

Adult sizes 3, 4, 5, 6.

AES Ultra Clear (AES)

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

Adult sizes 3, 4, 5, 6.

AES Ultra Clear CPV (AES)

Silicone cuff and PVC tube, laryngeal mask with CPV that constantly monitors cuff pressures.

Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6.

AES Ultra CPV (AES)

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

Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6.

AES Ultra EX (AES; distributed by Anesthesia Associates)

All-silicone, multiple-use laryngeal mask.

Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6.

AES Ultra Flex CPV (AES)

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

Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6.

AES Ultra Flex EX (AES; distributed by Anesthesia Associates)

All-silicone, wire-reinforced, multiple-use laryngeal mask.

Pediatric to adult sizes 1, 1.5, 2, 2.5, 3, 4, 5, 6.

air-Q Blocker Disposable Laryngeal Mask (Cookgas; 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. This channel provides access to the esophagus with a NGT or Blocker tube that allows clinicians to vent, suction and further block the esophagus.

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

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

Hypercurved intubating laryngeal airway with removable color-coded connectors. Anterior portion of mask is recessed; larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet.

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

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

Hypercurved intubating laryngeal airway that resists kinking, and removable airway connector. Anterior portion of mask is recessed; larger mask cavity allows intubation using standard ETs. Air-Q removal after intubation is accomplished by using air-Q reusable removal stylet.

Sizes (0.5, 1.0, 1.5, 2.0, 2.5, 3.5, and 4.5) that can accommodate standard ETs 4.0-8.5 mm.

air-Q SP (Cookgas; distributed by Mercury Medical)

Combines features of the air-Q disposable laryngeal masks with added advantage of a self-pressurizing mask. No inflation line or pilot balloon is needed. PPV or spontaneously breathing patients inflate the mask during the uptake of ventilation.

Sizes (1.0, 1.5, 2.0, 2.5, 3.5, 4.5) that can accommodate standard ET tubes ≤8.5 mm.

air-Q SP Reusable (Cookgas; distributed by Mercury Medical)

Combines features of the air-Q reusable laryngeal masks with added advantage of a self-pressurizing mask. No inflation line or pilot balloon is needed. PPV or spontaneously breathing patients inflate the mask during the uptake of ventilation.

Sizes (0.5, 1.0, 1.5, 2.0, 2.5, 3.5, 4.5) that can accommodate standard ETs 4.0-8.5 mm.

Ambu AuraFlex (Ambu)

Disposable wire-reinforced flexible LMA.

Adult and pediatric sizes 2-6.

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Clinical Applications

Special Features

SGA 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.

SGA 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. Indicated as primary airway device when oral ET is not necessary or as 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, NGTs 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 ≤8.5 mm.

Same as air-Q Reusable Laryngeal Mask.

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

Designed to minimize folding of the cuff tip on insertion. Integrated bite block reinforces the tube while diminishing need for a separate bite block. Color-coded removable connectors tethered to the airway tube, avoiding episodes of misplaced connectors.

Same as regular air-Q but eliminates need for mask inflation.

PPV self-pressurizes mask cuff. On exhalation, mask cuff decompresses to level of PEEP. Removable connector allows intubation with standard ETs.

More secure than a face mask and less invasive than intubation with an ET when tracheal intubation not necessary or during unexpected difficult airway situation.

Incorporates the air-Q design with Self-Inflating Mask.

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

Integrated pilot tube, and high flexibility enables positioning away from the surgical field, without 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. table continues on next page

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Table 5. Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

Ambu AuraGain (Ambu)

Second-generation laryngeal mask, featuring anatomic curve for rapid placement, gastric access for suction and decompression of the stomach via a gastric tube, and integrated direct intubation capability for management of expected or unexpected difficult airway.

Adult sizes 3-5.

Ambu Aura-i (Ambu)

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

Adult and pediatric sizes 1-6.

Ambu AuraOnce (Ambu)

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)

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)

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

Adult and pediatric sizes 1-6.

CobraPLA (Pulmodyne)

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

Adult and pediatric sizes 0.5-6.

CobraPLUS (Pulmodyne)

Similar to the CobraPLA. Includes temperature monitor and distal gas sampling in all sizes.

Adult and pediatric sizes 0.5-6.

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.

i-gel (Intersurgical)

SGA with a noninflating cuff, designed to mirror the anatomy over the laryngeal inlet, with an integral bite block, buccal cavity stabilizer, and gastric channel. Also incorporates widebore airway channel for use 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.

i-gel O2 Resus Pack (Intersurgical)

SGA with a supplementary oxygen port, an integral colorcoded hook ring to secure airway support strap and identify size; designed to facilitate ventilation. Includes noninflating cuff to mirror anatomy, with an integral bite block, buccal cavity stabilizer, and gastric channel. The pack contains an i-gel O2 second-generation SGA, a sachet of lubricant, and an airway support strap.

Adult sizes 3-5.Adult sizes accommodate ET sizes 6.0â&#x20AC;&#x201C;8.0 mm.

KING LT (Ambu)

Multi-use, 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). Color-coded connectors for each size.

Sizes 0-5.

KING LT-D (Ambu)

Same design as the KING LT, except disposable.

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

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Clinical Applications

Special Features

Useful for ventilation and intubation. Appropriate for management of expected or unexpected difficult airway.

Allowable ET size is designated on each device; gastric access channel ≤14 Fr tube.

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

Anatomically correct curve designed as Ambu AuraOnce and Ambu Aura40 but specially designed as a conduit for intubation. Compatible with standard ETs.

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 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.

Routine use SGA.

Reusable.

Routine use SGA.

Reusable. Available only in US.

Routine use SGA.

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

Routine use SGA. Added benefit: able to measure core temperature. Distal CO2 can be monitored in pediatric patients.

Similar to CobraPLA, but allows monitoring of patient’s core temperature. In neonatal and infant patients, has ability to increase the accuracy of end-tidal CO2 and volatile gas analysis. If intubation necessary or desired, will accommodate ET ≤8.0 mm. Single use.

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

Ventilation possible with either tracheal or esophageal intubation. Distal cuff seals off the esophagus to prevent aspiration of gastric contents. Allows passage of an oro-gastric 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). Gastric channel provides early warning of regurgitation, allows for the passing of a NGT to empty the stomach contents and can facilitate venting of gas from the stomach (except size 1).

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

Indicated for use in routine and emergency anesthesia and resuscitation in adult patients. Can be used as a conduit for intubation with fiber-optic guidance. i-gel O2 also can be used to provide supplementary oxygen during postoperative care or patient transfer. Gastric channel provides early warning of regurgitation, allows for the passing of NO tube to empty stomach contents and can facilitate venting of gas from the stomach.

Noninflating cuff allows easy and rapid insertion, provides high seal pressure, and minimizes risk for tissue compression. Supplementary oxygen port allows for administration of passive oxygenation as a component of cardio-cerebral resuscitation. Gastric channel provides early warning of regurgitation. Buccal cavity stabilizer reduces risk for rotation or displacement and integral bite block prevents occlusion of airway channel. The wide-bore airway channel also allows for use as a conduit for intubation with fiber-optic guidance.

Reusable SGA but with ventilator seal characteristics.

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

Same as KING LT.

Also available in a kit. Single use. table continues on next page

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Table 5. Supraglottic Ventilatory Devices

(continued)

Name (Manufacturer)

Description

Size

KING LTS (Ambu)

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

Adult sizes 3-5 and pediatric sizes 0, 1, 2, 2.5.

KING LTS-D (Ambu)

Same as KING LTS, except disposable.

Adult sizes 3-5.

LMA Classic (Teleflex)

Safe, general-purpose airway for routine elective inpatient and outpatient surgical procedures.

Adult sizes 3,4,5,6 and pediatric sizes 1, 1.5, 2, 2.5.

LMA Classic Excel (Teleflex)

Has the benefits of LMA Classic and its improved design facilitates intubation.

Adult sizes 3-5.

LMA Fastrach (Teleflex)

Designed to facilitate blind intubation without moving head or neck, allowing for single-handed insertion. Allows continuous ventilation between intubation attempts.

Adult sizes 3-5 that can accommodate special ETs 6.0-8.0 mm.

LMA Flexible (Teleflex)

Has a reinforced airway tube that allows it to be positioned away from the surgical field while maintaining a good seal.

Adult sizes 3, 4, 5, 6 and pediatric sizes 2, 2.5.

LMA ProSeal (Teleflex)

Double-cuff design enables seal pressures ≥30 cm H2O to be achieved and the drain tube separates the alimentary and respiratory tracts.

Adult sizes 3,4,5 and pediatric sizes 1, 1.5, 2, 2.5.

LMA Supreme (Teleflex)

Combines features of all previous LMAs to provide increased safety and ease of use. The higher seal pressure and gastric access provide a higher degree of safety. Designed to channel fluids away from the airway in the unlikely event of active or passive regurgitation and allows for diagnostic positioning.

Adult sizes 3, 4, 5 and pediatric sizes 1, 1.5, 2, 2.5.

LMA Unique (Teleflex)

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.

Adult and pediatric sizes 1-5.

Rüsch Easy Tube (Teleflex)

Disposable LT that combines the features of a conventional ET with those of an esophageal obturator airway similar in design to the Combitube.

Small, 28 Fr; large, 41 Fr.

Soft-Seal Laryngeal Mask (Smiths Medical)

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.

Adult and pediatric sizes 1-5.

Solus Satin Laryngeal Mask Airway (Intersurgical)

A range of single-use, latex-free LMAs with a softer airway tube to provide more flexibility.

Adult sizes 3-5.

Solus Standard Laryngeal Mask Airway (Intersurgical)

A range of single-use, latex-free LMAs.

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

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Clinical Applications

Special Features

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.

Same as KING LTS.

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

Although originally developed for airway management 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. 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 bridge to extubation and with pressure support or PPV.

May be used ≤40 times before discarding.

Improves on features of the original LMA Classic Airway, facilitating intubation, and is reusable ≤60 times.

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

Designed for anatomically difficult airway and included in AHA’s and ASA’s difficult airway algorithms.

Supplied in a sterile version for single-use only, as well as in a nonsterile reusable version, which may be used ≤40 times before discarding.

Ideal for ENT, ophthalmic, and dental surgery, or other procedures where the surgeon and anesthesiologist compete for airway access.

Supplied in a sterile version for single use only, as well as in a nonsterile reusable version that may be used ≤40 times before discarding.

The drain tube higher seal pressures together with the flexible airway tube enable longer periods of ventilation with minimal posterior pharyngeal wall damage, therefore expanding the types of procedures where a LMA can be used.

Second cuff allows tighter seal for PPV. Reusable.

For routine procedures or to manage higher-risk patients.

Allows for easy insertion, higher seal pressures, and provides gastric access to suction or to decompress the stomach. First Seal Technology is designed to provide adequacy of gas exchange. Second Seal Technology is designed to reduce risk for insufflation during ventilation. Designed to provide a passive conduit for unexpected regurgitation. The angle of the LMA Supreme Airway facilitates ease of insertion in various head positions.

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

Indicated for use in anesthesia and emergency medicine. Singleuse LMA, comes sterile and ready for use.

Classic cuff shape for optimum anatomic conformance with a firm, smooth-surfaced back plate to aid ease of insertion. Has a softer airway tube to provide more flexibility. Clear, pliable airway tube allows for early detection of rising fluids. Cuff size indicators are accurately aligned and prominently displayed at top of tube and on pilot balloon. Essential user information on exposed section of airway tube for quick visual reference.

Indicated for use in anesthesia and emergency medicine. Singleuse LMA, comes sterile and ready for use.

Classic cuff shape for optimum anatomic conformance with a firm, smooth-surfaced back plate to aid ease of insertion. Clear, pliable airway tube allows for early detection of rising fluids. Cuff size indicators are accurately aligned and prominently displayed at top of tube and on pilot balloon. Essential user information on exposed section of airway tube for quick visual reference.

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Table 6. 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)

Device for atomizing small doses of local anesthetics. 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 that 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 (Teleflex)

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 Airway Intubating Airway with Mucosal Atomization and Oxygen Delivery (Teleflex)

For difficult and awake airways requiring a fiber-optic scope, the device combines atomized topical anesthetic and oxygen delivery in an innovative and elegantly designed fiber-optic窶田ompatible oral airway.

Typical particle size 30-100 microns. System dead space 0.15 mL. Oxygen flow rate 2-3 L/min at 50 psi. Size 9 cm airway (6.5-8.0 ET).

LMA MADgicWand Mucosal Atomization Device (Teleflex)

Combines atomized topical anesthesia and oxygen delivery in a fiber-optic oral airway. Packaged in box of 20.

Typical particle size: 30-100 microns. System dead space: 0.25 mL.

LMA MADgic LaryngoTracheal Atomizer (Teleflex)

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

Typical particle size: 30-100 microns. System dead space: 0.25 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 MAD Nasal-Intranasal Mucosal Atomization Device (Teleflex)

Disposable, compact atomizer for delivery of medications to the nose and throat in a fine, gentle mist.

Typical particle size: 30-100 microns. System dead space: 0.13 and 0.07 mL. Tip diameter: 0.17 in (4.3 mm). Applicator length: 1.65 in (4.2 cm).

Available as a complete set in 6.0, 11, or 14 F. 14 F version includes Airway Exchange Catheter with Rapi-Fit adapters allow for delivery of oxygen.

6.0 F=50 cm; 14 F=60 cm, extra-stiff floppy tipped guidewire = 110 cm.

Awake Intubation

Retrograde Cook Retrograde Intubation Set (Cook Medical)

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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 all-metal 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 for use by those trained and experienced in techniques of flexible fiberoptic intubation.

An accessory to a bronchoscope. Delivery form: 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 atomizing nozzle, creating liquid spray. Gas flow adjusted to 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 toylike presentation make 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).

For use with FOB.

Intubating airway with mucosal atomization and oxygen delivery.

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.

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 patient’s anatomy. Delivery of a fine spray mist generated by a piston syringe. Luer connection adapts to any luer lock syringe. Nonsterile. Single use.

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

Rapidly effective (atomized nasal medications absorb directly into bloodstream, avoiding first-pass metabolism; atomized nasal medications absorb directly into the brain and cerebrospinal fluid 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).

Technique used for securing a difficult airway, either alone Packaged as a complete kit with everything needed to perform a or with other alternative airway techniques. Especially retrograde intubation. Recently added Arndt AEC allows for patient useful in patients with limited neck mobility or patients who oxygenation and facilitates placement of an ET. Disposable. have suffered airway trauma. 6.0 Fr places tubes ≥2.5 mm ID; 14 Fr places tubes ≥5 mm ID. table continues on next page

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Table 6. Devices for Special Airway Techniques Name (Manufacturer)

(continued) (continued)

Description

Size

Endoscopy Mask (VBM Medizintechnik)

Face mask with diaphragm to allow simultaneous ventilation and endoscopy.

Newborn, infant, child, and adult.

Flow-Safe II CPAP System (Mercury Medical)

Disposable CPAP with deluxe mask and comfortable head harness, color-coded manometer for verifying CPAP pressure and pressure-relief system. Flow-Safe II works with standard flowmeters that can deliver >10 cm H2O at 15 LPM. Accepts standard nebulizers and standard CO2 sampling lines.

Child, small adult, and large adult.

Flow-Safe II EZ CPAP System (Mercury Medical)

Disposable CPAP similar to Flow-Safe II that also includes an integrated nebulizer. The system requires only 1 oxygen source to run both the CPAP and nebulizer devices. CPAP system includes color-coded manometer for verifying CPAP pressure and pressure-relief system. Flow-Safe II EZ works with standard flowmeters that can deliver >10 cm H2O at 15 LPM. Higher flow pressures may be necessary when running both CPAP and the nebulizer.

Child, small adult, and large adult.

AincA Manual Jet Ventilator (Anesthesia Associates)

Portable jet ventilation device with thumb depression mechanism that initiates 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-lock male fitting. Connects to any tool or port that has a luer-lock female connection (ie, malleable stylets, various adapters, etc.).

Jet ventilation catheters of malleable copper with luer lock 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)

Similar to AincA Manual Jet Ventilator but certified MRI conditional窶田ompatible for use in units 竕､3.0 Tesla strength.

Jet ventilation catheters of malleable copper with luer lock fittings accommodate adults, children, and infants. MRI conditional 3.0 Tesla.

Enk Oxygen Flow Modulator Set (Cook Medical)

Complete set including 15-G 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 high-pressure tubing, and 4 ft of small-bore tubing.

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

Manujet III (VBM Medizintechnik)

Complete set including 13-ft high-pressure hose assembly with oxygen DISS fittings, 40-degree small bore tube assembly (with luer lock fitting) and 3 jet ventilation catheters (13, 14, and 16 G).

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

O2-Trio (Pulmodyne)

Emergency disposable CPAP device.

3 - FiO2 levels 3 - PEEP settings BiTrac ED Mask

Trans-tracheal Catheter (Acutronic Medical System)

Small jet needle for puncturing the trachea in an emergency for use with jet ventilation.

13 G, 14 G

Face Mask Ventilation

Transtracheal Jet Ventilation

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Clinical Applications

Special Features

• • • •

Available in different sizes and with different sizes of 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

Built-in manometer for verified pressure readings. No assembly of separate apparatus and the pressure-relief valve automatically adjusts to avoid excess pressure.

Lighter, easier to handle, and designed to form a better anatomical seal. The elastic head harness is easy to place with Velcro straps that easily adjust for patient comfort.

The Flow-Safe II EZ CPAP device is a respiratory aid intended for use with a face mask, nebulizer, and gassupplying device to elevate pressure in the patient’s lungs while delivering aerosolized medication.

Mask features elastic head harness; quick-disconnect clips, and straight rotating port. Built-in manometer and pressure-relief valve. CPAP and nebulization through a single oxygen source.

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 quick-disconnect 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 quick-disconnect 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 not available.

Packaged as 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. Partially reusable outlet tube is disposable. NOTE: Outlet tube is single use.

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 complete kit with jet ventilation catheters to perform TTJV. Includes gauge and regulator.

Offers PEEP levels 2.5–20 cm H2O. Allows dial in FiO2 levels of ~30%, 60%, and 90%. Constant flow obtained regardless of the amount of oxygen in the tank.

Disposable CPAP generator with ≤21 specific combinations of FiO2 and PEEP.

Applications in ICU for patients with severe lung injuries, ARDS, or bronchopleural fistulas.

Provides ventilation to patient who is unable to be intubated.

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Table 7. Positioning Devices Name (Manufacturer)

Description

Chin-UP (Dupaco; distributed by Mercury Medical)

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

Face-Cradle (Mercury Medical)

Fully adjustable cushion set accommodates most adult head sizes.

RAMP Rapid Airway Management Positioner (Airpal Patient Transfer Systems)

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 head elevated laryngoscopy position. Includes many accessories (head cradle, arm board pads, additional pillow).

Table 8. Cricothyrotomy Devices Name (Manufacturer)

Description

Size

6 Fr reinforced fluorinated ethylene propylene catheter.

5.0 and 7.5 cm.

Melker Emergency Cricothyrotomy Catheter Set (Cook Medical)

Complete set including syringe (10 cc), 2- to 18-G introducer needles with TFE catheter (short and long), 0.038-in diameter Amplatz extra-stiff 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 mm ID), and 7.5 cm (6 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 mm ID), 4 cm (3.5 mm ID), 4.1 cm (4 mm ID), and 4.4 cm (5.0 mm ID).

Quicktrach Emergency Cricothyrotomy Device (VBM Medizintechnik)

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

Adult (4 mm ID) and child (2 mm ID).

Melker Surgical Cricothyrotomy Set (Cook Medical)

Cuffed cricothyrotomy tube, scalpel, tracheal hook Trousseau dilator, and blunt, curved dilator in compact package for convenient storage.

9 cm (5 mm ID).

Melker Universal Emergency Cricothyrotomy Catheter Set (Cook Medical)

Same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for percutaneous technique. Also includes for surgical technique: tracheal hook, safety scalpel, Trousseau dilator, and blunt curved dilator.

9 cm (5 mm ID).

Surgicric (VBM Medizintechnik)

Surgical cricothyrotomy set. Surgicric I: rapid 4-step technique Surgicric II: classical surgical technique Surgicric III: Seldinger technique

6 mm ID.

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

Surgical Cricothyrotomy

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Clinical Applications

Special Features

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

Disposable polyurethane foam cushions.

For use in prone-position surgeries.

Fully adjustable offering the clinician greater visibility of patient’s face.

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

Base of 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, DL, and central venous access. Allows patients to breathe more comfortably during preoxygenation and regional anesthesia.

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

Clinical Applications

Special Features

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

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

Same as Emergency Transtracheal Airway Catheter. Intended for use with the Seldinger technique via cricothyroid membrane; however, has capability to be used as a surgical cricothyrotomy.

Packaged as 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 OR. Comes with 2 differently sized airway catheters to reduce number of kits needed in the field. Disposable.

Use in failed orotracheal or nasotracheal intubation, and/or fiber-optic bronchoscopy. Immediate airway control in patients with maxillofacial, cervical spine, head, neck, and multiple trauma. Also used when endotracheal intubation is impossible and/or contraindicated. Immediate relief of upper airway block.

Serves as an emergency cricothyrotomy or tracheostomy device that uses a patented splitting needle and dilator to perform rapid and simple procedures.

Same as Melker Emergency Cricothyrotomy Catheter Set.

Packaged as complete kit with everything needed to perform a percutaneous cricothyrotomy—even the neck tape and connecting tube. Removable stopper is used to prevent a “toodeep” insertion and avoid the possibility of perforating the rear tracheal wall. Conical needle tip allows for the smallest necessary stoma and reduces the risk for bleeding. Easily transported to offsite locations. Disposable.

This set provides the tools that clinicians can use if they prefer a surgical approach to performing emergency cricothyrotomy.

Complete and convenient packaging.

Same as Melker Emergency Cricothyrotomy Catheter Set.

50% of tray same as Melker Cuffed Emergency Cricothyrotomy Catheter Set for the percutaneous technique. The other 50% includes all items needed to perform a surgical emergency cricothyrotomy.

Three different sets that provide clinicians several choices for the performance of emergency cricothyrotomy.

Small pack size ideal for emergency bags. Soft tip is atraumatic. Locking mechanism prevents accidental dislocation.

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Table 9. 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 percutaneous tracheostomy tubes. 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, 26, and 28 Fr loading dilators and Shiley 6 or 8 percutaneous disposable dual-cannula tracheostomy tube. Tray version 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).

Laserjet Catheter (Acutronic Medical Systems)

Double-lumen jet catheter.

Diameter: 12 Fr; Length: 40 cm, 70 cm

Portex Ultraperc Percutaneous Dilatational Tracheostomy Kit (Smiths Medical)

Complete set with or without a tracheostomy tube.

70 mm (7 mm ID); 5.5 mm (8 mm ID); 81 mm (9 mm ID).

Weinmann Tracheostomy Exchange Set (Cook Medical)

Includes Cook Airway Exchange Catheter, Tracheostomy loading dilators, and a Blue Rhino dilator for redilation if necessary.

For use with tracheostomy tubes as follows: 74 mm (6.4 mm ID); 79 mm (7.6 mm ID).

Shiley TracheoSoft XLT Extended-Length Tracheostomy Tubes (Covidien)

Available in 4 ISO sizes (5, 6, 7 and 8 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 mm ID); 95 mm (6 mm ID); 100 mm (7 mm ID); 105 mm (8 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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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 dilatation and tracheal tube insertion in 1 step. Packaged as a complete kit with everything needed to perform a percutaneous dilatational tracheostomy.

Same as Portex Ultraperc Percutaneous Dilatation 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 Safe-T-J tip to reduce trauma. Disposable.

For use in laser airway procedures and difficult airway procedures.

Laser-safe tube, dual lumen provides extra ability for monitoring of pressures and end-tidal CO2.

Establishes transcutaneous access to the trachea below 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 singlestaged and prelubricated with an ergonomic handle to facilitate insertion. Disposable.

Used to facilitate exchange of adult tracheostomy tubes allowing for stomal redilation, if required.

The only device available that provides an AEC to maintain stomal access and that also allows redilation of stoma if resistance is met.

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

The only fixed-flange extended-length tube with disposable inner cannula. Flexible inner cannula conforms to shape of the outer cannula. 16 configurations to fit a wide variety of patients. Disposable.

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