Quality Assurance for Intraoperative Transesophageal Echocardiography Monitoring
Terence D. RaffertyKenneth R. LaMantiaElizabeth A. DavisDaniel PhillipsStephen N. HarrisJane CarterMichael D. EzekowitzGerald McCloskeyHenry K. GodekPhilip KrakerDavid D. JaegerCharles J. KoprivaPaul G. Barash
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We evaluated our experience with 846 consecutive transesophageal echocardiography (TEE) intraoperative monitoring procedures performed between November 1989 and July 1991. TEE frequency was 36 +/- 11 per month (range 16-55) and represented 69.8% of cardiac valve surgery cases, 40.2% of coronary artery bypass graft cases, and 2.2% of total operative caseload. Major patient complications consisted of transient vocal cord paresis and ingestion of glutaraldehyde-disinfectant solution. Minor complications consisted of a chipped tooth (one case) and pharyngeal abrasions (three cases). The Quality Assurance (Q/A) Program evaluated both record keeping and quality of imaging, as judged by cardiologist echocardiographer reviewers. The percentage of completion for each Q/A indicator was as follows: medical record documentation, 88%; database form annotation, 94%; and provision of videotape recording, 91%. TEE database forms were analyzed further in terms of the percentage of fields completed. Completion scores were 73%. The following scoring system was utilized for videotape evaluation by the cardiologists: 1 = excellent; 2 = good; 3 = poor. The median grade for both two-dimensional echocardiography and color flow Doppler (CFD) examinations was 2. Poor quality images (grade 3) were present in 15.2% of two-dimensional echocardiography and 20.3% of color flow Doppler examinations, and disproportionately associated with 4/26 attendings. Supplemental audit of the cardiology reviewers performance demonstrated 569/846 videotapes showed no objective evidence of review. The cardiology reviewer forms of the remaining 277 videotapes were evaluated in terms of the percentage of fields completed. The completion score was 56%. These data suggest the need for formal Q/A for intraoperative TEE, both for anesthesiologists and reviewing cardiologists.Keywords:
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Background: It has been observed that laryngoscopy and intubation leads to profound cardiovascular effects along with an increase in catecholamine concentrations. Multiple studies have been conducted to attenuate the same. McCoy blade has been found to decrease this pressor response as compared to the Macintosh blade used routinely. Therefore, a comparative study of heart rate (HR) and mean arterial pressure (MAP) changes during laryngoscopy and intubation using these two blades was conducted to establish the same. Methods: The study included 200 patients divided into two groups of 100 each. Laryngoscopy and intubation was performed either with Macintosh or McCoy blade. The HR and MAP were recorded at every 1 minute interval during laryngoscopy and intubation for 5 minutes. Apart from above observations, Mallampatti classification (MPC), Cormack and Lehane classification (C& L) and time required for intubation were noted. Results: There was no difference in baseline HR and MAP in both the groups i.e. Macintosh (MK) and McCoy (MY) . The percentage rise from baseline HR and MAP in MK group was highly significant during laryngoscopy and intubation and 1 minute after that as compared to MY group. Similarly, comparison of HR and MAP changes between both the groups revealed highly significant decrease in the parameters in MY group, during laryngoscopy and intubation and 1 minute after the procedure. No other complications of laryngoscopy & intubation were observed in our study. Conclusion: McCoy blade, primarily devised for difficult intubation has additional benefit of alleviating the pressor response to laryngoscopy and intubation. We recommend its use in patients with cardiovascular compromise, raised intracranial tension (ICT), apart from its established indications. Abbreviations: HRHeart Rate, MAPMean Arterial Pressure, ICT – Intracranial tension
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Summary We studied the success rates for tracheal intubation in 64 healthy patients during simulated grade III laryngoscopy after induction of anaesthesia, using either the single‐use bougie or oral flexible intubating fibrescope, both in conjunction with conventional Macintosh laryngoscopy. Patients were randomly allocated to either simulated grade IIIa or grade IIIb laryngoscopy, and also to one of the two study devices. Success rates for tracheal intubation (primary outcome measure) and times taken to achieve intubation (secondary outcome measure) were recorded. For the simulated grade IIIa laryngoscopy group, the fibreoptic scope was more successful than the bougie (16/16 successful intubations vs. 8/16; p = 0.02). For the simulated grade IIIb laryngoscopy group, the fibreoptic scope was also more successful than the bougie (8/16 successful intubations vs. 1/16; p = 0.02), but clearly use of the fibreoptic scope was not as successful as it had been in simulated grade IIIa laryngoscopy ( p = 0.04). With either device, median (range) total tracheal intubation times for successful attempts with either grade of laryngoscopy were less than 60 s (19–109) and there were no clinically important differences. We conclude that the fibrescope used in conjunction with Macintosh laryngoscopy is a more reliable method of tracheal intubation than the single‐use bougie in both types of grade III laryngoscopy. This finding has implications for the management of patients in whom grade III laryngoscopy is encountered unexpectedly after induction of anaesthesia, and also for the management of patients previously known to have grade III view at laryngoscopy.
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There is a growing body of evidence to support the use of rigid indirect laryngoscopy or ‘video’ laryngoscopy for tracheal intubation. We summarise some of the key issues, comparing rigid indirect laryngoscopy with direct conventional laryngoscopy.
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Background: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. Materials and Methods: 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. Results: Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. Conclusions: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.
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The relationship between the forces applied during laryngoscopy and cardiovascular changes were studied in patients undergoing laryngoscopy with or without intubation. This enabled us to differentiate between the cardiovascular effects of laryngoscopy and the effects of tracheal intubation. The forces applied during laryngoscopy were only weakly related to the cardiovascular changes, whereas tracheal intubation had a major influence. The many difficulties encountered in interpreting results from these studies are discussed. It is concluded that tracheal intubation causes more cardiovascular changes than laryngoscopy in routine uncomplicated procedures.
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Video laryngoscopy may be useful in the setting of the difficult airway, but it remains unclear if intubation success is improved in routine difficult airway management. This study compared success rates for tracheal intubation with the C-MAC® video laryngoscope (Karl Storz, Tuttlingen, Germany) with conventional direct laryngoscopy in patients with predicted difficult airway.We conducted a two arm, single-blinded randomized controlled trial that involved 300 patients. Inclusion required at least one of four predictors of difficult intubation. The primary outcome was successful tracheal intubation on first attempt.The use of video laryngoscopy resulted in more successful intubations on first attempt (138/149; 93%) as compared with direct laryngoscopy (124/147; 84%), P = 0.026. Cormack-Lehane laryngeal view was graded I or II in 139/149 of C-MAC attempts versus 119/147 in direct laryngoscopy attempts (P < 0.01). Laryngoscopy time averaged 46 s (95% CI, 40-51) for the C-MAC group and was shorter in the direct laryngoscopy group, 33 s (95% CI, 29-36), P < 0.001. The use of a gum-elastic bougie and/or external laryngeal manipulation were required less often in the C-MAC intubations (24%, 33/138) compared with direct laryngoscopy (37%, 46/124, P = 0.020). The incidence of complications was not significantly different between the C-MAC (20%, 27/138) versus direct laryngoscopy (13%, 16/124, P = 0.146).A diverse group of anesthesia providers achieved a higher intubation success rate on first attempt with the C-MAC in a broad range of patients with predictors of difficult intubation. C-MAC laryngoscopy seems to be a useful technique for the initial approach to a potentially difficult airway.
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I read with interest Cuvas et al.’s article assessing the influence of smoking and gender on haemodynamic response to tracheal intubation [1]. The haemodynamic response to laryngoscopy depends upon many factors including the force and duration of laryngoscopy [2]. Force of laryngoscopy would be directly related to laryngoscopy grade, as the anaesthetist applies more force in an attempt to visualise the glottis as grade becomes poorer. In Cuvas’ study, the authors classified laryngoscopy grades into three, but they did not compare these grades between groups. They compared only the duration of laryngoscopy in all the groups and this was comparable. A comparable duration of laryngoscopy does not mean comparable laryngoscopy grade and force of laryngoscopy. This contribution may have caused the significance seen in their results. In a standardised protocol, all the other parameters should be comparable before attributing a significant result to the study parameter.
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It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation.Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III-IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngoscopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded.Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P < 0.01 and P < 0.01, respectively).Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation.
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Objectives/Hypothesis The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population. Study Design Retrospective cohort study. Methods A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference. Results Twenty‐five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy ( P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation. Conclusions For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations. Level of Evidence 4 Laryngoscope , 131:1647–1651, 2021
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