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John J, Collins M, O'Flynn K, Briggs T, Gray W, McGrath J. Carbon footprint of hospital laundry: a life-cycle assessment. BMJ Open 2024; 14:e080838. [PMID: 38418230 PMCID: PMC10910404 DOI: 10.1136/bmjopen-2023-080838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/13/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES To assess greenhouse gas (GHG) emissions from a regional hospital laundry unit, and model ways in which these can be reduced. DESIGN A cradle to grave process-based attributional life-cycle assessment. SETTING A large hospital laundry unit supplying hospitals in Southwest England. POPULATION All laundry processed through the unit in 2020-21 and 2021-22 financial years. PRIMARY OUTCOME MEASURE The mean carbon footprint of processing one laundry item, expressed as in terms of the global warming potential over 100 years, as carbon dioxide equivalents (CO2e). RESULTS Average annual laundry unit GHG emissions were 2947 t CO2e. Average GHG emissions were 0.225 kg CO2e per item-use and 0.5080 kg CO2e/kg of laundry. Natural gas use contributed 75.7% of on-site GHG emissions. Boiler electrification using national grid electricity for 2020-2022 would have increased GHG emissions by 9.1%, however by 2030 this would reduce annual emissions by 31.9% based on the national grid decarbonisation trend. Per-item transport-related GHG emissions reduce substantially when heavy goods vehicles are filled at ≥50% payload capacity. Single-use laundry item alternatives cause significantly higher per-use GHG emissions, even if reusable laundry were transported long distances and incinerated at the end of its lifetime. CONCLUSIONS The laundry unit has a large carbon footprint, however the per-item GHG emissions are modest and significantly lower than using single-use alternatives. Future electrification of boilers and optimal delivery vehicle loading can reduce the GHG emissions per laundry item.
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Affiliation(s)
- Joseph John
- University of Exeter Medical School, Exeter, UK
- Getting It Right First Time Programme, NHS England, London, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Michael Collins
- Product Sustainability, Environmental Resources Management, Edinburgh, UK
| | - Kieran O'Flynn
- Getting It Right First Time Programme, NHS England, London, UK
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Tim Briggs
- Getting It Right First Time Programme, NHS England, London, UK
- Department of Surgery, Royal National Orthopaedic Hospital, London, UK
| | - William Gray
- Getting It Right First Time Programme, NHS England, London, UK
| | - John McGrath
- University of Exeter Medical School, Exeter, UK
- Getting It Right First Time Programme, NHS England, London, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
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Mowafi MM, Elbeialy MAK, Abusinna RG. Effect of magnesium sulfate on oxygenation and lung mechanics in morbidly obese patients undergoing bariatric surgery: a prospective double-blind randomized clinical trial. Korean J Anesthesiol 2023; 76:617-626. [PMID: 36539925 PMCID: PMC10718631 DOI: 10.4097/kja.22446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Respiratory mechanics are often significantly altered in morbidly obese patients and magnesium sulfate (MgSO4) is a promising agent for managing several respiratory disorders. This study aimed to examine the effects of MgSO4 infusions on arterial oxygenation and lung mechanics in patients with morbid obesity undergoing laparoscopic bariatric surgery. METHODS Forty patients with morbid obesity aged 21-60 years scheduled for laparoscopic bariatric surgery under general anesthesia were randomly allocated to either the control (normal saline infusion) or MgSO4 group (30 mg/kg lean body weight [LBW] of 10% MgSO4 in 100 ml normal saline intravenously over 30 min as a loading dose, followed by 10 mg/kg LBW/h for 90 min). The primary outcome was intraoperative arterial oxygenation (ΔPaO2/FiO2). Secondary outcomes included intraoperative static and dynamic compliance, dead space, and hemodynamic parameters. RESULTS At 90 min intraoperatively, the Δ PaO2/FiO2 ratio and the Δ dynamic lung compliance were statistically significantly higher in the MgSO4 group (mean ± SE: 16.1 ± 1.0, 95% CI [14.1, 18.1] and 8.4 ± 0.5 ml/cmH2O, 95% CI [7.4, 9.4]), respectively), and the Δ dead space (%) was statistically significantly lower in the MgSO4 group (mean ± SE: -8.0 ± 0.3%, 95% CI [-8.6, -7.4]) (P < 0.001). No significant differences in static compliance were observed. CONCLUSIONS Although MgSO4 significantly preserved arterial oxygenation and maintained dynamic lung compliance and dead space in patients with morbid obesity, the clinical relevance is minimal. This study failed to adequately reflect the clinical importance of these results.
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Affiliation(s)
- Marwa M. Mowafi
- Department of Anesthesiology, Intensive Care and Pain Management, Ain-Shams University Faculty of Medicine, Cairo, Egypt
| | - Marwa A. K. Elbeialy
- Department of Anesthesiology, Intensive Care and Pain Management, Ain-Shams University Faculty of Medicine, Cairo, Egypt
| | - Rasha Gamal Abusinna
- Department of Anesthesiology, Intensive Care and Pain Management, Ain-Shams University Faculty of Medicine, Cairo, Egypt
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Couture EJ, Carrier-Boucher A, Provencher S, Tanoubi I, Marceau S, Bussières JS. Effect of reverse Trendelenburg position and positive pressure ventilation on safe non-hypoxic apnea period in obese, a randomized-control trial. BMC Anesthesiol 2023; 23:198. [PMID: 37291541 PMCID: PMC10249289 DOI: 10.1186/s12871-023-02128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 05/07/2023] [Indexed: 06/10/2023] Open
Abstract
PURPOSE There is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP). METHODS Fifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH2O and an additional 10 cmH2O of PEEP while breathing spontaneously (RT/PPV group) according to randomization. RESULTS The SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO2) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p < 0.0001), a higher proportion of patients that reached the satisfactory FEtO2 of 0.90 (21/24, 88% vs. 13/24, 54%, p = 0.024), a higher FEtO2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p = 0.038). CONCLUSION In the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population. TRIAL REGISTRATION NCT02590406, 29/10/2015.
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Affiliation(s)
- Etienne J. Couture
- Department of Anesthesiology and Critical Care, Laval University, Quebec, Canada
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval, 2725, Chemin Sainte-Foy, Québec, QC G1V 4G5 Canada
| | - Antony Carrier-Boucher
- Department of Anesthesiology, Hôpital Sacré-Cœur, CIUSSS Nord de L’Île de Montréal, Montréal, Canada
| | - Steeve Provencher
- Department of Pneumology, Institut Universitaire de Cardiologie et de Pneumologie de Québec– Université Laval, Quebec, Canada
| | - Issam Tanoubi
- Department of Anesthesiology, Centre Intégré Universitaire de Santé Et de Services Sociaux de L’Est-de-L’Île-de-Montréal, University of Montreal Medical Simulation Center (CAAHC), Montréal, Canada
| | - Simon Marceau
- Department of Surgery, Institut Universitaire de Cardiologie , et de Pneumologie de Québec – Université Laval, Quebec, Canada
| | - Jean S. Bussières
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval, 2725, Chemin Sainte-Foy, Québec, QC G1V 4G5 Canada
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Lee S, Jang EA, Hong M, Bae HB, Kim J. Ramped versus sniffing position in the videolaryngoscopy-guided tracheal intubation of morbidly obese patients: a prospective randomized study. Korean J Anesthesiol 2023; 76:47-55. [PMID: 35912427 PMCID: PMC9902184 DOI: 10.4097/kja.22268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/30/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Ramped positioning is recommended for intubating obese patients undergoing direct laryngoscopy. However, whether the use of the ramped position can provide any benefit in videolaryngoscopy-guided intubation remains unclear. This study assessed intubation time using videolaryngoscopy in morbidly obese patients in the ramped versus sniffing positions. METHODS This is a prospective randomized study in patients with morbid obesity (n = 82; body mass index [BMI] ≥ 35 kg/m2). Patients were randomly allocated to either the ramped or the standard sniffing position groups. During the induction of general anesthesia, difficulty in mask ventilation was assessed using the Warters scale. Tracheal intubation was performed using a C-MAC® D-Blade videolaryngoscope, and intubation difficulty was assessed using the intubation difficulty scale (IDS). The primary endpoint was the total intubation time calculated as the sum of the laryngoscopy and tube insertion times. RESULTS The percentage of difficult mask ventilation (Warters scale ≥ 4) was significantly lower in the ramped (n = 40) than in the sniffing group (n = 41) (2.5% vs. 34.1%, P < 0.001). The percentage of easy intubation (IDS = 0) was significantly higher in the ramped than in the sniffing group (70.0% vs. 7.3%, P < 0.001). The total intubation time was significantly shorter in the ramped than in the sniffing group (22.5 ± 6.2 vs. 40.9 ± 9.0, P < 0.001). CONCLUSIONS Compared with the sniffing position, the ramped position reduced intubation time in morbidly obese patients and effectively facilitated both mask ventilation and tracheal intubation using videolaryngoscopy.
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Affiliation(s)
- Seongheon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Eun-A Jang
- Department of Anesthesiology and Pain Medicine, Chonnam National University School of Dentistry, Chonnam National University Hospital, Gwangju, Korea
| | - Minjae Hong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Joungmin Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea,Corresponding author: Joungmin Kim, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Chonnam National University Hospital, 160 Baekseo-ro, Dong-gu, Gwangju 61469, KoreaTel: +82-62-220-6893Fax: +82-62-232-6294
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Kang D, Bae HB, Choi YH, Bom JS, Kim J. A prospective randomized study of different height of operation table for tracheal intubation with videolaryngoscopy in ramped position. BMC Anesthesiol 2022; 22:378. [PMID: 36476332 PMCID: PMC9727988 DOI: 10.1186/s12871-022-01929-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Previous studies have reported that the ramped position provides a better laryngoscopic view, reduces tracheal intubation time, and increases the success rate of endotracheal intubation. However, the patient's head height changes while in the ramped position, which in turn changes the relative positions of the patient and intubator. Thus, making these changes may affect the efficiency of tracheal intubation; however, few studies have addressed this problem. This study analyzed intubation time and conditions during tracheal intubation using videolaryngoscope in the ramped position. METHODS This prospective study included 144 patients who were scheduled to receive general anesthesia for surgeries involving orotracheal intubation. The participants were randomly allocated to either the nipple or umbilical group according to the table height. Mask ventilation was assessed using the Warters grading scale. Tracheal intubation was performed using a McGrath MAC laryngoscope. The total intubation time, laryngoscopy time, tube insertion time, and difficulty of intubation (IDS score) were measured. RESULTS The umbilical group had a significantly shorter laryngoscopy time (10 ± 3 vs. 16 ± 4 s), tube insertion time (18 ± 4 vs. 24 ± 6 s), and total intubation time (28 ± 5 vs. 40 ± 7 s) compared to the nipple group. No significant difference in the difficulty of mask ventilation was observed between the two groups. The IDS score was higher in the nipple than umbilical group. CONCLUSION The lower (umbilical) table level reduced the intubation time and difficulty of videolaryngoscopy compared to the higher (nipple) table level. TRIAL REGISTRATION This study was registered at KCT0005987, 11/03/2021, Retrospectively registered.
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Affiliation(s)
- Dongho Kang
- grid.411602.00000 0004 0647 9534Department of Anesthesiology and Pain Medicine, Chonnam National University Hwasun Hospital, Hwasun, Chonnam, Korea
| | - Hong-Beom Bae
- grid.14005.300000 0001 0356 9399Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61469 Korea ,grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
| | - Yun Ha Choi
- grid.443803.80000 0001 0522 719XDepartment of Nursing, Honam University, Gwangju, Korea
| | - Joon-suk Bom
- grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
| | - Joungmin Kim
- grid.14005.300000 0001 0356 9399Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61469 Korea ,grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
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Effects of head-elevated position on tracheal intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway: a prospective randomized crossover study. BMC Anesthesiol 2022; 22:166. [PMID: 35637437 PMCID: PMC9150377 DOI: 10.1186/s12871-022-01706-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background The head-elevated laryngoscopy position has been described to be optimal for intubation, particularly in obese patients and those with anticipated difficult airways. Horizontal alignment of the external auditory meatus and sternal notch (AM-S) can be used as endpoints for optimal positioning. Thus, we aligned the head-elevated position with the AM-S in the horizontal plane and evaluated its effect on laryngeal visualization and ease of intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway. Methods Sixty-four patients were included in this prospective, crossover, randomized controlled trial. A cervical collar was used to restrict neck movement and mouth opening. The head-elevated position was achieved by raising the back section of the operation room table and ensuring that the end point was horizontally aligned with the AM-S (table-ramp method). The laryngeal view was randomly assessed in both head-flat and head-elevated positions based on the percentage of glottic opening (POGO) score and modified Cormack–Lehane (MCL) grade. External laryngeal manipulation was not permitted when laryngeal visualization was scored. The trachea was intubated only once (in the second position). The ease of intubation was assessed based on the need for optimization maneuvers, intubation difficulty scale (IDS) scores and time to intubation. Results The mean table-ramp angle required to achieve the horizontal alignment of AM-S was 17.5 ± 4.1°. The mean POGO score improved significantly in the head-elevated position (59.4 ± 23.8%) when compared with the head-flat position (37.5 ± 24%) (P < 0.0001). MCL grade 1 or 2a was achieved in 56 (85.9%) and 28 (43.7%) of patients in the head-elevated and head-flat positions, respectively (P < 0.0001). Optimization maneuvers for intubation were required in 7 (21.9%) and 17 (53.1%) patients in the head-elevated and head-flat positions, respectively (P < 0.0001). The IDS scores and time to intubation did not differ significantly between the two positions. Conclusion In the head-elevated position, aligning the AM-S in the horizontal plane consistently improved laryngeal visualization without worsening the view when the McGrath MAC videolaryngoscope was used in patients with simulated difficult airways. It also improved the ease of intubation, which reduced the need for optimization maneuvers. Trial registration This trial was registered with www.clinicaltrials.gov, NCT04716218, on 20/01/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01706-5.
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Dunn D. Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice. AORN J 2022; 115:423-436. [PMID: 35476194 DOI: 10.1002/aorn.13666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/15/2021] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Abstract
The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask-ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse's role as an assistant to the anesthesia professional when applying cricoid pressure.
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Seyni-Boureima R, Zhang Z, Antoine MMLK, Antoine-Frank CD. A review on the anesthetic management of obese patients undergoing surgery. BMC Anesthesiol 2022; 22:98. [PMID: 35382771 PMCID: PMC8985303 DOI: 10.1186/s12871-022-01579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/27/2022] [Indexed: 12/01/2022] Open
Abstract
There has been an observed increase in theprevalence of obesity over the past few decades. The prevalence of anesthesiology related complications is also observed more frequently in obese patients as compared to patients that are not obese. Due to the increased complications that accompany obesity, obese patients are now more often requiring surgical interventions. Therefore, it is important that anesthesiologists be aware of this development and is equipped to manage these patients effectively and appropriately. As a result, this review highlights the effective management of obese patients undergoing surgery focusing on the preoperative, perioperative and postoperative care of these patients.
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Affiliation(s)
- Rimanatou Seyni-Boureima
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Zongze Zhang
- Department of Anaesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China.
| | - Malyn M L K Antoine
- Department of Endocrinology, Zhongnan Hospital, Wuhan University, East Lake Road, 430071, Wuhan, Hubei, China
| | - Chrystal D Antoine-Frank
- Department of Anatomical Sciences, St. George's University, True Blue,Grand Anse, West Indies, St. George, Grenada
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Nikolla DA, Carlson JN, Jimenez Stuart PM, Asar I, April MD, Kaji AH, Brown C. Comparing postinduction hypoxemia between ramped and supine position endotracheal intubations with apneic oxygenation in the emergency department. Acad Emerg Med 2022; 29:317-325. [PMID: 34757633 DOI: 10.1111/acem.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ramped position and apneic oxygenation are strategies to mitigate hypoxemia; however, the benefits of these strategies when utilized together remain unclear. Therefore, we compared first-attempt, postinduction hypoxemia between adult emergency department (ED) endotracheal intubations performed with apneic oxygenation in the ramped versus supine positions. METHODS We used the National Emergency Airway Registry (NEAR), a multicenter registry of data on ED intubations from 25 academic and community sites. We included first-attempt intubations with direct (DL) and video (VL) laryngoscopy in subjects ≥ 18 years old with nontrauma indications receiving apneic oxygenation. We examined patient characteristics (e.g., sex, obesity) and key intubation outcomes, including hypoxemia (primary outcome), first-pass success, and other adverse events (e.g., bradycardia). In addition, we examined unadjusted odds ratios (OR) and adjusted ORs (aOR) for key variables and stratified by laryngoscope type. RESULTS We included 210 ramped cases and 1,820 supine cases in the DL cohort and 202 ramped and 1,626 supine cases in the VL cohort. Rates of postinduction hypoxemia were similar between supine and ramped position in both the DL cohort (supine 6.5% and ramped 7.6%, aOR [95% CI] = 0.96 [0.55 to 1.67]) and the VL cohort (supine 10.1% and ramped 12.4%, aOR [95% CI] = 0.97 [0.60 to 1.56]). Other outcomes were also similar between groups. CONCLUSION Using this large national data set, we did not identify a difference in postinduction hypoxemia between ramped and supine positions in this cohort of ED intubations with apneic oxygenation.
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Affiliation(s)
- Dhimitri A. Nikolla
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Jestin N. Carlson
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Paul M. Jimenez Stuart
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Irtaza Asar
- Department of Emergency Medicine Allegheny Health Network–Saint Vincent Erie Pennsylvania USA
| | - Michael D. April
- 40th Forward Resuscitative Surgical Detachment 627th Hospital Center Fort Carson Colorado USA
- Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda Maryland USA
| | - Amy H. Kaji
- Department of Emergency Medicine Harbor–UCLA Torrance California USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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Kim ST. Anesthetic management of obese and morbidly obese parturients. Anesth Pain Med (Seoul) 2022; 16:313-321. [PMID: 35139612 PMCID: PMC8828627 DOI: 10.17085/apm.21090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023] Open
Abstract
The prevalence of obese parturients is increasing worldwide. This review describes safe analgesic techniques for labor and anesthetic management during cesarean sections in obese parturients. The epidural analgesic technique is the best way to provide good pain relief during the labor phase and can be easily converted to a surgical anesthetic condition. However, the insertion of the epidural catheter in obese parturients is technically more difficult compared to that in non-obese parturients. The distance from the skin to the epidural space increases in proportion to the body mass index (BMI): 4.4 cm in mothers of normal weight and 7.5 cm in mothers with BMI 50 and above. Neuraxial blocks are the ideal anesthetic methods and gold standard techniques for cesarean section in pregnant women with obesity. Single-shot spinal anesthesia is the most common type of anesthesia used for cesarean sections. The advantage of single-shot spinal anesthesia is a dense-sufficient block of rapid onset. A combined spinal-epidural (CSE) anesthetic technique is also recommended as an attractive alternative method. In obese parturients, the operation time can be longer than expected, and therefore, the CSE technique provides the advantage of rapid onset and intense block for prolonged operation with postoperative pain control. The risk of postoperative complications is very high in obese parturients. Therefore, detailed communication of the parturient's medical condition and the details of surgery and anesthesia between the anesthesiologist and obstetrician is important prior to cesarean section in obese pregnant women.
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Affiliation(s)
- Sang Tae Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Chungbuk National University Hospital, Cheongju, Korea
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Singh P, Liew W, Negar A. Airway management in patients suffering from morbid obesity. Saudi J Anaesth 2022; 16:314-321. [PMID: 35898526 PMCID: PMC9311184 DOI: 10.4103/sja.sja_90_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/04/2022] Open
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Alimian M, Zaman B, Seyed Siamdoust SA, Nikoubakht N, Rounasi R. Comparison of RAMP and New Modified RAMP Positioning in Laryngoscopic View During Intubation in Patients with Morbid Obesity: A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e114508. [PMID: 34540638 PMCID: PMC8438731 DOI: 10.5812/aapm.114508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of obesity is increasing worldwide, and anesthesiologists are facing challenges in the airway management of such patients. Excessive adipose tissue influences pharyngeal spaces and affects the laryngoscopic grade. Standard ramp positioning is time-consuming and difficult to prepare, and requires expensive equipment. Objectives The aim of this study was to compare the standard ramp position with the proposed low-cost and easily accessible modified ramp position in laryngoscopic view during the intubation of patients with morbid obesity. Methods In this single-blind clinical trial, 84 patients candidate for bariatric surgery at Rasoul Akram Hospital in 2020 were assigned to the rapid airway management positioner (RAMP) (R) and new modified RAMP (MR) groups by the block randomization method. The laryngoscopic view of the glottis based on the Cormack-Lehane scale, ventilation quality, duration of intubation, intubation attempts, oxygen saturation at the end of intubation, and the need for backward, upward, rightward pressure (BURP) maneuver for successful intubation were recorded. Normal distribution tests and Mann-Whitney and Kruskal-Wallis tests were used to analyze the data. Results The results showed no significant differences between the two groups regarding ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for BURP maneuvers during intubation (P > 0.05). Conclusions The two methods are not significantly different, and the new modified ramp position can be used with more ease and availability and less cost.
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Affiliation(s)
- Mahzad Alimian
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Behrooz Zaman
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Seyed Alireza Seyed Siamdoust
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Nikoubakht
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Rounasi
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
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Wrigge H, Streibert F. [Intraoperative Ventilation in Adults]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:318-328. [PMID: 34038971 DOI: 10.1055/a-1189-8057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Avoiding postoperative pulmonary complications (PPC) is an important goal for anesthesiologists during general anesthesia, and ventilation strategies may play a role. It seems reasonable to apply knowledge from lessons we learned from ventilation of intensive care unit patients aiming at avoiding ventilator associated lung injury. Ventilation associated lung injuries occur frequently and are associated with substantial morbidity and mortality. Strategies of lung protective ventilation, like lower tidal volumes and the use of positive end-expiatory pressure (PEEP), can usually be transferred safely to perioperative ventilation, although some issues such as hemodynamic side effects must be considered. For some reasons, however, current evidence is conflicting and there is no consensus on ventilatory perioperative management to avoid PPCs so far. This paper briefly summarizes physiological backgrounds in a functional context, current evidence, and provides some recommendations at "expert" opinion level for perioperative ventilation procedures.Especially in patients at risk and/or during surgery with higher surgical trauma and inflammation, we recommend limiting tidal volume to 6 - 8 ml/kg predicted body weight and the use of PEEP, which should be individualized e.g. by minimizing driving pressure. Recruitment maneuvers may be considered and should be carried out by using the ventilator.Obese patients are an increasing entity and can be challenging during anesthesia and ventilation. From a physiological point of view, these patients require much higher ventilation pressures as currently used, although recent evidence is not in favor of using moderately higher PEEP, which is matter of discussion.
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Prevention of Oxygen Desaturation in Morbidly Obese Patients During Electroconvulsive Therapy: A Narrative Review. J ECT 2020; 36:161-167. [PMID: 32040021 DOI: 10.1097/yct.0000000000000664] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.
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Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review. J Anesth 2020; 34:924-943. [PMID: 32642840 PMCID: PMC7341705 DOI: 10.1007/s00540-020-02819-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 12/17/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.
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Hasanin A, Tarek H, Mostafa MMA, Arafa A, Safina AG, Elsherbiny MH, Hosny O, Gado AA, Almenesey T, Hamden GA, Mahmoud M, Amin S. Modified-ramped position: a new position for intubation of obese females: a randomized controlled pilot study. BMC Anesthesiol 2020; 20:151. [PMID: 32552691 PMCID: PMC7298754 DOI: 10.1186/s12871-020-01070-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 06/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization. METHODS Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view. RESULTS Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position. CONCLUSION Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position. CLINICAL TRIAL REGISTRATION Identifier: NCT03640442. Date: August 2018.
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Affiliation(s)
- Ahmed Hasanin
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt.
| | - Hager Tarek
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Maha M A Mostafa
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Amany Arafa
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | | | - Mona H Elsherbiny
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Osama Hosny
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Ahmed A Gado
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Tarek Almenesey
- Department of anesthesia and critical care medicine, Beni suef university, Beni suef, Egypt
| | - Ghada Adel Hamden
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Mohamed Mahmoud
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
| | - Sarah Amin
- Department of anesthesia and critical care medicine, Cairo university, Giza, Egypt
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Nikolla DA, Beaumont RR, Lerman JL, Datsko JS, Carlson JN. Impact of bed angle and height on intubation success during simulated endotracheal intubation in the ramped position. J Am Coll Emerg Physicians Open 2020; 1:257-262. [PMID: 33000040 PMCID: PMC7493484 DOI: 10.1002/emp2.12035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The ramped position is often used during endotracheal intubation to improve oxygenation, improve laryngeal views, and reduce airway complications. We sought to compare the impact of ramp angle and bed height on intubation outcomes during simulated endotracheal intubation. METHODS We enrolled emergency medicine residents and fourth-year medical students to perform simulated direct laryngoscopy and endotracheal intubation in random order with the mannequin in the following combinations of ramp angles and bed heights; ramp angles of 25° and 45° at bed heights including knee, mid-thigh, umbilicus, xiphoid, and nipple/intermammary fold. Our primary outcome was the reported percentage of glottic opening (POGO) score. Secondary outcomes included number of laryngoscopy attempts and intubation time. RESULTS We enrolled 25 participants. There was no difference in reported POGO scores at 25° between bed heights, but at 45°, the umbilicus bed height had an improved reported POGO score (20; 95% confidence interval [CI] 7-33, P < 0.01) relative to xyphoid. The nipple/inframammary fold height required longer intubation times in seconds (mean difference [MD] 95% CI) at 25°, (MD, 23.9 [4.6-37.6], P < 0.01) and more laryngoscopy attempts at 45° (MD, 0.48 [0.16-0.79], P < 0.01) relative to xyphoid. There was no difference in laryngoscopy attempts and video POGO between 25° and 45° at all bed heights, but reported POGO at the umbilicus position was better at 25° than 45° (12 [1-23], P = 0.03). CONCLUSION The umbilicus bed height resulted in the highest reported POGO at 45°. Nipple/inframammary fold height resulted in worse intubating conditions.
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Affiliation(s)
- Dhimitri A. Nikolla
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Ryann R. Beaumont
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Jessica L. Lerman
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Joseph S. Datsko
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Jestin N. Carlson
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
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Sinha A, Jayaraman L, Punhani D. Predictors of difficult airway in the obese are closely related to safe apnea time! J Anaesthesiol Clin Pharmacol 2020; 36:25-30. [PMID: 32174653 PMCID: PMC7047673 DOI: 10.4103/joacp.joacp_164_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/19/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. Material and Methods: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed. Results: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). Conclusion: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.
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Affiliation(s)
- Aparna Sinha
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Lakshmi Jayaraman
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Dinesh Punhani
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
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Carron M, Safaee Fakhr B, Ieppariello G, Foletto M. Perioperative care of the obese patient. Br J Surg 2020; 107:e39-e55. [DOI: 10.1002/bjs.11447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.
Methods
A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.
Results and conclusion
Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.
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Affiliation(s)
- M Carron
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - B Safaee Fakhr
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - G Ieppariello
- Department of Medicine – DIMED, Section of Anaesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - M Foletto
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padua, Padua, Italy
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20
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Taylor CR, Dominguez JE, Habib AS. Obesity And Obstetric Anesthesia: Current Insights. Local Reg Anesth 2019; 12:111-124. [PMID: 31819609 PMCID: PMC6873959 DOI: 10.2147/lra.s186530] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/18/2019] [Indexed: 12/26/2022] Open
Abstract
Obesity is a significant global health problem. It results in a higher incidence of complications for pregnant women and their neonates. Cesarean deliveries are more common in obese parturients as well. The increased burden of comorbidities seen in this population, such as obstructive sleep apnea, necessitates antepartum anesthetic consultation. These patients pose unique challenges for the practicing anesthesiologist and may benefit from optimization prior to delivery. Complications from anesthesia and overall morbidity and mortality are higher in this population. Neuraxial anesthesia can be challenging to place in the obese parturient, but is the preferred anesthetic for cesarean delivery to avoid airway manipulation, minimize aspiration risk, prevent fetal exposure to volatile anesthetic, and decrease risk of post-partum hemorrhage from volatile anesthetic exposure. Monitoring and positioning of these patients for surgery may pose specific challenges. Functional labor epidural catheters can be topped up to provide conditions suitable for surgery. In the absence of a working epidural catheter, a combined spinal epidural anesthetic is often the technique of choice due to relative ease of placement versus a single shot spinal technique as well as the ability to extend the anesthetic through the epidural portion. For cesarean delivery with a vertical supraumbilical skin incision, a two-catheter technique may be beneficial. Concern for thromboembolism necessitates early mobilization and a multimodal analgesic regimen can help accomplish this. In addition, thromboprophylaxis is recommended in this population after delivery—especially cesarean delivery. These patients also need close monitoring in the post-partum period when they are at increased risk for several complications.
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Affiliation(s)
- Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
| | - Jennifer E Dominguez
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
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21
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Myatra SN. Optimal position for laryngoscopy - Time for individualization? J Anaesthesiol Clin Pharmacol 2019; 35:289-291. [PMID: 31543573 PMCID: PMC6748012 DOI: 10.4103/joacp.joacp_254_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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22
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Semler MW, Janz DR, Casey JD, Russell DW, Rice TW. Response. Chest 2019; 152:1351. [PMID: 29223265 DOI: 10.1016/j.chest.2017.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.
| | - David R Janz
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Derek W Russell
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Scott JA, Walz JM, Heard SO. Should the Ramped Position Be "Sniffed at" in the ICU? Chest 2019; 152:693-694. [PMID: 28991539 DOI: 10.1016/j.chest.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- J Aaron Scott
- Department of Anesthesiology and Perioperative Medicine, UMass Memorial Medical Center, Worcester, MA.
| | - J Matthias Walz
- Department of Anesthesiology and Perioperative Medicine, UMass Memorial Medical Center, Worcester, MA
| | - Stephen O Heard
- Department of Anesthesiology and Perioperative Medicine, UMass Memorial Medical Center, Worcester, MA
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Evans S, McCahon R. Management of the airway in maxillofacial surgery: part 2. Br J Oral Maxillofac Surg 2018; 56:469-474. [DOI: 10.1016/j.bjoms.2018.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/28/2018] [Indexed: 12/20/2022]
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Sanaie S, Bilejani I, Mortazavi M, Mahmoodpoor A, Negargar S, Faramarzi E, Hazhir N, Golalizadeh Bibalan Q, Soleimanpour H. Effect of Manual Caudal and Downward Displacement of Lower Cervical Adipose Tissue on Laryngoscopic Grade of Patients with Morbid Obesity. Anesth Pain Med 2018; 8:e63061. [PMID: 29868457 PMCID: PMC5970290 DOI: 10.5812/aapm.63061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/29/2018] [Accepted: 02/05/2018] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of obesity has substantially increased all over the world in the past decades and anesthesiologists more commonly encounter these patients. Excess cervical adipose tissues can result in the narrowing of the pharyngeal opening and affect laryngoscopic grade. Objectives To evaluate the effect of manual caudal and cervical displacement of cervical adipose tissue on laryngoscopic view of morbid obese patients. Methods A total of 70 patients with a BMI ≥ 35 were enrolled in this study. All patients were placed in the ramp position. Manual caudal and downward displacement of cervical adipose tissue was performed by an anesthesiologist. Laryngoscopy was performed by an anesthesiologist before and after manual displacement. The anesthesiologist was blinded as we had drawn a curtain, therefore, he could not recognize if the maneuver was being performed or not. Thyromental distance, upper lip bite test, hyomental distance, and BMI were recorded for all patients. Results Age, weight, and BMI didn't have any significant relation with difficult intubation. There was a significant relationship between difficult intubation and thyromental distance, upper lip bite test, Mallampati score, and hyomentaldistance (P: 0.01, 0.04, 0.001, and 0.005, respectively). Cormack-Lehane grade significantly improved after the maneuver (P: 0.001). Conclusions Preparation and appropriate management of airway is very important for morbid obese patients. Manual caudal and downward displacement of adipose tissue has a significant effect on the improvement of laryngoscopic view in morbid obese patients. Therefore, ramped position or manual and caudal displacement of chest wall fat tissue can be added to "standard" preoperative airway assessment.
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Affiliation(s)
- Sarvin Sanaie
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Issa Bilejani
- Anesthesiology Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ata Mahmoodpoor
- Anesthesiology Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sohrab Negargar
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elnaz Faramarzi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazanin Hazhir
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Hassan Soleimanpour, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-9141164134, Fax: +98-4133352078, E-mail:
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26
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Ezri T, Waintrob R, Avelansky Y, Izakson A, Dayan K, Shimonov M. Pre-selection of primary intubation technique is associated with a low incidence of difficult intubation in patients with a BMI of 35 kg/m 2 or higher. Rom J Anaesth Intensive Care 2018; 25:25-30. [PMID: 29756059 DOI: 10.21454/rjaic.7518.251.ezr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background The incidence of difficult intubation (DI) in obese patients may reach a two-digit figure. No studies have assessed the effect of primary use of special intubation devices on lowering the incidence of DI. We assessed the effect of primary selection of special intubation techniques on the incidence of DI in patients with a BMI of 35 kg/m2 or higher. Patients and methods Data from 546 patients with a BMI of 35 kg/m2 or higher who underwent bariatric surgery at Wolfson Medical Center from 2010 through 2014 was retrospectively extracted and analyzed for demographics, predictors of DI and intubation techniques employed. Difficult intubation was defined as the presence of at least one of the followings: laryngoscopy grade 3 or 4, need for >1 laryngoscopy or intubation attempt, need for changing the blade size, failed direct laryngoscopy (DL), difficult or failed videolaryngoscopy (VL-Glidescope), difficult or failed awake fiberoptic intubation (AFOI) and using VL or awake AFOI as rescue airway techniques. Primary intubation techniques were direct DL, VL and AFOI. We correlated the predictors of DI with the actual incidence of DI and with the choice of intubation technique employed. Results The overall incidence of DI was 1.6% (1.5% with DL vs. 2.2 with VL + AFOI, p = 0.61). With logistic regression analysis, age was the only significant predictor of DI. Predictors of DI that affected the selection of VL or AFOI as primary intubation tools were Mallampati class 3 or 4, limited neck movement, age, male gender, body mass index and obstructive sleep apnea syndrome. Conclusion The lower incidence of DI in our study group may stem from the primary use of special intubation devices, based on the presence of predictors of DI.
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Affiliation(s)
- Tiberiu Ezri
- Department of Anesthesia, Wolfson Medical Center, Holon, affiliated to Sackler Medical School, Tel Aviv University, Israel
| | - Ronen Waintrob
- Department of Anesthesia, Poriya Medical Center, Tiberias, Israel
| | - Yuri Avelansky
- Department of Anesthesia, Wolfson Medical Center, Holon, affiliated to Sackler Medical School, Tel Aviv University, Israel
| | - Alexander Izakson
- Ziv Medical Center, Safed, Israel, Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Katia Dayan
- Department of Surgery B, Wolfson Medical Center, Holon, affiliated to Sackler Medical School, Tel Aviv University, Israel
| | - Mordechai Shimonov
- Department of Surgery A, Wolfson Medical Center, Holon, affiliated to Sackler Medical School, Tel Aviv University, Israel
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Sinha A, Jayaraman L, Punhani D. Scale-Ampule Assembly to Assess Ramp Position for Airway Management. Anesth Analg 2018; 124:2087. [PMID: 28430690 DOI: 10.1213/ane.0000000000002119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Aparna Sinha
- Anesthesia and Perioperative Division, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India,
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Zaidi N. Man behind the laryngoscopy is important. J Perioper Pract 2018; 27:49-53. [PMID: 29328743 DOI: 10.1177/175045891702700303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 06/10/2016] [Indexed: 11/16/2022]
Abstract
Tracheal intubation is the most fundamental and effective resuscitation skill in many emergency situations. It is also performed to facilitate various surgical procedures and mechanical ventilation in critically ill patients. Tracheal intubation is also one of the most commonly taught clinical skills.
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Dhar M, Karim HMR, Rajaram N, Prakash A, Sahoo SK, Narayan A. A randomised comparative study on customised versus fixed sized pillow for tracheal intubation in the sniffing position by Macintosh laryngoscopy. Indian J Anaesth 2018; 62:344-349. [PMID: 29910491 PMCID: PMC5971622 DOI: 10.4103/ija.ija_672_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background and Aims: The sniffing position has been most commonly used for positioning of the head and neck to facilitate tracheal intubation. However, the optimum degree of head elevation for the optimal laryngeal view is not well studied, especially in non-Western countries. The present study was aimed to compare the use of a fixed height pillow versus a customised pillow (CP) height for head elevation, in terms of glottis visualisation and time required for tracheal intubation. Methods: With research and ethics committee approval from the institute, this randomised study was conducted among patients of both sexes aged 16 years or more and American Society of Anesthesiologists physical Status I to IV. A total of 134 patients were randomly allocated into routinely used fixed-sized pillow (FP) and CP group (to achieve horizontal alignment of external auditory meatus [EAM] and sternal notch). Primary and secondary outcomes were Cormack–Lehane (C–L) grade of glottic visualisation and time required for tracheal intubation, respectively. They were compared using unpaired t-test and Fisher's exact test as applicable; P < 0.05 was considered statistically significant. Results: One hundred and nineteen patients completed the study. Both groups were similar in terms of demographic and external airway measurements. The mean ± standard deviation height of pillow required in Group CP was 6.26 ± 0.97 cm. Group FP had C–L Grade 3 view more often than Group CP (28.33% vs. 13.56%). In patients with modified Mallampati (MMP) Grade ≥3, the C–L grades and time required for intubation were both significantly lower in group CP. The time required for tracheal intubation was significantly lower in group CP (P = 0.04), even though the C–L grades were similar. Conclusion: Customising pillow for head elevation to horizontally align the EAM and the sternal notch gives better glottic visualisation and intubating conditions in patients with higher MMP grades.
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Affiliation(s)
- Mridul Dhar
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
| | - Habib Md Reazaul Karim
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India.,Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Narayanan Rajaram
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
| | - Avinash Prakash
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
| | - Sarasa K Sahoo
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
| | - Anilkumar Narayan
- Department of Anaesthesiology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
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Successful Anesthetic Management of Morbidly Obese Patients During Electroconvulsive Therapy With the ProSeal Laryngeal Mask Airway in a Head-up Position: A Report of 2 Cases. J ECT 2017; 33:e30-e31. [PMID: 28445183 DOI: 10.1097/yct.0000000000000415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Intern Emerg Med 2017; 12:513-518. [PMID: 27300036 DOI: 10.1007/s11739-016-1481-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.
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Affiliation(s)
- Joseph S Turner
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA.
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Enola R Okonkwo
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
- Carolinas Medical Center Emergency Medicine Residency, Medical Education Bldg., Third Floor 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Tyler M Stepsis
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Andrew C Stevens
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Christopher S Eddy
- Department of Anesthesia, Indiana University School of Medicine, Fesler Hall Room 204, 1130 West Michigan Street, Indianapolis, IN, 46202-5115, USA
| | - Erik G Sembroski
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
- Southern Illinois University Emergency Medicine Residency, 801 North Rutledge, PO Box 19638, Springfield, IL, 62794-9638, USA
| | - Anthony J Perkins
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
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Semler MW, Janz DR, Russell DW, Casey JD, Lentz RJ, Zouk AN, deBoisblanc BP, Santanilla JI, Khan YA, Joffe AM, Stigler WS, Rice TW. A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults. Chest 2017; 152:712-722. [PMID: 28487139 DOI: 10.1016/j.chest.2017.03.061] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/09/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. METHODS Multicenter, randomized trial comparing the ramped position (head of the bed elevated to 25°) with the sniffing position (torso supine, neck flexed, and head extended) among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four ICUs between July 22, 2015, and July 19, 2016. The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after intubation. Secondary outcomes included Cormack-Lehane grade of glottic view, difficulty of intubation, and number of laryngoscopy attempts. RESULTS The median lowest arterial oxygen saturation was 93% (interquartile range [IQR], 84%-99%) with the ramped position vs 92% (IQR, 79%-98%) with the sniffing position (P = .27). The ramped position appeared to increase the incidence of grade III or IV view (25.4% vs 11.5%, P = .01), increase the incidence of difficult intubation (12.3% vs 4.6%, P = .04), and decrease the rate of intubation on the first attempt (76.2% vs 85.4%, P = .02), respectively. CONCLUSIONS In this multicenter trial, the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position. The ramped position may worsen glottic view and increase the number of laryngoscopy attempts required for successful intubation. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - David R Janz
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Derek W Russell
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aline N Zouk
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Bennett P deBoisblanc
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Jairo I Santanilla
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA; Department of Pulmonary/Critical Care, Ochsner Health System, New Orleans, LA
| | - Yasin A Khan
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - William S Stigler
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Gudivada KK, Jonnavithula N, Pasupuleti SL, Apparasu CP, Ayya SS, Ramachandran G. Comparison of ease of intubation in sniffing position and further neck flexion. J Anaesthesiol Clin Pharmacol 2017; 33:342-347. [PMID: 29109633 PMCID: PMC5672506 DOI: 10.4103/joacp.joacp_100_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: Optimization of patient's head and neck position for the best laryngeal view is the most important step before laryngoscopy and intubation. The objective of this prospective crossover study was to determine the differences, if any, between the gold standard sniffing position (SP) and the further head elevation (HE) (neck flexion) with regard to the incidence of difficult laryngoscopy, intubation difficulty, and variables of the I ntubation Difficulty Scale (IDS) in adult patients undergoing elective surgery under general anesthesia. Material and Methods: In the “SP” the neck must be flexed on the chest by elevating the head with a cushion under the occiput and extending the head at the atlanto-occipital joint. Our study was carried out to evaluate the glottic view in SP compared to further HE by 1.5 inches during direct laryngoscopy in elective surgeries. Patients were randomly assigned to either Group A (“SP” during first laryngoscopy and “HE” during second laryngoscopy) or vice versa in Group B. The effect of patient position on ease of intubation was assessed using a quantitative scale - The intubation difficulty scale (IDS). Results: There were significant differences with regard to glottic visualization (P = 0.00), number of operators (P = 0.001), laryngeal pressure (P = 0.00), and lifting force (P = 0.00) required for intubation and IDS (P = 0.00), thus favoring further HE position. Conclusion: We conclude that the HE position is superior to standard SP with regard to ease of intubation as assessed by IDS.
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Affiliation(s)
- Kiran Kumar Gudivada
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
| | - Nirmala Jonnavithula
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
| | - Sai Lakshman Pasupuleti
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
| | - Chaitanya Prathyusha Apparasu
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
| | - Syama Sundar Ayya
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
| | - Gopinath Ramachandran
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Telangana, India
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The Bariatric Airway. Int Anesthesiol Clin 2016; 55:65-85. [PMID: 27941367 DOI: 10.1097/aia.0000000000000133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Reddy RM, Adke M, Patil P, Kosheleva I, Ridley S. Comparison of glottic views and intubation times in the supine and 25 degree back-up positions. BMC Anesthesiol 2016; 16:113. [PMID: 27852241 PMCID: PMC5112746 DOI: 10.1186/s12871-016-0280-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 10/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We explored whether positioning patients in a 25° back-up sniffing position improved glottic views and ease of intubation. METHODS In the first part of the study, patients were intubated in the standard supine sniffing position. In the second part, the back of the operating table was raised 25° from the horizontal by flexion of the torso at the hips while maintaining the sniffing position. The best view obtained during laryngoscopy was assessed using the Cormack and Lehane classification and Percentage of Glottic Opening (POGO) score. The number of attempts at both laryngoscopy and tracheal intubation, together with the use of ancillary equipment and manoeuvres were recorded. The ease of intubation was indirectly assessed by recording the time interval between beginning of laryngoscopy and insertion of the tracheal tube. RESULTS Seven hundred eighty one unselected surgical patients scheduled for non-emergency surgery were included. In the back-up position, ancillary laryngeal manoeuvres, which included cricoid pressure, backwards upwards rightward pressure and external laryngeal manipulation, were required less frequently (19.6 % versus 24.6 %, p = 0.004). The time from beginning of laryngoscopy to insertion of the tracheal tube was 14 % shorter (median time 24 versus 28 s, p = 0.031) in the back-up position. There was no significant difference in glottic views. CONCLUSIONS The 25° back-up position improved the ease of intubation as judged by the need for fewer ancillary manoeuvres and shorter time for intubation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02934347 registered retrospectively on 14th Oct 2016.
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Affiliation(s)
- Raj M Reddy
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Sarn Lane, Rhyl, LL18 5UJ, UK.
| | - Manish Adke
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Sarn Lane, Rhyl, LL18 5UJ, UK
| | - Pranava Patil
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Sarn Lane, Rhyl, LL18 5UJ, UK
| | - Irina Kosheleva
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Sarn Lane, Rhyl, LL18 5UJ, UK
| | - Saxon Ridley
- Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Sarn Lane, Rhyl, LL18 5UJ, UK
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Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115:827-48. [PMID: 26556848 PMCID: PMC4650961 DOI: 10.1093/bja/aev371] [Citation(s) in RCA: 1178] [Impact Index Per Article: 130.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
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Affiliation(s)
- C Frerk
- Department of Anaesthesia, Northampton General Hospital, Billing Road, Northampton NN1 5BD, UK
| | - V S Mitchell
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Crewe Road South, Edinburgh EH4 2XU, UK
| | - C Mendonca
- Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health, West Smithfield, London EC1A 7BE, UK
| | - A Patel
- Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London WC1X 8DA, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, PO Box 580, James's Street, Dublin 8, Ireland
| | - N M Woodall
- Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
| | - I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
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Akihisa Y, Hoshijima H, Maruyama K, Koyama Y, Andoh T. Effects of sniffing position for tracheal intubation: a meta-analysis of randomized controlled trials. Am J Emerg Med 2015; 33:1606-11. [DOI: 10.1016/j.ajem.2015.06.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 06/20/2015] [Indexed: 10/23/2022] Open
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Hodgson LE, Murphy PB, Hart N. Respiratory management of the obese patient undergoing surgery. J Thorac Dis 2015; 7:943-52. [PMID: 26101653 DOI: 10.3978/j.issn.2072-1439.2015.03.08] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/30/2015] [Indexed: 01/05/2023]
Abstract
As a reflection of the increasing global incidence of obesity, there has been a corresponding rise in the proportion of obese patients undergoing major surgery. This review reports the physiological effect of these changes in body composition on the respiratory system and discusses the clinical approach required to maximize safety and minimize the risk to the patient. The changes in respiratory system compliance and lung volumes, which can adversely affect pulmonary gas exchange, combined with upper airways obstruction and sleep-disordered breathing need to be considered carefully in the peri-operative period. Indeed, these challenges in the obese patient have led to a clear focus on the clinical management strategy and development of peri-operative pathways, including pre-operative risk assessment, patient positioning at induction and under anesthesia, modified approach to intraoperative ventilation and the peri-operative use of non-invasive ventilation (NIV) and continuous positive airways pressure.
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Affiliation(s)
- Luke E Hodgson
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Patrick B Murphy
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Hart
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Lee JH, Jung HC, Shim JH, Lee C. Comparison of the rate of successful endotracheal intubation between the "sniffing" and "ramped" positions in patients with an expected difficult intubation: a prospective randomized study. Korean J Anesthesiol 2015; 68:116-21. [PMID: 25844128 PMCID: PMC4384397 DOI: 10.4097/kjae.2015.68.2.116] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/10/2014] [Accepted: 12/10/2014] [Indexed: 02/08/2023] Open
Abstract
Background Optimal head and neck positioning and clinical experience are important factors for successful endotracheal intubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotracheal intubation between the sniffing and ramped positions in patients with an expected difficult intubation. Methods The study included 204 patients with an expected difficult intubation (airway difficulty score ≥ 8) based on the preoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffing position, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successful endotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position when the operating table was placed at two different heights. Results Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P < 0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operating table; but, it was not different within each group. Laryngeal view was not different between the two groups and within each group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologists achieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05) but not in group S. Conclusions Ramped position and clinical experience can be important factors for laryngeal view and success rate of endotracheal intubation in patients with an expected difficult intubation.
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Affiliation(s)
- Ju-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Hoe-Chang Jung
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Ji-Hoon Shim
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Iksan, Korea
| | - Cheol Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Iksan, Korea
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Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119-38. [PMID: 24132408 PMCID: PMC3825645 DOI: 10.1007/s12630-013-0020-x] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/13/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.
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Affiliation(s)
- J Adam Law
- Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada,
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Airway management and oxygenation in obese patients. Can J Anaesth 2013; 60:929-45. [DOI: 10.1007/s12630-013-9991-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/17/2013] [Indexed: 12/17/2022] Open
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BAHAMMAM AHMEDS, AL-JAWDER SUHAILAE. Managing acute respiratory decompensation in the morbidly obese. Respirology 2012; 17:759-71. [DOI: 10.1111/j.1440-1843.2011.02099.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Airway tube exchanger techniques in morbidly obese patients. Anesthesiol Res Pract 2012; 2012:968642. [PMID: 22400023 PMCID: PMC3287032 DOI: 10.1155/2012/968642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/27/2011] [Accepted: 11/07/2011] [Indexed: 11/27/2022] Open
Abstract
Morbidly obese patients may present a challenge during airway management. When airway tube exchange is required, it can even be more challenging than the primary intubation. With the increasing prevalence of morbid obesity over the years, there will be increasing numbers of these patients presenting for surgical procedures, including ones that require endotracheal tube exchanges. It is therefore important for anesthesiologists to be familiar with options and limitations of the airway tube exchanger techniques.
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Lebowitz PW, Shay H, Straker T, Rubin D, Bodner S. Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals. J Clin Anesth 2012; 24:104-8. [PMID: 22301204 DOI: 10.1016/j.jclinane.2011.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 06/20/2011] [Accepted: 06/28/2011] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE To determine whether shoulder and head elevation, such that the patient's ear lies at or higher than the sternum ("ramp"), improves laryngoscopic grade in adult patients of various body mass index (BMI) values. DESIGN Prospective, unblinded study, with patients and laryngoscopists acting as their own controls. SETTING Operating room of a university-affiliated hospital. PATIENTS 189 adult ASA physical status 1, 2, and 3 patients. INTERVENTIONS After performing a standard preoperative airway evaluation and inducing general anesthesia, the anesthetist performed and graded two laryngoscopies: one in the "ramp" position and one in the "sniff" position. MEASUREMENTS Patient BMI, Mallampati airway class, thyromental distance, neck circumference, cervical extension ability, Cormack and Lehane laryngoscopic grade for each laryngoscopy, subjective lifting force required, and need for external laryngeal pressure were recorded. MAIN RESULTS Use of the "ramp" provided significantly better or equal laryngoscopic views, relative to those with the "sniff" position, in the entire study population. CONCLUSIONS Shoulder and head elevation by any means that brings the patient's sternum onto the horizontal plane of the external auditory meatus maintains or improves laryngoscopic view significantly.
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Affiliation(s)
- Philip W Lebowitz
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY 10467, USA.
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Thangaswamy CR, Elakkumanan LB. Ramp position for intubating morbidly obese parturient: What's new? Indian J Anaesth 2011; 55:206-7. [PMID: 21712889 PMCID: PMC3106406 DOI: 10.4103/0019-5049.79881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Chitra Rajeswari Thangaswamy
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Abstract
Obstructive sleep apnea is the most prevalent breathing disturbance in sleep. It is linked to a host of preexisting medical conditions, and associated with poorer postoperative outcomes. Screening and vigilance during the preoperative assessment identifies patients at high risk of obstructive sleep apnea. Further diagnostic tests may be performed, and plans can be made for tailored intraoperative care. The STOP and the STOP-Bang questionnaires are useful screening tools. Patients with a known diagnosis of obstructive sleep apnea should be seen in the preoperative clinic, where risk stratification and optimization may be done before surgery. This review article presents functional algorithms for the perioperative management of obstructive sleep apnea based on limited clinical evidence, and a collation of expert knowledge and practices. These recommendations may be used to assist the anesthesiologist in decision-making when managing the patient with obstructive sleep apnea.
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Affiliation(s)
- Edwin Seet
- Department of Anesthesia, Alexandra Health Private Limited, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore
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