Training resident anesthesiologists in adult challenging intubation comparing Truview EVO2 and Macintosh laryngoscope: a preliminary study

AIM

Teaching airway management continues to be of high importance to the anesthesiologist, since the care of each individual patient depends on the expertise, training and knowledge of the anesthetist with different airway devices, techniques and algorithms. The aim of our study was to compare intubation performed by resident anesthesiologists in training, under senior supervision, using Truview EVO2 (Group 1) or Macintosh blade (Group 2) in a group of adult patients undergoing elective surgery.

METHODS

This was a pilot prospective study. Thirty patients who were scheduled for surgery under general anesthesia were randomized into two groups. In Group 1, intubation was performed by using the Truview EVO2, and in Group 2 intubation was performed by using the Macintosh blade. Mallampati score, thyromental distance and neck mobility were recorded for each patient. The exclusion criteria included a Mallampati score =or<2 and a Patil distance >6 cm. The time of intubation and any occurrence of complications were recorded.

RESULTS

Intubation was always successful on the first attempt in Group 1, while it failed for 46.7% of patients in Group 2 (P=0.006). The time of intubation was not different between the two groups. No complications were recorded for Group 1 (Truview), while seven were reported in Group 2 (Macintosh) (P=0.003).

CONCLUSIONS

The resident managed to intubate all patients on the first attempt with the Truview, which led to a lower incidence of complications. Despite the exiguity of the population in the study, Truview EVO2 and other videolaryngoscopes can be considered to be useful tools in training resident anesthesiologists in elective intubation.

Platypnea-orthodeoxia syndrome in interatrial right to left shunt postpneumonectomy

Platypnea-orthodeoxia is a syndrome characterized by dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia), and by the absence or reduction of symptoms and of hypoxemia in a supine position. We describe the case of a 64-year-old patient who had developed an acute respiratory insufficiency due to right-to-left shunt in a patent foramen ovale one month after right intrapericardiac pneumonectomy. The patient was initially treated unsuccessfully with bronchodilators, corticosteroids and oxygen therapy. He was then admitted to the ICU due to severe refractory hypoxemia. Diagnosis of platypnea-orthodeoxia syndrome was demonstrated by O2 saturation and arterial blood gas analysis in the supine and upright positions. The presence of a right-to-left interatrial shunt through a patent foramen ovale was documented by transesophageal echocardiography 24 h after admission to intensive care. The next day, the patient underwent a percutaneous occlusion procedure with an Amplatzer device after consultation with surgeons and cardiologists. The patient was dismissed from the ICU after 24 hours of monitoring, and successfully discharged to home after one week.

Prolonged independent lung respiratory treatment after single lung transplantation in pulmonary emphysema

Single lung transplantation (SLT) is now successfully used in patients with severe emphysema. Mechanical imbalance between the native emphysematous and the healthy transplanted lung can be easily managed, unless severe graft failure occurs, leading to acute respiratory failure. Emergency retransplantation has been used in this setting, since the conventional approach to adult respiratory distress syndrome (ARDS) (mechanical ventilation and positive end-expiratory pressure [PEEP]) fails, due to the mechanical discrepancy between the two lungs. We describe two cases of severe graft failure following SLT in emphysema patients that were successfully treated with prolonged independent respiratory treatment. Mechanical ventilation and PEEP were applied to the failing transplanted lung while the native emphysematous lung was maintained on spontaneous breathing to avoid hyperexpansion and barotrauma. The independent lung respiratory treatment lasted 35 and 25 days, respectively: to our knowledge, these are among the longest-lasting independent respiratory treatments reported. The management was simplified by the early use of a double-lumen tracheostomy cannula as an alternative to orotracheal double lumen tube.

Surveillance and treatment of liver transplant recipients for candidiasis and aspergillosis

Between June 1988 and May 1991 88 orthotopic liver transplants and 1 liver and pancreas transplant were performed at the Liver Transplantation Department of the Ospedale Maggiore of Milan. All the patients underwent mycological surveillance and received antifungal prophylaxis with oral amphotericin B (6000 mg/day) or oral or intravenous fluconazole (200 mg/day) from the time of their transplant. The incidence of Candida colonization was 67%. Fluconazole was superior to oral amphotericin B in the treatment of C. albicans colonization (9/9 vs 6/15), but less effective in the treatment of colonization by other Candida spp. (0/3 vs 3/3). Deep-seated candidiasis developed in 5 patients, caused by C. albicans in 4 cases and C. krusei in 1. C. albicans infection resolved rapidly with fluconazole in 2 subjects, with intravenous amphotericin B alone in 1, and with amphotericin B plus flucytosine in the other. On the contrary, C. krusei infection did not respond to treatment with amphotericin B combined with flucytosine. Aspergillosis was diagnosed in 11 patients, of whom 4 died from invasive aspergillosis, despite 15 and 26 days of amphotericin B treatment in 2. In another patient invasive aspergillosis, diagnosed a few hours before retransplantation, improved with liposomal amphotericin B, but this man died from cytomegalovirus infection one month later. Aspergillosis was eradicated by itraconazole in 4 other patients and by topical amphotericin B in 2 whose infection was localized to surgical wound.

Combined use of mask CPAP and minitracheotomy as an alternative to endotracheal intubation. Preliminary observation

We describe the combined use of mask CPAP (continuous positive airway pressure) and minitracheotomy as an alternative to conventional endotracheal intubation in 3 patients requiring CPAP, secretion removal and diagnostic procedures such as bronchoalveolar lavage and bronchial cultures. These requirements were fulfilled with the combined technique approach, thus preserving glottic function and avoiding the disadvantages of endotracheal intubation of tracheotomy. This approach seems particularly suitable in the treatment of immunocompromised patients because of its reduced invasiveness.

[Experiences in long-distance medical transport of high risk patients]

The Authors report their experience about the problem concerning sanitary transport programmed and of urgency either in Italy either abroad. They list the problem concerning this type of activity: transport's criteria, choice of the means of transport, medical assistance and technical suitable apparatus. In this paper the Authors refer the casuistry in the years 1978-1979: 111 sanitary transports, half by sanitary aeroplane in patients with high risk pathology, both in Italy and abroad. Authors' conclusions are that never they had a worsening in the clinical conditions of the patient during the transport; on the contrary, an earlier transport always allowed an anticipation of qualified and suitable treatment.