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VOLUME 10 • NUMBER 1
ANESTHESIA ABSTRACTS PROVIDING THE CLINICAL ANESTHETIST WITH UP-TO-DATE RESOURCES FOR EVIDENCE BASED PRACTICE.
Table of Contents Airway EDITOR Michael A. Fiedler, PhD, CRNA CONTRIBUTING EDITORS Mary A. Golinski, PhD, CRNA Dennis Spence, PhD, CRNA Steven R. Wooden, DNP, CRNA, NSPM-C ASSISTANT EDITOR Jessica Floyd, BS
First-attempt intubation success of video laryngoscopy in patients with anticipated difficult direct laryngoscopy: a multicenter randomized controlled trial comparing the C-MAC D-Blade versus the GlideScope in a mixed provider and diverse patient population
..........................................................................................................3 Early endotracheal tube insertion with the Glidescope: a randomized controlled trial ..............................................................6
Obstetric Anesthesia Randomized trial of labor induction in women 35 years of age or older ..................................................................................................8
Patient Safety Capnographic monitoring in routine EGD and colonoscopy with moderate sedation: a prospective, randomized, controlled trial .....11
Quality Improvement Evaluation of perioperative medication errors and adverse drug events ..............................................................................................15
Regional Anesthesia A smartphone-based decision support tool improves test performance concerning application of the guidelines for managing regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy ......................................................................19
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None of the editors or contributors have any real or potential conflicts of interest to disclose. Indicates Continuing Education Credit is available for this abstract and comment during the CE approval period. Continuing Education Credit is available to individual subscribers on the Anesthesia Abstracts web site at http:// www.anesthesiaabstracts.com/ceMenu.php.
New health information becomes available constantly. While we strive to provide accurate information, factual and typographical errors may occur. The authors, editors, publisher, and Lifelong Learning, LLC is/are not responsible for any errors or omissions in the information presented. We endeavor to provide accurate information helpful in your clinical practice. Remember, though, that there is a lot of information out there and we are only presenting some of it here. Also, the comments of contributors represent their personal views, colored by their knowledge, understanding, experience, and judgment which may differ from yours. Their comments are written without knowing details of the clinical situation in which you may apply the information. In the end, your clinical decisions should be based upon your best judgment for each specific patient situation. We do not accept responsibility for clinical decisions or outcomes.
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Airway F IRST - ATTEMPT
INTUBATION SUCCESS OF VIDEO LARYNGOSCOPY IN PATIENTS WITH ANTICIPATED DIFFICULT DIRECT LARYNGOSCOPY : A MULTICENTER RANDOMIZED CONTROLLED TRIAL COMPARING THE C-MAC D-B LADE VERSUS THE G LIDE S COPE IN A MIXED PROVIDER AND DIVERSE PATIENT POPULATION
Anesth Analg 2016;122:740-50 Aziz MF, Abrons RO, Cattano D, Bayman EO, Swanson DE, Hagberg CA, Todd MM, Brambrink AM Abstract
Patients were randomized to have intubation
Purpose The purpose of this study was to
performed with either the C-MAC D-Blade or
determine if the rate of first-attempt intubation
GlideScope no. 4 blade. Inclusion criteria were:
success was similar when using the C-MAC D-Blade
• Mallampati class III or IV • mouth opening 40 cm males & >38 cm females)
vs. the GlideScope in patients with anticipated difficult airways. Background
Video laryngoscopy is considered
Exclusion criteria were: • • • • •
by many the go-to device for anticipated or unanticipated difficult airways. The GlideScope (Verathon, Bothell, WA), has been on the market the longest; however, a new indirect video laryngoscopy device called the C-MAC D-Blade (Karl Storz. Tuttlingen, Germany) has recently come on the market. Currently it is unknown if similar success is found with both devices in anticipated difficult airways. Methodology This was a multi-center, randomized controlled trial designed to compare first-intubation success with the C-MAC video laryngoscope and DBlade to the GlideScope video laryngoscope with a number 4 blade in patients with an anticipated difficult airway. The study took place in three academic centers in different states. The investigators hypothesized that in this population that the C-MAC D-Blade first-attempt intubation success would be noninferior (not unacceptably less successful) to the GlideScope no. 4 blade.
history of easy intubation history of failed intubation history of failed mask ventilation unstable c-spine mouth opening < 2 cm
Anesthesia providers who participated were educated on both devices in a simulation center and were required to have video laryngoscopy experience and at least 6 months of clinical anesthesia training. Anesthetic induction agent was at the discretion of the anesthesia provider but included the administration of either succinylcholine or rocuronium. Intubation was attempted after resolution of fasiculations or after 90 seconds with succinylcholine or when the train-of-four measured at the ulnar nerve receded to 1 to 2 twitches when rocuronium was administered. The GlideScope stylet was used for all intubations and endotracheal tube size was at the discretion of the anesthesia provider. The primary outcome was first-attempt intubation success, defined as confirmation of persistent endtidal carbon dioxide with a single blade insertion and
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without blade manipulation of the laryngoscope by
First-attempt intubation success in the GlideScope
another provider. Laryngeal manipulation could be
group was 96.2%. First-attempt intubation success in
performed. Other outcomes included time to
the C-MAC D-Blade group was 93.4%. Since the
intubation, best laryngeal view obtained, and
upper 90.4% confidence interval difference between
complications. The investigators assumed any
the two devices was 4.8%, the C-MAC D-Blade was
difference of 40 cm, and 1.2% had a mouth
bronchoscope, and 1 with another type of video
opening 5 prior uses of the study device
96.1%
93.8%
4.68%
First-attempt success for patients with multiple predictors
95.6%
94.2%
4.16%
First-attempt success within 90 s while SpO2 >95%
94.3%
90.5%
6.52%
Success rate for multiple attempts
98.4%
98.3%
1.32%*
47
47
P = NS
72.1% 26.5% 1.5% 0.4%
88% 7.5% 1.5% 1.8%
First-attempt time to intubation (seconds) Best Laryngeal View Grade 1 Grade 2 Grade 3 Grade 4
P < 0.0001
Note: Significant differences were found in the grade view, favoring the MAC-C (P < 0.0001). No significant differences in time to intubation were found. *Noninferior. CI = confidence interval. ANESTHESIA ABSTRACTS IS A PUBLICATION OF LIFELONG LEARNING, LLC © COPYRIGHT 2016
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No differences were found in the first-attempt time to
The views expressed in this article are those of the author
intubation (Table 1). The glottic view was significantly
and do not reflect official policy or position of the
better in the C-MAC D-Blade group (Table 1).
Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or
Complications such as lip injury, SpO2 500 mL for vaginal delivery and >1,000 mL for cesarean delivery, and need for blood transfusion were recorded. Investigators hypothesized elective induction of labor would reduce the rate of cesarean delivery by 9% when compared to expectant management. Result
There were 305 women in the induction
group and 314 in the expectant management group. No significant differences were found in baseline characteristics between the two groups. Average age was 37 years (range 35-45), BMI was 27 kg/m2. In the induction group 87% of women completed the study in their assigned
Conclusion
Induction of labor at 39 weeks of
gestation did not decrease the rate of cesarean delivery, assisted vaginal delivery, or adverse maternal or neonatal outcomes compared to expectant management. Comment Some of you are probably wondering why I chose to review an obstetric article that has nothing directly to do with anesthesia. I think it is important that obstetric anesthesia providers keep up with the current literature in obstetrics, not just obstetric
Figure 1. Cesarean Delivery Rates
group compared to 95% of women in the expectant management group. The frequency of cesarean delivery was similar in the induction and expectant management groups (32% vs. 33%). Rates of cesarean delivery increased as the patient’s age increased irrespective of group (Figure 1). Indications for cesarean delivery were similar as were rates of ANESTHESIA ABSTRACTS IS A PUBLICATION OF LIFELONG LEARNING, LLC © COPYRIGHT 2016
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anesthesia. Staying current in our colleagues’ area
hours. In this study about a third of patients
helps inform our practice and aids in our
experienced a postpartum hemorrhage, and overall
communication with our obstetricians and midwives.
between 3% and 5% required a blood transfusion. If
When I teach students I encourage them to read the
one assumes only those who had a postpartum
excellent Obstetric Consensus guidelines published by
hemorrhage were transfused, then up to 15% of those
the American College of Obstetricians and
patients required a transfusion. This is not a low
Gynecologists that reviews how to safely prevent
number and speaks to the importance of having
primary cesarean
delivery.1
This article provides a
situational awareness and making oneself available to
nice overview of how obstetricians manage their
help with resuscitations after a postpartum
laboring patients.
hemorrhage. As anesthesia providers who are experts in resuscitation, we can help reduce complications
Knowing the indication for induction of labor is
from blood transfusion by helping to develop massive
important because it may impact our management of
hemorrhage protocols and ensuring our fellow
a labor deck. For example, maybe a patient is being
anesthesia providers stay up-to-date on these
admitted for severe preeclampsia at 34 weeks and is
protocols.
showing a down trending platelet count. We might want to interview that patient and develop a plan
Dennis Spence, PhD, CRNA
early in consultation with the obstetrician. Whereas, if you have a woman coming in for an elective induction at 39 weeks, you might wait to see her until you have taken care of the sicker patient. Having situational awareness and knowing how to prioritize care is critical on an obstetric unit.
1. Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery. The American College of Obstetricians and Gynecologists. https:// www.acog.org/-/media/Obstetric-Care-ConsensusSeries/oc001.pdf ? dmc=1&ts=20160315T1650041862. Published March 2014. Accessed April 22, 2016. The views expressed in this article are those of the author
So what about this study? Well, the authors’
and do not reflect official policy or position of the
hypothesis was not supported. Induction at 39 weeks
Department of the Navy, the Department of Defense, the
did not decrease the cesarean delivery rate. In fact,
Uniformed Services University of the Health Sciences, or
the rate was virtually the same. The results do suggest,
the United States Government.
at least for delivery and neonatal outcomes, that induction is safe. Do I expect in the U.S. that we will see this change induction practices? Probably not. What I found most interesting was the postpartum hemorrhage rates. They were similar, but a large number of patients in the expectant management group required induction for some maternal or fetal indication. Induction of labor is associated with increased rates of uterine atony, especially when >24 ANESTHESIA ABSTRACTS IS A PUBLICATION OF LIFELONG LEARNING, LLC © COPYRIGHT 2016
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Patient Safety C APNOGRAPHIC
MONITORING IN ROUTINE EGD AND COLONOSCOPY WITH MODERATE SEDATION : A PROSPECTIVE , RANDOMIZED , CONTROLLED TRIAL
Am J Gastroenterol 2016;111:395-404 Mehta PP, Kochhar G, Albeldawi M, Kirsh B, Rizk M, Putka B, John B, Wang Y, Breslaw N, Lopez R, Vargo JJ Abstract
undergoing either EGD or colonoscopy. Inclusion
Purpose The purpose of this study was to
criteria were: ASA I or II and aged 18 years or older.
compare differences in hypoxemia (SaO2
