The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. (Chandler)

Anesth Analg. 2013 Jul;117(1):144-9. PMID: 23687228

BACKGROUND: The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators.

METHODS: We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension.

RESULTS: There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL.

CONCLUSIONS: UEI using a VL as the primary device improved intubation success and decreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.

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Case report: profound hypotension after anesthetic induction with propofol in patients treated with rifampin. (Chandler)

Anesth Analg. 2013 Jul;117(1):61-4. PMID: 23687230

Rifampin is commonly used for the treatment of tuberculosis and staphylococcal infections, as well as for prevention of infection in cardiac valve and bone surgeries. We report a case of profound hypotension after anesthesia induction with propofol in a patient who was treated with two 600 mg doses of rifampin for prophylaxis of infection before surgery. In a retrospective case-control study of 75 patients, we confirmed this potentially serious drug-drug interaction. After rifampin, there was a significant and prolonged arterial blood pressure reduction when patients received propofol, but not thiopental.

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Intraocular pressure in pediatric patients during prone surgery. (Chandler)

Anesth Analg. 2013 Apr 4. PMID: 23558834

BACKGROUND: Intraoperative intraocular pressure (IOP) in the prone position and IOP changes over time have not been evaluated in pediatric surgical patients. We sought to determine time-dependent changes in IOP in children undergoing surgery in prone position.

METHODS: Thirty patients undergoing neurosurgical procedures in prone position were included. Using a pulse-mode pneumatonometer, IOP was measured in supine position after induction and before emergence of anesthesia and in prone position before the start and after the end of surgery. IOP changes over time in the prone position were assessed with a linear mixed model (i.e., random slope and intercept model) to adjust for the within-patient correlation.

RESULTS: IOP in prone position increased by an average of 2.2 mm Hg per hour (P < 0.001). Sixty-three percent of patients (95% confidence interval [CI], 46%-81%) had at least 1 IOP value exceeding 30 mm Hg, and 13% (95% CI, 1%-25%) had at least 1 IOP value exceeding 40 mm Hg while prone. Mean IOP increased 7 mm Hg (95% CI, 6-9) during the position change from supine to prone (P < 0.001) and decreased 10 mm Hg (95% CI, 9-12) after changing the position from prone back to supine (P < 0.001).

CONCLUSIONS: Changing position from supine to prone significantly increases IOP in anesthetized pediatric patients. Moreover, the IOP continued to increase during surgery and reached potentially harmful values, especially when combined with low mean arterial blood pressures that are common during major surgery.

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