Anesthesia and Analgesia 2015


1. Kim H, Jung SM, Yu H, Park SJ. Video Distraction and Parental Presence for the Management of Preoperative Anxiety and Postoperative Behavioral Disturbance in Children: A Randomized Controlled Trial. Anesth Analg. 2015 Sep;121(3):778-84. doi: 10.1213/ANE.0000000000000839.

CONCLUSIONS: Video distraction, parental presence, or their combination showed similar effects on preoperative anxiety during inhaled induction of anesthesia and postoperative behavioral outcomes in preschool children having surgery. PMID: 26176357

Comments: Can Sponge Bob Square Pants calm a child with high separation anxiety?  And does it matter if parents are present with or without a distracting video?  There was no significant difference in baseline, parents only, or parents + video in kids getting sevoflurane induction.  As I think back, I remember induction with an inhaled anesthetic when I got PE tubes as a kid.  I fought like a fiend when they slapped the mask on my face!  It was not pretty!  I think I drew blood from the anesthesiologist, poor guy.  My experience in the ED has been remarkably different.  With topical LET for a laceration removing pain, a video on a tablet device not only positions the child's head properly but is an excellent distractor in most children.  But there are some kids that you know are going to fight.  For these, nasal midazolam is helpful, though some still loudly protest while I sew them up with "tickly string" even with adequate local anesthesia.  Another option our Child Life specialist used recently was a ViewMaster.  Kids are zoned out looking at Captain America and can't see me approaching with a needle.  Also, I have found that having a parent hold and cuddle the child during the procedure often helps.  So I'm not sure how to reconcile this study except to say that no wary child is going to happy when you smother them with a stinky gas mask - been there...done that.

2. Aziz MF, Abrons RO, Cattano D et al. 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. Anesth Analg. 2015 Nov 17. [Epub ahead of print]

CONCLUSIONS: Head-to-head comparison in this large multicenter trial revealed that the newly introduced C-MAC D-Blade does not yield the same first-attempt intubation success as the GlideScope in patients with predicted difficult laryngoscopy except in the hands of attending anesthesiologists. Additional research would be necessary to identify potential causes for this difference. Intubation success rates were very high with both systems, indicating that acute-angle video laryngoscopy is an exceptionally successful strategy for the initial approach to endotracheal intubation in patients with predicted difficult laryngoscopy. PMID: 26579847

Comments: Video laryngoscopy should not just be used for predicted difficult airway but for every airway in the ED.  But what about scopes that have an acute angle and don't readily allow both direct and video view, like the Storz C-MAC (not D-blade)?  In this study of anesthesiologists, first pass success was slightly higher with the Glide Scope (96.2%) vs Storz C-MAC D-blade (93.4%).  But the difference is not clinically significant in my opinion.  I personally don't like either of these blades.  I like the plain C-MAC because I can either look directly at the glottic opening or divert my eyes to the video screen, as the camera helps me "see around the corner."  Also, I have had equipment failure in mid-procedure and just intubated direct with the C-MAC.  If the Glide Scope or D-blade video fails, these are not designed for direct laryngoscopy, and you are going to have to pull out and grab a normal Mac or Miller blade.

3. Moore A, Gregoire-Bertrand F, Massicotte N et al. I-gel Versus LMA-Fastrach Supraglottic Airway for Flexible Bronchoscope-Guided Tracheal Intubation Using a Parker (GlideRite) Endotracheal Tube: A Randomized Controlled Trial. Anesth Analg. 2015 Aug;121(2):430-6. doi: 10.1213/ANE.0000000000000807.

CONCLUSIONS: The use of the IG supraglottic airway device as a conduit for flexible bronchoscope-guided tracheal intubation results in a success rate equivalent to the use of the LMA-FT. However, the IG allows for shorter intubation times and a better visualization of the glottic opening compared with the LMA-FT. PMID: 26076387

Comments: We think of intubating through the Fastrach LMA, but what about the I-Gel?  Both used flexible bronchoscope for ETT insertion through the supraglottic device.  Both worked fine for this with the I-Gel allowing significantly better glottic view and faster passage.  But without a brochoscope at the ready, I would opt for the Fastrach LMA.  It was designed for blind ETT insertion through the device, with the handle allowing lift toward the glottis.







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