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Middle East Journal of Anesthesiology
Vol. 22, No. 5, June 2014
CONTENTS
editorial
Preoxygenation-Routine Preoxygenation During Induction And Recovery From Anesthesia Is
Recommended As A Minimal Safety Precaution
��������������������������������������������������������������������������������������������������������������������������������� Anis Baraka
445
review article
Fentanyl-Induced Cough-Pathophysiology And Prevention
����������������������������������������������������������������������� Mabelle C. Tannous El Baissari, Samar K. Taha,
Sahar M. Siddik-Sayyid
449
scientific articles
Cerebral “Hyperoxygenation” With Inhalational Induction Of Anesthesia In Children: A
Retrospective Comparison Between Vasoparalytic Sevoflurane Vs. Vasoneutral Fentanyl
������������������������������������������������������������������ Deepak Gupta, Rami Bzeih, Maria Markakis Zestos
Comparison Between Intravenous Patient Controlled Analgesia And Patient Controlled
Epidural Analgesia In Cirrhotic Patients After Hepatic Resection
������������������������������������������������Nirmeen A. Fayed, Hatem B. Abo El-Wafa, Nahla M. Gab-Alla,
Khaled A. Yassen, Mamdouh E. Lotfy
457
467
Simulation Training In Endotracheal Intubation In A Pediatric Residency
�������������������������������������������������������������� Rana Sharara-Chami, Sahar Taher, Roland Kaddoum,
Hani Tamim, Lama Charafeddine
A Simple Protocol To Improve Safety And Reduce Cost In Hemodialysis Patients Undergoing
Elective Surgery
����������������������������������������������������������������������������������������������� Johnathan R. Renew, Sher-Lu Pai
Emetogenicity-Risk Procedures In Same Day Surgery Center Of An Academic University
Hospital In United States: A Retrospective Cost-Audit Of Postoperative Nausea Vomiting
Management
�������������������������������������������������������������������������������������������������������Deepak Gupta, Halim Haber
The Use Of Airtraq Laryngoscope Versus Macintosh Laryngoscope And Fiberoptic Bronchoscope
By Experienced Anesthesiologists
�������������������������������������� Kemal T. Saracoglu, Murat Acarel, Tumay Umuroglu, Fevzi Y. Gogus
477
487
493
503
case reports
Ultrasound-Guided Regional Anesthesia In A Pediatric Patient With Acute Intermittent
Porphyria: Literature Review And Case Report
�������������������������������������������������������������������������������� Yetunde Olutunmbi, Harshad G. Gurnaney,
Jorge A. Galvez, Allan F. Simpao
443
511
M.E.J. ANESTH 22 (5), 2014
Anesthetic Considerations And Management Of A Patient With Unsuspected Carcinoid Crisis
During Hepatic Tumor Resection
�������������������������������������������������������������������������������������������������������������������������������Clark K. Choi
515
Unusually Difficult Intraesophageal Bougie Insertion In An Intubated Pediatric Patient
����������������������������������������������������������������������������������������������������������� Xiaoyu Zhang, Xuan Zhao
519
LETTER TO THE EDITOR
Successful Intubation Using Mcgrath® Mac In A Patient With Treacher Collins Syndrome
���������������������������������������������������������������Takatoshi Tsujimoto, Satoshi Tanaka, Yuki Yoshiyama,
Yuki Sugiyama, Mikito Kawamata
523
CORRESPONDENCE
Anesthesia Care Providers’ Based Interdisciplinary Peri-Operative Cross-Over Post-MarketSafety-Surveillance: Is It Futuristic Patient Safety Idea? Running Title: Post-Hire Pmss
For Interventionists
������������������������������������������������������������������������������������������������������������������������������ Deepak Gupta
444
527
GUIDELINES FOR AUTHORS
The Middle East of Anesthesiology publishes original
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American University of Beirut Medical Center
Beirut, Lebanon
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M.E.J. ANESTH 22 (5), 2014
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2. ROBINSON JS: Modern Trends in Anaesthesia, Evans
and Gray Ch. 8, Butterworth Pub. Co., London 1967.
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EDITORIAL
PREOXYGENATION-Routine preoxygenation during
induction and recovery from anesthesia
is recommended as a minimal safety precaution
With the introduction of the rapid sequence induction of anesthesia and tracheal intubation
technique in the 1950s in patients who are at risk for aspiration of gastric contents, preoxygenation
became an essential component of the technique1. In 1955, Hamilton and Eastwood showed that
“denitrogenation” was 95% complete within 2 to 3 minutes in subjects breathing normally from a
circle anesthesia system with 5 L/min oxygen2.
Baraka et al 1999 reported that rapid and effective preoxygenation can be achieved by
using eight deep breaths within 60 seconds, and an oxygen flow of 10 L/min. This technique can
produce PaO2 values comparable to that achieved by the “traditional” preoxygenation technique.
Also, it delays the onset of subsequent apnea-induced hemoglobin desaturation more significantly
than following the other techniques of preoxygenation3. The mean times from the onset of apnea
until hemoglobin desaturation from 100% to 99% was significantly longer following eight-deep
breaths preoxygenation compared with the traditional 3 min of tidal volume breathing. The slower
desaturation during apnea following the eight-deep breaths preoxygenation technique despite the
comparable initial PaO2 values was unexpected. It is possible that deep breathing for 60 sec may
open collapsed airways and/or lung alveoli with a consequent increase of the oxygen store in the
functional residual capacity (FRC). Rapid preoxygenation with the eight deep breaths can be used
as an alternative to the traditional 3-min tidal volume breathing technique3.
In his Editorial, Benumof suggested that the report of Baraka et al1 describes a new method
of preoxygenation that may be best with regard to both efficacy and efficiency4. He also suggested
that maximal preoxygenation is indicated not only during rapid sequence induction of anesthesia in
patient with full stomach, but also in any patient with oxygen transport limitations (who desaturate
the fastest), and in any patient in whom difficulty in managing the airway is suspected. Moreover,
because the development of a cannot-ventilate, cannot-intubate situation is largely unpredictable,
the desirability/need to maximally preoxygenate is theoretically present for all patients4.
The original American Society of Anesthesiologists (ASA) difficult airway algorithm (1993)
makes no mention of preoxygenation. In his editorial, Benumof 1999 recommended maximal
preoxygenation in patients with oxygen transport limitations who desaturate the fastest, and
in patients with a difficult airway4. Along this line of though, the ASA inserted 2003 a new
statement in the updated difficult airway algorithm “Actively pursue opportunities to deliver
supplemental oxygen throughout the period of difficult airway management”5,6. Moreover, because
the development of the cannot-ventilate, cannot-intubate situation is largely unpredictable, the
desirability/need to maximally preoxygenate is theoretically present for all patients. However, it
must be noted that the safe period of apnea following preoxygenation, is still limited.
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M.E.J. ANESTH 22 (5), 2014
446
The SaO2 may be misleading as a guide to
alveolar denitrogenation and efficient preoxygenation.
A saturation of 100% measured by pulse oximetry is
not a reason to stop denitrogenation, and may occur
well before the lungs are adequately denitrogenated.
Conversely, failure of SpO2 to increase substantially
during denitrogenation does not necessarily indicate
failure of preoxygenation. With normal lung function,
the oxygen wash in and the nitrogen washout are
exponential. The end tidal O2 or N2 can be used to
monitor preoxygenation7.
Preoxygenation followed by oxygen insufflations
during subsequent apnea via a patent airway maintains
SaO2 by apneic diffusion oxygenation7,8. In the apneic
adult, the VO2 averages 230 ml/min, whereas the
output of CO2 to the alveoli is limited to about 21 ml/
min only, and the remaining CO2 production is buffered
within the body tissues. Therefore, a pressure gradient
is created between the upper airway and the alveoli
resulting in a mass movement of O2 down the trachea
into the alveoli. Because of this mass movement of
O2 down the trachea, CO2 is not exhaled, and hence
the alveolar CO2 concentration shows an initial rise
of about 8-16 mmHg during the first minute and a
subsequent fairly linear rise of about 3 mmHg/min.
The increase in CO2 during apneic mass-movement
oxygenation and not hypoxemia becomes the limiting
factor.
During apneic mass movement oxygenation via
an open airway the increase in time to Hb desaturation
baraka a.
achieved by increasing the FiO2 from 0.9 to 1.0
is greater than that caused by increasing the FiO2
from 0.21 to 0.99. The technique of preoxygenation,
followed by mass-movement oxygenation during the
subsequent apnea is highly recommended in patients
who may rapidly desaturate.
In conclusion, “Routine” preoxygenation before
rapid-sequence induction of general anesthesia in
patients with full stomach, is also recommended in
patients with suspected difficult airway, as well as in
patients with increased oxygen consumption associated
with decreased functional residual capacity of the
lungs such as children, the pregnant and the morbidly
obese patients, as well as in all critically ill patients.
The technique is also indicated not only during
induction of anesthesia, but also during reversal of
neuromuscular block and emergence from anesthesia7.
Moreover, because the development of hypoxemia
may be unpredictable, ‘routine” preoxygenation
during both induction of and recovery from anesthesia
is recommended in all patients as a minimal safety
precaution, similar to “fasten your seat belt” during
takeoff and landing of planes.
Anis Baraka, MD, FRCA (Hon)
Emeritus Professor of Anesthesiology
American University of Beirut
Beirut - Lebanon
PREOXYGENATION-Routine preoxygenation during induction and recovery from anesthesia
is recommended as a minimal safety precaution
447
References
1. Morton HJV, Wylie WD: Anaesthetic deaths due to regurgitation
and vomiting. Anaesthesia; 1951, 6:190.
2. Hamilton WK, Eastwood DW: A study of denitrogenation with
some inhalation anesthesia systems. Anesthesiology; 1955, 61:861867.
3. Anis S. Baraka, Samar K. Taha, Marie T. Aouad, Mohamad F.
El-Khatib, Nadine I. Kawkabani: Preoxygenation. Comparison
of maximal breathing and Tidal volume Breathing Techniques.
Anesthesiology; 1999, 91:612-616.
4. Jonathan Benumof: Editorial. Preoxygenation - Best method for
Efficacy and Efficiency? Anesthesiology; 1999, 91:603-609.
5. American Society of Anesthesiologists Task Force on Management
of the difficult airway. Practice guidelines for management of the
difficult airway. Anesthesiology; 1993, 78:597-602.
6. Ansgar M, Brambrink, Carin A. Hagberg: The ASA Difficult
Airway Algorithm. Analysis and presentation of a new algorithm Benumof and Hagberg’s Airway management Third edition, Chapter
10, pp. 222-239, 2013.
7. Anis S. Baraka, M. Ramez Salem: Preoxygenation: Benumof and
Hagberg’s Airway Management. Third edition, Chapter 13, pp. 280297, 2013.
8. Holmdahl MH: Pulmonary uptake of oxygen, acid-base metabolism,
and circulation during prolonged apnea. Acta Chir Scan; 1956, 212
(supp): 1-128.
9. Framery DD, Roe G: A model to describe the rate of oxyhemoglobin
desaturate during apnea. Br J Anesth; 1996, 76:284-291.
10.Baraka AS, Taha SK, Siddik SM, et al: Supplementation of
preoxygenation in morbidly obese patients using nasopharyngeal
oxygen insufflations. Anaesthesia; 2007, 62:769-773.
M.E.J. ANESTH 22 (5), 2014
REVIEW ARTICLE
Fentanyl - Induced Cough - Pathophysiology
and Prevention
Mabelle C. Tannous EL Baissari*, Samar K. Taha**,
and S ahar M. S iddik -S ayyid ***
Abstract
Many reports have demonstrated that intravenous administration of a bolus of fentanyl at
induction of anesthesia can cause coughing with varying degrees. This cough can be benign, but
sometimes it causes undesirable side effects including an increase in intraabdominal, intracranial
or intraocular pressure. Many studies demonstrated that the incidence and severity of fentanylinduced cough could be related to age, ethnicity, history of smoking, as well as to the rate, route,
dose and concentration of fentanyl administered. This cough was described by several mechanisms
including an inhibition of central sympathetic system leading to vagal predominance, reflex
bronchonstriction after the stimulation of tracheobronchial tree receptors, or histamine release.
The efficacy of several measures to avoid fentanyl-induced cough have been demonstrated, and
several anesthetics adjuncts can be given prior to fentanyl administration aiming at decreasing this
unwanted side effect.
Introduction
Fentanyl and its derivatives sufentanil, alfentanil, and recently remifentanil are the most
frequently used opioids in clinical anesthesia. These synthetic potent opioids derived from
phenylpiperidine are primarily administered for their analgesic effect especially prior to induction
of anesthesia. They are also used to produce sedation for many procedures including endoscopy,
cardiac catheterization, lumbar puncture and bone marrow aspirate/biopsy in pediatric oncology
patients, as well as in the management of chronic pain including cancer pain, and others.
Fentanyl, first synthesized in 1960, is a µ-opioid receptor agonist and has clinical potency
ratio 50 to 100 times that of morphine. It is characterized by its rapid onset, short duration of action,
profound dose-dependent analgesia, and cardiovascular stability mainly during laryngoscopy and
endotracheal intubation, and is less likely to cause histamine release1,2.
As any other opioid, fentanyl has several side effects including nausea, constipation, dry
mouth, somnolence, asthenia, hypoventilation, and apnea. Another important side effect is the
fentanyl-induced cough. Many reports have demonstrated that a bolus of fentanyl at induction of
* MD, Chief Resident.
** MD, Associate Professor.
*** MD, FRCA, Professor.
Affiliation: Department of Anesthesiology American University of Beirut-Medical Center, Beirut-Lebanon.
Corresponding author: Sahar Siddik-Sayyid, MD FRCA, Professor, American University of Beirut Department of
Anesthesiology P.O. Box: 11-0236 Beirut, Lebanon. Tel: 9611350000, Fax: 961 1 745249. E-mail: [email protected]
449
M.E.J. ANESTH 22 (5), 2014
450
anesthesia can cause coughing with varying degrees.
Cough was also described after alfentanil, sufentanil,
and remifentanil bolus administration at anesthesia
induction3,4. This side effect can be transient, benign
and self-limiting for most patients, but at times it can
be spasmodic, explosive5, and life threatening6.
Fentanyl-induced cough should be avoided
in patients who have potential for an increase in
intracranial pressure such as cerebral aneurysms,
arterio-venous malformation, cerebral tumor, or
have already increased intracranial pressure such
as ruptured cerebral aneurysms, and in patients with
acute glaucoma, penetrating eye injuries, or dissecting
aortic aneurysm. Although fentanyl-induced cough is
not more frequent in chronic obstructive pulmonary
disease or asthmatic patients7, it is wise to avoid cough
in this group of patients who have hypersensitive
airway.
Fentanyl-induced cough pathophysiology
Cough is a well-integrated reflex resulting from
mechanical and chemical stimulations of sensory
receptors. The most likely receptors are the rapidly
adapting pulmonary stretch receptors (RARs) with
small diameter A delta myelinated fibers (localized
mainly at the larynx) and the pulmonary and bronchial
C-fiber receptors with nonmyelinated afferents. These
fibers constitute the afferent limb which interacts
with brainstem cough center, while the efferent limb
consists of motor nerves that supply the muscles of
coughing8. A new concept of the central regulatory
system for cough reflex has been suggested. Coughgating neurons, located in the ventrolateral nucleus
tractus solitarius, play a crucial role in the generation
of cough reflex. In fact, the second order relay
neurons in the nucleus tractus solitarius receive
peripheral tussigenic inputs. The cough-gating
neurons, constituting the gating mechanism, integrate
these afferents inputs and activate the central cough/
respiratory pattern generator by producing triggering
signals. Finally, the produced cough motor task is
transmitted to the inspiratory and expiratory muscles
through activation of respiratory motoneurons. The
cough pattern generator in the brainstem appears to
be identical to the respiratory pattern generator and
el baissari tannous M. C. et. al
to function by reshaping of the discharge pattern of
respiratory neurons9.
Regarding the mechanism of cough induced
by opioids, several hypotheses were implicated. The
rapidly adapting receptors present on the mucosa of the
proximal tracheobronchial airway can be stimulated
by fentanyl causing bronchoconstriction and cough
which can be suppressed by inhaled beta 2-agonists
such as terbutaline10 or salbutamol11. In addition,
Tanaka et al. demonstrated that the topical application
of citrate on C fibers of the airway induces cough in
animals and humans12. Since fentanyl is available as
citrate salts, citrate can stimulate C fibers (known
also as J-receptors) present on the smooth muscles
of trachea and bronchi releasing neuropeptides such
as tachykinins or bradykinins responsible for the
cough. These J receptors are accessible via pulmonary
circulation and are very sensitive to chemical irritants13.
The differences in the incidence and severity of cough
among different opioids may be attributed to the
amount of citrate in opioids14.
Histamine release is a possible cause for inducing
cough by fentanyl, but this is not clear as fentanyl
rarely causes histamine release in mast cells of the
lungs. However, Argwal et al study showed that
sodium chromoglycate, a mast cell stabilizer, led to a
decrease in the incidence of fentanyl-induced cough11.
Fentanyl has been shown to enhance vagal activity
while inhibiting sympathetic nervous system leading
to reflex bronchoconstriction and cough15. Recently,
it appears unlikely that the vagal system stimulation
mediates fentanyl-induced cough as premedication by
anticholinergic drugs as atropine does not decrease its
incidence7,16.
Alternative hypothesis that should be verified by
further studies is that the muscle rigidity produced by
fentanyl can cause sudden adduction of vocal cords
or supraglottic obstruction17, and a priming dose of
vecuronium could decrease the incidence of fentanylinduced cough7.
Incidence of fentanyl-induced cough
The discrepancies in the incidence of fentanylinduced cough may be related to age, ethnicity,
Fentanyl - Induced Cough - Pathophysiology and Prevention
smoking, as well as to different doses, rates and routes
of fentanyl administration.
1.Age: The incidence of fentanyl-induced cough is
high in infants and children, even in small doses
(1 µg/kg)18-20. This can be explained by an increase in
irritant cough receptors17. However, Lin et al showed
that age has no effect on the incidence of cough21.
2.Ethnicity: Fentanyl-induced cough may be more
evident in Asian population than European one16,22.
Schapermeier and Hopf demonstrated that the
incidence of cough following intravenous (IV)
fentanyl 1.5 µg/kg ranges between 3% and 6% in
European patients22 whereas Phua et al showed that
this incidence is 28% using the same fentanyl dose in
Asian patients16.
3.Smoking: There is a controversy regarding the
implication of smoking in increasing the incidence
of fentanyl-induced cough. Baley reported that
fentanyl-induced cough was noticeable in smokers23.
However, Dimitriou et al. demonstrated that the
incidence of cough in the non-smoker and smoker
group (more than 10 cigarettes per day) was similar
after administration of 2-3 µg/kg of fentanyl during
anesthesia induction24. Lin et al. demonstrated that
light smoking may be a protective factor against
fentanyl-induced cough. They showed that smokers
who smoked fewer than 10 cigarettes per day have
less fentanyl-induced cough than nonsmokers after
administration of 2 µg /kg of fentanyl, but there was
no difference between heavy smokers (more than 10
cigarettes per day) and non-smokers21. This can be
explained by the inhibitory effects of nicotine on C
fibers in current light smokers which are abolished in
heavy smoker patients25.
4.Doses of injection: As shown in several previous
studies, the incidence of fentanyl-induced cough
increases proportionally with the doses. With a
speed of injection of fentanyl less than 2 seconds at
induction time, the cough incidence increased from
6.6% to 61% when fentanyl dose increased from
2 µg/kg to 4 µg/kg (table 1). All these doses were
administered peripherally.
5.Speed of injection: Schapermeier and Hopf showed
in their study that injection of 1.5 µg /kg of fentanyl
over 2, 5 or 10 seconds leads to similar incidence
of cough ranging from 3% to 6%, concluding that
451
the speed of injection does not affect the incidence
of cough22. However, Lin et al showed that a longer
injection time can reduce the incidence of fentanylinduced cough. Fentanyl injection (2 µg/kg) induced
cough in 18% of patients with an injection time
less than 2 seconds; increasing injection time to 30
seconds yielded a drop in the incidence of evoked
cough to 1.3%21. This can be explained by less
chance of fentanyl to reach the threshold of plasma
concentration as the mean time of fentanyl to reach
the peak plasma concentration is 15 seconds25.
In another study, Lin et al study showed that
administration of 2.5 µg /kg of fentanyl over two
seconds can reach 65 %17.
6.Route of administration: The different routes of
fentanyl administration have been evaluated in
different studies. High incidence of fentanyl-induced
cough has been observed when fentanyl was given
at a high dose and via a central line. Bohrer et al.
showed that IV administration of large dose of
fentanyl 7 µg /kg via a central line causes cough
with an incidence reaching 45%. vs 2.7% when the
same dose was given peripherally, which can explain
the direct fentanyl stimulation of the pulmonary
chemoreflexes13.
Onset of fentanyl-induced cough
In addition to the pharmacokinetic property of
fentanyl, the dose, speed of injection, and route of
administration contribute to the onset time of cough.
Chen et al study showed that the rate of fentanyl
injection through the same peripheral venous access at
the same dose may affect both the incidence and onset
time of cough. At the same dose and injection rate of
fentanyl, forearm venous access of injection resulted in
earlier onset of cough than lower limb venous access
with a similar incidence26. In two other studies, the
onset of cough was 9 seconds when 7 µg/kg fentanyl
bolus was administered via a central line13 and 42±8
seconds when 5 µg /kg was injected over 5 seconds
peripherally10.
Pharmacological intervention to reduce
fentanyl-induced cough
M.E.J. ANESTH 22 (5), 2014
452
el baissari tannous M. C. et. al
Table 1
Incidence of cough after fentanyl administration through peripheral line and summary of effective methods to prevent it. The articles
are listed as per increasing fentanyl doses.
Incidence of
Incidence of Medications to prevent cough
References
Number of cases Fentanyl Time of
cough after
cough after
per group
dose (μg/ injection
medication (%)
fentanyl
(seconds)
kg)
(control) (%)
Lida et al, 200953.
No intervention
NA
6.6
106
1
22.5
3
44.3
5
Phua et al. 199116.
30
50
1.5
NA
28
Atropine (0.01mg/kg)
6
Morphine (0.2mg/kg)
40
Midazolam (7.5mg)
Chung-Chang et al.
200735.
Horng et al. 200736.
Lin et al. 200521.
180
1.5
5
21.6
Ketamine (0.15mg/kg)
7.2
150
150
2
~2
<2
<2
15
30
38.7
18
8
1.3
Clonidine (2 μg /kg)
No intervention
17.3
108 (fentanyl
group)/80
(Dexamethasone
group)
Argwal et al. 200311.
50
~2
2
21.3
Dexamethasone 10mg)
6.3
2
5
28
Qing et al. 201046.
Hung et al. 201051.
Tang et al. 201049.
93
200
30
2
~2
2.5
2
NA
1.5±0.3
22.6
18.5
80
(Intralipid
0.15ml/kg)
Lin et al. 200417.
31
2.5
2
65
Yu et al. 201240.
110
3
NA
40.9
Pandey et al. 200431.
Pandey et al. 200532.
251
80
3
3
NA
NA
34.22
35
Yu et al. 200719.
50
3
3-5
32
Lin et al. 200744.
Liang et al. 201237.
100
4
<2
61
Lui et al. 199610.
Sun et al. 201147.
Bohrer et al. 199013.
30
60
37
5
5
7
NA
<2
1
43
70
2.7
NA (Not available)
One puff Salbutamol
One puff Beclomethasone
One puff Sodium
chromoglycate
Pentazocine (0.5mg/kg)
Preemptive fentanyl dose 25µg
Propofol (1mg/kg)
Propofol (1.5mg/kg)
Propofol (2mg/kg)
Lidocaine (2mg/kg)
Ephedrine (5mg):
Propofol (0.6mg/kg):
Midazolam (0.6mg/kg)
Dexmedetomidine (0.6 μg /kg)
Midazolam(0.6mg/kg)+dex(0.6
μg /kg)
Lidocaine (1.5mg/kg):
Lidocaine (0.5mg/kg):
Lidocaine (1mg/kg):
Lidocaine (1.5mg/kg):
Dilution of fentanyl from
50µg/ml to 25µg/ml
50µg/ml to 10µg/ml
50µg/ml to 10µg/ml+
prolonged time to injection
Dexmedetomidine (0.5 μg /kg):
Dexmedetomidine (1mcg/kg):
Terbutaline (5mg):
Dezocine (|0.1mg/kg)
No intervention
6
0
4
4.3
7.5
40
6.7
3.3
14
21
37
63.6
22.7
0
13.1
13.75
15
13.75
16
12
2
40
18
3
0
Fentanyl - Induced Cough - Pathophysiology and Prevention
Several pharmacological interventions were done
to decrease this side-effect with varying success.
1.Lidocaine: IV lidocaine has been demonstrated
to decrease airway reflexes including cough
reflex during tracheal intubation27, extubation28,
and bronchography29. As a proposed mechanism,
lidocaine can act centrally by depression of brainstem
functions or peripherally by blocking tracheal and
hypo-pharyngeal cough receptors30. Pandey and coauthors demonstrated that 1.5 mg/kg of lidocaine
administered one minute before 3 µg/kg of fentanyl
can decrease significantly the incidence of cough31.
In a dose-response study, he demonstrated that
administration of a low dose of lidocaine (0.5 mg/kg
IV) over 5 seconds, one minute prior to an induction
bolus of fentanyl 3 µg /kg, is effective in decreasing
fentanyl-induced cough and that increasing lidocaine
dose up to 1.5 mg/kg does not reduce the incidence
and severity of fentanyl-induced cough32. Lin et al
showed the administration of lidocaine 2 mg/kg one
minute before fentanyl 2.5 µg/kg over 2 seconds at
induction can suppress cough reflex17. A recent metaanalysis showed that lidocaine reduces the incidence
and severity of fentanyl-induced cough, and that the
lowest effective dose of lidocaine for preventing
the prevalence of cough was 0.5 mg/kg. No severe
adverse effects were reported33.
2.Beta 2-adrenergic receptors: As previously
mentioned, one of the proposed mechanisms for
fentanyl-induced cough is fentanyl-triggered
bronchoconstriction. Ephedrine, a sympathomimetic
drug that acts as a bronchodilator, can be safely
administered intravenously at a small dose (5 mg) in
healthy patients, but it is relatively contraindicated in
patients with severe hypertension or coronary artery
disease17. Other beta-2 adrenergic receptor agonists
such as nebulized terbutaline10 and salbutamol11 were
effective in decreasing the incidence of fentanylinduced cough.
3.Ketamine: It has been also demonstrated that
excitatory amino acids and N-methyl - D-aspartate
(NMDA) receptor agonists present in the larynx,
lungs and airways are capable of stimulating
cough reflex34; ketamine, an NMDA receptor
antagonist, characterized by its potent analgesic and
bronchodilator effect has been used as premedication
453
with a dose of 0.15 mg/kg and was effective in
decreasing the incidence of fentanyl-induced cough
and delaying its onset35.
4.Alpha 2-adrenoreceptor agonist: Clonindine, an alpha
2-adrenoreceptor agonist known by its analgesic,
anxiolytic, and sedative effects, is widely used as
premedication before surgery. Horng and co-authors
demonstrated that premedication with 2 µg /kg of
clonidine followed 2 minutes later by administration
of 2 µg/kg of fentanyl within 2 seconds decreases the
incidence of cough from 38.7% to 17.3%36. Recently,
the usage of dexmedetomidine, a highly selective
alpha 2-adrenoreceptor agonist at doses of 0.5 µg /
kg and 1 µg /kg has been effective in reducing cough
when 4 µg/kg of fentanyl was injected in less than
2 seconds without causing major cardiovascular
instability. However, the severity and onset of time of
cough were not affected37. The mechanism by which
these alpha 2-agonists decrease cough is unclear.
It could be attributed to the sedative and bronchorelaxant properties as for ketamine, midazolam and
propofol38. Hung speculated that clonidine suppresses
opioid-induced cough by reducing opioid-induced
muscle rigidity that causes the sudden adduction
of the vocal cords or supraglottic obstruction39.
Yu et al. showed that the premedication with
dexmedetomidine 0.6 µg/kg and midazolam 0.06
mg/kg, 2 minutes before injecting fentanyl 3 µg/kg
within 2 seconds, suppresses completely fentanylinduced cough, while an incidence of 22.7% was
observed after the administration of 0.6 µg/kg of
dexmedetomidine alone40.
5.Dexamethasone: Tachykinin release stimulates
the rapidly activating receptors either directly
by contracting smooth muscles or indirectly by
inducing histamine release from airway masts
cells. It has been reported that dexamethasone
can stabilize mast cells41 and reduce tachykinininduced bronchoconstriction in guina pigs, but this
needs more investigation in humans42. In addition,
it has been reported that dexamethasone stimulates
neutral endopeptidase which reverses the enhanced
airway reactivity of airway epithelial cells43. Lin et
al study showed that 10 mg of dexamethasone 5
min prior to injection of fentanyl 100 µg/kg in 4069 kg patient or 150 µg/kg in a 70-90 kg patient
M.E.J. ANESTH 22 (5), 2014
454
reduces the incidence of fentanyl-induced cough44.
Yu and coauthors demonstrated also that 10 mg of
dexamethasone can decrease cough from 26.5% to
6.5% when remifentanil was used and reached a
target concentration of 5 ng/ml45.
6.Agonist-antagonist opioid: Recently, pentazocine,
an agonist of kappa and sigma receptors and a weak
antagonist of µ-receptors, has been shown to be
effective in decreasing cough. Qing et al. showed
that 0.5 mg/kg of pentazocine given 5 min prior to
administration of 2 µg/kg of fentanyl over 2 seconds
decreases the incidence of cough from 22.6% to
4.3%46. Also, dezocine, a full antagonist-kappa
receptor and partial agonist-mu receptor, was used to
decrease cough when administered at a dose of 0.1
mg/kg 10 minutes prior to injection of 5 µg /kg of
fentanyl; however, more studies are needed to clarify
the effects and mechanisms of action of dezocine in
suppressing fentanyl-induced cough47.
7.Propofol: This drug is known to have a bronchodilator
effect38,48, and priming doses ranging from 1 mg/kg
to 2 mg/kg administered before anesthesia induction
were effective in suppressing the cough49. However,
Lin et al observed that premedication with 0.6 mg/
kg of propofol could not inhibit fentanyl-induced
cough17.
8.Priming doses of fentanyl: It has been shown that a
priming fentanyl dose of 0.5 µg/kg50 or preemptive
use of 25 µg fentanyl administered 1 minute prior
to 125 µg or 150 µg of fentanyl51 could suppress
el baissari tannous M. C. et. al
effectively the cough. The preemptive dose of
fentanyl releases neurotransmitters that do not reach
the threshold to cause cough. However, after a larger
dose of fentanyl, there will be an exhaustion of these
neurotransmitters resulting in a lower incidence of
cough50.
9.Dilution of fentanyl: Yu et al found that fentanyl
diluted from 50 µg/ml to 25 µg/ml and 10 µg/ml
injected over 3-5 seconds reduces the incidence of
cough, and that administration of 3 µg/kg of fentanyl
diluted to 10 µg/ml combined with a prolonged
injection time to 30 seconds eliminates completely
fentanyl-induced cough19.
10.Non-therapeutic modalities: Ambesh et al. reported
a significantly reduced cough (32% to 4%) induced
by 2.5 µg/kg of fentanyl if a huffing maneuver was
done before induction of anesthesia52.
Conclusion
Cough with varying degrees of severity can be
caused by intravenous administration of fentanyl bolus
at induction of anesthesia. Although most of the time
benign, it can be sometimes associated with undesirable
side effects. In order to decrease its incidence and
severity, the route, rate, dose, and concentration of
fentanyl injection should be taken into consideration,
and several adjuncts can be given prior to fentanyl
administration.
Fentanyl - Induced Cough - Pathophysiology and Prevention
455
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scientific articles
Cerebral “Hyperoxygenation” with Inhalational
Induction of Anesthesia in Children: A Retrospective
Comparison between Vasoparalytic Sevoflurane vs.
Vasoneutral Fentanyl
Deepak Gupta*, Rami Bzeih** and Maria Markakis Zestos*
Abstract
Background: The higher levels of oxygen in cerebrum may contribute to neuro-apoptosis,
analogous to direct tissue injury induced by toxic levels of oxygen. Earlier report highlighted the
possibility of cerebral “hyperoxygenation” secondary to inhalational induction of anesthesia with
sevoflurane in small number of children.
Objective: The aim of this retrospective review was whether similar cerebral
“hyperoxygenation” trends can be seen in larger and retrospective patients’ database.
Methods: Data of patients who had undergone cardiac surgeries at Children’s Hospital
during the two-year period (2010-2011) was retrieved during this retrospective review: (a) stored
computer data from INVOS®™ Cerebral/Somatic Oximeter for oximetry numbers and total
duration of oximetry monitoring, (b) paper chart perfusion records of the cardiac surgeries for
age and sex of the patient, urgency of the surgery, type of induction (inhalational or intravenous),
and total duration of cardiopulmonary bypass, (c) general medical records for inpatient setting vs.
outpatient setting of the patient, and (d) anesthesia medical records for name of the medications
used during induction of anesthesia to segregate the patients who had fentanyl as a lone induction
agent and sevoflurane as a lone induction agent, for final statistical calculations and analysis. For
the two-year period (2010-2011), data of 358 patients who had cardiac surgeries at Children’s
Hospital were reviewed. However, after deletions of various patients’ data due to various reasons,
only 69 patients (0-4 years of age) who had sevoflurane induction were analyzed for final statistical
comparisons to 14 patients (0-4 years of age) who had fentanyl induction.
Results: Cerebral and renal “hyperoxygenation” occurred during the first 127 minutes
with sevoflurane as compared to fentanyl though the percentage changes from pre-induction
values in oximetry during this time did not reach level of significance. However, only cerebral
“hyperoxygenation” persisted in the last 127 minutes when patients had been induced with
sevoflurane as compared to fentanyl.
Conclusion: Cerebral “hyperoxygenation” occurs with inhalational induction of anesthesia
with vasoparalytic sevoflurane in children 0 to 4 years of age when compared to anesthesia
*MD.
**Graduate Student.
Affiliation: Department of Anesthesiology, Wayne State University, Detroit, Michigan, United States.
Corresponding author: Maria Markakis Zestos, MD. Chief of Anesthesiology, Children’s Hospital of Michigan,
Associate Professor, Wayne State University, 3901 Beaubien St, Suite 3B-17, Detroit Michigan 48201,
United States. Office: 1-313-745-5535. Tel: 1-313-745-5448. E-mail: [email protected]
457
M.E.J. ANESTH 22 (5), 2014
458
induction with vasoneutral fentanyl.
Introduction
The higher levels of oxygen in cerebrum may
contribute to neuro-apoptosis, analogous to direct
tissue injury induced by toxic levels of oxygen. In
an earlier case series discussion1, we presented the
possibility of cerebral “hyperoxygenation” secondary
to inhalational induction of anesthesia with sevoflurane.
Oxygen’s potential to possibly cause neuro-apoptosis
needs further investigations to define the exact toxic
levels that could harm anesthetized brains of different
age groups. However, the case series discussion
prompted us to investigate whether similar cerebral
“hyperoxygenation” trends can be seen in larger
number of patients. Such trends, if present, would
warrant further randomized controlled prospective
trials to comprehensively validate the observations of
our case series discussion1.
The current retrospective review was focused
on the 0-4 years age group because this particular
age group reflects a vulnerable stage in human brain
development with possibly heightened sensitivity
to deleterious effects of anesthesia and related perianesthesia factors. Moreover, this age group is also
the focus of investigation by SmartTots (Strategies
for Mitigating Anesthesia-Related neuroToxicity in
Tots) for validating patient safety when anesthesia
is being delivered to young patients in 0-4 years age
group2. As propofol is very rarely used for intravenous
induction of anesthesia in small children (0-4 years
of age) presenting for cardiac surgeries, the objective
of this retrospective review was to compare the
tissue oximetry data for the patients who received
inhalational induction of anesthesia with sevoflurane
for their cardiac surgeries versus the patients who had
intravenous induction of anesthesia with fentanyl.
Methods
After institutional review board approval, the
patients who had undergone cardiac surgeries at
Children’s Hospital during the two-year period (20102011) were included in this retrospective review. As
cerebral tissue oxygen monitoring as well as somatic
Gupta d. et. al
(renal) tissue oxygen monitoring with INVOS®™
Cerebral/Somatic Oximeter (®Somanetics Corporation,
Troy, Michigan, United States; ™Covidien, Mansfield,
Massachusetts, United States) are routinely applied
for cardiac surgeries at our Children’s Hospital. The
following patient care data was retrieved during this
review for final analysis and comparison: (a) stored
computer data from INVOS®™ Cerebral/Somatic
Oximeter for oximetry numbers and total duration of
oximetry monitoring, (b) paper chart perfusion records
of the cardiac surgeries for age and sex of the patient,
urgency of the surgery, type of induction (inhalational
or intravenous), and total duration of cardiopulmonary
bypass, (c) general medical records for inpatient setting
vs. outpatient setting of the patient, and (d) anesthesia
medical records for the medications used during
induction of anesthesia to segregate the patients who
had fentanyl as a lone induction agent and sevoflurane
as a lone induction agent.
Although the initial plan for data collection
was inclusive of five-year period (2007-2011), major
paucity of computerized oximetry data in years
prior to year 2010 and inhomogeneous availability
of comprehensive peri-operative characteristics
of patients led to our decision to perform the final
statistical calculations and analysis for a two-year
period (2010-2011). The positive side of this decision
was that despite being a small data (n=83 patients over
two-year period), the post-hoc power analysis of the
compared data was adequate.
For final statistical comparisons, the patients
were divided into two groups: the group who received
sevoflurane as a lone induction agent and the group
who received fentanyl as a lone induction agent. Each
approximate-30-second-interval oximetry numbers
were tabulated for ANOVA-Analysis of Repeated
Measures for approximately first 127 minutes (first
time zone) of the oximetry monitoring (anesthesia
duration) and approximately last 127 minutes (second
time zone) of the oximetry monitoring. To avoid
ANOVA-Analysis of Repeated Measures deleting
individual patient’s whole oximetry data wherein that
patient had few time-points with missing oximetry
numbers, these tabulations were re-formatted to delete
all those interspersed time-point data columns wherein
any single patient had a missing data-point of oximetry
Cerebral “Hyperoxygenation” with Inhalational Induction of Anesthesia in Children: A
Retrospective Comparison between Vasoparalytic Sevoflurane vs. Vasoneutral Fentanyl
number at that particular time-point. Therefore, an
acquisition rate was defined as the ratio of time-point
data columns (repeated measures) finally analyzed vs.
the total time-point data columns available for that
particular time zone (254 time-points of approximate30-second-interval). Other statistical tests used were:
ANOVA Single Factor for comparing means of
continuous data, Chi-Square test and two tailed Fisher
Exact test for comparing proportions and Regression
analysis for correlating data. A P-value of <0.05 was
considered as significant.
Results
For the two-year period (2010-2011), data of
358 patients who had cardiac surgeries at Children’s
Hospital were reviewed. However, after deletions of
various patients’ data due to reasons specified in the
CONSORT diagram (Figure 1), only 69 patients (0-4
years of age) who had sevoflurane induction were
analyzed for final statistical comparisons to 14 patients
(0-4 years of age) who had fentanyl induction. Fentanyl
induction was significantly higher in inpatients
Fig. 1
CONSORT Diagram of the Analyzed Patients’ Data after
Various Deletions/Exclusions
459
Table 1
Patients Pre-Morbid Characteristics (Demographics)
Characteristic
Sevoflurane
Induction
(n=69)
Fentanyl
Induction
(n=14)
P Value
Age (in years)
1.13 ±1.17
0.51 ±1.04
0.07
Sex (F/M)
35 F/34 M
8 F/6 M
0.77
13 INPT/1
SDA
<0.0001
9 INPT/60
Inpatient/Same Day
Admit Setting (INPT/ SDA
SDA)
Elective/Non-Elective 64 E/5 NE
3 E/11 NE
<0.0001
Surgery (E/NE)
F: Females; M: Males
INPT: Inpatient Setting; SDA: Same Day Admit Setting
E: Elective Surgery; NE: Non-Elective Surgery
(P<0.0001) and in patients undergoing non-elective
(urgent/emergent) cardiac surgeries (P<0.0001)
(Table 1). Though the baseline pre-induction values
of both cerebral and renal oximetry were similar
between sevoflurane induction and fentanyl induction,
the baseline values of cerebral oximetry and renal
oximetry correlated significantly only in sevoflurane
induction patients (r=0.48; P<0.0001) (Table 2). The
end values of cerebral oximetry (P=0.0007) and renal
oximetry (P=0.0001) at skin closure were significantly
different between sevoflurane induction and fentanyl
induction. However the correlation between end
values of cerebral oximetry and renal oximetry was
significant only in sevoflurane induction patients
(r=0.37; P=0.002) (Table 2).
Baseline cerebral oximetry (r=0.39; P=0.0002)
as well as baseline renal oximetry (r=0.47; P<0.0001)
proportionally increased with patients’ age (Table 3).
However, only the inpatients (P=0.04) and patients who
had undergone non-elective cardiac surgeries (P=0.004)
had significantly lower baseline renal oximetry values
(Table 3). Durations of cardiopulmonary bypass and
oximetry monitoring did not correlate with percent
changes from pre-induction baseline values to end
values of both cerebral and renal oximetry irrespective
of the type of anesthesia induction performed (Table 4).
During final comparisons of tissue oximetry
(cerebral and renal) across the two time-zones (first
127 minutes and last 127 minutes), there was some
overlapping of data in seven out of 83 patients because
M.E.J. ANESTH 22 (5), 2014
460
Gupta d. et. al
Table 2
Tissue Oximetry and Surgical Characteristics
Characteristic
Sevoflurane Induction (n=69)
Fentanyl Induction (n=14)
P Value
Cerebral Oximetry Baseline Value (in %)
63.84 ±11.98
61.36 ±12.98
0.49
Renal Oximetry Baseline Value (in %)
72.29 ±15.04
65 ±16.38
0.11
Correlation of Baseline Cerebral and Renal
Oximetry
Correlation Coefficient=0.48
(P<0.0001)
Correlation
Coefficient=0.46 (P=0.1)
Cardio-Pulmonary Bypass Duration (in mins)
112.87 ±50.32
126.29 ±63.69
0.39
Oximetry Monitoring Duration (in mins)
341.41 ±71.77
380.29 ±105.67
0.09
Cerebral Oximetry End Value (in %)
75.86 ±12.8
61.86 ±16.59
0.0007
Renal Oximetry End Value (in %)
92.46 ±6.14
79.93 ±22.37
0.0001
Correlation of End Values of Cerebral and
Renal Oximetry
Correlation Coefficient=0.37
(P=0.002)
Correlation Coefficient=0.5
(P=0.07)
Table 3
Effect of Pre-Morbid Characteristics on the Pre-Induction Baseline Values of Tissue Oximetry
Correlating Factor
Patients’ Age (n=83)
Patients’ Sex F/M (n=83)
Patients’ Setting Inpatient (INPT)/Same
Day Admit (SDA) (n=83)
Surgeries’ Urgency Elective (E)/NonElective (NE) (n=83)
Correlation of Baseline
Cerebral Oximetry
Correlation Coefficient=0.39 (P=0.0002)
F: 64.37 ±10.55
M: 62.4 ±13.65
(P=0.46)
INPT: 61.32 ±13.29
SDA: 64.18 ±11.68
(P=0.35)
E: 63.81 ±12.02
NE: 61.81 ±12.73
(P=0.56)
Correlation of Baseline
Renal Oximetry
Correlation Coefficient=0.47 (P<0.0001)
F: 72.37 ±15.67
M: 69.65 ±15.21
(P=0.43)
INPT: 65.18 ±16.17
SDA: 73.18 ±14.7
(P=0.04)
E: 73.39 ±14.23
NE: 61.31 ±16.81
(P=0.004)
Table 4
Effect of Durations of Cardiopulmonary Bypass and Oximetry Monitoring
on the End Values of Tissue Oximetry at Skin Closure
Correlating Factor with Correlation
Coefficient (r)
Correlation of Percent Change from
Baseline to End Value
Cerebral Oximetry
Correlation of Percent Change from
Baseline to End Value
Renal Oximetry
Cardiopulmonary Bypass Duration in
Sevoflurane Induction Patients (n=69)
r= -0.07 (P=0.58)
r= -0.003 (P=0.98)
Total Duration of Oximetry Monitoring
in Sevoflurane Induction Patients (n=69)
r= 0.002 (P=0.99)
r= 0.07 (P=0.56)
Cardiopulmonary Bypass Duration in
Fentanyl Induction Patients (n=14)
r= 0.25 (P=0.4)
r= -0.22 (P=0.46)
Total Duration of Oximetry Monitoring
in Fentanyl Induction Patients (n=14)
r= 0.001 (P>0.99)
r= -0.3 (P=0.3)
Cerebral “Hyperoxygenation” with Inhalational Induction of Anesthesia in Children: A
Retrospective Comparison between Vasoparalytic Sevoflurane vs. Vasoneutral Fentanyl
461
Table 5
Acquisition Rate Database used before comparing Sevoflurane Induction vs. Fentanyl Induction
Time Zone (for Both Absolute
and Percentage Numbers)
Missing Data Points (Cells)
For Comparison Between
Sevoflurane and Fentanyl
Induction
Remaining Time Points
(Columns) For Comparison
After Removal (t)
Acquisition Rate
[(t/254)*100]
First 127 Minutes of
Cerebral Oximetry
(n=69Sevo+14Fent=83)
212 (Average per patient=2.55)
119 per patient
47%
[Figure 2(a) and Figure 3(a)]
First 127 Minutes
of Renal Oximetry
(n=69Sevo+14Fent=83)
111 (Average per patient=1.34)
164 per patient
65%
[Figure 2(b) and Figure 3(b)]
Last 127 Minutes of
Cerebral Oximetry
(n=69Sevo+14Fent=83)
142 (Average per patient=1.71)
151 per patient
59%
[Figure 4(a) and Figure 5(a)]
Last 127 Minutes
of Renal Oximetry
(n=69Sevo+14Fent=83)
224 (Average per patient=2.7)
39 per patient
15%
[Figure 4(b) and Figure 5(b)]
Table 6
Acquisition Rate Database used before comparing/correlating Cerebral Oximetry vs. Renal Oximetry
Remaining Time
Points (Columns) For
Comparison After
Removal (t)
Acquisition Rate
[(t/254)*100]
Time Zone (for Both Absolute
and Percentage Numbers)
Missing Data Points (Cells) For
Comparison Between Cerebral
and Renal Oximetry
First 127 Minutes of
Sevoflurane Induction
(n=69Cer+69Ren=138)
213 (Average per patient=1.54)
104 per patient
41%
[Figure 2(c) and Figure 3(c)]
First 127 Minutes of
Fentanyl Induction
(n=14Cer+14Ren=28)
110 (Average per patient=3.93)
171 per patient
67%
[Figure 2(d) and Figure 3(d)]
Last 127 Minutes of
Sevoflurane Induction
(n=69Cer+69Ren=138)
68 (Average per patient=0.49)
195 per patient
77%
[Figure 4(c) and Figure 5(c)]
Last 127 Minutes of
Fentanyl Induction
(n=14Cer+14Ren=28)
298 (Average per
patient=10.64)
35 per patient
14%
[Figure 4(d) and Figure 5(d)]
total duration of oximetry monitoring in these seven
patients was less than 254 minutes with lowest
duration of oximetry monitoring being 224 minutes.
The acquisition rates of interspersed time-points (timepoint being each instance of recorded 30-second tissue
oximetry value) within the two time zones varied from
15% to 65% when patients were being compared based
on type of anesthesia induction (Table 5). Conversely,
the acquisition rates varied from 14% to 77% when
patients were being compared for the differences
in their cerebral oximetry vs. their renal oximetry
(Table 6). However, in spite of varied acquisition
rates for oximetry data, the overall statistical powers
were adequate (1-β ≥ 0.7) (Figures 2-5) except for
M.E.J. ANESTH 22 (5), 2014
462
Gupta d. et. al
Fig. 2
Absolute Number Changes in Tissue Oximetry over Time in the First 127 Minutes of Anesthesia
Fig. 3
Percent Changes from the Pre-Induction Baseline in Tissue Oximetry over Time in the First 127 Minutes of Anesthesia
Cerebral “Hyperoxygenation” with Inhalational Induction of Anesthesia in Children: A
Retrospective Comparison between Vasoparalytic Sevoflurane vs. Vasoneutral Fentanyl
463
Fig. 4
Absolute Number Changes in Tissue Oximetry over Time in the Last 127 Minutes of Anesthesia
Fig. 5
Percent Changes from the Pre-Induction Baseline in Tissue Oximetry over Time in the Last 127 Minutes of Anesthesia
M.E.J. ANESTH 22 (5), 2014
464
comparisons of cerebral and renal oximetry in last
127 minutes time-zone for fentanyl induction patients
[Figures 4(d), 5(d)] where statistical powers were
inadequate (1-β <0.3).
Per oximetry assessment, the final significant
results as depicted in Figures 2-5 were as follows: (i)
cerebral and renal “hyperoxygenation” occurs during
first 127 minutes with sevoflurane as compared to
fentanyl [Figure 2(a-b)] though percentage changes
from pre-induction values in oximetry during this time
did not reach level of significance [Figure 3(a-b)], and
(ii) cerebral “hyperoxygenation” persisted (absolute
and percentage changes) in the last 127 minutes when
patients were induced with sevoflurane as compared to
fentanyl [Figures 4(a), 5(a)].
Discussion
As elicited in our previous case series
discussion1, this current retrospective review takes
the next step in confirming our hypothesis that
cerebral “hyperoxygenation” occurs with inhalational
induction of anesthesia with sevoflurane. This
“hyperoxygenation” per cerebral oximetry may be
reflecting the disproportionately increased delivery
of oxygen to the cerebrum secondary to sevoflurane’s
vasodilatory properties and decreased consumption
of oxygen by cerebrum secondary to sevoflurane’s
anesthetic properties-related decreased cerebral
metabolic rates. Consequently, cerebral oxygen levels
are above normal after sevoflurane induction and
they remain elevated most likely due to additive (and
similar) vasodilatory and anesthetic effects of slowly
accumulating maintenance inhalational agents (usually
isoflurane) despite dissipating vasodilatory effect of
high-doses of sevoflurane used during inhalational
induction of anesthesia.
In
our
case
series
discussion,
this
“hyperoxygenation” was termed as luxury
oxygenation1 with sevoflurane as compared to cerebrovasoconstrictive propofol. However, after completing
the analysis for this retrospective review, we observed
that this relative luxury oxygenation was also present
(with good degree of statistical significance) when
compared with fentanyl as induction agent that is
considered vaso-neutral as compared to propofol
Gupta d. et. al
and sevoflurane. Moreover, significant cerebral
“hyperoxygenation” with sevoflurane as compared
to fentanyl persisted at the end of cardiac surgery
as compared to insignificantly different renal
“hyperoxygenation” between sevoflurane and fentanyl.
This can only be explained by innate physiological
differences in the way cerebral and renal (somatic)
tissues behave when exposed to inhalational agents.
The “hyperoxygenating” changes were unique to
cerebrum compared to kidney (somatic tissue) because
there were significant differences in the patterns of
cerebral oximetry changes vs. renal oximetry changes
over time [Figures 2(c-d), 3(c-d), 4(c), 5(c)] wherein
cerebral oximetry values attempted to recover back
closer to pre-induction values at the end of cardiac
surgery as compared to renal oximetry values that
remained elevated (and higher than cerebral oximetry
values) once elevated in the initial stages of the
cardiac surgery. The innate physiological behavior
where renal “hyperoxygenation” did not attempt to
recover to baseline values at the end of the surgery
as compared to cerebral “hyperoxygenation” may be
possibly explained by underlying relative plasticity of
renal (somatic) vasculature as compared to underlying
relative dynamicity of cerebral vasculature.
Although cerebral “hyperoxygenation” attempted
to recover closer to baseline pre-induction values at the
time of skin closure, these attempts reflecting return
of cerebral vaso-reactivity were incompletely possible
from the state of maximal vasodilatation induced by
high doses of sevoflurane induction. Hence, it was
observed that cerebral “hyperoxygenation” induced by
sevoflurane was significantly different as compared to
that was induced by fentanyl. Although the standard of
practice to use isoflurane as maintenance inhalational
agent might have contributed to additional cerebral
“hyperoxygenation” after induction of anesthesia with
either sevoflurane or fentanyl, this additional cerebral
“hyperoxygenation” could not bridge/overcome the
initial differences in cerebral oxygen levels attained
secondary to anesthesia induction agents (sevoflurane
and fentanyl). As renal (somatic) “hyperoxygenation”
behaved differently than cerebral “hyperoxygenation”
by being higher at most of the analyzed time-points,
it can be safely said that this “dynamic” cerebral
“hyperoxygenation” cannot be attributed to forehead
skin’s “plastic” vaso-reactivity to inhalational agents
Cerebral “Hyperoxygenation” with Inhalational Induction of Anesthesia in Children: A
Retrospective Comparison between Vasoparalytic Sevoflurane vs. Vasoneutral Fentanyl
that would have been similar in time-trend patterns to
“plastic” renal (somatic) “hyperoxygenation”.
Although
cardiopulmonary
bypass
and
anesthesia durations did not significantly induce
changes in the end values of tissue oximetry, it can
be subjectively seen in Figures 4(a) and 5(a) that the
sudden appearance of step-up in the middle of absolute
cerebral oximetry’s graph (for both sevoflurane and
fentanyl) was approximate reflection of the timeframe when patients would have been weaning from
cardiopulmonary bypass machine. It is interesting
to observe that similar step-up was absent in the
absolute renal oximetry’s graph [Figures 4(b), 5(b)]
suggesting that cerebral oxygenation recovery curve
from cardiopulmonary bypass behave differently from
renal (somatic) oxygenation recovery curve. It would
have been interesting to segregate the time zones into
pre-bypass, intra-bypass and post-bypass periods for
evaluating any time-zone-specific tissue oximetry
changes; however, the stored computerized database
did not have saved snapshot times of initiation and
culmination of cardiopulmonary bypass period thus
precluding the division into abovementioned three
time-zones for statistical comparisons.
This retrospective review has a few limitations.
Although this review affirmed the presence of cerebral
“hyperoxygenation” with sevoflurane, how this level
of cerebral “hyperoxygenation” will affect the young
patients’ brain remains unknown and un-quantified.
Although oxygen toxicity has been known to medical
community for decades3-6 with new concerns about
its relation to neuro-apoptosis7, the direct cellular
and clinical effects of cerebral “hyperoxygenation”
elicited per cerebral oximetry will require laboratory
investigations and randomized controlled trials
respectively to affirm and validate our results. Future
trials will also need to comprehensively investigate
465
the confounding factors that were not included in our
current study due to retrospective review’s logistics.
These confounding factors would have been (but
not limited to) presence of cardio-pulmonary shunts,
sequential arterial blood gas parameters, coagulation
characteristics, hemoglobin and hematocrit levels,
bilirubin levels, vaso-active medications use,
intracranial pathologies, and volume status of the
patients.
Conclusion
Cerebral “hyperoxygenation” occurs with
inhalational induction of anesthesia with vasoparalytic
sevoflurane in children 0 to 4 years of age when
compared to anesthesia induction with vasoneutral
fentanyl.
Acknowledgement
The authors sincerely acknowledge the support
and efforts of Henry L. Walters III, MD, Chief,
Cardiovascular Surgery, Children’s Hospital of
Michigan and Grant C. Whittlesey, CCP, Director,
Pediatric Perfusion, Children’s Hospital of Michigan
in supporting this anesthesiology research by sharing
computerized oximetry and recorded perfusion
databases. The authors also acknowledge Wayne State
University Anesthesiology Faculty namely Edward
Kaminski, MD, Jaspreet Sangha, MD and Harold
Michael Marsh, MBBS for their input and guidance.
Finally, the authors acknowledge the efforts of Eric
Nowicki, Medical Student during data collection and
George Mckelvey, PhD during statistical calculations
and analysis.
M.E.J. ANESTH 22 (5), 2014
466
Gupta d. et. al
References
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brains? [about 1 screen]. Available from: http://www.fda.gov/
ForConsumers/ConsumerUpdates/ucm364078.htm
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oxidant effects of normobaric hyperoxia in rat tissues. Acta Physiol
Scand; 1992, 145: 151-7.
5. Masamoto K, Tanishita K: Oxygen transport in brain tissue. J
Biomech Eng; 2009, 131:074002.
6. Allen BW, Demchenko IT, Piantadosi CA: Two faces of nitric
oxide: implications for cellular mechanisms of oxygen toxicity. J
Appl Physiol; 2009, 106: 662-7.
7. Sifringer M, Brait D, Weichelt U, Zimmerman G, Endesfelder
S, Brehmer F, Von Haefen C, Friedman A, Soreq H, Bendix I,
Gerstner B, Felderhoff-Mueser U: Erythropoietin attenuates
hyperoxia-induced oxidative stress in the developing rat brain.
Brain Behav Immun; 2010, 24:792-9.
Comparison between intravenous patient
controlled analgesia and patient
controlled epidural analgesia in cirrhotic
patients after hepatic resection
Nirmeen A. Fayed*, Hatem B. Abo El-Wafa**, Nahla M. Gab-Alla*,
Khaled A. Yassen* and Mamdouh E. Lotfy**
Abstract
Background: Postoperative pain is one of the most important problems that confront surgical
patients. The aim of this work is to compare pain control using intravenous patient controlled
analgesia (PCA) and patient controlled epidural analgesia (PCEA) in cirrhotic patients undergoing
elective hepatic resection.
Methods: Thirty four adult patients ASAI and II scheduled for liver resection were randomly
allocated into two groups-Group (P) with I.V (PCA) with fentanyl and Group (E) (PCEA) via
epidural catheter using Bubivacaine 0.125% plus 2 microgram per ml fentanyl. Coagulation
changes were followed and pain score was compared in both groups.
Results: 34 child A cirrhotic patients, undergoing liver resection were studied. The
demographic data were comparable in both groups. There was a significant decrease in pain score
in both groups during the follow up period when compared to their initial score. When comparing
average pain score between both groups, the PCEA group had significantly lower values. The
changes in prothrombin time (PT), INR, and hemoglobin (Hb), were significant all over the follow
up period compared to their corresponding base line values. 2 cases needed FFP to normalize the
INR for epidural removal. There was no significant difference regarding postoperative nausea and
vomiting (PONV) in both groups, no clinical manifestation suggesting epidural hematoma, and no
cases were recorded to have respiratory depression. There were no significant differences in patient
satisfaction and ICU stay.
Conclusion: The two modalities of pain control seems to be nearly equivalent, but considering
the risk of epidural catheter insertion and removal in cirrhotic patients who are further exposed to
hepatectomy with subsequent additional coagulopathy, it may be wise to consider IVPCA technique
as a policy for pain management in cirrhotic patient undergoing hepatectomy.
Keywords: Post-operative pain, liver resection, Patient controlled intravenus analgesia,
Patient controlled epidural analgesia.
*National Liver Institute.
**Faculty of medicine.
Affiliation: Anaesthesiology and intensive care unit, Menoufyia University, Shebein Al-Koom.
Corresponding author: Nirmeen Fayed; Anesthesiology and intensive care department, National Liver Institute, Menoufyia
University, Shebein Al- Koom, Egypt, Tel: 00201113320976. E-mail: [email protected]
467
M.E.J. ANESTH 22 (5), 2014
468
Introduction
Postoperative pain is one of the most important
complications that confront surgical patients. The aim
of postoperative pain treatment is to provide subjective
comfort in addition to inhibiting trauma-induced
nocioceptive impulses in order to blunt autonomic and
somatic reflex responses to pain and subsequently to
enhance restoration of function by allowing the patient
to breathe, cough and move more easily1-3. Liver
resection is used with increasing frequency for treating
primary neoplasms of the liver, which are frequently
related to liver cirrhosis. It has been assumed that
sufficient pain relief will improve the surgical outcome
with reduced morbidity, need for hospitalization and
convalescence1,4. Postoperative analgesia in cirrhotic
patients remains a challenge, mainly because of the
narrow dose range between the analgesic and side
effects of drugs used,1 in addition to alteration of the
endogenous opioid system which have been reported in
patients with liver disease2,5. Epidural analgesia is one
of the best methods for the provision of postoperative
pain relief in patients recovering from major upper
abdominal operations. Being an invasive technique,
epidural analgesia carries an inherent risk of several
complications. Also the remaining liver’s capacity
to produce clotting factors is decreased for several
days following resection which makes the epidural
analgesia of concern3,6. Among the most commonly
used pain-relieving techniques is patient-controlled
intravenous analgesia (PCA) with opioids which may
be an attractive alternative in this category of patients
in whom epidural may carry possible risks. This study
aims to compare epidural versus intravenous patient
controlled analgesia in cirrhotic patients undergoing
hepatic reactions.
Methods
This study was approved by of the local ethical
committee and a written informed consent was
obtained from each patient. Thirty-four patients ASA I
and II, Child A cirrhotic patients, who were undergoing
major liver resection, were classified into two groups:
Group (P) received intravenous patient
controlled analgesia (PCA) with fentanyl while Group
fayed n. a. et. al
(E) received patient-controlled epidural analgesia
(PCEA) with Bubivacaine 0.125% plus 2 microgram
per ml fentanyl. All surgeries were performed under
standardized general anesthesia.
Patients included in the study are of 25 years or
older, not on anticoagulant therapy and undergoing
major hepatic resection surgery for tumor removal.
Exclusion criteria included failure of the surgery to
proceed as planned, development of post operative
complications limiting assessment, objection to
an epidural catheter or inability to use PCA pump,
postoperative need for mechanical ventilation, patients
having contraindication to regional technique as
infection and anatomical spinal abnormality and
preexisting severe pulmonary or psychiatric diseases.
In group (E) epidural catheters were placed at
(T11-l2) interspaces while the patient is awake before
anesthesia, in sitting position using loss of resistance
to air technique and a median approach using an 18G
touhy needle and a 20G epidural catheter after negative
suction of blood and cerebrospinal fluid. A test dose of
lidocaine 2% (total test dose of 3ml) was injected. All
PCEA pumps were programmed for a basal infusion
rate of 6 ml/hr and a patient-activated bolus of 3ml
every 15 minutes. All PCEA were initiated within first
2 hours after induction at a basal rate only.
Patients in group (P) with IVPCA were well
educated about the pump with detailed description of
the plan of pain management. An I.V line was inserted
and fentanyl 15 μg bolus was injected with 10 min lock
out interval, 90 μg/hr maximum and no back ground
infusion.
General anesthesia was induced on for all patients
with fentanyl (1-2 μg/kg), propofol (1-2 ml/kg), and
rocronium (0.6 ml/kg) and after intubation anesthesia
was maintained with isoflurane in a 50% oxygen-air.
IV muscle relaxant was administered as appropriate.
Intra operative monitoring included ECG,
pulse oximetry, capnography, fraction of inspired
O2, body temperature, urine output, central venous
pressure (C.V.P), and blood pressure. Tidal volume
and ventillatory rate were adjusted to maintain end
tidal CO2 between 35-40 mmHg. Intra operative
hypothermia was prevented by forced air surface
warming (Model 750-Bair Hugger Temperature
Management Unit, Arizant Healthcare Inc, USA).
Comparison between intravenous patient controlled analgesia and patient controlled
epidural analgesia in cirrhotic patients after hepatic resection
At the end of surgery, all patients were awakened
and extubated in the operating room and transferred
to the surgical intensive care unit. Data collected
included age, sex, surgery performed, length of
surgery, intra- operative blood products requirements,
hospital and I.C.U. length of stay and day of epidural
catheter removal. Epidural catheters were removed
when platelet count was more than 80 x 109 and
INR <1.4. All patients were contionously observed
for clinical signs of spinal cord compression. Blood
tests, including complete blood count, prothrombin
time (PT), activated partial thromboplastin time, were
determined preoperatively, immediately on admission
to the recovery room and the third postoperative day
(POD).
Base line heart rate and non-invassive blood
pressure were continuously monitored.
Post operative pain was assessed by a10cm visual
analogue scale (VAS) (0 to 10) 0 no pain, and 10 worst
pain at rest and during movements (inspiration and
cough). Side effects such as nausea, vomiting and were
also noted.
The primary out-come was to compare both
techniques regarding pain control. Secondary outcomes
included evaluation of complications such as sedation,
nausea, vomiting, urinary retention, post operative
pulmonary complications, epidural neurological
complications, return of bowel function and the length
of intensive care and hospital stay.
Statistical procedure
Data was statistically analyzed using SPSS
(statistical package for social science) program version
13 for windows and Epi info program version for all the
analysis a p value <0.05 was considered statistically
significant:
- Data are shown as mean, range or value and
95% confidence interval (95% CI) and frequency and
percent.
- Fischer exact test for 2 × 2 tables when expected
cell count of more than 25% of cases was less than 5
and p-value <0.05 was considered significant.
- Student t-test was done for normally distributed
quantitative variables to measure mean and standard
469
deviation and p-value <0.05 was considered significant.
- Mann-Whitney test was done for quantitative
variables which are not normally distributed and
p-value <0.05 was considered significant.
- Paired t test was done to detect mean and
standard deviation of normally distributed pre and
post values of the same variable of the same group of
patients and p-value <0.05 was considered significant.
- Wilcoxon test was done to detect mean and
standard deviation of not normally distributed pre and
post values of the same variable of the same group of
patients and p-value <0.05 was considered significant.
- Repeated measures ANOVA test was performed
to differentiate changes in different follow up results
of normally distributed studied variables and p-value
<0.05 was considered significant.
- Friedman test was performed to differentiate
changes in different follow up results of different
studied variables and p-value <0.05 was considered
significant.
All data are tested with kolmogorov-Smirnov Z
test and most of them were found normally distributed
and so presented with mean ± SD; and using parametric
testes on doing association or correlation.
17 patients in arm 1 with intravenous PCA and
17 patients in arm 2 with PCEA were recruited based
on the following assumptions: with the power of 80 %,
α = 0.05 and the ratio of cases to controls = 1:1. The
required sample size was determined using PS (power
and sample size calculation) software.
Results
Patients’ characteristics and operative data are
shown in Table 1. The mean arterial blood pressure
and heart rat tended to be better controlled in IVPCA
group however the comparison was statistically
insignificant (P value >0.05) when comparing both
groups. PCEA and IV PCA were found to be similar
and effective in pain control at rest during the first
three days postoperatively, Mean intensity of pain
on a numerical analogue scale (0-10) at rest on day
1 was 5/10, day 2 was 3/10, and day 3 was 2/10, but
on cough both groups suffered out breaks of pain on
M.E.J. ANESTH 22 (5), 2014
470
fayed n. a. et. al
Table 1
Patient characteristics (mean +/- SD)
Table 3
Sedation score of both groups on POD1
IVPCA
(n = 17)
PCEA
(n = 17)
Age (years)
50.1 +/- 9.7
50.8 +/- 11.5
Sex (M/F)
10/7
15/2
81.7 +/- 15.7
78.8 +/- 14.8
Right hepatectomy
(focal lesion)
6/35.3
10/58.8
Right hepatectomy +
left radiofrequency (focal
lesion)
3/17.6
0/0
Left hepatectomy (focal
lesion)
6/35.3
4/23.5
Right hepatectomy
(Cyst)
2/11.8
1/5.9
Left hepatectomy
(hydatid)
0/0
1/5.9
Right hepatectomy
(Haemangioma)
0/0
1/5.9
Weight (Kg)
Type of operation (n / %)
Data are presented as Mean +/- SD, Student t-test was used
comparing age, weight, Intensive care unit; ICU stay between
groups; p >0.05 considered not significant.
first day that needed intravenous meperidine. On day
2 and 3; patients of PCEA group suffered less pain
during cough (Table 2). Postoperative sedation score
showed significant difference between both groups
during the first day followed by a significant mean
Table 2
Post-operative pain score on cough Mean +/- SD
Time
Studied
variables
Groups
Mean +/ - SD
Sedation score
IVPCA
3.6 (0.51)
PCEA
2.94 (1.14)*
Data are presented as Mean (SD), Mann Whitney test was used
comparing sedation score, POD1; postoperative day 1,* P <0.05
was considered significant.
decrease in score by 2nd and 3rd days post operatively
in the IVPCA group (Table 3). Four out of 17 cases
in the epidural group complained of bilateral lower
limb numbness during the first postoperative day in
the PCEA group, due to the established epidural block,
but only one patient developed moderate motor block
and in this sole case the epidural infusion was stopped
with close follow up of the motor status. Regarding the
coagulation changes, there was significant increase in
INR and prothrombin time, with peak changes at the
3rd POD with no significant changes in platelets count
when compared to corresponding base line values in
both groups. The mean time for the epidural catheter
stay was 5.88 ± 1.27 days before removal; two cases
demanded the infusion of fresh frozen plasma units
before removal in order to achieve acceptable level
of the prolonged prothrombin time and elevated INR.
Patients in the PCEA group were less sedated and had
fewer incidences of side effects as nausea/vomiting.
Table 4
Drug consumption differences all over the follow up period
in intravenous fentanyl patient controlled analgesia group
(IVPCA)
IVPCA (n = 17)
PCEA (n = 17)
2hrs POD1
3.18 0.81
3.82 (1.13)
Studied variable
8hrs POD1
6.35 (0.78)
6.59 (0.79)
12hrs POD1
6.76 (0.66)
7.00 (0.71)
24hrs POD1
6.61 (0.69)
6.29 (0.68)
POD2
6.59 (0.94)
5.65 (1.22)*
POD3
6.00 +/- 1.12
4.47 +/- 1.26**
Data are presented as Mean +/- SD, student t-test was used for
postoperative pain score, *P <0.05 is considered significant and
**P <0.01 is considered highly significant, POD; postoperative day.
D1
D2
D3
Fentanyl (µg)
1255.6
(287.2)
1318.3
(413.3)*
1163.1
(398.5)**
Bolus number
121.3
(26.4)
136.3
(31.7)*
112.6
(23.2)*
Demand
number
83.7
(19.1)
85.2
(28.1)
77.9
(25.9)
Paired t-test was used in fentanyl, bolus and demand to study
differences, * indicates statistically significant difference (P
<0.05) and ** indicates highly significant difference (P <0.01).
Comparison between intravenous patient controlled analgesia and patient controlled
epidural analgesia in cirrhotic patients after hepatic resection
Table 5
Drug consumption differences all over the follow up period in
patient controlled epidural analgesia (PCEA)
Studied
variable
D1
D2
D3
Marcaine (ml)
352.6
(101.5)
411.6
(183.7)**
362.4
(92.1)
Fentanyl (μg)
575.5
(133.1)
628.6
(119.2)**
577.4
(172.8)
Bolus
107.6
(21.2)
99.5
(21.9)
87.4
(27.7)**
Demand #
60.9
(17.8)
55.5
(24.3)
52.7
(18.6)
Data are presented as Mean (SD), repeated measures ANOVA
test was used for Marcaine, Fentanyl and Bolus, P <0.01 was
considered highly significant. # Wilcoxon test was used for
Demand. Paired t-test was used in Bubivacaine, fentanyl and
bolus to study differences with day 1, P <0.05 was considered
significant.
Table 6
Satisfaction score analysis differences between patients of both
groups
Satisfaction score
IVPCA
PCEA
excellent
2 (11.7)
4 (23.5)
good
7 (41.2)
8 (47.1)
fair
8 (47.1)
5 (29.4)
poor
0 (0.0)
0 (0.0)
Data are presented as number (%), Chi square test; X² was used,
P-value >0.05 was considered not significant.
There was an increase in the amount of fentanyl used
by patients in the IVPCA group by the second day post
operatively followed by a decrease in the third day,
matching with the PCA boluses and demands trends.
The demand (number of button pushes by the patient)
increase in the second day post operatively followed by
a decrease in the third day, as shown in Table 4. Table 5
data presented the amount of Bubivacaine and fentanyl
used by the patients in the PCEA group throughout the
follow up period. No significant difference as regard
the satisfaction assessment of both groups was reported
(Table 6).
471
Discussion
The main finding of our study was that both PCEA
and IV PCA can provide complete control of pain at
rest; however, upon movement and coughing PCEA
was superior to IV PCEA. Finally, both techniques
were equivalent as to patients’ satisfactions.
In this study, the pain control was effective and
similar during the first postoperative day between
PCEA and IV PCA groups, but during movement
and on cough both were not efficient enough to
control the pain, which mandates use extra analgesic
supplementation in both techniques. Both groups
required the use of analgesia by the second day more
than the first day that may be due to the decline of
the residual anesthetic effect and/or the increased
frequency of movement and physiotherapy during the
second day. By the third day the need for analgesia
decreased in both groups and this could be attributed to
the normal sequel of the decrease in the stress response.
The PCEA group showed a gradual decrease in
VAS score on movement during the follow up period
on the 2nd and 3rd post operative days, with less bolus
and less demands, but still intravenous opioids were
needed to cover for the pain outbreaks for several
patients.
No sole technique was able to provide a full
pain relief. A multimodal approach in the form
of intravenous pethedine and paracetamol was
implemented to control pain in 6 out of 17 cases in
PCEA group and in 8 out of 17 cases in IVPCA group.
The need for supplementary intravenous opioid with
PCEA is supported by Revie EJ et al7 who found that
20% of patients undergoing open liver resection with
epidural analgesia for postoperative pain requested
additional intravenous opioids for pain control.
The use of continuous background infusion
in the PCEA group in this study to reduce the pain
on day 2 and 3 was reported also by Komatsu et al
and Vercauteree et al who found that the use of a
background infusion of a mixture of bupivacaine
and fentanyl reduced the incidence of postoperative
pain significantly in particular the pain associated
with cough and movement after upper abdominal
surgery8.The option of using a back ground infusion
of fentanyl in the IVPCA group was omitted for fear of
M.E.J. ANESTH 22 (5), 2014
472
fayed n. a. et. al
side effects in particular respiratory depression in this
group of cirrhotic patients undergoing liver surgery
and expecting a possible temporary postoperative liver
dysfunction as reported previously10.
level allowing epidural catheter removal. None of the
cases developed any clinical manifestation suspecting
epidural hematoma or showed signs of neurological
deficits.
Previous studies reported effective pain control
when a multimodal approach for post-operative pain
control was adopted11,12.
These results were similar and in agreement
with the study by Schumann et al17 which also showed
a transient postoperative coagulopathy after liver
resection among their healthy liver patients.
Katz et al13 added intrathecal morphine and
fentanyl with bupivicaine for post-operative pain
control and achieved better results with reduction in
IV morphine consumption postoperatively. But, as
reported by several previous studies, pain management
of post liver resection is sometimes difficult to control
and out breaks of pain can be reported in particular
with early ambulation and physiotherapy which will
need additional IV opioids, but the rate of consumption
is significantly reduced if a planned multimodal
analgesic technique is adopted14. The relatively less
pain score in PCEA group compared with IVPCA
group may also be due to the combined use of local
anesthetic with opioid. Brodner et al15 reported that the
production of the proinflammatory cytokines IL-1ß
and IL-6 was more increased in the intravenous PCA
group compared with the PCEA group, especially at 24
hours after surgery. This may be attributed to the local
anesthetics effect which can reduce the postoperative
inflammatory response in two ways: first blocking
neural transmission at the site of tissue injury and
thus may attenuate the neurogenic inflammation,
second, having systemic anti-inflammatory properties
of their own. This has been proved through reducing
the postoperative inflammatory index in patients with
continuous epidural analgesia, consisting of local
anesthetics and opiates16.
The use of an epidural catheter in patients
undergoing resection remains controversial because of
the postoperative changes in the coagulation profiles
of these patients suffering from hepatic cirrhosis which
are further aggravated by the effect of liver resection.
The prolongation of the prothrombin time and
increase in INR were reported in this study, INR
increased gradually till the third day and began to
normalize by the fifth or the sixth day, which delayed
the epidural removal till the 5th and even the 7th day
postoperatively in some cases. Two cases needed fresh
frozen plasma to help reduce INR to an acceptable
Matot I et al18 also showed the same findings
with a conclusion that the extent of liver resection may
affect the magnitude and duration of postoperative
coagulation disturbances and, therefore, they
concluded that the proper timing of epidural catheter
removal need also to be revised with the coagulation
laboratory results day by day before removal.
Tran SB et al19 also documented that in healthy
livers subjected to minor liver resection the PT returns
to a normal value in one to two days, while in major
resection it might need up to 5 days to normalize. All
the previous factors may account for a delay of removal
of the epidural catheter until day 7 and for the need
for fresh frozen plasma transfusion in some cases as
reported by the current study and the study of Tran SB.
Most of cases in this study started oral sips of
water and juice by the 1st day post operatively. The
incidence of nausea and vomiting in this study was
(3/17) in the IVPCA group and (1/17) in the PCEA
group, few cases needed medical intervention for
symptomatic relief, this may be attributed to the choice
of using fentanyl in both groups which is known to
have a lower incidence of post operative nausea and
vomiting than morphine. This was in agreement with
Koo PJ, et al20 and Rob et al21. Studies which found
that IV PCA fentanyl have a significant lower rate of
common opioid side effects (nausea/vomiting) when
compared to other methods of analgesia.
In contrast, Bozkurt P et al22 has reported a
higher incidence of nausea and vomiting in children
after epidural opioids of approximately 30%, and 87%
with IV PCA.. This higher incidence may be due to
the different patient populations. This age category
variation in incidence was supported by Leman et al23
who reported that children have an average vomiting
incidence more than 40% almost twice as frequent as
the rate in adults and the incidence tapers by reaching
puberty.
Comparison between intravenous patient controlled analgesia and patient controlled
epidural analgesia in cirrhotic patients after hepatic resection
Epidural analgesia with local anesthetics offers
potential means to attenuate several mechanisms of
postoperative ileus. Sympathetic block from epidural
local anesthetics may help attenuate postoperative
reflex inhibition of GI motility. Suppression of the
surgical stress response and systemic absorption of
epidural local anesthetics may reduce the inflammatory
response and attenuate the postoperative ileus. Both
postoperative pain and use of systemic opioids increase
the risk of ileus. In Consistent with these mechanisms,
experimental data indicates that epidural analgesia with
local anesthetics shortens time of intestinal paralysis,
increases the strength of colonic contractions, and
does not impair anastomotic healing or increase risk of
anastmotic leakage24,25.
The level of the epidural catheter was intended
to be thoracic to keep its tip in the target dermatome
for perfect pain control especially with using fentanyl,
sparing of lumbosacral segments to minimize urinary
retention and limit motor effects as reported by Basse
et al26.
In this study, urinary retention as an expected
complication could not be assessed due to the presence
of a urinary catheter.
In agreement with Veering BT et al study27,
patients in the epidural group showed better control
of systolic blood pressure and heart rate than in the
IVPCA group, which may be due to a better pain
control.
Respiratory depression in patients undergoing
major upper abdominal surgery is of great concern
due to impaired of diaphragmatic, intercostal, and
abdominal muscle functions and in case of inadequate
analgesia the tidal volume will be also further reduced,
hence an adequate pain control is of a major priority.
In this study we did not record any manifestations
of respiratory depression as assessed by continuous
monitoring of respiratory rate, oxygen saturation,
and degree of consciousness in both groups and no
naloxone was required.
In the study by Wu CL28 epidural modality
conferred superior analgesia compared with that
from systemic opioids including IVPCA, which may
improve voluntary respiratory function. Segmental
block from thoracic epidural anesthesia may result in
increased tidal volume and vital capacity related in
473
part to improved pain control and also to interruption
of the reflex inhibition of phrenic nerve activity, thus
improving diaphragmatic activity. However, effects
from the typical dilute solutions of local anesthetics
and opioids used for thoracic epidural analgesia (TEA)
are unclear. It has also been demonstrated that TEA
with bupivacaine 0.25% does not impair ventilatory
mechanics, respiratory muscle strength, or airway
flow even in patients with severe chronic obstructive
pulmonary disease29.
Various degrees of sedation in the post-operative
period in cirrhotic patients have to be expected due to
use of opioids. Our patients were closely monitored
with sedation score. There was a significant degree
of sedation all over the study period in both groups
with highest score during the 1st day which could
be attributed to the residual effect of the general
anaesthetic agents and intra operative opioids used,
the following declining in scores was associated with
a decrease in severity of pain during the following
postoperative days and subsequent decrease in drug
consumption. Trends of sedation were higher in IVPCA
group as expected with the use of IV opioids, with no
recorded deep sedation as indicated by absence of any
manifestation of respiratory depression. Butkovic, et
al30 found that the type of analgesia either IVPCA or
PCEA has no effect on the Ramsay sedation score,
implying that both analgesic regimes produced the
same level of sedation, however, a meta-analysis
of several different studies found less respiratory
depression with administration of continuous epidural
opioids compared with parentral opioids31.
In order to encourage early mobilization and
achieve patient satisfaction and pain relief, a local
anesthetic concentration of 0.125% was used in PCEA
group to reduce possible motor weakness, however
4 out of 17 cases complained of bilateral lower limb
numbness on the first postoperative day. Only one
patient developed moderate motor block and the
epidural infusion was stopped with close follow up
of the motor status. Christopher32 reported better pain
relief at the expense of higher incidence of motor
block with the use of continuous epidural analgesia
compared with PCEA. John et al33 correlated the
density and duration of block with the concentration
of the local anesthetic as both the 0.125% and 0.25%
M.E.J. ANESTH 22 (5), 2014
474
groups had significantly denser maximum motor
blockade than the 0.0625% group, indicating a degree
of dose-dependent response. In this study the effect
of various concentrations of bupivacaine was not
evaluated, as the study was restricted to one protocol;
however pain control and degree of motor and sensory
block were acceptable.
In a study by Pitimana et al34, the satisfaction
analysis indicated excellent score in 11%patients of
IVPCA and 23% of PCEA group undergoing total knee
replacement, this difference may be because of the
ability of epidural analgesia to promote patient well
being in the form of better pain control particularly
on movement, faster recovery of bowel function and
earlier patient mobility, but this did not alter the ICU
stay when compared to the PCA group35.
In another study by Butkovic et al30 IVPCA
with fentanyl was as effective as epidural block
with bupivacaine and fentanyl in controlling the
postoperative pain of children after thoracoscopic
surgery for pectus excavatum repair.
One study found no significant differences in
patients’ satisfaction after living donor liver resection
in those receiving either IVPCA opioids or PCEA,
also the authors warned from the post operative
coagulopathy that may affect the removal of the
catheter36.
In our study, there was no evident clinical
significance between the two techniques regarding
the efficacy in pain control during rest, but not on
fayed n. a. et. al
movement. There were no differences as well in the
severity of any complications including sedation,
respiratory and GIT side effects apart from sedation
during the first day post operatively. In view of the
choice of a safer method to control pain in cirrhotic
patients it may be wise to recommend IVPCA in order
to avoid the remote incidence of epidural hematoma
which may be more prevalent with post liver resection
associated coagulopathy particularly when it is not
possible to assess the neurological condition of the
patients during the long hours of the surgery until
recovery.
One of the limitations of the current study is the
inability to alter the settings of the PCA pumps for both
groups during the course of the study period and the
inability to modulate the Bupivacaine concentration.
Also, the use of background infusion in cirrhotic
patients and their safety need to be studied in further
planed research work. Conclusion: IVPCA with
fentanyl was used with no reported side effects in
Child A cirrhotic patients. Also, PCEA was delivered
safely with no clinical evidence of epidural hematoma,
but in view of the associated coagulation changes in
conventional tests, it seems wiser to recommend the
IVPCA opioids for cirrhotic patients. A multimodal
approach is recommended as no sole technique was
enough to control out breaks of pain for such a surgical
procedure. Each patient should be informed and
consented before surgery about pros and cons of the
two techniques and risks weighed against benefits.
Comparison between intravenous patient controlled analgesia and patient controlled
epidural analgesia in cirrhotic patients after hepatic resection
475
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36.Jean-Denis R, Luc Massicotte A: Comparison of Intrathecal
Morphine/Fentanyl and Patient-Controlled Analgesia with PatientControlled Analgesia Alone for Analgesia After Liver Resection.
Anes Analg; 2006, 103:990-994.
Simulation Training in Endotracheal
Intubation in a Pediatric Residency
Rana Sharara-Chami*, Sahar Taher**, Roland Kaddoum***,
Hani Tamim**** and Lama Charafeddine*
Abstract
Background: Airway management and endotracheal intubation are essential skills for
pediatric residents. Simulation-based technology is used for training residents but it remains
unclear whether high fidelity simulation results in better retention of skills compared to low
fidelity. The study assesses high fidelity simulation of endotracheal intubation and traditional low
fidelity training in improving pediatric residents’ knowledge retention and technical skills; and if
the difference translates into higher “real time” intubation success rates.
Methods: Second and third year pediatric residents were randomized into high fidelity
(intervention) or low fidelity simulation (control) groups. Airway management and intubation skills
were taught using a didactic lecture and demonstration on low fidelity mannequins. Knowledge
was assessed before randomization (T0) and 6 months after training (T6). Other outcome measures
were: 1) airway management and intubation skills at T6 and T12 (12 months later) and 2) successful
intubation of actual patients by T12.
Results: 10 out of 11 residents completed the intervention. Theoretical knowledge improved
for both groups. Participants made less mistakes (M) overtime: M (T0) =3.2 and M (T6) =2.6 for
the intervention group, and M (T0) =4 and M (T6) =2.40 for the control. There was no significant
effect of fidelity on intubation skills or the number of successful intubations recorded in logbooks
(all p >0.05). In some instances intubation skills showed regression over time.
Conclusion: High fidelity simulation showed no impact on residents’ airway management
and intubation skills. Retention of theoretical knowledge persisted over time while practical skills
remained at baseline or declined.
Keywords: simulation, resident education, intubation skills, knowledge assessment.
*
MD, Department of Pediatrics and Adolescent Medicine.
** BA, Department of Psychology.
*** MD, Department of Anesthesia.
****PhD, Department of Internal Medicine, Biostatistics Unit, Clinical Research Institute; Affiliation: American University of
Beirut.
Corresponding author: Lama Charafeddine, MD, FAAP; Department of Pediatrics and Adolescent Medicine; American
University of Beirut Medical Center; P.O. Box: 11-0236. Riad El-Solh 1107 2020; Beirut-Lebanon. Tel: +9611350000.
E-mail: [email protected]
477
M.E.J. ANESTH 22 (5), 2014
478
Introduction
Pediatric airway management is one of the most
difficult skills to acquire during residency. It includes
bag-mask ventilation, laryngoscope handling and
endotracheal intubation skills. Most cardiac arrests
in infants are respiratory in origin. Of those children
who experience cardiac arrest in a clinical setting,
75% to 80% survive while those who do not receive
proper intervention have a 5% chance of survival
along with a heavy toll of neurological damage1.
Airway management is therefore a life-saving and
necessary skill and is an integral part of pediatric
training2. Many factors may contribute to a deficient
intubation. Inexperience or improper management
of the airway can cause the patient’s condition to
deteriorate, not the mention the negative effect of the
stressful clinical setting. The success of an intubation
might therefore also require practice in a comfortable
and non-threatening environment where patients are
not at risk so that trainees are more confident in reallife situations.
Residents report feeling inadequately prepared
when it comes to managing such stressful situations
in the clinical setting. At the beginning of their
residency, residents take the Pediatric Advanced Life
Support (PALS) and Neonatal Resuscitation Program
(NRP)3,4,5,6. These educational programs help with
standard training. However, studies have shown that
after one year, retention of knowledge and practical
skills are poor7, and airway intubation skills tend to
deteriorate within a few weeks if not practiced3. In
fact, Nadel et al7 showed that, one year after taking
PALS only 18% of residents could effectively perform
and succeed at an endotracheal intubation. Other
studies suggest also that PALS training is insufficient
for providing residents with the adequate skills,
competence and self-confidence to perform successful
resuscitations3,7,8,1.
Educational programs such as PALS and NRP
offer codes of conduct according to situations but
have shown to come short in building solid skills
for the clinical setting. Furthermore once trained,
the residents do not receive many opportunities to
practice their skills due to the relative infrequency
of such pediatric cardiac arrest in the clinical setting.
sharara chami r. et. al
The need for endotracheal intubation is unlikely to
arise when treating children and the limited residency
training hours make it difficult to acquire expertise in
intubation3,6.
In order to address this need, new educational tools
based on simulation or high-fidelity training have been
used to enhance airway management and intubation
skills of residents. High-fidelity medical simulation
replicates a clinical scenario and helps standardize
the procedure for the individual practicing his or her
own procedural and decision making skills within a
productive anxiety level conducive for learning1,9. The
created environment serves as an acceptable substitute
for the actual clinical setting. In this environment,
residents are given the opportunity to experiment
through trial and error, retry, and practice without
unfavorable outcomes. Simulation training permits
and builds upon a process of learning derived from
concrete experience5, laying foundations for residents
to practice in a supervised, standardized and patientsafe setting10. It allows for retention of knowledge
through practice, and enhances the resident’s sense of
mastery, competence and efficacy11.
Some studies show that residents who were
taught Advanced Cardiac Life Support using highfidelity simulation training performed better than
their counterparts who received solely conventional
training12,13,14. While there is some evidence that clinical
skills are retained for a year after a single simulation
training session8, it is not clear whether improved skill
performance during simulation translates into better
performance during actual patient care.
The purpose of this study was to investigate
whether training of pediatric residents using high
fidelity simulation would result in retention of
knowledge and improved performance during actual
patient care, as compared to the traditional model of
teaching at the American University of Beirut Medical
Centre (AUBMC).
Methods
Study design
Pilot, randomized controlled.
Simulation Training in Endotracheal Intubation in a Pediatric Residency
Setting
Pediatric residency program at a tertiary care
center, the American University of Beirut Medical
Center.
This study was approved by the Institutional
Review Board of the American University of Beirut
and all residents signed a detailed informed consent
before participating in the study.
Participants
Pediatric residents in their second and third
years were recruited to take part in the study. Eleven
consented of which only ten completed the study.
Residents had completed the Pediatric Advanced Life
support (PALS) course and the American Academy
of Pediatrics Neonatal Resuscitation Program (NRP)
course in their first and second year of residency
respectively. Those who consented to participate were
randomized to either receive traditional teaching (low
fidelity assessment method) (N=5) or high fidelity
simulation training and assessment (N=6) in airway
management. None had participated in a high-fidelity
simulation scenario involving endotracheal intubation
prior to the study. Residents had diverse backgrounds,
some having completed their medical studies in the
same institution while others from different institutions
in the same country and other Arab countries.
Inclusion/Exclusion
All residents in their second and third year were
invited to participate in the study. Those who did not
consent were excluded.
Process
A didactic lecture entitled “Pediatric Airway
Management” was presented to all. In order to assess
theoretical knowledge at baseline, all residents were
given a pretest before beginning the lecture. The pretest
was devised as eleven multiple-choice and true/false
questions that were adapted from the official American
Academy of pediatrics NRP and PALS courses. After
collecting the pretest, the residents were given the
479
lecture in addition to a demonstration of an intubation
procedure performed on a low fidelity pediatric
mannequin. This lecture was based on information
found in “The Textbook of Pediatric Intensive Care”15,
the American Academy of Pediatrics and the American
Heart Association resuscitation recommendation
(Pediatric Advanced Life Support). It covered topics on
airway anatomy, basic airway management, intubation
technique and the equipment needed.
After completion of both pretest and lecture,
informed consent forms were distributed and collected.
Only pretests of those participating in the study were
kept.
Intervention
The two groups were invited into the simulation lab
for a first hands-on training session at T0 (beginning of
study), a second training session at T3 (3 months later)
and one last assessment at T6 (6 months later). The
two hands-on training sessions, at T0 and T3 gave the
participants ample time to deliberately practice. Both
groups were exposed to one and the same environment
and used the available equipment, including the same
mannequin (SimBaby the advanced infant patient
simulator from Laerdal and The SimBaby software
Version 1.4.1 EN produced in 2007 both acquired by
HSON in 2009). The mannequin was plugged into the
modem and monitor for the experimental group, hence
becoming a high-fidelity mannequin.
T0 session: The first session proceeded in
different steps. Each participant was individually
invited to the lab for a session of 30 minutes. The
participant was first asked to properly cite the
equipment needed for an intubation of a 6 to 8 month
old infant and to then prepare the material in order to
commence the procedure. The participant was allowed
to practice intubations with direct feedback by a
physician expert in pediatric airway management and
high-fidelity medical simulation (RSC and LC). Two
scenarios were then given in which a final intubation
was needed. The traditional group had the vital signs
and physical exam findings read out by the present
supervisor, while the experimental group used the high
fidelity mannequin. The scenarios were videotaped
without face identification.
M.E.J. ANESTH 22 (5), 2014
480
Logbooks were then distributed to all participating
residents. Residents were asked to log in their book
each intubation procedure whether successful or not.
This measure served as a means to follow up on each
resident to compare the intubation success rate in actual
clinical settings. The logbooks would be collected 6
months later.
sharara chami r. et. al
Fig. 1
Randomization of participants into either high or low fidelity
groups; all participating residents received a lecture and were
subjected to a pretest and each group was given the same
sequence in the intervention phase.
T3 session: A training session was scheduled
3 months later (T3). Residents were invited to
the simulation laboratory to deliberately practice
a minimum of 10 intubations. The control group
practiced on the low fidelity mannequin while the
experimental group practiced on the high-fidelity
mannequin. No scenarios were given.
T6 session: The final phase of the study
consisted of a final hands-on session similar to the
first. Scenarios were read according to each group’s
assignment. The scenarios were videotaped without
face identification. After completing both scenarios,
supervisors debriefed participants and gave them
feedback on their performance. The residents were
asked to reflect on their own performance by watching
it on videotape. They were given the opportunity to
express their feelings and thoughts, contemplating
corrective actions. A posttest was finally given to
all participating residents, and the logbooks were
collected (Figure 1).
Data Collection
A pediatric anesthesiologist (R.K), blinded to
the time of intervention (T0 vs T6) and to the level
of training, reviewed the endotracheal intubation
procedure, captured on videotape during the 2
encounters 6 months apart. Evaluation of the
participants’ skills in proper handling of laryngoscope,
positioning of patient, use of equipment and number of
attempts were all relevant criteria.
Statistical analysis
The Statistical Package for Social Sciences
(SPSS) version 20 was used for the data management
and analyses. Descriptive statistics was carried out
by reporting the number and percent for categorical
variables, whereas the mean, median, range and
standard deviation were reported for continuous
variables. Association between the intervention
group and the different variables was assessed using
non-parametric tests, mainly, Fishers’s Exact test for
categorical variables and the Mann Whitney test for
continuous ones. A p-value of ≤0.05 was considered to
indicate statistical significance.
Results
The sample consisted of seven participants in
their second year of residency and four participants
in their third year. Ten out of the eleven participating
residents completed the project (Table 1). Theoretical
knowledge was assessed at T0 and T6. There was no
effect of fidelity on theoretical knowledge. Theoretical
knowledge improved with time for both groups,
regardless of fidelity. The average number of mistakes
(M) varied for both groups: the intervention group
showed M (T0) =3.2 and M (T6) =2.6 and the control
group showed M (T0) =4.0 and M (T6) =2.4 (Table 2).
There was no significant effect of fidelity on
Simulation Training in Endotracheal Intubation in a Pediatric Residency
481
Table 1
Basic characteristics of participants in both high and low fidelity groups
Low Fidelity
N (%)
Gender
High Fidelity
N (%)
P-value
Male
0 (0.0%)
3 (60.0%)
Female
5 (100.0%)
2 (40.0%)
0.17
Age
Mean (SD)
26.6 (0.5)
26.8 (0.4)
0.69
Med School year
2009
2 (40.0%)
0 (0.0%)
2010
1 (20.0%)
4 (80.0%)
2011
2 (40.0%)
1 (20.0%)
Foreign
2 (40.0%)
2 (40.0%)
Lebanon
3 (60.0%)
3 (60.0%)
Yes
1 (20.0%)
1 (20.0%)
No
4 (80.0%)
4 (80.0%)
Worse
2 (40.0%)
1 (20.0%)
Same or better
3 (60.0%)
4 (80.0%)
Worse
1 (20.0%)
3 (60.0%)
Same or better
4 (80.0%)
2 (40.0%)
Worse
1 (20.0%)
1 (20.0%)
Same or better
4 (80.0%)
4 (80.0%)
Worse
2 (40.0%)
2 (40.0%)
Same or better
3 (60.0%)
3 (60.0%)
Worse
1 (20.0%)
1 (20.0%)
Same or better
4 (80.0%)
4 (80.0%)
Worse
0 (0.0%)
1 (20.0%)
Same or Better
5 (100.0)
4 (80.0%)
Worse
1 (20.0%)
2 (40.0%)
Same or better
4 (80.0%)
3 (60.0%)
Med_school_location_
Formal training
Progression_equipment
Progression_positioning
Progression_Ambubag
Progression_laryngo
Progression_Technique
Progression_ETT_placement
Progression_overall
0.13
1.00
1.00
1.00
0.52
1.00
1.00
1.00
1.00
1.00
M.E.J. ANESTH 22 (5), 2014
482
sharara chami r. et. al
Table 2
Overall Assessment and Logbook Entries in both high and low fidelity groups Pretest and posttest performance, overall assessment,
number of attempts at intubation at T0 and T6, total intubations and total number of successful intubations recorded in logbooks
Low Fidelity
Pretest mistakes
Posttest mistakes
Overall Assessment T0
Overall Assessment T6
Attempts T0
Attempts T6
Total intubations recorded in logbook
Successful intubations in logbook
High Fidelity
Mean
4.0
3.2
Median (range)
4.0 (3.0)
3.0 (3.0)
SD
1.2
1.3
Mean
2.4
2.6
Median (range)
2.0 (3.0)
3.0 (4.0)
SD
1.1
1.5
Mean
1.6
1.6
Median (range)
1.0 (3.0)
1.0 (2.0)
SD
1.3
0.9
Mean
1.4
1.0
Median (range)
1.0 (1.0)
1.0 (0.0)
SD
0.5
0.0
Mean
1.2
1.0
Median (range)
1.0 (1.0)
1.0 (0.0)
SD
0.4
0.0
Mean
1.0
1.6
Median (range)
1.0 (0.0)
2.0 (1.0)
SD
0.0
0.4
Mean
2.6
1.8
Median (range)
1.0 (7.0)
1.0 (5.0)
SD
2.9
1.9
Mean
2.0
0.8
Median (range)
1.0 (5.0)
0.0 (3.0)
SD
2.0
1.3
P-value
0.42
0.69
0.84
0.31
0.69
0.15
0.84
0.31
Simulation Training in Endotracheal Intubation in a Pediatric Residency
483
Table 3
Evaluation of participants’ performance at T0 in both high and low fidelity groups
Low Fidelity
High Fidelity
Equipment Use T0
Positioning T0
Ambubag use T0
Laryngoscope Handling T0
Intubation Technique T0
ETT Placement Confirmation T0
Mean
1.8
1.6
Median (range)
1.0 (3.0)
1.0 (2.0)
SD
1.3
0.9
Mean
1.4
1.6
Median range
1.0 (2.0)
2.0 (1.0)
SD
0.9
0.5
Mean
1.6
1.4
Median (range)
1.0 (3.0)
1.0 (2.0)
SD
1.3
0.9
Mean
1.8
1.6
Median (range)
1.0 (3.0)
1.0 (2.0)
SD
1.3
0.9
Mean
1.6
1.4
Median (range)
1.0 (3.0)
1.0 (2.0)
SD
1.3
0.9
Mean
1.2
1.2
Median (range)
1.0 (1.0)
1.0 (1.0)
SD
0.4
0.4
P-value
1.00
0.55
1.00
1.00
1.00
1.00
Table 4
Evaluation of participants’ performance at T6 in both high and low fidelity groups
Low Fidelity
Equipment Use T6
Positioning T6
Ambubag use T6
Laryngoscope Handling T6
Intubation Technique T6
ETT Placement Confirmation T6
High Fidelity
Mean
1.6
1.8
Median (range)
2.0 (1.0)
2.0 (1.0)
SD
0.5
0.4
Mean
1.4
1.0
Median (range)
1.0 (1.0)
1.0 (0.0)
SD
0.5
0.0
Mean
1.4
1.2
Median (range)
1.0 (1.0)
1.0 (1.0)
SD
0.5
0.4
Mean
1.8
1.0
Median (range)
2.0 (2.0)
1.0 (0.0)
SD
0.8
0.0
Mean
1.4
1.0
Median (range)
1.0 (1.0)
1.0 (0.0)
SD
0.5
0.0
Mean
1.2
1.0
Median (range)
1.0 (1.0)
1.0 (0.0)
SD
0.4
0.0
P-value
0.69
0.31
0.69
0.15
0.31
0.69
M.E.J. ANESTH 22 (5), 2014
484
practical skills. Equipment use, positioning, ambubag use,
laryngoscope handling, intubation technique and ETT
placement were not different (p>0.05) when comparing
both groups at t(0) (Table 3) or t(6) (Table 3/4).
Successful intubations recorded in the logbook
did not vary as a function of fidelity across groups
(p=0.31).
Discussion
Theoretical knowledge improved as a function of
time and with recurrent examination for both groups,
regardless of exposure to either high or low fidelity.
Practical skills did not improve for any group and
even regressed in some individual cases. High fidelity
simulation had no effect on theoretical or practical skills
of residents. This finding shows that practical skills
may need more training than theoretical knowledge.
The second aim of the study was to compare
the intubation success rate in actual clinical settings
of pediatric residents in the intervention group vs. the
traditional teaching group during the first 6 months of
the intervention. This was assessed with the help of
logbooks. The results of successful intubations and the
number of intubations in the logbook were not in any
way correlated to participant groups. High simulation
training did not therefore affect intubation success rate
in the actual clinical setting.
The third aim was to contrast the effect of
simulation and traditional teaching on retention of
knowledge and rate of successful intubation of actual
patients 6 months after completion of the intervention.
Knowledge retention was indeed found to be solid at
T6. Participants made fewer mistakes on the post-test
questionnaire than they did on the pre-test. This was
found once again regardless of fidelity, and consistent
with the first hypothesis. The rate of successful
intubations on actual patients after completion of the
intervention did not vary as a function of fidelity.
Fidelity had therefore no significant effect on
practical skills or theoretical knowledge. This finding
can be due to many limitations.
Previous literature found that establishment of
mock codes program during residency helped improve
residents’ perception in overall skills16. Residents who
previously fired a defibrillator on a mannequin were
more likely to successfully use the defibrillator in a
sharara chami r. et. al
simulated scenario17 and simulated-based mock codes
significantly correlate with improved pediatric patients
cardiopulmonary arrest survival rates3. Consistent with
the literature, practical skills need much practice and
training. Even after training, feedback and multiple
scenarios across a stretch of 6 months, residents still
had difficulty with both the traditional and the highfidelity training. The literature does emphasize the
importance of repetitive training and the inefficiency
of PALS alone to solidify knowledge and acquisition
of a difficult skill like endotracheal intubation. Even
though this study has endorsed more rigorous training
than what residents are usually offered, it still fell
short in terms of efficient training to improve practical
skills. Frequent and repetitive training in intubation is
therefore important for skill maintenance over time.
Limitations
A major limitation is the small sample size of the
residency program. This however allowed for one-onone training and immediate and direct feedback from
the trainer. The attitude of the participants was also
an issue. Some participants did not want to be tested
despite consenting to the study and the videotaping.
A reluctance to properly engage with the study might
have affected their performance and their whole
disposition towards the study. This might be due to a
problem in the methodology regarding the way their
performance was recorded for later assessment. The
problem was not recorded in studies using similar
methods18,19 potentially highlighting cultural issues.
Conclusion
In conclusion, in a small residency program,
high-fidelity and low-fidelity airway training did
not affect residents’ intubation technique or actual
procedural success when followed over one year.
Future studies should involve a higher number of
participants, multi-center design, potentially across
several specialties where endotracheal intubation is a
required competency.
Acknowledgements
The authors would like to thank Ms. Randa
Farha, the simulation lab coordinator, for setting up the
mannequins and booking the lab for the study.
Simulation Training in Endotracheal Intubation in a Pediatric Residency
485
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M.E.J. ANESTH 22 (5), 2014
A Simple Protocol to Improve Safety and Reduce
Cost in Hemodialysis Patients Undergoing
Elective Surgery
Johnathan R. Renew* and Sher-Lu Pai*
Abstract
Background: When patients with end-stage renal disease (ESRD) miss their routine
intermittent hemodialysis (IHD), electrolyte abnormalities and volume overload often occur. An
institutional protocol to ensure that patients receiving IHD have elective surgeries scheduled within
24 hours after their dialysis may reduce procedural delays or cancellations caused by hyperkalemia
and hypervolemia after a missed IHD session. The effect of this protocol was evaluated.
Methods: A retrospective chart review was performed for ESRD patients receiving IHD
who underwent surgery from 6 months before to 6 months after the institutional protocol was
implemented. Preoperative potassium values, timing of IHD relative to surgery, and the nature of
surgery (elective or emergent) were documented. The percentage of patients having IHD more than
24 hours before their elective surgery was compared before and after protocol implementation.
Average potassium values were compared when IHD occurred within 24 hours vs. more than 24
hours, using t test analysis. Cost associated with delay and cancellation for IHD was also explored.
Results: Of the 15,799 cases performed, 190 involved ESRD patients receiving IHD. Before
the protocol, 32.1% of elective cases (n=17) involved patients scheduled for surgery more than 24
hours after IHD vs. 12.0% (n=6) after the protocol. Preoperative potassium values were less when
patients underwent IHD within 24 hours than at more than 24 hours (mean [SD], 4.32 [0.6] mEq/L
vs 4.63 [0.8] mEq/L; P=.03).
Conclusions: The simple scheduling policy is effective at reducing both cost and unnecessary
perioperative risks for patients.
Keywords: Cost effectiveness, Elective surgeries, End-stage renal disease, Hemodialysis,
Hyperkalemia, Hypervolemia, Patient safety.
Abbreviations: ESRD, end-stage renal disease; IHD, intermittent hemodialysis.
*MD.
Affiliation: Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida.
Corresponding author: Sher-Lu Pai, MD, Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL
32224. E-mail: [email protected]
487
M.E.J. ANESTH 22 (5), 2014
488
Introduction
Since the beginning of 2012, prevalent
population included more than 395,000 ESRD
patients in the United States requiring intermittent
hemodialysis (IHD)1. This patient population presents
distinct preoperative considerations. Most of these
patients have multiple comorbidities, including
anemia, cardiovascular disease, and diabetes mellitus.
Independent of the stress of surgery, this patient
population has an adjusted all-cause mortality rate that
is 6.5- to 7.9-fold higher than the general population2.
Merely 52% of hemo­dialysis patients are still alive
three years after the start of ESRD therapy in 20062.
Investigators have found that the overall mortality
rate for ESRD patients undergoing general surgery is
approximately 4%3. ESRD patients receiving IHD
have a 10-fold increase of in-hospital death following
spinal surgery4. The need for IHD has been found to
be an independent risk factor for postoperative stroke
in patients undergoing noncarotid major vascular
surgery5. When these patients undergo cardiac surgery,
they have higher morbidity rates6, an increased
operative mortality rate of 4.8%7, a 30-day mortality
rate as high as 18.3%8, and a long-term mortality rate
of 29%9. Because of these risks, ESRD patients require
effective cooperation and communication between
nephrology, anesthesia, and surgical staff.
The role of anesthesiologists expands into
perioperative care with the advent of the “surgical
home” concept. Thus, it is important to gain adequate
understanding of medical optimization of patients with
ESRD who receive IHD. One particular concern is the
management of electrolyte levels, volume status, and
the logistical issues relating to perioperative provision
of hemodialysis. Given their renal dysfunction, patients
receiving IHD are at increased risk for preoperative
hyperkalemia (serum potassium, >5.5 mEq/L),
with an incidence as high as 19% to 38%10. Volume
status is an important issue because patients may
require intraoperative transfusion of blood products,
necessitating that they be as close to their dry weight
as possible to reduce the risk of volume overload.
Because of these issues, the timing of IHD needs
to be considered. Although no practice guidelines
or recommendations exist for scheduling elective
Renew j. r. et. al
surgery with respect to IHD, the suggestion has been
that IHD should be performed within 24 hours of the
operation3,11-13.
At our institution, we have observed instances
involving ESRD patients not having IHD within
24 hours of their elective surgeries. Subsequently,
the surgical procedures were cancelled or delayed
for emergent hemodialysis to correct electrolyte
abnormalities and volume overload. To avoid
unnecessary cancellation and delays, we implemented
an institutional protocol stating that patients receiving
IHD would have their elective surgery scheduled within
the 24 hours after dialysis. This protocol was shared
with medical personnel involved in preoperative care
and scheduling (eg, surgeons, physician extenders,
preoperative clinic staff).
The purpose of the present study was to establish
the efficacy of such a scheduling protocol, to evaluate
the preoperative potassium trends of ESRD patients
undergoing surgery, and to explore the cost of
cancellation and delays due to not scheduling surgery
within 24 hours of a patient undergoing IHD.
Methods
After approved by the Mayo Clinic Institutional
Review Board, a retrospective chart review was
performed for ESRD patients receiving IHD who had
surgery from 6 months before to 6 months after the
following protocol was implemented and conveyed to
personnel involved in preoperative patient care:
1.Patients with ESRD who received IHD were
identified through the preoperative interviewing
process and medical record.
2.Patients receiving IHD were scheduled to have
their elective surgeries less than 24 hours following
IHD.
3.Preoperative laboratory tests were performed to
check serum potassium level on the day of surgery,
to ensure proper management of potassium if the
reading was greater than 5.0 mEq/L.
This scheduling protocol was implemented on
November 15, 2011, with data collection ranging from
May 15, 2011, to May 15, 2012. Patients included
were those undergoing surgery both in the main
A Simple Protocol to Improve Safety and Reduce Cost in Hemodialysis Patients Undergoing
Elective Surgery
operating rooms and the outpatient surgery center
at our institution. Patients undergoing procedures
in our interventional radiology, cardiology, and
gastroenterology suites were excluded as these patients
were not routinely evaluated by the preoperative clinic
at our institution. Two patients were excluded because
it was unclear from the chart review when they
last underwent IHD. We documented preoperative
potassium values, emergent or elective surgery, and
whether the patient received hemodialysis within 24
hours of surgery. Furthermore, we investigated the
cost of delaying or cancelling elective surgery when
a patient did not have IHD within 24 hours of surgery.
To examine the effectiveness of this protocol, we
calculated the percentage of elective cases involving
ESRD patients undergoing IHD more than 24 hours
before surgery both before and after the policy was
implemented. In addition, we calculated the percentage
of elective cases that had preoperative potassium
values checked before and after policy implementation.
Potassium values were averaged among two subsets of
patients-those who had IHD within 24 hours of surgery
and those who did not-regardless of whether the case
was elective or emergent.
Statistical Analysis
A t test was performed on these potassium
averages to determine whether having IHD within 24
hours of surgery produced a statistical difference.
Results
During the study period, a total of 15,799
surgical cases were performed in our operating rooms.
Of these cases, 190 involved patients with ESRD
who were receiving IHD at the time of surgery. These
patients comprised the following cases: kidney and
liver transplant (n=72), vascular (n=49), orthopedic
(n=18), cardiac (n=11), urology and gynecology
(n=19), general (n=18), ear, nose, and throat (n=2),
and neurosurgery (n=1) procedures. Before the
implementation of this protocol, 32.1% of the elective
cases (n=17) involved patients being scheduled for
surgery more than 24 hours after undergoing IHD,
with this figure decreasing to 12.0% (n=6) after the
489
protocol (Table 1).
Table 1
Effect of Policy on Elective Surgery Scheduling
Case
Elective cases of patients
receiving IHD, No.
Elective cases of patients with
IHD >24 h of surgery, No. (%)
Prepolicy
Postpolicy
53
50
17 (32.1)
6 (12.0)
Abbreviation: IHD, intermittent hemodialysis.
One ESRD patient had an elective
parathyroidectomy delayed before the protocol was
implemented because the patient had a potassium
value of 7.3 mEq/L. This patient was receiving IHD on
a Monday-Wednesday-Friday schedule and presented
for surgery as the first case on a Monday morning,
having gone nearly 72 hours without IHD.
Another ESRD patient had an elective
arteriovenous fistula formation cancelled because of
hyperkalemia after the policy was implemented, with a
potassium value of 5.7 mEq/L despite having IHD the
day before surgery. In reviewing this patient’s chart,
we learned that the patient consumed a meal high in
potassium the night before surgery after undergoing
IHD earlier that day.
Potassium values drawn the day of either elective
or emergent surgery were analyzed. For patients who
had IHD within 24 hours, the mean (SD) potassium
value was 4.32 (0.6) mEq/L. Of patients undergoing
surgery more than 24 hours after IHD, the mean (SD)
potassium value was 4.63 (0.8) mEq/L. After t test
analysis, these two average potassium values were
found to be statistically different (P=.03). In addition
to requiring that ESRD patients have their elective
surgery scheduled within 24 hours of IHD, the protocol
also conveyed the need to check potassium values on
the day of surgery. The effect of policy on preoperative
laboratory tests was evaluated (Table 2).
Additional expenses associated with delaying
elective cases for emergent preoperative hemodialysis
included the costs of dialysis, extra perioperative
personnel staffing time from the delay, resterilization of
the instruments from the surgery suite, stat laboratory
tests after dialysis, and lost income from having an
unused operating room.
M.E.J. ANESTH 22 (5), 2014
490
Renew j. r. et. al
Table 2
Effect of Policy on Checking Preoperative Potassium Values
Case Characteristics
Cases with patients receiving IHD, No.
Patients with potassium values checked preop, No. (%)
Emergent cases with patients receiving IHD, No.
Emergent cases with patient potassium values checked preop, No. (%)
Elective cases with patients receiving IHD, No.
Elective cases with patient potassium values checked preop, No. (%)
Abbreviations: IHD, intermittent hemodialysis; preop, preoperation.
Discussion
This retrospective study examined the
implementation of a protocol requiring patients with
ESRD to have IHD within 24 hours of elective surgery
and to have their preoperative potassium values
obtained before surgery. This policy was conveyed
through e-mail correspondence and educational
conferences to personnel involved in preoperative care
of surgical patients. Indeed, this protocol was effective
at decreasing the percentage of ESRD patients having
elective surgery more than 24 hours after IHD.
Although no universal practice guidelines specify the
timing of elective surgery for patients receiving IHD,
several studies have recommended that IHD be done
within 24 hours of surgery3,11-13. These strategies are
targeted toward avoiding unnecessary perioperative
risks, such as hyperkalemia and hypervolemia.
Hyperkalemia can induce deadly cardiac
arrhythmias and alter the anesthetic plan. For
instance, succinylcholine therapy may have to be
avoided for a patient with a difficult airway if the
patient has preoperative hyperkalemia. Thus, it
has been recommended that the serum potassium
concentration be less than 5.5 mEq/L for elective
surgery14. Fortunately, the use of succinylcholine in
normokalemic patients with ESRD has been shown to
be safe because it increases serum potassium values to
the same degree as in patients without ESRD15.
The protocol failed at encouraging perioperative
staff to check potassium values on the day of surgery.
Of patients with ESRD undergoing either elective or
emergent surgery, 85.3% had preoperative potassium
Prepolicy
Postpolicy
95
95
81 (85.3)
70 (73.7)
42
45
41 (97.6)
44 (97.8)
53
50
40 (75.5)
26 (52.0)
values checked before the protocol’s implementation
vs 73.7% after it. Interestingly, in two instances-1
preprotocol and 1 postprotocol-patients with ESRD
underwent emergent surgery without first checking
serum potassium values. From reviewing the charts,
we presumed that these patients had IHD within 24
hours of the emergent case and the anesthesiologist felt
comfortable proceeding without this information. We
caution against such practices and suggest the routine
checking of preoperative potassium level, regardless
of when IHD was last performed. Eight patients in this
study had IHD within 24 hours yet still had potassium
values of 5.5 mEq/L or greater. Requiring that patients
have IHD within 24 hours will not eliminate the
incidence of preoperative hyperkalemia; average
potassium values were statistically lower when patients
had IHD within 24 hours than when patients did not.
Investigators
have
recommended
that
hemodialysis patients be as close to dry weight as
possible preoperatively16. Hypervolemia is a particular
concern in this population because patients often have
anemia from ESRD. Because of lower hemoglobin
content, they may require intraoperative blood
products more often than patients without ESRD who
have hemoglobin levels within the normal limits.
Transfusion of blood products has its own risk factors,
including an increased potassium burden. In addition,
when patients not at dry weight preoperatively receive
a transfusion, they may be at risk for acute congestive
heart failure. Furthermore, when these patients have
an unanticipated surgical bleeding that necessitates
massive volume replacement, the use of intraoperative
dialysis may be warranted-an expensive endeavor that
A Simple Protocol to Improve Safety and Reduce Cost in Hemodialysis Patients Undergoing
Elective Surgery
may have been avoided if volume status was optimized
before surgery. The potential for these risks can be
reduced by ensuring that patients have IHD within 24
hours of an elective surgical procedure.
In addition to improving patient safety, our
scheduling protocol can have a marked cost-saving
benefit. Although the savings is difficult to quantify,
there is undeniable increased expense when surgical
procedures are delayed or canceled.
A question remains about whether IHD on the
day before surgery is safer for patients than IHD on
the same day of and immediately preceding surgery.
Heparin use during IHD suggests that IHD should be
done 12 hours before surgery. However, to reduce the
effects on coagulation, most centers now can perform
heparin-free IHD10.
Having IHD on the same day of surgery may
place the patient at risk for dialysis disequilibrium
syndrome. The rate of urea removal during IHD is a
crucial factor in the development of this syndrome, and
patients may undergo dialysis at increased blood flow
rates the day of surgery, in an effort not to delay their
upcoming procedure.17. This practice may be avoided
by having IHD on the day before elective surgery.
Yukioka et al18 investigated the effects of IHD
administered at 24 hours vs 3 hours before surgery.
Serum potassium values were similar for the 2
groups preoperatively; however, the patients with
IHD at 3 hours before surgery were more likely to
have intraoperative hyperkalemia. The investigators
attributed this outcome to the removal of less fluid
during the IHD of these patients.
A potential criticism of the present study is the
491
small sample size when looking at scheduling trends
involving 6 months before and 6 months after the
protocol implementation. Expanding the study period
may show that more providers are not adhering to the
recommendations, necessitating the need for repeat
educational efforts to ensure the hemodialysis patients
have their elective surgeries scheduled according
to the protocol. Noting the volume status of these
patients while potassium values were recorded would
have been interesting. Unfortunately, dry weight was
rarely noted and was not easily accessible during the
present chart review. In addition, a connection was not
made between having surgery more than 24 hours after
IHD and clinical outcomes such as death and major
morbidity.
Heldt et al19 described ESRD patients who had
similar clinical outcomes (eg, blood loss, complication
rate, postoperative stay, and positive margins) as
patients not on dialysis when IHD was performed the
day before radical prostatectomy. Likewise, Gulati et
al20 reported that patients with ESRD receiving IHD
had similar blood loss and median time to discharge
as patients who had normal renal function while
undergoing laparoscopic radical nephrectomy when
the patients were kept on their normal IHD routine,
including IHD on the day before surgery. Future
efforts warrant further exploration to see whether such
a scheduling protocol has impact on patient outcomes.
In conclusion, the implementation of a scheduling
policy for ESRD that states that IHD should be done
within 24 hours before elective surgery is simple to
conduct, may reduce cost, and does reduce potential
unnecessary risks for patients.
M.E.J. ANESTH 22 (5), 2014
492
Renew j. r. et. al
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Chronic Kidney Disease and End-Stage Renal Disease in the United
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and Digestive and Kidney Diseases, Bethesda, MD, 2013.. volume
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Fam Physician. 2002 Oct 15;66(8):1471-6, 1379.
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Surgical management of the dialysis patient. Ann Surg; 1973 Aug;
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12.Haimov M, Glabman S, Schupak E, Neff M, Burrows L: General
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Emetogenicity-Risk Procedures in Same Day
Surgery Center of an Academic University Hospital
in United States: A Retrospective Cost-Audit
of Postoperative Nausea Vomiting Management
Deepak Gupta* and Halim Haber*
Abstract
Background: Despite the variable results of published studies, it is imperative for ambulatory
surgery centers to self-audit local cost-implications for post-operative nausea and vomiting (PONV)
management.
Objective: Our retrospective cost-audit assessed if there were comparative peri-anesthesia
care cost-trends among patients who had undergone Low-Emetogenicity-Risk Procedures (LERP),
Moderate-Emetogenicity-Risk Procedures (MERP) and Severe-Emetogenicity-Risk Procedures
(SERP).
Methods: This study was a review of Same Day Surgery Center practices in an academic
university hospital setting during a three-year period (2010-2012). The patient lists were accessed
from CIS and CITRIX App Bar for time audit and OR (operating room) schedule reports.
Subsequently, OR pharmacy department ran a search for peri-operative anti-emetics and opioids
that were billed for the patients at Same Day Surgery Center for the review period. The primary
outcomes were the comparative costs/charges of these medications and comparative durations/
charges for these patients’ stay in the post-anesthesia care unit (PACU). Secondary outcomes
analyzed in the study included peri-anesthesia durations.
Results: A total of 8,657 patient records were analyzed. Almost all analyzed variables revealed
statistically significant inter-variable positive correlations. The patients’ age was significantly (P
<0.001) different among LERP/MERP/SERP patients (LERP: 48.8 ± 14.7 years; MERP: 61.8 ±
14.6 years; SERP: 51.3 ± 14.5 years). In regards to primary and secondary outcomes, the statistical
significant differences among LERP/MERP/SERP patients (after correcting for both patients’ age
as well as patients’ sex) were only achieved for preoperative times (P = 0.002; Power = 0.9),
operating room recovery times (P = 0.003; Power = 0.9), PACU stay times (P <0.001; Power = 1.0),
and PACU charges (P <0.001; Power = 1.0).
Conclusion: PACU stay times and PACU charges were significantly higher in patients who
had undergone SERP as compared to patients who had undergone LERP or MERP at our Same
Day Surgery Center.
*MD.
Affiliation: Department of Anesthesiology, Wayne State University, Detroit, Michigan, United States.
Corresponding author: Halim Haber, MD. Clinical Associate Professor, Anesthesiology, Wayne State University/Detroit
Medical Center, Box No 162, 3990 John R, Detroit, MI 48201, United States, Tel: 1-313-745-7233, Fax: 1-313-993-3889.
E-mail: [email protected]
493
M.E.J. ANESTH 22 (5), 2014
494
Introduction
Prevention of postoperative nausea and vomiting
(PONV) is a highly prioritized expectation among
the patients who present for same day surgeries at
ambulatory surgery centers1-3. Breast surgeries and
strabismus surgeries are highly emetogenic surgical
procedures4 and are being increasingly performed as
same day surgeries. Therefore, PONV management
(including pre-emptive anti-emesis) is a warranted
tool in the arsenal of anesthesia care personnel who
practice anesthesia at ambulatory surgery centers.
There have been studies5-7 investigating costrelated efficacies for various anti-emetics regimens.
Despite the variable results of published studies, it
is imperative for ambulatory surgery centers to selfaudit their institutional performance to both increase
PONV prevention rates and improve their patients’
PONV treatments. This self-auditing should also place
particular emphasis on periodic assessment of local
cost-implications for PONV management.
In this study, our retrospective cost-audit assessed
if there were comparative peri-anesthesia care costtrends among patients who had undergone LowEmetogenicity-Risk Procedures (LERP), ModerateEmetogenicity-Risk Procedures (MERP) and SevereEmetogenicity-Risk Procedures (SERP). This study
was a review of Same Day Surgery Center practices in
an academic university hospital setting.
Methods
After institutional review board approval for
retrospective audit with waived consent, medical
records for patients aged 18 years and above who
presented to Same Day Surgery Center for their
surgeries during a three-year period (2010-2012), were
reviewed. The patient lists were accessed from CIS
and CITRIX App Bar for time audit and OR (operating
room) schedule reports. Subsequently, OR pharmacy
department ran a search for the common anti-emetics
that were billed for the patients at Same Day Surgery
Center for the review period. The reported antiemetics included ondansetron, metoclopramide,
dexamethasone, diphenhydramine, scopolamine,
promethazine, prochlorperazine and droperidol.
Gupta d. et. al
Simultaneous reports were also run for peri-operative
opioids as a potential confounding factor for PONV. The
primary outcomes were the comparative costs/charges
of these medications and comparative durations/
charges for these patients’ stay in the post-anesthesia
care unit (PACU). Patients’ surgical procedures were
post-hoc-categorized as LERP, MERP and SERP
(Appendix A). Secondary outcomes analyzed in the
study included peri-anesthesia durations, such as preoperative times (in the pre-operative holding area),
pre-incision times (operating room entry to surgical
incision), surgery times (skin incision to skin closure)
and operating room recovery times (skin closure to
operating room exit).
For statistical analysis, correlations between
continuous variables were analyzed using Pearson
correlation coefficients. Comparisons of continuous
variables were analyzed using appropriate ANOVA
tests. Categorical proportions were analyzed using the
Chi Square test (Fisher Exact Tests). The final analysis
for significance among LERP/MERP/SERP patients
was performed based on corrections for confounding
factors namely patients› age as a covariate, and
patients› sex as independent variable for the compared
outcomes/variables. P values of <0.05 were considered
as statistically significant.
Results
As shown in CONSORT diagram (Fig. 1), a total
of 8,657 patient records were analyzed. From these
patients (n = 8657), almost all of the ten analyzed
variables (Table 1) revealed statistically significant
inter-variable positive correlations. The only nonsignificant correlations were charges for parenteral
opioids, oral opioids and combined drugs not
correlating with pre-operative times; and charges for
oral opioids and parenteral anti-emetics not correlating
with charges for parenteral opioids. The correlation
coefficient for PACU stay times and PACU charges
was almost 1 (= +0.99) as PACU charges were directly
calculated from PACU stay times as per 219 USD
for first 30 minutes and 179 USD for each additional
30 minutes. Similarly the correlation coefficient for
parenteral opioids charges and combined drugs charges
(sums of charges for parenteral opioids, oral opioids
Emetogenicity-Risk Procedures in Same Day Surgery Center of an Academic University
Hospital in United States: A Retrospective Cost-Audit of Postoperative Nausea Vomiting
Management
495
Appendix A
Lists of Same Day Surgery Center's surgical procedures that have been post-hoc-categorized according
to their emetogenic potential
Low-Emetogenicity-Risk Procedures
Moderate-Emetogenicity-Risk
Severe-Emetogenicity-Risk Procedures
(LERP)
Procedures (MERP)
(SERP)
Amputation Finger(s)
Abdominoplasty
Biopsy Breast
Amputation Hand
Biopsy Conjuctiva
Biopsy Breast Excisional
Arthrodesis Carpal/Metacarpal
Biopsy Lacrimal Gland
Biopsy Breast w/Needle Localization
Arthroplasty Metacarpal
Biopsy LEEP
Capsulectomy Breast
Arthroplasty Thumb
Biopsy Testes
Cholecystectomy Laparoscopic
Biopsy Chest Wall
Bleb Needling
Excision Breast Mass
Biopsy Lymph Node
Blepharoplasty (OPH)
Excision Breast Mass Bilateral
Biopsy Lymph Node Axillary
Blepharoplasty (PLA)
Excision Breast Wide w/Sentinal Node Bx
Biopsy Temporal Artery
Cannulation Tear Duct
Eye Muscle Surgery
Block Celiac Plexus
Chelation Band Keratopathy
Insert Breast Expander
Block Celiac Plexus Neurolytic w/
Cryosurgery Eye
Insertion Skin/Tissue Expander
Block Celiac Plexus Radiofrequency
Cutler Beard Eye Stage 2
Ligation Tubal Laparoscopic
Block Epidural
D&C
Lumpectomy Breast
Block Epidural Caudal
D&C Hysteroscopy
Mammoplasty Augmentation
Block Facet
D&C Suction
Mammoplasty Reduction
Block Ganglion
Dacryocystorhinostomy (OPH)
Mastectomy
Block Nerve
Dacryocystorhinostomy Endo (OPH)
Mastectomy Bilateral
Block Nerve Facet
Dacryocystorhinostomy External
Mastectomy Modified Radical
Alcohol
(OPH)
Block Nerve Selective
Decompression Orbit
Mastectomy Partial
Block Superior Hypogastric Neurolytic
Dilation Probe Irrigate Tear Duct
Mastectomy Radical
Block Sympathetic Lumbar
Drainage Choroidal Effusion
Mastopexy
Block/Injection Joint Lumbar Facet
DSEK
Recession-Resection Eye Muscle
Bronchoscopy w/EBUS
Enucleation
Reconstruct Breast
Bunionectomy
Evisceration Eye
Reconstruct Breast w/Expander
Capsulotomy
Exam Under Anesthesia Eye
Reconstruct Nipple Areolar
Closed Reduction Finger
Excision Abdominal Mass
Repair Eye Muscle Laceration
Closed Reduction Finger
Excision Abdominal Mass
Repair Eye Muscle Laceration
Closed Reduction Finger Perc Pinning
Excision Chalazion
Revision Breast Scar
Closed Reduction Hand
Excision Facial/Head Mass
Closed Reduction Metacarpal Perc
Excision Orbital Dermoid
Pinning
Closed Reduction Wrist Perc Pinning
Excision Pterygium
Cystectomy Pilonidal
Excision w/Biopsy Neck Mass/Lesion
Debridement Decubitus Ulcer
Extcap Cataract Extract w/IOL Implant
Dissection Axillary Node
Extcap Cataract Extract w/IOL Implant
and Trabeculectomy
M.E.J. ANESTH 22 (5), 2014
496
Gupta d. et. al
Low-Emetogenicity-Risk Procedures
Moderate-Emetogenicity-Risk
Severe-Emetogenicity-Risk Procedures
(LERP)
Procedures (MERP)
(SERP)
Dissection Lymph Node
Flap Latissimus
Exam Under Anesthesia Rectal/Anal
Flap Rotation
Excision Axillary Mass
Flap Tram
Excision Back Mass
Ganciclovir Implant
Excision Bone Cyst
Graft Dermal Orbit
Excision Buttock Mass
Graft Skin Full Thickness (PLA)
Excision Ganglion Cyst
Graft Skin Split Thickness (PLA)
Excision Ganglion Cyst (ORT)
Herniorrhaphy Umbilical
Excision Groin Mass
Herniorrhaphy Ventral
Excision Hidradenitis
Hydrocelectomy
Excision Hip Mass
Hysteroscopy
Excision Keloid
Injection Silicone Oil
Excision Lesion
Insert Orbital Implant
Excision Limb Mass
Insertion Ahmed Valve
Excision Mass Upper Limb
Insertion Crawford Tube
Excision Rectal/Anal Mass
Insertion Implant Lens Secondary
Excision Scar
Insertion Molteno Implant
Excision Shoulder Mass
Insertion Radioactive Plaques
Exostectomy
Insertion Retisert Implant
Fistulectomy Anal
Insertion Valve w/Scleral Graft
Fistulectomy Anal
Insertion Valve w/Scleral Graft
Flap Cross Finger
Iridectomy
Fulguration Wart(s)
Laser Photocoagulation
Fusion Hand/Wrist
Lensectomy/Vitrectomy
Graft Bone
Ligation Spermatic Vein
Harvest Bone Marrow
Lipectomy
Hemorrhoidectomy
Liposuction
Herniorrhaphy
Liposuction Abdomen
Herniorrhaphy Inguinal
Marsupilization Bartholin Cyst
Incision & Drainage
Orbitotomy
Incision and Drainage
Orchiectomy
Injection Caudal Epidural
Phacoemulsification Cataract Implant
Insert Cath Epidural Tunneled Titanium
Photocoagulation Pan Retinal
Insert Catheter Epidural
Reconstruct Canthus
Insert Catheter Hemodialysis
Reconstruct Ear
Insert Catheter/Port
Reconstruct Eyelid
Insert Pump Pain
Reconstruction Orbital w/Graft
Irrigate & Debride (ORT)
Remove Corneal Sutures
ORIF Hand
Remove Frgn Body Intraocular
ORIF Metacarpal/Carpal
Remove Frgn Body Orbit
Emetogenicity-Risk Procedures in Same Day Surgery Center of an Academic University
Hospital in United States: A Retrospective Cost-Audit of Postoperative Nausea Vomiting
Management
Low-Emetogenicity-Risk Procedures
Moderate-Emetogenicity-Risk
Severe-Emetogenicity-Risk Procedures
(LERP)
Procedures (MERP)
(SERP)
ORIF Thumb
Remove Radioactive Plaques
ORIF Wrist
Remove Silicone Oil
Release Carpal Tunnel (ORT)
Repair Anterior
Release Trigger Thumb/Finger
Repair Canalicular Laceration
Removal Foreign Body
Repair Corneal Laceration
Remove Catheter/Port
Repair Dehiscence Eye Wound
Remove K-Wire
Repair Ectropion
Repair Artery Radial
Repair Entropion
Repair Laceration Tendon/Artery/Nerve
Repair Laceration Lid (PLA)
497
(PLA)
Repair Mallet Finger
Repair Orbital Fracture
Repair Mallet Finger
Repair Orbital Fracture
Revision Amputation Finger(s)
Repair Ptosis
Tenolysis
Repair Retinal Detachment
Transposition Ulnar Nerve
Repair Ruptured Globe
Reposition Lens
Revision Ahmed Valve
Revision Bleb
Scleral Buckle
Septorhinoplasty
Shunt Express Eye
Tap Anterior Chamber
Tarsorrhaphy
Thyroidectomy (GEN)
Trabeculectomy
Transplant Cornea
Vasectomy (Surgical)
Vasovasostomy
Vitrectomy
Vitrectomy Anterior
Vitrectomy Pars Plana 20 Ga w/Scleral
Buckle
Vitrectomy Pars Plana 20 Gauge
Vitrectomy Pars Plana 23 Ga w/Scleral
Buckle
Vitrectomy Pars Plana 23 Gauge
Vitrectomy Pars Plana 25 Ga
Vitrectomy Pars Plana 25 Ga w/Scleral
Buckle
Vitreous Washout
M.E.J. ANESTH 22 (5), 2014
498
Gupta d. et. al
and parenteral anti-emetics) was almost 1 (= +0.98)
as oral opioids charges and parenteral anti-emetics
charges nullified each other’s effects on correlations by
having opposite regression directions (-0.01 and +0.01
respectively). Even though medications databases
indicated that 60% medications were administered
by anesthesia providers (as indicated by Manual
Charge) and 40% medications were administered
by PACU nursing staff (as indicated by Charge
on Administration), the administered medications
could not be categorized whether they were given as
prophylaxis or as rescue dosing for analgesia and/or
anti-emesis. One interesting observation was that the
patients’ medication charges were multiples of x-times
factor to hospital’s medication costs [Median x: 10
(Range x: 9-124); Mode x: 10; Mean x (± SD): 18 (±
22)].
Fig. 1
CONSORT Diagram
years; SERP: 51.3 ± 14.5 years). Therefore, when
ANOVA analysis was performed for the variables with
patients’ sex and emetogenic risk category of surgical
procedures as two independent factors, patients’ age
was required to be analyzed as a covariate for this
ANOVA analysis. Hence, even though the means
table for this analysis of variables (Table 2) appear to
have clinically significant differences, the statistical
significant differences among LERP, MERP and
SERP categories (after correcting for both patients’
age as well as patients’ sex) were only achieved for
preoperative times (P = 0.002; Power = 0.9), operating
room recovery times (P = 0.003; Power = 0.9), PACU
stay times (P <0.001; Power = 1.0), and PACU charges
(P <0.001; Power = 1.0). Among LERP/MERP/SERP
patients, one reason for the absence of statistical
significance for other variables (preincision times,
surgery times, parenteral opioid charges, oral opioid
charges, parenteral anti-emetic charges and combined
drugs charges) was low statistical power (1-beta) for
those variables (Power <0.6; after patients’ age and
patients’ sex correction).
Discussion
In the Society for Ambulatory Anesthesia PONV
Guidelines (2007)8, ten procedures were documented
as risk factors for PONV in adults. For our center’s
retrospective cost-audit, we sub-categorized the first
four procedures (laparoscopy, laparotomy, breast and
strabismus) as SERP and the remaining six procedures
(plastic, maxillofacial, gynecological, abdominal,
neurologic, ophthalmologic and urologic) as MERP.
Although Society for Ambulatory Anesthesia PONV
Guidelines (2014)9 updated only cholecystectomy,
gynecological and laparoscopic surgeries (compared
to general surgeries) as emetogenic-risk procedures,
we based our retrospective cost-audit on 2007 PONV
Guidelines that were current standard practices for the
studied three-year period (2010-2012).
After categorizing the patient records among
LERP, MERP and SERP based on the emetogenicity
of the surgical procedures, the patients’ age was
significantly (P <0.001) different among these three
groups (LERP: 48.8 ± 14.7 years; MERP: 61.8 ± 14.6
As far as patients’ medication charges being
multiples of x-times factor to hospital’s medication
costs, these were based on local pharmacy charge
masters10 that take into account complex and varied
interactions of medications’ prices (in wholesale
markets), categories and routes of administrations,
Emetogenicity-Risk Procedures in Same Day Surgery Center of an Academic University
Hospital in United States: A Retrospective Cost-Audit of Postoperative Nausea Vomiting
Management
499
Table 1 (a)
Pearson correlation coefficients among the recorded variables
n = 8657
Pre-Operative
Time
Pre-Incision
Time
Surgery Time
Operating
Room
Recovery Time
Post Anesthesia
Care Unit Stay
Time
Pre-Operative Time
Not Applicable
0.07**
0.09**
0.1**
0.13**
Pre-Incision Time
0.07**
Not
Applicable
0.54**
0.4**
0.39**
Surgery Time
0.09**
0.54**
Not
Applicable
0.37**
0.4**
Operating Room Recovery Time
0.1**
0.4**
0.37**
Not Applicable
0.44**
Post Anesthesia Care Unit Stay
Time
0.13**
0.39**
0.4**
0.44**
Not Applicable
Post Anesthesia Care Unit
Charges
0.13**
0.38**
0.39**
0.44**
0.99**
Parenteral Opioid Charges
0.01
0.16**
0.16**
0.1**
0.19**
Oral Opioid Charges
0.02
0.04**
0.03*
0.09**
0.12**
Parenteral Anti-Emetic Charges
0.04**
0.25**
0.33**
0.3**
0.21**
Combined Drugs Charges
0.02
0.21**
0.22**
0.15**
0.23**
**: Correlation is significant <0.01 (2-tailed)
*: Correlation is significant <0.05 (2-tailed)
Table 1 (b)
Pearson correlation coefficients among the recorded variables
Post Anesthesia
Care Unit
Charges
Parenteral
Opioid Charges
Oral Opioid
Charges
Parenteral
Anti-Emetic
Charges
Combined
Drugs Charges
Pre-Operative Time
0.13**
0.01
0.02
0.04**
0.02
Pre-Incision Time
0.38
0.16
0.04
0.25
**
0.21**
Surgery Time
0.39**
0.16**
0.03*
0.33**
0.22**
Operating Room Recovery
Time
0.44**
0.1**
0.09**
0.3**
0.15**
Post Anesthesia Care Unit
Stay Time
0.99**
0.19**
0.12**
0.21**
0.23**
Post Anesthesia Care Unit
Charges
Not Applicable
0.18**
0.12**
0.2**
0.22**
Parenteral Opioid Charges
0.18**
Not Applicable
-0.01
0.01
0.98**
Oral Opioid Charges
0.12**
-0.01
Not Applicable
0.03*
0.04**
Parenteral
Charges
0.2**
0.01
0.03*
Not Applicable
0.2**
Combined Drugs Charges
0.22**
**: Correlation is significant <0.01 (2-tailed)
0.98**
0.04**
0.2**
Not Applicable
n = 8657
Anti-Emetic
**
**
**
*: Correlation is significant <0.05 (2-tailed)
M.E.J. ANESTH 22 (5), 2014
500
Gupta d. et. al
Table 2
Various recorded variables for comparative analysis among three types of ambulatory surgeries based on their emetogenic potential
Recorded Variable
Low-Emetogenicity-Risk
Procedures (LERP)
Moderate-Emetogenicity-Risk
Procedures (MERP)
Severe-Emetogenicity-Risk
Procedures (SERP)
Females
(n = 895)
Males
(n = 548)
Females
(n = 3310)
Males
(n = 2502)
Females
(n = 1288)
Males
(n = 114)
109.0 ± 52.7
105.8 ± 45.6
113.2 ± 48.2
113.9 ± 53.3
164.3 ± 96.1
114.4 ± 54.7
Pre-Incision Time
(mins)
20.9 ± 9.8
21.0 ± 8.6
19.2 ± 7.2
20.8 ± 8.2
28.3 ± 9.4
21.5 ± 7.0
Surgery Time (mins)
40.2 ± 35.3
42.8 ± 32.3
42.4 ± 43.7
58.7 ± 59.4
101.3 ± 69.7
47.3 ± 33.0
5.3 ± 4.3
5.6 ± 4.5
3.9 ± 4.3
5.0 ± 5.6
9.4 ± 5.5
11.9 ± 5.8
Post-Anesthesia
Care Unit Stay Time
(mins)
99.6 ± 55.5
103.6 ± 61.8
66.0 ± 38.7
69.8 ± 39.6
135.5 ± 53.5
106.5 ± 44.5
Post-Anesthesia Care
Unit Charges (USD)
720.4 ± 336.6
742.9 ± 370.3
524.9 ± 232.4
545.5 ± 238.3
934.9 ± 323.7
770.1 ± 275.8
Parenteral Opioids
Charges (USD)
23.3 ± 102.2
27.1 ± 98.3
9.2 ± 13.8
10.2 ± 18.4
26.3 ± 29.9
16.8 ± 19.6
Oral Opioids Charges
(USD)
0.8 ± 2.1
0.9 ± 2.3
0.6 ± 1.8
0.6 ± 1.8
1.0 ± 2.4
1.8 ± 4.0
Parenteral AntiEmetics Charges
(USD)
4.8 ± 8.0
4.1 ± 6.8
4.8 ± 8.2
6.6 ± 9.1
6.5 ± 9.4
9.5 ± 7.5
Combined Drugs
Charges (USD)
28.9 ± 102.1
32.2 ± 98.3
14.6 ± 16.8
17.4 ± 21.5
33.8 ± 31.5
28.1 ± 19.7
Pre-Operative Time
(mins)
Operating Room
Recovery Time
(mins)
and pharmacists’ involvements in dispensing the
charged medications. Additionally, there is a standard
sophisticated mark-up tables that also account for any
overhead costs involved.
From published reports, we reviewed two
studies analyzing PONV costs. The first one was a
retrospective database study (n = 3641) by Habib et
al.11 and the second one was a prospective study (n =
100) by Parra-Sanchez et al.12 Habib et al.11 reported
prophylactic anti-emetics administration in 79%
patients and rescue anti-emetics administration in
26% patients. Comparatively, in our study, 40% LERP
patients, 41% MERP patients and 50% SERP patients
(42% overall patients; n = 8657) had received at least
one parenteral anti-emetic agent during peri-anesthesia
period (P <0.001); however, proportions of patients
who had received at least one parenteral opioid during
peri-anesthesia period were not significantly different
(88% LERP patients, 89% MERP patients and 90%
SERP patients; P = 0.17).
Parra-Sanchez et al.12 reported significant PACU
recovery costs differences (640 USD vs. 730 USD; P
= 0.006) between patients without PONV vs. patients
reporting PONV respectively. Comparatively, in our
study, mean PACU charges were 720-743 USD for
LERP patients, 525-546 USD for MERP patients
Emetogenicity-Risk Procedures in Same Day Surgery Center of an Academic University
Hospital in United States: A Retrospective Cost-Audit of Postoperative Nausea Vomiting
Management
and 770-935 USD for SERP patients (P <0.001). An
interesting observation (Table 2) was that patients
who had undergone LERP stayed longer in PACU
as compared to patients who had undergone MERP
even though the parenteral anti-emetics charges did
not follow a similar trend between LERP patients and
MERP patients. However, parenteral opioid charges
followed a similar trend (LERP patients’ charges
>>MERP patients’ charges). Thereafter, a sub-analysis
using both parenteral opioid charges and patients’ age
as covariates reduced statistical significance for PACU
stay times (P = 0.02; Power = 0.7) and PACU charges
(P = 0.007; Power = 0.8). This loss in statistical
significance suggested that pain management acted
as an independent confounding factor for prolonged
PACU stay in patients who had undergone LERP as
compared to patients who had undergone MERP. To
assess surgery times effect on PACU stay times and
PACU charges across LERP/MERP/SERP, a further
sub-analysis was performed with surgery time as an
additional covariate besides parenteral opioid charges
and patients’ age as other covariates. Using these three
covariates removed all statistical significance level for
both PACU stay times (P >0.99; Power = 0.05) and
PACU charges (P = 0.96; Power = 0.06) suggesting
that surgery times (besides patients’ age and parenteral
opioid charges) were an independent factor that
confounded the differences in PACU stay times and
PACU charges across LERP/MERP/SERP.
Our study has a few limitations. It was a
retrospective study that only explored the anesthesiabased billed surgical procedures’ database and
pharmacy-based billed peri-anesthesia medications’
database. Therefore, in our study, other data like
preoperative risk factors for PONV, peri-operative pain
scores vs. peri-operative emesis scores, intraoperative
501
medication administration timings vs. postoperative
medication administration timings, and prophylactic
medications vs. rescue medications were not available
to be evaluated/compared. Our analysis was primarily
based on categorizing the billed charges data according
to the emetogenicity-risk procedures and absence
of the above-mentioned potentially confounding
variables may have skewed our results (means, level
of significance and correlation coefficients).
Conclusion
In summary, PACU stay times and PACU
charges were significantly higher in patients who had
undergone SERP as compared to patients who had
undergone LERP or MERP at our Same Day Surgery
Center.
Acknowledgement
The authors are deeply indebted to the appreciative
efforts of Ms Janice Dale, Data Analyst, Department
of Anesthesiology, and Ms. Connie Tourangeau,
Pharmacist, and Mr. Xavier Bell, Field Engineer,
Department of Pharmacy, Harper Hospital, Detroit
Medical Center, Detroit, Michigan, United States in
regards to their retrospective enlisting of the same day
surgery patients according to their surgical procedures
as well as according to the medications that they had
received per their databases. The authors are also
grateful to Dr Ronald Thomas, Children’s Research
Center of Michigan, Wayne State University, Detroit,
Michigan and George Mckelvey, PhD, Department
of Anesthesiology, Harper Hospital, Detroit Medical
Center, Detroit, Michigan, United States for their help
during statistical calculations and analysis.
M.E.J. ANESTH 22 (5), 2014
502
Gupta d. et. al
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DI, Temo J, Tramèr MR, Vander Kolk C, Watcha M: SOCIETY
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Watcha M, Chung F, Angus S, Apfel CC, Bergese SD, Candiotti
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The use of Airtraq laryngoscope versus Macintosh
laryngoscope and fiberoptic bronchoscope by
experienced anesthesiologists
Kemal T. Saracoglu*, Murat Acarel**,
Tumay Umuroglu*** and Fevzi Y. Gogus****
Abstract
Objective: The aim was to compare the hemodynamic parameters, intubation times, upper
airway trauma and postoperative sore throat scores of the patients with normal airway anatomy,
intubated with the Airtraq, Macintosh laryngoscope and fiberoptic bronchoscope, by experienced
anesthesiologists.
Methods: Ninety patients, scheduled to undergo elective surgery under general anesthesia were
randomly divided into three groups (n=30): Group A: Airtraq laryngoscope, Group M: Macintosh
laryngoscope and Group FB: fiberoptic bronchoscope. The time to intubation and success rates
were recorded. The hemodynamic parameters before and one minute after the anesthesia induction
were recorded and the measurements were repeated 3, 4 and 5 minutes after the endotracheal
intubation. The postoperative sore throat scores and signs of any trauma were also recorded.
Results: Mean arterial blood pressure and heart rate were not significantly different between
the three groups. The mean intubation time interval did not differ between groups. Highest
postoperative sore throat scores were recorded at the 6th hour post extubation. The scores were 37.6
± 20.9 in Group A, 13.3 ± 16.8 in Group M and 13.6 ± 14.0 in Group FB. The scores in Group A
were significantly higher compared to other groups. The number of patients requiring additional
analgesia to relieve sore throat was also significantly higher in Group A.
Conclusion: The Airtraq laryngoscope seems to be a more traumatic airway device in the
routine endotracheal intubation compared to Macintosh laryngoscope and fiberoptic bronchoscope,
when used by experienced anesthesiologists. It also does not offer advantage over the first-attempt
success rates, the intubation times and hemodynamic parameters.
Keywords: airway management; laryngoscope; Airtraq; Macintosh laryngoscope; fiberoptic
bronchoscope; intubation.
*
Assistant Prof. MD.
**MD.
*** Assoc. Prof. MD.
****Prof. MD.
Affiliation: Department of Anesthesiology, Marmara University School of Medicine, Istanbul, Turkey.
Corresponding author: Kemal Tolga SARACOGLU. Department of Anesthesiology, Marmara University School of
Medicine, Fevzi Cakmak Mah. Ust Kaynarca, Pendik, Istanbul, Turkey. Tel: +902166570606, Fax: +902164144731.
E-mail: [email protected]
503
M.E.J. ANESTH 22 (5), 2014
504
Introduction
Recent technological advances including the lightemitting diodes, rechargeable batteries, optical systems
with adjustable position capability and modified
laryngoscope blades allowed the development of new
devices such as Airtraq laryngoscope (Airtraq, Prodol
Meditec Limited, China), to facilitate and improve the
success rate of endotracheal intubation1,2. Although
originally designed to facilitate difficult intubation,
thesee devices can also be used in the management of
the normal airway1,2.
The special design of the Airtraq allows the
direct exposure of the glottic opening without the
necessity of optimal alignment of the oral, pharyngeal
and laryngeal axes. The results of the meta-analysis
comparing the Airtraq with the conventional Macintosh
laryngoscope concluded that the use of Airtraq results
in a rapid and accurate intubation3. The Macintosh
laryngoscope possess a curved blade facilitating the
glottic view, reducing potential tongue and epiglottic
trauma. The use of the fiberoptic bronchoscope
(FOB, Pentax Corporation, Japan) is of great value in
performing endotracheal intubation, but with the main
disadvantage for being of high cost, and the need for
long practical experience.
Studies on the effectivity and complications of the
Airtraq and FOB are mainly conducted on manikins5-8.
In these studies, the intubations are mainly performed
by novices or paramedics5,6. To our knowledge,
a comparison of the endotracheal intubation with
Airtraq, Macintosh laryngoscope and FOB performed
by the experienced anesthesiologists is lacking.
Furthermore, determination of the postoperative sore
throat incidence and airway trauma is not possible in
manikins or in simulation scenarios.
The purpose of this study was to compare
the hemodynamic parameters, intubation times,
complications during and after intubation and
postoperative sore throat scores of the patients having
normal airway anatomy, intubated with Airtraq,
Macintosh laryngoscope or FOB, by experienced
anesthesiologists. The primary outcome variables
were the first-attempt success rate, time to successful
intubation. The secondary outcome variables were the
effects of the intubation on hemodynamic parameters,
Saracoglu k.t. et. al
the postoperative sore throat scores and trauma to the
upper airways.
Methods
Following the approval of the Marmara
University Ethics Committee, 90 patients, aged
between 18-65 years, with American Society of
Anesthesiologists (ASA) physical status classification
of 1 or 2, undergoing elective surgery under general
anesthesia and requiring endotracheal intubation
were included in the study. The exclusion criteria for
participation in this study were: patients with ASA 3
or 4, Mallampati score of 3 or 4, history of difficult
intubation, thyromental distance less than 6.5 cm,
sternomental distance less than 12.5 cm, body mass
index higher than 35 kg/m2 and limited neck mobility.
All patients gave their written informed consent.
A prospective and randomised study design was
employed and the randomisation was done with the help
of a random number generator downloaded from ‘http//
www.random.org’9. The endotracheal intubations were
performed by three experienced anesthesiologists.
Anesthesiologists who had practiced at least 500
intubations with the Macintosh laryngoscope, 50
intubations with the FOB were considered as being
‘experienced’10. The preoperative Mallampati
scores were recorded and maximum mouth opening,
thyromental and sternomental distances of the patients
were measured. All patients were premedicated with
0.015 mg/kg IM atropine sulphate and 0.07 mg/kg IM
midazolam. The patients’ positions in the operation
room were supine with no pillow under the head.
Monitoring included electrocardiogram, noninvasive
blood pressure and peripheral pulse oximetry (SpO2),
end tidal carbon dioxide (ETCO2) and end tidal
sevoflurane concentrations. Preoxygenation was not
performed. Anesthesia was induced with 5-7 mg/kg
IV thiopental sodium and 0.6 mg/kg IV rocuronium
bromide. The administration of the opioid analgesics
was not allowed in the induction period.
The patients were randomly divided into three
groups (n=30) and orotracheal intubated with Airtraq
(group A), Macintosh laryngoscope (group M) and
FOB (group FB). In group A, the standard inventor’s
technique was used. Airtraq was positioned into the
The use of Airtraq laryngoscope versus Macintosh laryngoscope and fiberoptic
bronchoscope by experienced anesthesiologists
vallecula and upward lifting of the epiglottis made
glottic opening visible. The tube was then inserted
to the trachea. In group M, direct laryngoscopy was
performed with a Macintosh blade size 3. In group FB,
endotracheal intubation was performed with a FOB
with attached tracheal tube. If a satisfactory vision
was not achieved in any group, the applications of
optimization maneuvers such as jaw thrust, tracheal
pressure, lifting, tilting or orientation of devices or
the assistance of a second person were allowed and
recorded. Train-of-four (TOF) (Watch SX; Organon
Ltd Drynam Road Swords, Co. Dublin, Ireland) was
used to measure the level of neuromuscular blockade.
Anesthesia was maintained with 1 MAC sevoflurane
and %70 N2O in oxygen.
The intubation time (the time from the device
insertion into the oral cavity and the view of the
tube crossing the vocal cords) was measured by a
chronometer. The intubation was failed, if it could not
be performed less than 120 seconds. In this instance the
patient was excluded from the study. Complications
such as esophageal intubation, upper airway mucosa
laceration, dental trauma or iatrogenic endotracheal
cuff rupture were noted. The success or failure of
the process was also recorded. Mean arterial blood
pressure, heart rate, SpO2 and ETCO2 concentrations
were measured before the anesthesia induction (0.
min) and one min after the induction. The time interval
between anesthesia induction and endotracheal
intubation was considered to be 2 min. Hemodynamic
parameters were also recorded 3, 4 and 5 min after the
intubation.
Meperidine hydrochloride 1 mg/kg IV was
administered to all patients in the early postoperative
505
period. At the end of 30 minutes, the sore throat scores
of the patients were evaluated after direct questioning,
using a 0-100 mm visual analogue scale (VAS).
Postoperative sore throat VAS scores were recorded
at the 6th, 12th and 24th hour. The anesthesiologist
evaluating the postoperative sore throat scores was
blinded to the intubation devices used. Patients having
VAS scores higher than 30 mm were administered 20
mg IV meperidine hydrochloride as a rescue analgesic.
In all patients, 1 mg/kg meperidine hydrochloride IV
was given every 6 h for the first 24 h, as a postoperative
analgesia.
Statistical Package for Social Sciences for
Windows (SPSS) version 20.0 (SPSS Inc., Chicago,
IL, USA) was used for the statistical analysis. One
of the primary outcomes was the time to successful
tracheal intubation. Based on previously published
studies11,12, we estimated that 24 patients would be
required for each group to detect a mean difference of 6
seconds in the overall duration of intubations, between
groups, with a power of 80% and a significance level
(a) of 0.05. So, we enrolled 30 patients per group.
Data are summarized using mean ± SD for continuous
variables. Statistical comparisons between the groups
were performed using analysis of variance (ANOVA)
with Kramer as a post hoc test. Repeated parameters
were analysed by repeated measures ANOVA,
with Newman-Keuls as a post hoc test. Data for the
success of tracheal intubation attempts, the differences
between patients with or without complications were
investigated by Fisher’s exact test. P < 0.05 was
considered statistically significant.
Table 1
Patient characteristics of groups
Group A
Group M
Group FB
P
Age (Years)
42.3 ± 13.5
40.7 ± 17.0
43.2 ± 14.5
0. 631
Weight (kg)
72.7 ± 12.9
70.7 ± 13.0
73.3 ± 13.1
0.891
Height (cm)
168.6 ± 9.5
166.9 ± 9.4
169.8 ± 9.6
0. 631
16/15
14/16
15/15
0.875
Sternomental distance (cm)
13.6 ± 1.9
13.5 ± 1.0
13.8 ± 1.4
0. 491
Thyromental distance (cm)
7.41±1.54
7.36±1.63
7.93±1.78
0.265
Male/Female ratio
M.E.J. ANESTH 22 (5), 2014
506
Saracoglu k.t. et. al
Table 2
Maximal mouth opening (cm), intubation time (sec) and first attempt success rate
Group A
Group M
Group FB
P
5.1 ± 1.71
4.7 ± 1.41
4.45 ± 0.69
0. 223
11.23 ± 2.90
9.46 ± 2.70*
9.96 ± 1.82
0.009
First attempt success rate
4 (13.3%)
2 (6.7%)
2 (6.7%)
0.578
End-tidal CO2
34.16±2.19
33.18±2.47
32.68±2.92
0.192
Maximal mouth opening (cm)
Intubation time (sec)
* Difference with Group A p < 0.05.
Table 3
Patients requesting additional analgesia to relieve sore throat
Group A
Group M
Group FB
P
30. min
*46.6 %
13.3 %
6.6 %
0.000
6. h
*63.3 %
23.3 %
16.6 %
0.000
12. h
*50.0 %
16.6 %
13.3 %
0.002
24. h
*50.0 %
6.6 %
3.3 %
0.000
* Difference with Group A p < 0.05.
Results
Ninety patients were included in the study.
Demographic data of the three groups were similar
(Table 1). There were no statistical differences
between groups regarding maximum mouth opening,
sternomental and thyromental distance and time to
endotracheal intubation (Table 1 and 2). The mean
arterial blood pressure and the heart rate values of
the three study groups were not significantly different
throughout the study period (Figure 1 and 2). End-tidal
carbon dioxide concentrations were 34.16, 33.18 and
32.68 mmHg in groups A, M, FB respectively and SpO2
values were 98.36%, 98.54% and 98.62% in groups A,
M, FB respectively in the first 5 min, with no statistical
Fig. 1
Mean arterial blood pressure (mmHg)
Fig. 2
Heart rate (beat/min)
T1: 0. min, T2: 1. min, T3: 2. min, T4: 3. min,
T5: 4. min, T6: 5. Min
T1: 0. min, T2: 1. min, T3: 2. min, T4: 3. min,
T5: 4. min, T6: 5. Min
The use of Airtraq laryngoscope versus Macintosh laryngoscope and fiberoptic
bronchoscope by experienced anesthesiologists
Fig. 3
VAS scores of patients for postoperative sore throat
difference between groups. The highest postoperative
sore throat VAS scores were recorded at the 6th h in all
groups, the significantly highest scores were found in
group A (Figure 3). At all times, sore throat VAS scores
of the group A were significantly higher compared to
other groups (p< 0.01) (Figure 3). The percentage of
patients requiring rescue analgesics to sore throat was
significantly higher in group A (p< 0.05) (Table 3).
All patients in the study were successfully intubated.
On removal of the laryngoscope following intubation,
blood spot on the blade was observed in 4 patients
in group A, but a detailed intraoral examination
revealed nolaceration or lesion. Complications such
as esophageal intubation, dental trauma or iatrogenic
endotracheal tube cuff rupture were not observed
in any patients in all groups. The help of another
anesthesiologist was required in 4 patients in group A
and for 2 patients in group F. The rotation maneuver
was used in 6 patients in group A. None of the patients
in all groups required jaw thrust maneuver.
Discussion
The results of the present study indicate that the
use of Airtraq by experienced anesthesiologists may
be more traumatic in the endotracheal intubation of
patients with normal airways, without shortening
the time for successful intubation when compared to
Macintosh laryngoscope and FOB.
Airtraq use on manikins and simulators is widely
investigated in novices, but little is known about the
efficacy and complications of the Airtraq device
when used by experienced anesthesiologists13,14.
Furthermore, the exact incidence of sore throat
507
or mucosal injury caused by the Airtraq is hard to
determine, because studies on this field are mainly
manikin studies. Airtraq facilitates endotracheal
intubation in a more rapid manner than the Macintosh
laryngoscope and it is user friendly, especially when
used by novices3. Its main advantage is that it allows
the visualization of the glottis without the need of
alignment of the oral, pharyngeal and tracheal axes.
The Macintosh laryngoscope retracts the tongue and
epiglottis, exposing the oral, pharyngeal and tracheal
axes in a straight line. Correct laryngoscope handling
and correct interaction of the Macintosh blade with the
perilaryngeal structures necessitate anesthesiologist’s
experience, whereas Airtraq may easily be used by
unskillful anesthesiologist residents or novices15.
The superiority of the Airtraq over Macintosh
laryngoscope in patients at increased risk for difficult
intubation and simulated difficult airway scenarios
has been demonstrated, when used by experienced
anesthesiologists16,17. It also seems that the Airtraq
may be a good choice for the use by novices and
inexperienced laryngoscopists who are not used to
perform routine endotracheal intubation. Nevertheless,
to our knowledge there is no clinical study comparing
the hemodynamic parameters, intubation times, sore
throat scores and upper airway trauma incidence in
patients with normal airways intubated with fiberoptic
bronchoscope, Airtraq and Macintosh laryngoscope,
by experienced anesthesiologists.
Hemodynamic parameters and time to intubation
were similar between groups, indicating that Airtraq
does not offer any advantage in these regards. These
results are not surprising since anesthesiologists
involved to the study are all experienced in the use of
these devices.
The presence of blood spot on the tip of the
device and significantly high postoperative sore throat
scores in our patients intubated with Airtraq, suggest
that the Airtraq may be a potentially traumatic device,
when used in patients with normal airway anatomy.
Upper airway injury is possible during laryngoscopy18.
Dental trauma, tongue lacerations or hematomas are
the most commonly encountered upper airway injuries
related to the use of various endotracheal intubation
devices. Injury to the tongue is usually related to the
force applied by the laryngoscope on the tongue19.
M.E.J. ANESTH 22 (5), 2014
508
Gaszynski20 suggested that the use of Airtraq resulted in
less pressure on the tongue compared to the Macintosh
laryngoscope. We observed blood spot on the tip of
the device in 4 patients, following the removal of the
Airtraq. Although a detailed intraoral examination
revealed no laceration, we suggested that the Airtraq
use may result in minor trauma to the upper airway.
The presence of blood on the tip of the device suggests
that trauma made by the Airtraq is not related to the
force applied on the tongue, but on the force applied
to the vallecula. Similar to Macintosh laryngoscope,
adjusting the position of Airtraq in the pharynx is
required. In accordance with the habituel practice with
Macintosh laryngoscope or to optimise the view of the
glottis, the blade of the Airtraq can be intuitively lifted
up. In the literature, some intuitive small amplitude
movements performed by the anesthesiologists are
already described21. These maneuvers may easily
harm the vallecula in normal airways. Maharaj et
al.10 suggested that in patients at increased risk for
difficult tracheal intubation, minor force has to be
applied during laryngoscopy with the Airtraq device
because there is no need to align the oral, pharyngeal
and tracheal axes. Depending on previous studies
demonstrating the success of Airtraq on tracheal
intubation in patients with difficult airway, it may be
hypothesized that the exaggerated curvature of the
Airtraq blade may easily improve the glottic exposure
in abnormal airways with anteriorly located larynx22,23.
Dhonneur et al.21 found that anaesthesiologists learning
to use the Airtraq in patients with potentially difficult
airways, are placing the Airtraq in the pharynx with
a significant distal pressure on the tip of the blade to
overcome the narrowing at the junction between the
oral and pharyngeal spaces. We suggest that in normally
positioned larynx also, the tip of the blade may apply
some pressure to the vallecula. A detailed examination
of the upper airway did not reveal any mucosal injury
but the examination of the vallecula was not performed
in order not to affect the postoperative sore throat
scores.
A positive correlation is determined between
force used during intubation attempts and incidence
of complications such as sore throat intensity19.
Saracoglu k.t. et. al
Postoperative sore throat scores were high in the
Airtraq group. Optimization maneuvers were common
in the use of Airtraq and in order to perform the
intubation, the rotation maneuver was obligatory in
6 patients intubated with Airtaq. These findings may
also explain that more forces had to be applied to the
patients during the use of Airtraq.
The major limitation of our study was that we did
not record any videos during airway manipulation of
the patients and internal views of the larynx.
Conclusion
The Airtraq use in patients with normal airway
anatomy may result in minor upper airway trauma and
significant sore throat. Experienced anesthesiologists
are able to intubate the patients with normal airway
anatomy with devices requiring skill and familiarity,
such as Macintosh laryngoscope or FOB. According to
the results of this study, we underline that the Airtraq
should not take place in the routine endotracheal
intubation practice of the patients with normal airways,
in the hands of experienced anesthesiologist; the use
of the airtraq should be limited to the manipulation
of patients with difficult airways and limited neck
extension.
Acknowledgments
The authors would like to acknowledge Yigit
Medical Systems, Ankara, Turkey for loan of Airtraq
devices for this study. The authors declare no financial
support or sponsorship.
Abbreviations
FOB: fiberoptic bronchoscope, ASA: American
Society of Anesthesiology, IM: intramuscular, IV:
intravenous, SpO2: peripheral pulse oximetry, ETCO2:
end tidal carbon dioxide, TOF: Train-of-four, VAS:
visual analogue scale, SPSS: Statistical Package for
Social Sciences for Windows, ANOVA: analysis of
variance.
The use of Airtraq laryngoscope versus Macintosh laryngoscope and fiberoptic
bronchoscope by experienced anesthesiologists
509
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M.E.J. ANESTH 22 (5), 2014
CASE REPORTS
Ultrasound-guided regional anesthesia
in a pediatric patient with acute intermittent
porphyria: literature review and case report
Yetunde Olutunmbi*, Harshad G. Gurnaney**,
Jorge A. Galvez* and Allan F. Simpao*
Abstract
Ultrasound-guided regional anesthesia techniques placed under general anesthesia have not
been reported in pediatric patients with acute intermittent porphyria (AIP). A 9-year-old male
with AIP presented for right inguinal herniorraphy. Family history included one relative’s death
after anesthesia. Preoperative preparation included reviewing medications safe for AIP patients,
minimizing known AIP triggers (fasting, stress) and ensuring access to rescue medications.
Intraoperative management included a propofol induction with the patient’s mother present in
the operating room. We performed an ultrasound-guided ilioinguinal-iliohypogastric nerve block
under general anesthesia. The surgery proceeded without complications and the patient did not
demonstrate signs of an AIP crisis.
Sources of financial support: This study was funded solely with departmental funding.
Introduction
Acute intermittent porphyria (AIP) is an autosomal dominant deficiency in porphobilinogen
deaminase that can manifest as a sudden, possibly fatal neurovisceral crisis, symptoms of which
include severe abdominal pain, seizures, respiratory and limb weakness, hypertension, and
tachycardia1,2. In rare occasions, AIP may present with symptomatic hyponatremia secondary to
syndrome of inappropriate antidiuretic hormone secretion3 acute pancreatitis4, or spontaneous
hemothorax5. Triggers include many aspects of the perioperative setting, such as fasting, stress,
dehydration and medications6.
*MD.
**MBBS, MPH.
Affiliation: Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of
Pennsylvania and The Children’s Hospital of Philadelphia, Philadelphia, PA.
Corresponding author: Allan F. Simpao, MD; Department of Anesthesiology and Critical Care Medicine at Perelman School
of Medicine at the University of Pennsylvania and the Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd.,
Suite 9329, Philadelphia, PA, 19104, Tel: 1-215-590-1000, Fax: 1-215-590-1415. E-mail: [email protected]
511
M.E.J. ANESTH 22 (5), 2014
512
Case Description
A 9-year-old, 25.7 kg male with a confirmed
genetic marker for acute intermittent porphyria (AIP)
presented for right inguinal hernia repair. Clinical signs
on admission included an innocent heart murmur and
anxiety. The family history was rife with anesthetic
complications: one relative died on induction with a
barbiturate, an aunt had an AIP episode while under
anesthesia necessitating alkaline heme treatments,
and the patient’s mother had “nearly died” during an
anesthetic for cardiac surgery.
Pre-operative management included a thorough
AIP literature search, a metabolism and genetics
consultation, and extensive communication with the
surgeon and the patient’s mother prior to the surgery.
Evidence-based lists of safe medications in AIP were
reviewed7 and a clinical pharmacist was contacted to
verify the information. Gabapentin and hemin were
ordered and available in the pharmacy in case of a
crisis8,9.
Olutunmbi y. et. al
continued; a glucose check was within the normal
range. Patient temperature was maintained between
36-38C via an underbody circulating water mattress
and an upper body forced-air blanket.
Fig. 1
Ultrasound-guided ilioinguinal-iliohypogastric
nerve block
The patient was encouraged to drink clear white
grape juice until 2 hours prior to surgery. On the
recommendation of metabolism/genetics, the patient
received an intravenous (IV) catheter in the holding
area, and an infusion of dextrose 10%/saline 0.45%
(D10/0.5NS) was started. A comprehensive metabolic
profile was checked to rule out inappropriate secretion
of antidiuretic hormone; the lab values were in the
normal range. In lieu of administering oral midazolam
(due to conflicting safety data in AIP patients), we
arranged a parental induction and gave IV fentanyl
for mild sedation prior to transport into the operating
room.
During the procedure, a left inguinal hernia
and undescended left testes were discovered by the
surgeon. The patient’s mother was contacted and she
consented to a bilateral surgical procedure. The patient
was given a 1.5 mg of IV morphine bolus prior to the
initiation of the left-sided portion of the procedure.
Ondansetron 4mg IV was administered during skin
closure. To minimize the stress of emergence, we
removed the LMA under deep plane of anesthesia (i.e.,
1.3 MAC) after ensuring that the patient was breathing
spontaneously with tidal volumes of approximately 5-6
mL/kg. A plastic oral airway was placed to maintain
airway patency.
We performed a parental-presence IV induction
with propofol, placed a laryngeal mask airway (LMA)
and administered sevoflurane. We performed a rightsided ultrasound-guided ilioinguinal-iliohypogastric
nerve block using a Sonosite S (Sonosite, Bothell,
WA) with an L25X (6-13 MHz) probe with clear
visualization of both nerves. Four mL of 0.25%
bupivacaine with 1:200,000 epinephrine were injected
with satisfactory spread of local anesthetic visualized
with the ultrasound in the plane between the internal
oblique and the transversus abdominis muscles around
the two nerves (Fig. 1). The D10/0.5NS infusion was
A nurse practitioner spoke with the mother during
a post-operative phone call 72 hours after discharge
The patient was transported uneventfully with
supplemental oxygen delivered via a Mapleson circuit
and face mask to the post-anesthesia care unit (PACU),
where he emerged safely from anesthesia. The patient
received a total of two 1mg boluses of IV morphine
over the following 15 minutes for reported 5/10 pain
located in the left inguinal region. There were no AIP
sequelae noted (e.g. abdominal pain, neurological
findings) and vital signs were stable throughout the
two-hour PACU stay prior to discharge home.
Ultrasound-guided regional anesthesia in a pediatric patient with acute intermittent
porphyria: literature review and case report
and determined that no AIP symptoms nor anesthesiarelated problems had occurred. Furthermore, the
patient had no new complaints nor any reported AIPrelated symptoms at his one-month follow-up visit with
the surgeon.
The Institutional Review Board at The Children’s
Hospital of Philadelphia gave permission to publish
this report and written informed consent was obtained
from the parent of the patient.
Discussion and Literature Review
Acute intermittent porphyria is caused by an
inherent error of porphyrin metabolism characterized
by a deficiency of porphobilinogen deaminase and
increased activity of delta-aminolevulinic acid
synthase. An increased concentration of heme
precursors results from the dysfunction of these two
key heme biosynthesis enzymes10,11.
Porphyric crisis can be precipitated by many
anesthetic and nonanesthetic drugs6,12,13. The
medications that are recommended as safe for use
in anesthesia for AIP patients is largely based on
cumulative anecdotal experiences (i.e. case reports and
case series)13,14. A constantly updated list is maintained
by the American Porphyria Foundation, which rates
medications’ safety in AIP patients based on evidence
in the literature7, In light of this patient’s strong family
history of anesthesia-related AIP complications, the
decision was made in conjunction with the patient’s
mother to use solely those medications that had
received the top safety rating of “OK!” (i.e. “very
likely to be safe for prolonged use by individuals with
an acute porphyria, based on consistent evidence”).
The list of planned perioperative medications was
verified as safe by a clinical pharmacist.
Acute seizures can present a treatment challenge
in AIP patients, as some medications given to ameliorate
acute seizures (e.g. barbiturates) are either known or
questionable AIP crisis precipitants13. Lorazepam and
magnesium have been shown to be safe treatments for
acute seizures in AIP patients15,16. Gabapentin-a GABA
analog prescribed commonly both as an antiepileptic
drug and to treat neuropathic pain-has been shown
to be a safe, effective treatment of status epliepticus
due to AIP8,17. Gabapentin pharmacokinetic profiles in
513
children ages 1 month to 12 years has shown similar
peak plasma concentrations across the entire age group
after a single dose of 10 mg/kg, and gabapentin doses
of 24 to 70 mg/kg/day were shown to be well tolerated
and have sustained efficacy in a large population of
children aged 3 to 12 years18,19,20. If seizures continue
despite gabapentin administration, then propofol (1-1.5
mg/kg IV bolus over 5 min followed by 1-2mg/kg/hr IV
infusion) can be delivered as a concurrent treatment21.
Electrolyte abnormalities that are associated with AIP
and can cause seizures (e.g. hyponatremia) should be
corrected2,3.
Hemin (i.e. exogenous heme) was made available
preoperatively as a precaution. Hemin has been shown
to be an effective treatment for acute AIP attacks after
conservative measures have been employed (e.g. IV
fluids containing carbohydrates); hemin ameliorates
symptoms via down-regulation of aminolevulinic acid
synthase22,23,24,25. Side effects experienced in cases
of overdose or overly rapid administration include
reversible renal shutdown and liver failure26,27.
In addition to extensive medication safety review
and preparations, thorough precautions were taken
to limit non-pharmacological stressors that might
precipitate an AIP attack1,2. Both a liberal fasting protocol
and preoperative IV placement with administration of
dextrose-containing fluids were initiated to minimize
dehydration and calorie restriction1,3. A parentalpresence induction, placement of a regional block, and
LMA removal under a deep plane of anesthesia were
all undertaken to minimize the stresses of anxiety and
pain. Lastly, steps were taken to identify AIP crisis
sequelae (e.g. preoperative comprehensive metabolic
panel to assess for hyponatremia)3.
While regional techniques in AIP patients have
been reported in the literature28,29,30, ultrasound-guided
regional anesthesia techniques placed under general
anesthesia have not been described in pediatric patients
with acute intermittent porphyria. In summary, we
present a successful general and ultrasound-guided
regional anesthetic course in a high-risk pediatric
AIP patient following the careful selection of safe
perioperative and rescue medications, liberal fasting
policy and preoperative administration of dextrosecontaining IV fluids, and vigilant minimization of
other potential AIP crisis precipitants.
M.E.J. ANESTH 22 (5), 2014
514
Olutunmbi y. et. al
References
1.Pischik E, Kauppinen R: Neurological manifestations of acute
intermittent porphyria. Cell Mol Biol; 2009, 55:72-83.
2.Bylesjö I, Forsgren L, Lithner F, Boman K: Epidemiology and
clinical characteristics of seizures in patients with acute intermittent
porphyria. Epilepsia; 1996, 37:230-5.
3.Gázquez Sisteré I, Luján Mavila K, Chordá Ribelles J, Touzón
López C: Acute intermittent porphyria: a diagnostic dilemma.
Gastroenterol Hepatol; 2010, 33:436-9.
4.Shen FC, Hsieh CH, Huang CR, Lui CC, Tai WC, Chuang YC:
Acute intermittent porphyria presenting as acute pancreatitis and
posterior reversible encephalopathy syndrome. Acta Neurol Taiwan;
2008, 17:177-83.
5.Buitrago J, Santa SV: Acute intermittent porphyria presenting as
spontaneous hemothorax. Biomedica; 2009, 29:339-47.
6.Sheppard L, Dorman T: Anesthesia in a child with homozygous
porphobilinogen deaminase deficiency: a severe form of acute
intermittent porphyria. Ped Anesth; 2005, 15:426-8.
7.American Porphyria Foundation. Available at http://www.
porphyriafoundation.com/testing-and-treatment/drug-safety-inacute-porphyria. Accessed April 1, 2014.
8.Zadra M, Grandi R, Erli LC, Mirabile D, Brambilla A: Treatment
of seizures in acute intermittent porphyria: safety and efficacy of
gabapentin. Seizure; 1998, 7:415-6.
9.Muthane UB, Vengamma B, Bharathi KC, Mamatha P: Porphyric
neuropathy: prevention of progression using haeme-arginate. J
Intern Med; 1993, 234:611-3.
10.Khanderia U, Bhattacharya A: Acute intermittent porphyria:
pathophysiology and treatment. Pharmacotherapy; 1984, 4:144-50.
11.Bloomer JR, Bonkovsky HL: The porphyrias. Dis Mon; 1989, 35:154.
12.Disler PB, Moore MR: Drug therapy in the acute porphyrias. Clin
Dermatol; 1985, 3:112-24.
13.James MFM, Hift RJ: Porphyrias. Br J Anesth; 2000, 85:143-53.
14.Hsieh CH, Hung PC, Chien CT, Shih YR, Peng SK, Luk HN, Tsai
TC: The use of rocuronium and sevoflurane in acute intermittent
porphyria-a case report. Act Anaesthesiol Taiwan; 2006, 44:169-71.
15.Holroyd S, Seward RL: Psychotropic drugs in acute intermittent
porphyria. Clin Pharmacol Ther; 1999, 66:323-5.
16.Sadeh M, Blatt I, Martonovits G, Karni A, Goldhammer Y:
Treatment of porphyric convulsions with magnesium sulfate.
Epilepsia; 1991, 32:712-5.
17.Tatum WO 4th, Zachariah SB: Gabapentin treatment of seizures in
acute intermittent porphyria. Neurology; 1995, 45:1216-7.
18.Haig GM, Bockbrader HN, Wesche DL, Boellner SW, Ouellet
D, Brown RR, Randinitis EJ, Posvar EL: Single-dose gabapentin
pharmacokinetics and safety in health infants and children. J Clin
Pharmacol; 2001, 41:507-14.
19.Appleton R, Fichtner K, LaMoreaux L, Alexander J, Maton S,
Murray G, Garofalo E: Gabapentin as add-on therapy in children
with refractory partial seizures: a 24-week, multicentre, open-label
study. Dev Med Child Neurol; 2001, 43:269-73.
20.McLean MJ, Gidal BE: Gabapentin dosing in the treatment of
epilepsy. Clin Ther; 2003, 25:1382-406.
21.Pandey CK, Singh N, Bose N, Sahay S: Gabapentin and propofol
for treatment of status epilepticus in acute intermittent porphyria. J
Postgrad Med; 2003, 49:285.
22.Peterson A, Bossenmaier I, Cardinal R, Watson CJ: Hematin
treatment of acute porphyria. Early remission of an almost fatal
relapse. JAMA; 1976, 235:520-2.
23.Bissell DM: Treatment of acute hepatic porphyria with hematin. J
Hepatol; 1988, 6:1-7.
24.Mustajoki P, Nordmann Y: Early administration of heme arginate
for acute porphyric attacks. Arch Intern Med; 1993, 153:2004-8.
25.Bonkovsky HL, Healey JF, Lourie AN, Gerron GG: Intravenous
heme-albumin in acute intermittent porphyria: evidence for
repletion of hepatic hemoproteins and regulatory heme pools. Am J
Gastroenterol; 1991, 86:1050-6.
26.Dhar GJ, Bossenmaier I, Cardinal R, Petryka ZJ, Watson CJ:
Transitory renal failure following rapid administration of a relatively
large amount of hematin in a patient with acute intermittent
porphyria in clinical remission. Acta Med Scand; 1978, 203:437-43.
27.Frei P, Minder EI, Corti N, Muellhaupt B, Geier A, Adams H,
Dutertre JP, Rudiger A, Dutkowski P, Maggiorini M, Ganter CC:
Liver transplantation because of acute liver failure due to heme
arginate overdose in a patient with acute intermittent porphyria.
Case Rep Gastroenterol; 2012, 6:190-6.
28.McNeill MJ, Bennet A: Use of regional anaesthesia in a patient
with acute porphyria. Br J Anaesth; 1990, 64:371-3.
29.Böhrer H, Schmidt H: Regional anesthesia as anesthetic technique
of choice in acute hepatic porphyria. J Clin Anesth; 1992, 4:259.
30.Rigal JC, Blanloeil Y: Anaesthesia and porphyria. Minerva
Anestesiol; 2002, 68:326-31.
Anesthetic Considerations and Management
of a Patient with Unsuspected Carcinoid
Crisis During Hepatic Tumor Resection
Clark K. Choi*
Abstract
Anesthetic management for massive blood loss in liver surgery concomitant with
hemodynamic instability secondary to carcinoid crisis can be challenging in the perioperative
setting. Hypotension, diarrhea, facial flushing, bronchospasm, and tricuspid and pulmonic
valvular diseases are the common manifestations of carcinoid syndrome. This report illustrates the
importance of early recognition and treatment for signs and symptoms of carcinoid syndrome not
only in the preoperative setting but also in the intraoperative phase to prevent undue cardiovascular
collapse.
Keywords: Octreotide, carcinoid crisis, neuroendocrine hepatic tumor, hypotension.
Introduction
Carcinoid tumor is a rare form of neuroendocrine cancer that is derived from enterochromaffin
cells. Approximately 74% of carcinoid tumors originate from the gastrointestinal tract, most
commonly from the small bowel (29%) and appendix (19%), and 25% from the lungs1. The annual
incidence is reported to be 0.28 per 100,000 population2. The tumor secretes serotonin, histamine,
bradykinins, and vasoactive intestinal peptides that produce vessel permeability, hypotension,
flushing, diarrhea, and wheezing when released into the systemic circulation from liver metastases
or extrahepatic carcinoid tumor during surgical manipulation3.
Case Report
A 64-year-old male (83 kg, 185 cm) with past medical history of hyperlipidemia and left
hepatic tumor, presented with bronchitis, diarrhea, and flushing for 9 months. A liver biopsy
confirmed intermediate grade neuroendocrine tumor of unknown primary neoplasm. The patient
underwent hepatic artery embolization and received monthly somatostatin depot for symptomatic
relieve before he was evaluated for surgical intervention.
* MD, MS.
Corresponding author: Clark K. Choi. Department of Anesthesiology and Perioperative Medicine, The University of Texas
MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030. Tel: (718) 909-6806, Fax: (713) 563-3808.
E-mail: [email protected]
515
M.E.J. ANESTH 22 (5), 2014
516
Choi C. K.
On the day of surgery, the patient appeared wellnourished with stable vital signs (BP=114/69 mmHg,
P=79 beats/min, RR=18 breaths/min, SpO2=98%, and
T=37 ºC). Electrocardiogram and chest radiography
revealed sinus rhythm and no metastatic lesions,
respectively. Computerized tomography of the chest,
abdomen, and pelvis was unremarkable. Laboratory
values were the following: Na=140 mEq/L, K=4.1
mEq/L, Cl=102 mEq/L, CO2=25 mEq/L, BUN=21
mg/dL, Cr=1.1 mg/dL, Glu=71 mg/dL, Hct=43.5%,
PLT=143 × 109/L, PTT=28.7 sec, and PT=13.8 sec.
Two large bore peripheral intravenous catheters
(14- and 16-gauge) and a radial arterial line were
inserted. He was pretreated with levoalbuterol for mild
bronchitis and midazolam for anxiety. Patient tolerated
induction and intubation without hemodynamic swings.
Octreotide 100 mcg was injected subcutaneously after
intubation. Ciprofloxacin and metronidazole were
administered for his penicillin drug allergy.
Arterial pressure fell abruptly to 43/26 mmHg 30
minutes after skin incision (Figure 1). Manipulation
of the tumor was stopped as fluid and intravenous
Fig. 1
Intraoperative hemodynamic measurements
Anesthetic Considerations and Management of a Patient with Unsuspected Carcinoid Crisis
During Hepatic Tumor Resection
octreotide (>450 mcg) were immediately administered
to temporize the sudden drop in blood pressure and
intermittent clamping of the hepatic artery to prevent
the release of hepatic carcinoid mediators. No facial
flushing or wheezing was noticed. Blood pressure
was maintained with phenylephrine, ephedrine, and
vasopressin boluses for refractory hypotension4.
After 4 hours of surgery, the oxygen saturation
dropped gradually to 81% on the pulse oximeter.
Because of concerns for pneumothorax from
inadvertent diaphragmatic injury or venous air
embolism5, the inspiratory oxygen concentration was
increased from 50% to 100%. Ascultation of breath
sounds were clear and pulmonary compliance on bag
ventilation was adequate. Peak airway pressure and
end-tidal carbon dioxide were unchanged. An arterial
blood gas showed PaCO2=39 mmHg and PaO2=459
mmHg. Hypoperfusion secondary to blood loss could
be a possibility that accounted for the low oxygen
saturation, but it steadily improved as 2 units of packed
red blood cells were transfused and more vasopressors
given. Estimated blood loss and urine output were
1-L and 1.8-L, respectively. A total of 2.5-L of 5%
albumin and 5-L of crystalloid were infused. Patient
was successfully extubated in stable condition with a
post-transfusion hematocrit of 31%.
Discussion
Currently the drug of choice for treatment of
carcinoid syndrome is octreotide, a somatostatin analog
that inhibits the release of vasoactive mediators6,7.
The optimal dose for octreotide administered
subcutaneously is 100 mcg before induction, or 25
mcg to 100 mcg intravenous boluses during surgery
to achieve a desired effect8. Other adjunct but obsolete
therapies include antagonists that block specific
517
histamine (H1 and H2)3 and serotonin (5-HT2)9,10
receptors, or bradykinin11 production. The effectiveness
of these medications for preventing carcinoid crisis is
inconclusive as studies have disputed their efficacy.
Indirect adrenergic agonist (e.g., ephedrine)
that causes catecholamine release is typically
contraindicated because they worsen the mediator
cascade. However, their role is unclear in preventing
hypotension since ephedrine has been used in the
intraoperative setting after octreotide therapy has
failed12. On the other hand, direct adrenergic agonist
(e.g., phenylephrine) and vasopressin, which acts
on the V1 receptor, increase blood pressure by
vasoconstriction of blood vessels are not involved
in catecholamine release. Therefore, both are useful
drugs to prevent carcinoid hypotension.
While much emphasis is placed on the
pharmacological
strategies
that
target
the
pathophysiology of carcinoid syndrome, it underscores
the perioperative considerations and its anesthetic
implications. The key points in the management
for this case include: (1) a complete preoperative
assessment and optimization of electrolyte imbalance
(e.g., hypokalemic hyperchloremic metabolic acidosis)
from diarrhea before surgery13; (2) avoidance of
medications that trigger allergic reactions or histamine
release; (3) minimization of stress response that can
release catecholamines during induction, intubation,
and surgery14; (4) placement of an arterial line for
monitoring rapid changes in blood pressure and blood
draws for electrolytes, and large bore intravenous
catheters, or even a central line, for infusion of blood
and fluids; (5) availability of vasopressors and blood
products in anticipation for hemodynamic instability
and potential blood loss; and (6) good communication
between the surgical and anesthesia team in case of
emergency.
M.E.J. ANESTH 22 (5), 2014
518
Choi C. K.
References
1. Modlin IM, Sandor A: An analysis of 8305 cases of carcinoid
tumors. Cancer; 1997, 79:813-29.
2. Farling PA, Durairaju AK: Remifentanil and anaesthesia for
carcinoid syndrome. Br J Anaesth; 2004, 92:893-5.
3. Vaughan DJ, Brunner MD: Anesthesia for patients with carcinoid
syndrome. Int Anesthesiol Clin; 1997, 35:129-42.
4. Cortinez F. LI: Refractory hypotension during carcinoid resection
surgery. Anaesthesia; 2000, 55:505-6.
5. Koo BN, Kil HK, Choi JS, Kim JY, Chun DH, Hong YW: Hepatic
resection by the Cavitron Ultrasonic Surgical Aspirator increases the
incidence and severity of venous air embolism. Anesth Analg; 2005,
101:966-70.
6. Roy RC, Carter RF, Wright PD: Somatostatin, anaesthesia, and the
carcinoid syndrome. Peri-operative administration of a somatostatin
analogue to suppress carcinoid tumour activity. Anaesthesia; 1987,
42:627-32.
7. Parris WC, Oates JA, Kambam J, Shmerling R, Sawyers JF: Pretreatment with somatostatin in the anaesthetic management of a
patient with carcinoid syndrome. Can J Anaesth; 1988, 35:413-6.
8. Dierdorf SF: Carcinoid tumor and carcinoid syndrome. Curr Opin
Anaesthesiol; 2003, 16:343-7.
9. Mason RA, Steane PA: Anaesthesia for a patient with carcinoid
syndrome. Anaesthesia; 1976, 31:243-6.
10.Solares G, Blanco E, Pulgar S, Diago C, Ramos F: Carcinoid
syndrome and intravenous cyproheptadine. Anaesthesia; 1987,
42:989-92.
11.Vaughan DJ, Howard JM, Brunner MD: Refractory hypotension
during carcinoid resection surgery. Anaesthesia; 2000, 55:927.
12.Kinney MA, Warner ME, Nagorney DM, Rubin J, Schroeder DR,
Maxson PM, Warner MA: Perianaesthetic risks and outcomes of
abdominal surgery for metastatic carcinoid tumours. Br J Anaesth;
2001, 87:447-52.
13.Kleine JW, Khouw YH, Heeres MG: Hypovolemia and hypotension
with carcinoid syndrome. Anesthesiology; 1978, 49:55.
Mancuso K, Kaye AD, Boudreaux JP, Fox CJ, Lang P, 14.
Kalarickal PL, Gomez S, Primeaux PJ: Carcinoid syndrome
and perioperative anesthetic considerations. J Clin Anesth; 2011,
23:329-41.
UNUSUALLY DIFFICULT INTRAESOPHAGEAL BOUGIE
INSERTION IN AN INTUBATED PEDIATRIC PATIENT
Xiaoyu Zhang* and Xuan Zhao**
Introduction
The insertion of an intraesophageal bougie has been a common step in hiatal repair procedures.
This process is similar to insertion of a gastric tube (GT) in anesthetized, paralyzed, and intubated
patients that can be difficult. We report an unusually difficult intraesophageal bougie insertion in
an intubated pediatric patient owing to esophageal stricture.
Case Presentation
A 7-month-old male weighing 6.8 kg was scheduled for elective laparoscopic hiatal repair due
to repetitive regurgitation. The patient had no past history of recent upper respiratory tract infection
or deglutition difficulty. On physical examination, the patient had no anatomical throat variants other
than malnutrition. Laboratory values were normal and an upper gastrointestinal contrast revealed
the diagnosis of hiatal hernia (Fig. 1). Anesthesia was induced with atropine 0.5 mg, midazolam
0.5 mg, propofol 15 mg and remifentanil 5µg. After intravenous administration of cisatracurium,
the patient was uneventfully intubated with an uncuffed armored tracheal tube (ID: 4.0 mm). Her
direct laryngoscopic view was grade 1 according to the Cormack and Lehane classification with no
pharynx and throat deformity. Anesthesia was maintained with sevoflurane and remifentanil. The
patient received pressure-controlled ventilation with a peak inspiratory pressure of 20 cmH2O. The
operation was otherwise uneventful. During the surgery, an intraesophageal bougie was requested
to be inserted by a senior anesthesiologist in order to confirm proper wrap size and placement,
as well as testing the security of the sutures holding the wrap in place. The placement of the
intraesophageal bougie was attempted several times with no success. Various methods, including
stiffening the bougie with ice water, using a guide wire, blind insertion of an endotracheal tube
as an introducer, and direct laryngoscopy and assistance with Magill’s forceps, failed to advance
the bougie tip more than 14 cm to 15 cm from incisor into esophageal. Considering the inherent
risk of esophagogastric perforation associated with this maneuver, the surgeons decided to
proceed with the repair and fundoplication without the aid of a bougie. Towards the end of the
surgery, an attempt was made to insert a gastric tube to facilitate gastric emptying, but the tube
*MM
**MD
Affiliation: Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665
Kongjiang Road, Shanghai, 200092, China.
Corresponding author: Xuan Zhao, MD, Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University
School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China. Phone and Fax: +86 021 25078999. E-mail address:
[email protected]
519
M.E.J. ANESTH 22 (5), 2014
520
Fig. 1
Preoperative upper gastrointestinal contrast revealed the
diagnosis of hiatal hernia
Zhang x. et. al
could only be inserted around 15 cm and no stomach
contents could be quilted from the tube. After tracheal
extubation, the patient was shifted to the PICU, and
in order to further decompress the stomach, insertion
of a nasogastric tube into the esophagus was attempted
under direct visualization using a pediatric flexible
fiberoptic gastroscopy and guide wire. Gastroscopy
revealed confirmed an esophageal stricture located
15 cm from the incisors and a super slim endoscope
with an outer diameter of 5 mm could not be pushed
down owing to the stricture (Fig. 2). On follow-up in
PICU, the child underwent a dilatation of the stricture
by using a through-the-scope balloon (Fig. 3) and she
was transferred to the ward on the 7th postoperative
day in a healthy state.
Fig. 2
A super slim endoscope (outer diameter 5 mm) inserted until
15 cm from the incisors and could not be pushed down owing
to the stricture
UNUSUALLY DIFFICULT INTRAESOPHAGEAL BOUGIE INSERTION IN AN INTUBATED PEDIATRIC PATIENT
Fig. 3
The child underwent a dilatation of the stricture
by using a balloon
Discussion
The use of an intraesophageal bougie has
traditionally been an integral step in the repair of
large hiatal hernia and fundoplication. Many times
the passage of the bougie is not performed by the
surgeon but rather by the anesthesiologist. This
process is similar to insertion of a gastric tube (GT)
in anesthetized, paralyzed, and intubated patients. The
521
piriform sinuses and the arytenoid cartilages are the
most common sites of impaction during the insertion.
Manipulations for improvement of insertion have
included insertion of the bougiealong the posterior
or lateral pharyngeal wall, flexion of the neck and
application of lateral patient’s neck pressure1 or
turning the head to one side1,2. Other techniques
involve the use of direct laryngoscopy and assistance
with Magill’s forceps, the use of a slit endotracheal
tube, the use of a ureteral guidewire as a stylet, and the
use of a gloved finger to steer the NGT after laryngeal
impaction3-7. However, all of these techniques failed
to advance the bougie through the esophagus in this
patient because of the esophageal stricture. Pediatric
esophageal stricture may occur following congenital
esophageal atresia repair or as complications from
reflux esophagitis, caustic ingestion, or restrictive
Nissen fundoplication8. In this case, the patient had
no past history of esophageal surgery, chemical injury
or burns. Possible mechanisms include complication
from reflux esophagitis, or esophageal tissue edema
caused by intraoperative surgical injury.
Anesthetists should be aware of difficulties in
inserting gastric tube or intraesophageal bougie in
intubated patient, particularlyin pediatric patients
with upper gastrointestinal disease, and because of
impaired cognition, anatomical factors, complications
of gastrointestinal disease, and difficult intubation
Blind maneuvers for insertion of intraesophageal
bongie can be traumatic and unreliable. Inadvertent
intracranial introduction of a NG tube9, as well
as cases of unintentional insertion of the NG tube
into the trachea alongside a cuffed endotracheal
tube, have been described10,11. A direct visualization
technology can be used when insertion of a NG tube or
intraesophageal bougie is necessary despite otherwise
difficult conditions.
M.E.J. ANESTH 22 (5), 2014
522
Zhang x. et. al
References
1.Bong CL, Macachor JD, Hwang NC: Insertion of the nasogastric
tube made easy. Anesthesiology; 2004, 101:266.
2.Ozer S, Benumof JL: Oro-and nasogastric tube passage in intubated
patients: fiberoptic description of where they go at the laryngeal
level and how to make them enter the esophagus. Anesthesiology;
1999, 91:137-43.
3. Mahajan R, Gupta R: Another method to assist nasogastric tube
insertion. Can J Anaesth; 2005, 52:652-3.
4.Flegar M, Ball A: Easier nasogastric tube insertion. Anaesthesia;
2004, 59:197.
5.Sprague DH, Carter SR: An alternative method for nasogastric tube
insertion. Anesthesiology; 1980, 53:436.
6.Campbell B: A novel method of nasogastric tube insertion.
Anaesthesia; 1997, 52:1234.
7.Appukutty J, Shroff PP: Nasogastric tube insertion using different
techniques in anesthetized patients: a prospective, randomized
study. Anesth Analg; 2009, 109:832-5.
8.Ball WS, Strife JL, Rosenkrantz J, et al: Esophageal strictures
in children. Treatment by balloon dilatation. Radiology; 1984,
150:263-264.
9.Seebacher J, Nozik D, Mathieu A: Inadvertent intracranial
introduction of a nasogastric tube: a complication of severe
maxillofacial trauma. Anesthesiology; 1975, 42:l00-2.
10.Sweatman AJ, Tomasello PA, Loughhead MG, et al: Misplacement
of nasogastric tubes and oesophageal monitoring devices. Br J
Anaesth; 1978, 50:389-92.
11.Saha AK: The insertion of nasogastric tubes in the anaesthetized
patient. Anaesthesia; 1974, 29:367.
LETTER TO THE EDITOR
SUCCESSFUL INTUBATION USING MCGRATH ® MAC
IN A PATIENT WITH TREACHER COLLINS SYNDROME
Takatoshi Tsujimoto*, Satoshi Tanaka**, Yuki Yoshiyama*,
Yuki Sugiyama*** and Mikito Kawamata****
Treacher Collins syndrome (TCS) is a congenital malformation of craniofacial development,
which is associated with difficult tracheal intubation1. Several video laryngoscopes that have
recently been developed have been shown to improve the laryngeal view in pediatric patients
with difficult airways, including patients with TCS2-4. McGRATH® MAC (MAC; Aircraft Medical,
Edinburgh, UK) has more recently been developed as a new video laryngoscope modified from
McGRATH® Series 5 and may provide a better view of the glottis for intubation in adult patients5.
However, there has been no report on the usefulness of MAC for intubation in pediatric patients
with difficult airways.
A 13-year-old boy (146 cm; 36 kg) with TCS was scheduled for exotropia surgery under
general anesthesia. Tetralogy of Fallot repair had been performed at the age of 4 years, when
the trachea was intubated using a Macintosh laryngoscope despite Cormack-Lehane classification
grade 3. At the age of 11 years, when mandibular distraction osteogenesis was performed,
fiberoptic scope-guided endotracheal intubation was accomplished after failure of intubation
using a Macintosh laryngoscope at a regional hospital. The patient showed the characteristic facial
appearance of TCS such as micrognathia (Fig. 1-A). Thyromental and interincisor distances were
40 mm and 18 mm, respectively, showing moderate trismus. A magnetic resonance imaging scan
revealed a relatively long distance from the mouth to the larynx (Fig. 1-B). Since we considered
the airway to be patent in this patient under mask ventilation, general anesthesia was induced with
70 mg of propofol after setting up alternative devices to secure the airway, including equipment
for percutaneous tracheostomy and a transtracheal jet ventilator. After mask ventilation has been
successfully achieved, neuromuscular block was induced with 20 mg of rocuronium. In order to
check the difficult airway in this patient, we used a Macintosh blade no. 3 and failed to visualize the
epiglottis, defined as Cormack-Lehane classification grade 4. An attempt was then made to intubate
using MAC with blade no. 3 (Fig. 1-C). The blade was easily inserted into the larynx and exposed
the epiglottis and the vocal cord, defined as Cormack-Lehane classification grade 1. The trachea
was successfully intubated with an ID 6.0 mm tracheal tube without difficulty.
*
MD, Resident anesthesiologist.
** MD, Assistant Professor.
*** MD, Instructor.
**** MD, Professor and Chairman.
Affiliation: Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine.
Corresponding author: Dr. Mikito Kawamata, Department of Anesthesiology and Resuscitology, Shinshu University
School of Medicine, 3-1-1, Asahi, Matsumoto, Nagano 390-8621, JAPAN. Tel: +81-263-37-2670, Fax: +81-263-35-2734.
E-mail: [email protected]
523
M.E.J. ANESTH 22 (5), 2014
524
Tsujimoto t. et. al
Fig. 1
(A) Lateral view of a 13-year-old boy with
Treacher Collins syndrome.
(B) Sagittal magnetic resonance imaging
showed no abnormalities in the pharynx
and larynx but revealed a relatively long
distance from the mouth to the larynx. The
curved dashed line traces the air passage
from the incisor to the epiglottis. The
length of the line is 120 mm.
(C) McGRATH® MAC with blade no. 3.
Video-laryngoscopes such as the GlideScope®,
Glidescope Cobalt® (Verathon Medical Inc., Bothell,
WA, USA) and Pentax-Airway Scope ® (AWS; Hoya
Co., Tokyo, Japan) have been reported to be useful for
tracheal intubation in patients with difficult airways2-4.
However, the usefulness of video laryngoscopes differs
in patients with difficult airways, depending on features
and severity of their anatomical abnormality in the oral
cavity, pharynx and larynx6. Features of TCS include
micrognathia, small mouth, high arched palate, cleft
palate and velopharyngeal incompetence, and tracheal
intubation becomes difficult with advance of age1. In
this patient, blade no. 3 of MAC could easily reach the
larynx and visualize the glottis and vocal cord. This is
probably because the shape of the blade of MAC fitted
to the oropharyngeal features in this patient. Thus, the
McGrath MAC may be useful for tracheal intubation
in pediatric patients who have micrognathia and a
small mouth as were seen in this patient.
SUCCESSFUL INTUBATION USING MCGRATH ® MAC IN A PATIENT WITH TREACHER COLLINS SYNDROME
525
References
1.Hosking J, Zoanetti D, Carlyle A, Anderson P, Costi D: Anesthesia
for Treacher Collins syndrome: a review of airway management in
240 pediatric cases. Pediatr Anesth; 2012, 22:752-8.
2. Lee JH, Park YH, Byon HJ, Han WK, Kim HS, Kim CS, Kim JT: A
comparative trial of the GlideScope® video laryngoscope to direct
laryngoscope in children with difficult direct laryngoscopy and an
evaluation of the effect of blade size. Anesth Analg; 2013, 117:17681.
3. Iguchi H, Sasano N, So M, Hirate H, Sasano H, Katsuya H:
Orotracheal intubation with an Airway Scope in a patient with
Treacher Collins syndrome. J Anesth; 2008, 22:186-8.
4. Ilies C, Fudickar A, Thee C, Dütschke P, Hanss R, Doerges V, Bein
B: Airway management in pediatric patients using the Glidescope
Cobalt®: a feasibility study. Minerva Anestesiol; 2012, 78:1019-25.
5. Healy DW, Maties O, Hovord D, Kheterpal S: A systematic
review of the role of videolaryngoscopy in successful orotracheal
intubation. BMC Anesthesiol; 2012, 12:32. http://www.biomedentral.com/ 1471-2253/12/32.
6. Hyuga S, Sekiguchi T, Ishida T, Yamamoto K, Sugiyama Y,
Kawamata M: Successful tracheal intubation with the McGrath®
MAC video laryngoscope after failure with the Pentax-AWS™ in
a patient with cervical spine immobilization. Can J Anaesth; 2012,
59:1154-5.
M.E.J. ANESTH 22 (5), 2014
CORRESPONDENCE
Anesthesia Care Providers’ Based Interdisciplinary
Peri-operative Cross-Over Post-Market - SafetySurveillance: Is it Futuristic Patient Safety Idea?
Running Title: Post-Hire PMSS
for Interventionists
Deepak Gupta*
Education and practice of medicine potentially provides an unexplored avenue for anesthesia
care providers wherein currently practiced anesthesia care providers’ initiated quality-assurance
(QA) can grow out of the bounds of peri-anesthesia events. These QA processes should expand into
anesthesia care providers’ based interdisciplinary peri-operative cross-over post-market (post-hire)
safety surveillance (PMSS) as similar to PMSS for devices1 and drugs2. Anesthesia care providers
witness plethora of surgical interventions, multiple ways of performing same interventions and
comparative peri-operative variability across surgical operators. Hence, their understanding of
peri-operative outcomes with system- and operator-based risk factors can guide them to generate a
local and indigenous rating system for operators that guide (a) the operators themselves, (b) their
supervisory administrators, and (c) their paying patients to make appropriate decisions wherein
consequently (a) the operators are given procedure-specific privileges based on their personal
understanding of their limitations, (b) the administrators’ decisions are guided by statistical
analysis of local peri-operative outcomes and (c) the patients’ shopping capabilities are enhanced
by transparent local ratings of the operators’ procedures-specific proficiency.
The cross-over will be the operators themselves preempting similar avenues for the
administrators who may decide against blanket privileges3 for the anesthesia care providers who
themselves by default are practitioners of procedural medicine. This PMSS will not mean an excuse
for letting go personnel but healthcare-generated wealth will be re-distributed according to the
health care providers’ proficiency as adjudged by local patient outcomes. Redistribution according
to dynamics of allowable and restricted procedure-related privileges will ensure each interventionist
gets his/her share without losing his/her elite economic status in the society. The secondary benefit
will be that the rising incomes of proficient proceduralists will inspire peer practitioners to either
accept their limited access to perform procedures or improve their proficiency to target top end
elite salaries4-5.
*MD.
Affiliation: Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States.
Corresponding author: Dr. Deepak Gupta, Box. No. 162, 3990 John R. Detroit, MI 48201, United States. Tel: 1-313-7457233, Fax: 1-313-993-3889. E-mail: [email protected]
527
M.E.J. ANESTH 22 (5), 2014
528
The new PMSS will be asking simple questions to
the anesthesia care providers that whether they would
want the particular operative procedures performed
upon them or their next of kin by operators being rated.
Analogously, the operators would be asked whether
they would want specific anesthesia procedures and
specific practice of anesthesia provided to them or
to their next of kin or to their patients by anesthesia
care providers being rated. Though the documentation
of interventionists’ rating per procedure will be
a three-pronged question “Definitely-Not SureNever” and the cumulative datasheets generated
will reflect percentages per rated procedure for the
interventionists, these comprehensive datasheets will
be restricted for limited personal as well as in-house
management. However, the selective datasheets that
reflects only the proficiency “Definitely” data (and not
the deficiency “Never” data) of rated interventionists
will be shared with the future patients who will have
electively decided to undergo the rated procedure at
the rating health institution, and will need in-house
informational support in terms of health institution’s
local rating systems of its interventionists.
Although in-house QA processes already exist,
the perceptive positive reinforcements (“I prefer this
interventionist for me and/or my next of kin” instead
of “I do not prefer this interventionist for me and/or
my next of kin”) from these in-house processes will be
able to percolate into the awareness of future patients
who are coming for elective interventions. Moreover,
compared to lay persons, the educated peers would be
better guides for the prospective patients so that they
can make informed decisions based on their choices
as well as the urgencies of their clinical situations
where-in deciding for/against the rated operating
interventionist is an immense question for the patients.
When evaluating a care-giving system where
focus is only on prevention of mortality, that system is
apparently visualizing only the tip of iceberg. The iceberg
of patient safety is constituted of unappreciated or
under-reported morbidities that can be easily quantified
by continual QA/PMSS processes with potential
corrections/preventions by pre-emptive re-allocation
and re-organization of the locally and objectively
peer-rated interventionists’ teams in question. Hence,
the sole aim of this PMSS will be to ensure constant
Gupta d.
vigilance and regular review about procedure-specific
privileges based on patient outcomes secondary to
mortality and morbidity as well as supporting medical
staff’s perceived outcomes secondary to near-hitsnear-misses so that the operators (including anesthesia
care providers) can themselves find their niche in any
of the following: (a) blanket clinical privileges (b)
restricted procedure-specific privileges (c) academics
(d) research (e) administration-management6. This will
ensure that the providers’ remunerations do not cease
but the proportions of avenues (clinical privilege based,
experience and seniority based, local patient outcome
based, academics based, research based, and managerial
based avenues) generating these reimbursements are
safer for the patients, the administrators as well as the
operators wherein clinical interventions involving the
major risks for patient safety are only performed by the
interventionists proficient in those areas as adjudged
by the continual QA/PMSS processes whereas notso-safe proceduralists can primarily focus on other
avenues as well as interventions that involve only
minor risks for patient safety.
The local ratings system cannot be anonymous to
avoid the appeasing traits of the inter-dependent peers
as well as to ensure that the PMSS raters stand by their
ratings performed daily with each patient encounter/
procedure performed by the rated operators. Another
avenue as a direct result of this PMSS process is
that there will be a need for creating transient phase
of provisional restrictions to blanket privileges. The
interventionists will be allocated to the transient
phase when they will be learning new techniques or
adjusting their old techniques to timely improve their
worsening outcomes/ratings. Similarly, the permanent
restrictions to blanket privileges will not mean that
these restrictions cannot be overturned depending on
the vigor of the rated interventionist who is ready to
learn and improvise. This arrangement will always be
dynamic because PMSS process will not be meant for
vindications but to honestly aim at preemptively acting
in response to personal failures that, if overlooked, can
affect the patient safety outcomes.
Every process (including PMSS) will always have
a paradox of an eventual slippery slope. However, the
intentions are clean and honest so that base salaries and
base stature of interventionists will not change; and only
Anesthesia Care Providers’ Based Interdisciplinary Peri-operative Cross-Over Post-MarketSafety-Surveillance: Is it Futuristic Patient Safety Idea?Running Title: Post-Hire PMSS for
Interventionists
the transcendental salaries will be at constant dynamic
adjustment pathways according to the interventionists’
prowess and proficiency for the procedures as well as
their results and patient outcomes. The rating systems
will ensure that the salary adjustments are transparent
without any malign. In summary, analogous to PMSS
for drugs and devices, the novice application will
529
ensure post-hire PMSS for operators/interventionists
by interdisciplinary peers who will apply lay persons’
understanding, interpretations and sensibilities but
will possess more than just lay persons’ experience
in regards to medical knowledge, clinical skills,
communication skills, decision-making capacity and
professionalism when rating an interventionist.
M.E.J. ANESTH 22 (5), 2014
530
Gupta d.
References
1.FDA.gov http://www.fda.gov/ MedicalDevices/ Safety/CDRHP
ostmarketSurveillance/default.htm Accessed on March 26, 2014.
2.FDA.gov http://www.fda.gov/drugs/guidancecomplianceregulatory
information/surveillance/ucm204091.htm Accessed on March 26,
2014.
3. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R (Eds): Handbook of clinical anesthesia 7th edition, Ch. 2,
Wolters Kluwer Health/Lippincott Williams &Wilkins, Philadelphia
2013.
4.Medscape.com
http://www.medscape.com/features/slideshow/
compensation/2013/anesthesiology Accessed on March 26, 2014.
5. MacIntyre P, Stevens B, Collins S, Hewer I: Cost of education and
earning potential for non-physician anesthesia providers. AANA J;
82:25-31, 2014.
6. Reich DL, Galati M, Krol M, Bodian CA, Kahn RA: A
mission-based productivity compensation model for an academic
anesthesiology department. Anesth Analg; 2008, 107:1981-8.