clock practice power point for sam meeting, chicago 2010.ppt [modo de ad

8/8/2019 Clock Practice Power Point for Sam Meeting, Chicago 2010.Ppt [Modo de ad

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CEDIVA Dnia, Training Center in Difficult Airway ManagementAnesthesia and ICU Department

Hospital de Dnia


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Francisca Llobell, Daniel Paz,Ins Carpi, Remedios Prez, Isabel Estruch,Maria Serna, Jose Luis Dieguez, Juan Cardona.

Annual Meeting14th Annual Society for AirwayManagement Scientific Meeting


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Prospectively evaluate the effectiveness of a simplemanikin practice in teaching the technique flexible

fiberscope to anesthesia trainees during anesthesiaresidency .

OBJETIVE


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CEDIVA DENIA | FORMACIN CONTINUADA EN VA AREA

In the workshop Cediva have a training program fibreopticintubation during anesthesia residency that includes anumber of methods of initiation into the use of the device

on mannequins before fibreoptic oro/nasotrachealintubations in the operating room. The first method mustpractice the trainee is PRACTICE CLOCK (SEE FIG 1).


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Address to the centralpoint . Try verticalmovement followingthe numerical

sequences. Repeatevery one 10 times.(figure 2)

* 12 * 6

* 6 * 12


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Vertical movement of thetip of the fiberscopefollowing the numericalsequence (fig 3)

Repeat this sequence fourtimes.

* 12 * 12 * 12 * 12 *

* 6

* 12 * 6 * 12 * 6 *


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Horizontal motion of thetip of the fiberscopefollowing the numericalsequence (Fig. 4)

Repeat this sequencefour times.

* 9

* 3

* 9 * 3 * 9 * 3 *


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* 12 9 6 9 12 *

* 12 3 6 3 12 *

Rotational movementof the tip of thefiberscope in thesequence number(fig 5) Repeat the

sequence four times.


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Combined drawing a Z Movement; further sequence of letters ABCDmaneuver repeated four times.(Figure 6)

* A B C D C B A ** B A D C D A B *

Figure 6


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With this method, assisted, the resident acquires theability to direct manual fiberscope tip oriented inthree dimensions and must be the practice ofinitiation in the advanced management of difficultairway requires the use of flexible fiberoptic devicethat demonstrated that solves 100% of cases ofpatients with difficult airway.

CLOCK PRACTICE


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CEDIVA DENIA | Training Center in Difficult AirwayAnesthesia and ICU Department. Dnia Hospital 2010

Annual events and References


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CEDIVA DENIA | Training Center in Difficult Airway Management

Annual Meetings in Dnia Hospital


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CEDIVA DENIA | Training Center in Difficult Airway Management.


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American Society of

Anesthesiologist (ASA)Annual Meeting



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CEDIVA DENIA | FORMACIN CONTINUADA EN VA AREAASA 2007


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Extubating the difficult airway: A protocol for t iming and not burning bridgesFrancisca Llobell, M.D.1, Patricia Marzal, M.D.1, Luis Gonzalez, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2

1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Results

Abstract

Discussion

Title: Extubating the difficult airway: A protocol for t iming and not burning bridges

Francisca Llobell, M.D., Patricia Marzal, M.D., Luis Gonzalez, M.D., Lauren K Hoke, B.S. and Yvon F Bryan, M.D..Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

Introduction

Different airway devices may be used to f acilitate extubating patients with difficult airways (1, 2). The timing anddevices needed to bridge the extubation, howe ver, depend on the patients condition and risk. The possibility ofaspiration, experiencing potential difficulty with oxygenation and ventilation and the need for re-intubation areproblems frequently encountered. A protocol for extubation musttake into account these problems and combinethem with the timing of extubation and the availability of the necessary airway devices needed to b ridge. Wepresent our experience using a protocol for extubating patients with difficult airways.

Methods

The protocol for extubating patients with difficult airways combined the timing ( immediate versus delayed) ofextubation with the availability of the necessary airway devices required for bridging (see Figure 1). A table ofairway devices set up according to their function was used for the patients (3).

Results

No complications occurred in any patients in which the protocol was used (see Table 1).

Discussion

The extubation protocol provided a strategy for timing the extubation with the necessary airway devices neededto bridge the extubation. The protocol was designed to take into account the risks associated with the patientsunderlying condition and/or surgical intervention with the airway device best suited for the patient. By allowingfor versatility, the protocol facilitated reassessing the patients need to remain intubated, to bridge or to delay theextubation. Further studies are needed in the management of patients with difficult airways during extubation.

References

1) Anesth Analg 2007; 105:1357-1362.

2) Anesth. Analg. 2007; 105: 11821185.

3) Llobell F, et al. Euroanaesthesia 2008 Annual Meeting.

Methods

Timing extubation in patients with difficultairways (DAs) is critical

Device choice for delaying or bridging extubationdepends on urgency and potential problemsencountered after extubation

We present our initial experience wit h a protocolused for extubating patients with DAs

Protocol combines timing of extubation withavailability of necessary devices

Protocol provided strategy for timing

extubation with the availability of devicesneeded to bridge

Protocol allowed for versatility inmanaging various patient conditions

Further research required in establishingextubation protocols for DAs

ASA 2008


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CEDIVA DENIA | FORMACIN CONTINUADA EN VA AREAASA 2008

Managing the difficult airw ay at extubation: Vices or devicesFrancisca Llobell, M.D.1, Patricia Marzal, M.D.1, Maria Serna, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2

1.Hospita l G. U. Marina Alta , Denia (Al icante), Spa in 2. Wake Forest Univers ity Baptist Medica l Center, Winston-Sa lem, NC

Introduction

Results

Abstract

Discussion

Title: Managing the difficult airway atextubat ion: Vices or devices

Francisca Llobell, M.D., Patricia Marzal, M.D., Maria Serna, M.D., Lauren K Hoke, B.S. and Yvon FBryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

Introduct ion

Problems encountered during extubation of patients with difficultair ways are prevalent though formal guidelines

seem to be lacking (1). This dichotomy of problems occurring at extubation and a lack of specific strategies may

be due to anesthesiologist experience and/or training with specialized airway devices required during the

management of the difficult airway (2). Certain airway devices may be best suited for rescue (oxygenation and

ventilation) while others are better used to bridge (reintubation) and to delay the extubation. We surveyed

Spanish anesthesiologists about their clinical practice management for the extubation of patients with difficult

airways.

Methods

A survey was sent tothe anesthes iology departments of 38 hospitals in the provinces of the Comunidad Valenciana (Castellon, Valencia, Alicante) and cities int he Comunidad Murciana (Murcia, Orihuela) of Spain. The

survey consisted of 10que stions pertaining to the clinical management at extubation of patients with difficultairways (see Table 1). The surveys were completed anonymously and returned via self-return envelope to

Hospital G.U. Marina Alta in Denia (Alicante), Spain.

Results

A total of 10 out of 38anesthes iology departments comple ted and returned the survey (as of March 1, 2008)

totaling 120 anesthesiologists. Problems at extubation were reported by 95% of respondents with only 12%

having a formal extubation protocol. 34% reported experiencing difficulty with reintubation and 23% reported

patients requiring surgical access for airway support. 7% reported a patient death or a severe brain injury as a

consequence of problems occurring at extubation. Of the airway devices used to rescue, 76% were

supralaryngea l devices (LMA, ILMA, Proseal LMA). Tobridge the extubation, supralaryngeal devices and airway

exchange catheters were used 53% and 16% of the time, respectively. See Table 2.

Discuss ion

Our survey found a very high incidence of problems occurring at extubation in patients with difficult airways. A

lack of established extubation protocols and training with specialized airway devices may be the reason for theproblems. The devices used to rescue and bridge the extubation by the majority of respondents were

supralaryngea l in nature. This may have reflectedt he individuals training with these devices, the unavailability ofcertain devices or not being familiar with other types of devices (ie, airway exchange catheters). Further research

is required in the management of the difficult airway to discern which devices are best suited for rescuing and/orbridging during extubation.

References

1) Anesthesiology 2005:103(1);33-9.

2) Anesthesiology 2007:100;A934

Methods

Table 1: Extubation survey questionsDevices used during intubation may not besuccessful during extubation and/or re-intubation

Timing of extubation depends on patientcondition and practioner experience

We present the experience ofanesthesiologists during extubation ofpatients wit h DAs in a region of Spain

Survey consisted of 10 questions regardingmanagement of DA during extubation

Surveyed 38 anesthesiology departments in theregions of Valenciana and Murciana in Spain

Methods

Our survey found a high incidence ofproblems occuring at extubation

Anesthesiologist experience and familiaritywith different airway devices may haveinfluenced choice of device

Further research is required in developingprotocols for use during extubation inpatients with DAs


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IARS- International

Anesthesia Research SocietyIARSAnnual Meeting

USA



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IARS 2007, San Francisco USA

The new VAMA intubating airway: a unique design for fiberoptic intubation

Patr ic ia Marzal , M.D.1, , Juan Cardona , M .D.1, Andres Madr id 1, Va l en t i n Mad r i d , M .D .1, Yvon F. Bryan, M.D.2*

1.Hospital G. U. Marina Alta, Denia (Alicante), Spain 2 . Cincinnati Childrens Hospital Medical Center, Cincinnati,OH

Introduct ion Methods

Abstract

Discussion

Resu l ts

Title: The new VAMA intubating airway: au nique design for fiberopticintubation

Authors:Marzal Patricia, LlobellFrancisca, Cardona Juan, MadridAndres, Madrid Valentin, Bryan

Yvon

Introduction

Several availableintubating airwaysfacilitate performingf iberoptic intubation andplacing an

endotracheal tube(1,2). The new VAMA intubating airwayincorporates design features which address

common problems encountered during fiberopticin tubation. Aline withan arrow (lasermark)

embedded on the distal part of the ventral surface ofthe posterior portion of theairway facilitates

orientation (see Figure1). Adetachable pieceon the proximal portionof theairway facilitates removing

theVAMA airwaywhile thee ndotracheal tube( ETT) remains connectedto the circuit; thus avoiding

interruptionin ventilation and inadvertent extubation. Wedescribe our experiencewith theVAMA

intubatingairway for fiberopticin tubation.

Methods

After obtainingverbal consent, 19p atientsundergoing surgeryand requiring endotracheal(ETT)

intubationwere recruited. After generalanesthesia or sedation andtopical anesthesia, a5.5 mm flexible

fiberscope wasloaded withan ETT and placedorallyv ia the VAMA airway. Usingl asermarkon the

VAMA for guidance, theFFB wasinserted until theglottic opening wasvisible. After advancing the

FFB throughthe vocal chords, the ETTwasra ilroadedinto the tracheaand theposition was confirmed.

The detachablepieceof theVAMA wasfirst removedandwhileholdingthe ETT, theremainingpart

oftheVAMA airwaywas removedwithoutdisconnectingthe ETTfrom circuit.

Results

The meanandrange of age and timeto intubationwere57.5years (31-86)and 42seconds(25-70). In

13patients, theglottic opening was visualizedon first pass of theFFB placedin the VAMA airway. In

6 patients, achin lift exposed the glotticopening. All intubations occurred on first attempt, except one

which requiredthree attempts. Five patients hadknown difficult airways(DA), 7in tubations wereawakeand in 7patients, paralyticagents wereused. Discussion

The lasermarkof the VAMA airwayhelps identify theanatomical landmarks necessaryfor fiberoptic

intubation. Disconnectingthe removablepiece facilitates completeremoval oft heVAMA airway.

Further researchis required comparing too ther intubatingairways in patientswith known DAs who are

both awake and anesthetized.

References

1)J Clin Anesth 200416:66-73.

2)Anaesth200459: 173176.

3)VAMACanula Package Insert www.ajlsa.com

Methods

Valentin Andres Madrid Airway (VAMA) is anew intubating airway

New design features of VAMA facilitate FFBintubation

We present our initial experience using VAMAairway

*Wake Forest University Baptist Medical Center

19 patients underwent FFB using VAMAAwake/sedation with topical anesthesia or generalanesthesia

Lasermark of VAMA facilitates orientationDetachable piece facilitates removal of VAMAairway while ETT remains connected

Removal of VAMA does not interrupt ventilation orrisk inadvertent extubation

Age (mean and range) = 57.5 years (31-86)Time to intubation (mean,range) = 42 seconds(25-70)

Visualization of glottic opening on initial FFBintroduction = 13/19 (68%) patients

Chin lift required for exposure of glottic opening= 6/19 (32%) patients

Intubations on first attempt (one patient required3 attempts) = 18/19 (95%) patients

5 patients with known difficult airways7 intubations performed awake/sedation, 7intubations using paralytics

Lasermark on VAMA allowed clinician toorient FFB

Detachable piece of airway facilitated removalof VAMA without accidental ETT removal

Further research required using VAMA inpatients with difficult airways

A. B.

C. D.
http://www.ajlsa.com/http://www.ajlsa.com/


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European Society of

AnesthesiaEuroanesthesia


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TITULO SEMINARIO | SUBTTULO

Aqu se escribe el texto

F.Llobell, P.Marzal; M.Echeverri,L.Hoke, Y.Bryan . Strategy forextubation of the difficult airway: Aprotocol and table of airway devices.

Eur J Anaesthesiol 2008; 25 (Suppl 44):19AP6-8.


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SEDAR Sociedad Espaola

de Anestesia y ReanimacinAnnual Meeting 2009



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M. B. Serna; F. Tarn; R. Prez; F. Llobell. Hospital de Denia

El manejo de la va area difcil conocida exige elaborar un plan para minimizar el riesgode hipoxia aguda ante una demora en la intubacin siguiendo la estrategia establecidasegn los algoritmos de referencia (Anesthesiology 2003).

CASO CLNICO Mujer, 43 aos. Obesidad, DMNID. Varios episodios de crisis tnico-clnicas por Encefalitis de

Hashimoto. Nuevo episodio refractario a tratamiento mdico (Fenitona y Diazepam i.v.).

VENTILACIN DIFCIL - IMC 34,6 kg/m2

INTUBACIN DIFCIL Historia de VAD anticipada, cuello corto y grueso, retraccinmandibular, macroglosia

COOPERACIN - NO, dada la situacin clnica TRAQUEOSTOMA DIFCIL - SI

MANEJO

* La ASA recomienda valorar:

SEDOANALGESIA CONTROL DE LA VA AREA

INTUBACIN ENDOTRAQUEAL

VA AREA DIFCILVA AREA DIFCIL


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ESTRATEGIA* Considerar ventajas y desventajas de:

INTUBACIN DESPIERTO

TCNICA NO INVASIVA

MANTENIMIENTO DE LA VENTILACIN

ESPONTNEA

INTUBACIN TRAS INDUCCIN

TCNICA INVASIVA

SUPRESIN DE LA VENTILACIN

ESPONTNEA

ESTRATEGIA PRIMARIA

ESTRATEGIA SECUNDARIA

ALGORITMO 1 ASAFIBROBRONCOSCOPIO FLEXIBLE VA NASAL

CEDIVA DENIA |Formacin Continuada en Va AreaServicio de Anestesiologa y Cuidados Crticos del Hospital de Dnia

MASCARILLA LARNGEA CON CANAL DE DRENAJE GSTRICO: Supreme, Proseal

Limitaciones en el paciente crtico vs. urgencia.

MATERIAL NECESARIO

Cnula nasal Rschn26TET reforzado n7

Oximetazolina Spray

LidocanaMAD Mucosal AtomizationDevice

MADgic Laryngo-Tracheal Mucosal AtomizationDevice


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CONCLUSIN

DESCRIPCIN DE LA TCNICA

Instilacin de Oximetazolina para evitarhemorragias.Atomizacin de Lidocana 3% mediante

MAD de fosa nasal.Atomizacin de Lidocana al 4% medianteMADgic de cuerdas vocales.

Introducir cnula de Rusch a travs delorificio nasal elegido.Introducir el TET reforzado y lubricado atravs de la nariz.

Progresar a travs del TET elfibrobroncoscopio hasta visualizar lascuerdas vocales. Una vez abiertasllegaremos hasta carina. Deslizar el tuboaplicando giro antihorario para facilitar suinsercin.

LA TCNICA DE INTUBACIN CON FIBROSCOPIA CONSCIENTE ES APLICABLE ENSITUACIN DE URGENCIA SI EL ESCENARIO LO PERMITE Y EL PACIENTE LOREQUIERE.

Bibliografa:ASA2002 Practice Guidelines for Management of the Difficult Airway.Engel TP, Applegate RL, Chung DM, Sanchez A. Management of the difficult airway. Gasnet, 2001.


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CEDIVA DENIA | Training Center in Difficult Airway. Dnia Hospital

1. Llobell F, Madrid V, Taghon TA, Bryan Y. The Difficult Airway Extubation Table: A buffet of AirwayDevices and Management Strategies. En: ASA Annual Meeting 2006; pp 437.

2. Romagosa H, Charco P, Llobell F, Madrid V, Garrido P. Prevencin del edema larngeo

postextubacin. Estrategias para una extubacin segura. Rev Esp Anestesiol Reanim 2005; 52:202-3.

3. Llobell F, Marzal P, Bryan y, Charco P, Martinez-Pons V, Madrid V. Complicaciones tras la Extubacin:Dimensionando el problema. 13 Congreso Hispano-Luso de Anestesiologa. Valencia, Abril 2007.

4. Llobell F. Estrategia para el intercambio de un TET. Algoritmo de Extubacin. XXVII Congreso de laSEDAR.Resmenes de Ponencias. 2005;pp 71-3.

5. Llobell F, Madrid V, Marzal P, Hoke Lauren K, Bryan Y. Airway Management Strategies of DifficultAirways at Extubation: Despite Risk Much Left to Chance. En: ASA Annual Meeting 2007; A934.

6. F.Llobell, P.Marzal; M.Echeverri, L.Hoke, Y.Bryan . Strategy for extubation of the difficult airway: Aprotocol and table of airway devices. Eur J Anaesthesiol 2008; 25 (Suppl 44): 19AP6-8.

7. F.Llobell, P. Marzal, M. Serna, L. Hoke, Y Bryan. Managing the Difficult Airway at Extubation: Vices orDevices. A1725 ASA 2008.

8. F.Llobell, P. Marzal, L.Gonzalez, L. Hoke, Y Bryan. Extubating the Difficult Airway: A protocol for Timingand not Burning Bridges. A1729 ASA 2008.


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CEDIVA DENIA |Training Center in Difficult Airway ManagementAnesthesia and ICU Department

Dnia Hospital

w w w . c e d i v a . e u

i n f o @ c e d i v a . e u

Tel. 648 22 15 15
http://www.cediva.eu/mailto:[email protected]:[email protected]://www.cediva.eu/

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