Evaluation of a Difficult Airway Educational Intervention on Residents’ Performance of Endotracheal Intubation in the Emergency Department.

Aims: To evaluate the effectiveness of a brief educational intervention and a predictive difficult airway (DA) checklist on performance of emergency endotracheal intubation by residents. Place and Duration of Study: The Emergency Department (ED) of Interim Louisiana State University Public Hospital, the level one trauma center in New Orleans, from September 2006 to June 2010. Methodology: We performed a retrospective chart review of patients intubated in the ED during the study period. Demographic, physiologic and procedural data had been previously recorded on a worksheet immediately following each intubation. In July 2008, residents received a lecture on management strategies for the DA and participated in simulation exercises based on DA scenarios. A detailed checklist of DA predictors was added to the standard intubation form, and completed by the resident prior to each intubation. Procedural outcomes were compared for number of attempts, time to successful intubation, faculty involvement and use of adjunct devices for the pre-and post-intervention periods using generalized estimating equations and z statistics. Results: There were 266 intubations in the pre-intervention period and 373 in the postintervention period. 50.3% of post-intervention intubations met criteria for DA. Time to successful intubation did not vary between the two groups (11.6 minutes pre; 10.8 post, P=0.30). There was no significant difference in the number of attempts (1.4 pre; 1.3 post, P =0.44) or faculty interventions (1.5 v. 3.75%) or the number of successful intubations that were assisted by adjuncts (P =0.22). Success on the second attempt was more likely if an adjunct was used (P =0.24). Conclusion: A brief DA educational module and the application of a standard preintubation checklist resulted in few appreciable changes in EM resident intubations. Further research is needed to more clearly define the relationship between DA education and resident intubation performance.

The fate of small renal masses, less then 1 cm size: outcome study

PURPOSE: We evaluated the outcome and etiologies of small renal masses (less than 1 cm in size) discovered incidentally on 2 consecutive CTs that investigated non-urologic abdominal complaints. MATERIALS AND METHODS: A retrospective search for incidentally discovered small renal masses, less then 1 cm in size, was carried out in the files of 6 major US medical centers. 4822 such lesions had been reported over a 12 year period. A search of these patients' records revealed 1082 subsequent new CTs for non urologic complaints, allowing the assessment of the fate of the masses. Lesions enlarging, of ambivalent contour or enhancement were examined by a third multiphasic MDCT. The findings were interpreted by 2 blinded radiologists. RESULTS: Six hundred and four masses could no longer be identified, 231 were significantly smaller, 113 unchanged in size and 134 larger. Of the disappearing lesions 448 were located in the medulla, 94 both in medulla and cortex and 62 in cortex. Multiphasic MDCTs obtained in 308 masses enlarging, unchanged in size or of ambivalent appearance, revealed 7 neoplasms, 45 inflammatory lesions, 8 abscesses and 62 renal medullary necrosis. Concurrent antibiotic therapy of GI conditions may have caused some of the 496 lesions to disappear. CONCLUSION: It is questionable whether the small number of malignant neoplasms (0.4%), inflammatory lesions (5%) and renal medullary necrosis (6%) justify routine follow-up CTs and exposure to radiation. The delay in intervention in neoplastic lesions probably didn't influence tumor-free survival potential and clinical symptoms would soon have revealed inflammatory conditions. With exception of ambivalent lesions, clinical surveillance appears adequate.

Risks and benefits of the intercostal approach for percutaneous nephrolithotripsy

OBJECTIVE:The objective of our retrospective study was to provide evidence on the efficacy of the intercostal versus subcostal access route for percutaneous nephrolithotripsy. MATERIAL AND METHODS: 642 patients underwent nephrolithotomy or nephrolithotripsy from 1996 to 2005. A total of 127 had an intercostal access tract (11th or 12th); 515 had a subcostal access tract. RESULTS: Major complications included one pneumothorax (1.0 percent), one arterio-calyceal fistula (1.0 percent) and three arteriovenous fistulae (2.7 percent) for intercostal upper pole access; two pneumothoraces (1.7 percent), one arteriovenous fistula (1.0 percent), one pseudoaneurysm (1.0 percent), one ruptured uretero-pelvic junction (1.0 percent), 4 perforated ureters (3.4 percent) for subcostal upper pole access; one hemothorax (1.6 percent), one colo-calyceal fistula (1.6 percent), one AV fistula (1.6 percent), and two perforated ureters (3.2 percent) with subcostal interpolar access. Diffuse bleeding from the tract with a subcostal interpolar approach occurred 3.2 percent of the time compared with 2.4 percent with a lower pole approach. Staghorn calculi demonstrated similar rates of complications. CONCLUSION: Considering the advantages that the intercostal access route offers the surgeon, it is reasonable to recommend its use after proper pre-procedural assessment of the anatomy, and particularly the respiratory lung motion.