Anesthesia for penetrating injury of the oropharynx in a child: a case report

BackgroundPenetrating injury of the oropharynx occurs frequently in children, however, anesthetic management is seldom described in such cases.Case presentationA 2-year old child came to the emergency room with a toothbrush impacted in the gingivobuccal sulcus making airway management difficult. We used a simple yet unique approach to secure the airway safely given the lack of pediatric size fibreoptic and videolaryngoscopes in our emergency operation theatre. The patient was kept in Pediatric ICU and watched for any complications and discharged on the 4th postoperative day.ConclusionsThus, ingenious non-invasive techniques to secure the airway can prevent the patient from undergoing surgical tracheostomy.

General Anesthesia Strategies for Safe, Rapid Recovery, Fast Turnaround, and Same-Day Discharge for Complix Abalations in the Ep-Specialized Asc Setting

Background: Many EP procedures are moving from the hospital to the ambulatory surgery center (ASC) outpatient setting. The COVID-19 pandemic and the CMS Hospitals Without Walls (HWW) program has been an impetus in accelerating this transition. Anesthesia provider perioperative management is critical in facilitating safe procedures with rapid, same-day discharge. Our EP-dedicated 2-OR ASC completed more than 3,000 procedures and more than 500 left-sided ablations utilizing general anesthesia with endotracheal intubation with same-day discharge. To our knowledge, this experience is unique within an ASC setting in both volume and complexity. Objective(s): We present our comprehensive anesthesia strategy and lessons learned to facilitate safe, efficient procedures and discharge in an EP ASC. Method(s): A nurse anesthesiologist with more than a decade of EP-dedicated experience developed and taught a perioperative anesthesia strategy to facilitate high volume, safe and quick discharge care. Fundamental to this is the avoidance of opioids and benzodiazepines whenever possible. Propofol or general anesthesia with sevoflurane and complete reversal with sugammadex allow for quick recovery. Mandatory video laryngoscope utilization minimizes airway trauma, while liberal antiemetic use eliminates most nausea. All femoral access is device closed. Positive inotropes are used liberally during anesthetic to avoid heart failure. The goal is to deliver all patients to PACU on room air with stable hemodynamics. Anesthesia providers manage the preop and recovery area. Result(s): More than 90% of all patients undergoing general anesthesia and heparinization for left-atrial ablation were discharged home in under 3 hours. Nearly all procedures not requiring femoral access were discharged within 30-60 minutes. High procedure volumes with efficiencies far exceeding our in-hospital experience were thus facilitated with improved patient safety. Since HWW began, five patients have required transfer to the hospital without any deaths. All others were discharged same day. Conclusion(s): We suggest that a dedicated anesthesia team with a tailored perioperative anesthesia plan facilitates performing nearly all EP-related surgical procedures in an ASC. This success is facilitated by appropriate patient selection, preoperative evaluation, intraoperative care prioritizing quick return to baseline, and end-to-end anesthesia perioperative management. We believe this type of anesthesia management is critical to the transition of EP procedures to ASCs.Copyright © 2023

Intubation of Critically Ill COVID-19 Patients Using Conventional Laryngoscope in the ICU

Background: Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and avoid complications. It is not available in some places and thereby forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID-19 patients are challenging and may lead to adverse complications which may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in intubations of COVID-19 patients in ICU. Method(s): A prospective observational study was done in COVID Intensive Care Unit of the Base Hospital-Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. The data was collected using a Performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures the actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Result(s): Approximately 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72 % were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusion(s): Intubation of Critically ill COVID-19 patients are challenging but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.Copyright © 2023, College of Anaesthesiologists of Sri Lanka. All rights reserved.

SASA 2023 Congress

The proceedings contain 34 papers. The topics discussed include: comparison of intra-arterial blood pressures versus two noninvasive measuring systems: a cross-sectional analytic study employing Bland-Altman and error grid analyses;prevalence of vitamin D deficiency amongst anesthesia providers at the Universitas Academic Hospital;chemical and physical stability of an admixture of anesthetic drugs;postoperative pulmonary complications in adult surgical patients in low- and middle-income countries: a systematic review and meta-analysis;the prevalence of SARS-CoV-2 infection in an academic department of anesthesiology;evaluation of the use of a 3D printed video laryngoscope for tracheal intubation in a manikin;the prevalence of caregiver anxiety in theatre at universitas academic hospital;the spectrum of disease and short-term outcomes of obstetric patients with cardiac disease at a tertiary hospital in South Africa;and almost 30% reduction in carbon footprint using volatile anesthesia - a quality improvement project introducing low-flow anesthesia in a regional hospital.

A novel negative pressure isolation device reduces aerosol exposure: A randomized controlled trial

Background and aim: The COVID-19 pandemic has led to a proliferation of intubation barriers designed to protect healthcare workers from infection. We developed the Suction-Assisted Local Aerosol Containment Chamber (SLACC) and tested it in the operating room. The primary objectives were to determine the ease and safety of airway management with SLACC, and to measure its efficacy of aerosol containment to determine if it significantly reduces exposure to health care workers. Method(s): In this randomized clinical trial, adult patients scheduled to undergo elective surgery with general endotracheal anesthesia were screened and informed consent obtained from those willing to participate. Patients were randomized to airway management either with or without the SLACC device. Patients inhaled nebulized saline before and during anesthesia induction to simulate the size and concentration of particles seen with severe symptomatic SARS-CoV-2 infection. Result(s): 79 patients were enrolled and randomized. Particle number concentration (PNC) at the patients' and healthcare workers' locations were measured and compared between the SLACC vs. control groups during airway management. Ease and success of tracheal intubation were recorded for each patient. All intubations were successful and time to intubation was similar between the two groups. Healthcare workers were exposed to significantly lower particle number concentrations (#/cm3) during airway management when SLACC was utilized vs. control. The particle count outside SLACC was reduced by 97% compared to that inside the device. Conclusion(s): The SLACC device does not interfere with airway management and significantly reduces healthcare worker exposure to aerosolized particles during airway management.Copyright © 2023 Elsevier Ltd

DON'T CUT THE NECK: A NOVEL OPTION FOR DEFINITIVE RESCUE AIRWAY

SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: COVID-19 has resulted in many patients presenting in severe hypoxemic respiratory failure without the ability to achieve adequate oxygenation despite non-invasive positive pressure ventilation prior to attempting endotracheal intubation. Recently, the American Academy of Anesthesiology (AAOA) released an updated 2022 guideline addressing difficult airway management. Though evidence is limited, the use of a combination maneuvers with a supraglottic airway and lighted stylet yielded a greater than 75% intubation success rate after failed direct laryngoscopy [1]. The following case emphasizes a novel definitive airway rescue option for an anatomically and physiologically difficult airway, complicated by an inability to ventilate and oxygenate in the setting of severe hypoxemic respiratory failure. CASE PRESENTATION: The patient is a 58 year old, morbidly obese (BMI-58) female with severe COVID-19 pneumonia and severe refractory hypoxemia on Bi-Level non-invasive ventilation (inspiratory pressure 20, expiratory pressure 15, 100% fraction inspired oxygen) complicated by an acute complete opacification of the left hemi-thorax and right pneumothorax with oxygen saturation (SpO2) of 80%. Rapid sequence induction was attempted, however failed despite multiple maneuvers. Due to continued deterioration of the patient's oxygenation, a laryngeal mask airway (LMA) was placed with improvement of the patient's oxygen saturation. A single-use disposable bronchoscope was then placed through the LMA with successful navigation through the vocal cords and direct visualization of the tip within the right main-stem bronchus. Using trauma shears, the handle of the bronchoscope was cut away from the insertion tube. The LMA was then retracted (Fig. 1) and forceps were utilized to maintain position of the insertion tube (Fig. 2) during this maneuver. The video laryngoscope blade was then reinserted into the oropharynx for visualization of the insertion tube coursing through the vocal cords. Using the insertion tube from the single-use bronchoscope as a stylet, intubation was successfully accomplished by inserting a 7.5mm ETT over the insertion tube under direct visualization with the video laryngoscope (Fig. 3). DISCUSSION: Single use bronchoscope devices have been successfully used for planned awake intubations [2] as well as confirmation of endotracheal tube placement [3] after emergent intubation. The novel technique described above can be a useful measure to facilitate intubation under direct visualization in complicated airway scenarios without the need for a surgical airway. CONCLUSIONS: This technique offers a number of advantages to include direct visualization of the airway, navigational capability of bronchoscopy and confirmation of placement with video laryngoscopy. The combination of these techniques can be considered as an alternative prior to pursuing an invasive surgical option. Reference #1: Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O'Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung;2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 Reference #2: Kristensen MS, Fredensborg BB. The disposable Ambu aScope vs. a conventional flexible videoscope for awake intubation – a randomised study. Acta Anaesthesiol Scand. 2013 Aug;57(7):888-95. doi: 10.1111/aas.12094. Epub 2013 Mar 15. PMID: 23495767 Reference #3: Mitra A, Gave A, Coolahan K, Nguyen T. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting. World J Emerg Med. 2019;10(4):210-214. doi: 10.5847/wjem.j.1920-8642.2019.04.003. PMID: 31534594;PMCID: PMC6732169 DISCLOSURES: No relevant r lationships by John Levasseur No relevant relationships by Lauren Sattler No relevant relationships by Tyson Sjulin

Comparative Study to Evaluate the Effect of Intubation Box on Tracheal Intubation Difficulty with King Vision ® and Truview Video Laryngoscope in Manikin in a Tertiary Care Hospital

Background: The procedures related to airway can be associated with increased risk of aerosolization of SARS-CoV-2 virus posing a high risk to the personnels involved. Novel methods like the intubation box have been developed to increase the safety of healthcare workers during intubation. Methods: In this study, 33 anaesthesiologist and critical care specialists intubated the trachea of the airway manikin (US Laerdal Medical AS) 4 times using a King Vision ® videolaryngoscope and TRUVIEW PCD TM videolaryngoscope (with and without an intubation box as described by Lai). Intubation time was primary outcome. Secondary outcomes were first-pass intubation success rate, percentage of glottic opening (POGO) score and peak force to maxillary incisors measured with a pressure sensing device. Results: Intubation time and the pressure exerted on the incisors (detected by a click sound) were considerably higher in both groups when an intubation box was used. (Table 1) When comparing the two laryngoscopes, intubation time with the King Vision ® video laryngoscope was lower than that of TRUVIEW laryngoscope, both with and without the intubation box. (P<0.001) In both groups, rate of first pass successful intubation was higher without the intubation box, although the difference was statistically insignificant. POGO Score was not affected by intubation box but higher score was observed with King Vision ® laryngoscope. (Table 1,2). Conclusion: This study indicates that use of an intubation box makes intubation difficult and increases the time. King Vision ® videolaryngoscope results in lesser intubation time and better glottic view as compared to TRUVIEW laryngoscope.

Intubation Performance with Stylet and Preloaded Bougie for Rapid Sequence Intubation in Patients Undergoing General Anaesthesia: A Randomised Clinical Trial

Introduction: Rapid sequence induction requires quick and single attempt intubation to secure airway without any untoward complications. As the number of attempts increase, risk of desaturation and aspiration increase which is potentially life threatening. In such circumstances, miscalculation may cost loss of time which may prove fatal. Various adjuncts and techniques have been devised to prevent such calamities. Aim: To compare ease of intubation with angulated stylet versus distally preloaded bougie for rapid sequence intubation in elective general anaesthesia procedures. Materials and Methods: This randomised trial was conducted in 100 patients belonging to 18-60 years of age from November 2019 to October 2020. Patients were intubated using rapid sequence including cricoid pressure by either styletted endotracheal tube (Group S) or distally preloaded bougie (Group B), for surgeries performed under general anaesthesia. The primary outcome was to determine mean time to intubation (TTI) and number of attempts, while secondary outcomes were haemodynamic responses to intubation and complications. Data comparison between independent groups in this normally distributed data was done using student -t test while intragroup analysis was done using chi-square test. Results: A total of hundred patients were randomized into two groups- group S (mean age: 41.12 years) and group B (mean age: 37.34 years), of 50 patients each. Number of intubation attempts with stylet were single in 82%, two in 18% cases while with preloaded bougie, it was 80% and 14%, respectively (p-value=0.196). Time to intubation was 22.16 seconds (group S) versus 33.78 seconds (group B) (p-value <0.05). The haemodynamic assessments revealed that tachycardia, hypertension and increased End tidal carbon dioxide (EtCO2) was seen for 10 minutes immediately post induction in both the groups, though the intergroup difference was non significant. The incidence of sore throat was higher with stylet than bougie, though non-significant (p-value=0.118). Conclusion: Stylet should be preferred for ease of intubation in rapid sequence inductions. However, the insertion and removal of stylet must be done cautiously to prevent postoperative sore throat.

Operator Perception of the Ability of Multiple Single-Use Bronchoscopes to Engage Difficult Airway Segments

Introduction: The COVID-19 pandemic has increased the prevalence of single-use bronchoscopes outside the operating room, where they had previously been employed primarily as intubation adjuncts. However, direct comparisons of the performance of these bronchoscopes has been limited. In this study, we describe our initial experience studying operator perception of how well multiple different bronchoscopes are able to engage difficult airway segments in an ex-vivo model. Methods: Nine faculty and fellows from the Pulmonary and Critical Care Division at UCSD were recruited to complete an airway survey of an ex-vivo model using three single use bronchoscopes (Olympus H-SteriScope, Ambu A-Scope 4, Verathon GlideScope B-Flex). This survey included engagement into traditionally difficult airway segments (RB1, RB6, LB1/2 and LB6) with and without a tool in the working channel. Immediately after completing these bronchoscopies, participants were directed to complete an anonymous survey rating each bronchoscopes ease of maneuverability into the difficult segments on a scale of 1-100 with a higher number representing a more favorable rating. The participant's ability to successfully engage each of these segments was also recorded. Results: Participants rated the ability to maneuver into difficult airway segments with a tool in the working channel by the Olympus singleuse bronchoscope (97.2 [94.3-100]) and Ambu single-use bronchoscope (84.7[74.2-95.2]) higher than the GlideScope single-use bronchoscope (49.3[36.3-64.3]) (Table 1). Additionally, a greater number of participants were able to successfully engage the selected difficult airway segments using the Olympus and Ambu single-use bronchoscopes both with and without a tool in the working channel when compared to the GlideScope single-use bronchoscope (Table 2 and Table 3). Conclusions: In this singlecenter study, the Olympus H-SteriScope and Ambu A-Scope 4 single-use bronchoscopes had a higher perceived maneuverability and were better able to engage difficult airway segments than the GlideScope B-Flex single-use bronchoscope. Further studies are needed to compare these single-use bronchoscopes to reusable bronchoscopes.

Evaluating Efficacy, Global Impact, & Trainee Perception of International Speech Therapy Trainings

Background/Purpose: This presentation highlights the benefits and challenges of implementing speech therapy trainings utilizing a train-the-trainer model. Children born with CL+/-P need comprehensive care from a cleft team to ensure that they can meet their highest potential and engage in all aspects of life in their communities. However, in these areas it can be difficult to locate health professionals with the capacity to address cleft palate speech characteristics. As a result, many children speak with these characteristic speech patterns post-palate repair. Research has shown that in low- and middle-income countries (LMICs) a partner hospital model improves the quantity and quality of cleft care services (Purnell, McGrath, & Gosain, 2015). However, there are varying models as to how to structure and build these programs once a partner hospital is established. Limited research has been conducted focusing on the efficacy of speech therapy trainings intended to provide a sustainable impact on these communities. Methods/Description: This poster shares comprehensive data from a survey distributed to training attendees from the past 5 years. Trainings were organized by Smile Train and facilitated by local health professionals who went on to become future trainers. The survey was distributed in August 2020 and consisted of three sections: Personal & Demographic information, Global Impact & Outreach, and Speech Training Feedback. The survey elicited a group of respondents (n=55) who each attended one or more of 14 trainings over a five year span (2015-2020). Authors collected demographic data of respondents, measured respondents' self perception of competency in this area before and after speech therapy trainings, and gathered trainee feedback for future trainings. Results: Surveys were analyzed via SurveyMonkey platform. Researchers analyzed trainee's multiple choice selections, scaled scores, and open-ended responses. Results indicated that trainee confidence in treating those with speech conditions resulting from a CL +/-P significantly increased after the training (on average, trainee confidence was scored a 4/10 before training and improved to 9/10 after training). Further, 56% of trainees have now begun to train other health professionals in their communities. Constructive feedback included the need for continuing education after trainings concluded and the need to address the lack of resources/funding in home countries. Finally, trainees report difficulties in implementing tools acquired from the trainings as a result of the COVID-19 pandemic. Conclusions: Utilization of a train-the-trainer model for speech trainings can provide a lasting, sustainable impact for LIMCs based on respondent feedback. Continued survey distribution is imperative to continuously evaluate the efficacy of these trainings. Further discussion is also needed to determine how trainings can effectively provide tools and education within the constraints of the COVID-19 pandemic.

McGRATH™ video laryngoscope versus Macintosh for intubation in hypoxemic COVID-19 ICU patients

Introduction: Airway management and intubation are challenging in the ICU especially for COVID-19 patients with severe hypoxemia. Although recommended for COVID-19 patients, because of their capacity to reduce transmission to healthcare providers, there is no evidence that video laryngoscopes improve airway management and reduce time for intubation. The purpose of this study was to compare the McGRATH video laryngoscope and the Direct Laryngoscope (DL) in COVID-19 ICU patients with acute respiratory failure. Methods: Forty patients meeting tracheal intubation criteria for respiratory failure were enrolled and equally randomized into 2 groups according to the used device: McGRATH Group and DL group. All patients had pre oxygenation with noninvasive ventilation withFiO2 = 1, Pep and pressure support levels were set to achieve a tidal volume of 6 ml/kg of ideal body weight. Demographic data, difficult intubation criteria were recorded. Our primary outcome was time to intubation defined as the time from the introduction of the blade in patient's mouth until the first efficient breath delivered. Secondary outcomes were the lowest SpO2 recorded during the procedure, the drop in SpO2, the number of attempts, the use of alternative methods for intubation and the experience of the operators. Results: The 2 groups were comparable concerning demographic data, BMI and difficult intubation criteria (p = 0.091). Time to intubation was shorter in the McGRATH group with no significant difference (p = 0.597). The Delta SpO2 and the lowest SpO2 were similar (p = 0.546 and 0.458 respectively). No difference was noticed concerning the number of attempts (p = 0.378), the use of alternative methods (p = 0.276) and the operator's skills (p = 0.076). Conclusions: These results show that the DL is as effective as the recommended McGRATH video laryngoscope for intubation in COVID patients with severe hypoxemia.

Evaluation of the conventional and modified aerosol boxes during tracheal intubation in normal and difficult airways: a randomized, crossover, manikin simulation study.

The aim of this study was to evaluate conventional and modified aerosol boxes in terms of intubation time, first-pass intubation success, and mouth-to-mouth distance between the laryngoscopist and patient during tracheal intubation in simulated patients with normal and difficult airways. Sixteen anesthesiologists performed tracheal intubations with direct laryngoscope or three different videolaryngoscopes (McGRATH MAC videolaryngoscope, C-MAC videolaryngoscope, and Pentax-AWS) without an aerosol box or with a conventional or a modified aerosol boxes in simulated manikins with normal and difficult airways. Intubation time, first-pass intubation success, and mouth-to-mouth distance during tracheal intubation were recorded. Compared to no aerosol box, the use of a conventional aerosol box significantly increased intubation time in both normal and difficult airways (Bonferroni-corrected P-value (Pcorrected) = 0.005 and Pcorrected = 0.003, respectively). Intubation time was significantly shorter with the modified aerosol box than with the conventional one for both normal and difficult airways (Pcorrected = 0.003 and Pcorrected = 0.011, respectively). However, no significant differences were found in intubation time between no aerosol box and the modified aerosol box for normal and difficult airways (Pcorrected = 0.336 and Pcorrected = 0.112, respectively). The use of conventional or modified aerosol boxes significantly extended the mouth-to-mouth distances compared to not using an aerosol box during tracheal intubation with each laryngoscope (all Pcorrected < 0.05), and the distances were not different between the conventional and modified boxes in normal and difficult airways. The use of modified aerosol box did not increase intubation time and could help maintain a distance from the simulated patients with normal and difficult airways.

Time to intubation with McGrath™ videolaryngoscope versus direct laryngoscope in powered air-purifying respirator: a randomised controlled trial.

INTRODUCTION: During the COVID-19 pandemic, multiple guidelines have recommended the videolaryngoscope for tracheal intubation. However, there is no evidence that videolaryngoscope reduces time to tracheal intubation, which is important for COVID-19 patients with respiratory failure. METHODS: To simulate intubation of COVID-19 patients, we randomised 28 elective surgical patients to be intubated with either the McGrath™ MAC videolaryngoscope or the direct laryngoscope by specialist anaesthetists donning 3M™ Jupiter™ powered air-purifying respirators (PAPR) and N95 masks. Primary outcome was time to intubation. RESULTS: The median (IQR) times to intubation were 61s (37-63 s) and 41.5s (37-56 s) in the videolaryngoscope and direct laryngoscope groups respectively (p = 0.35). The closest mean (SD) distances between the anaesthetist and the patient during intubation were 21.6 cm (4.8 cm) and 17.6 cm (5.3 cm) in the videolaryngoscope and direct laryngoscope groups, respectively (p = 0.045). There were no significant differences in the median intubation difficulty scale scores, proportion of successful intubation at first laryngoscopic attempt and proportion of intubations requiring adjuncts. Intubations for all the patients were successful with no adverse event. CONCLUSION: There was no significant difference in the time to intubation by specialist anaesthetists who were donned in PAPR and N95 masks on elective surgical patients with either the McGrath™ videolaryngoscope or direct laryngoscope. The distance between the anaesthetist and patient was significantly further with the videolaryngoscope. The direct laryngoscope could be an equal alternative to videolaryngoscope for specialist anaesthetists when resources are limited or disrupted due to the pandemic.

Comparative performance of two protective barriers during tracheal intubation of COVID-19 patients: A simulation cross-over study.

COVID-19 was declared a pandemic by the WHO in 2020. In light of the global shortage of PPE and concerns regarding the safety of healthcare providers, clinicians have resorted to the use of novel protective barriers, such as aerosol boxes and plastic sheets, during aerosol generating procedures, especially tracheal intubation. We compared the effect of these barriers on the tracheal intubation of simulated patients with severe COVID-19 in a crossover study. The study was approved by the Ethics Committee of King Faisal Specialist Hospital, and the procedures were compliant with the COVID-19 airway management guidelines of the Saudi Anesthesia Society. The time to intubation was our primary outcome. Secondary outcomes included number of optimization maneuvers, number of intubation attempts, time to glottic view and ventilation of the lungs, and damage to PPE. Thirteen consultant anesthetists performed 39 tracheal intubations on a manikin using each of three approaches (aerosol box, plastic sheet, and no-barrier). Data were collected via direct and video observation. The plastic sheet approach demonstrated the highest time to intubation (mean ± StE [95% CI]: 33.3s ± 3.5 [25.8- 40.9]) compared to the aerosol box (22.0s ± 2.5 [16.5 - 27.5], P < 0.01) and no-barrier approaches (16.1s ± 1.1 [13.7 - 18.4], P < 0.0001). Similarly, the plastic sheet approach had the highest time to glottic view, and ventilation intervals compared to the other two approaches, while the no-barrier approach had the shortest time intervals. There were no failed intubations or damage to the PPE sustained during the use of any of the three approaches. The aerosol box does not impose a significant delay in tracheal intubation using video laryngoscopy, unlike the plastic sheet barrier. Further research on the aerosolization risk is warranted before these protective barriers can be considered as mainstay approaches during aerosol generating procedures.

Simulation of pediatric intubation using a low-cost videolaryngoscope in the setting of the COVID-19 pandemic. / Simulación de intubación pediátrica con videolaringoscopio de bajo costo en contexto de pandemia por COVID-19.

In patients with SARS-CoV-2 infection, endotracheal intubation is a procedure with a high risk for transmission. A videolaryngoscopy is a supplementary level of health care provider protection, but commercial videolaryngoscopes are expensive and not always available in pediatric intensive care units in Argentina. Our objective was to describe intubation practice using an infant head mannequin with a low-cost, handcrafted videolaryngoscope. Fifteen pediatricians with no prior experience using the device participated in an intubation practice in a head mannequin with a handcrafted videolaryngoscope. The average time for the first attempt was 116.4 seconds (95 % confidence interval [CI]: 84.8- 148.0) and, for the second one, 44.2 seconds (95 % CI: 27.7-60.6). Time decreased significantly for the second attempt (p: 0.0001). A successful intubation was achieved with the device in all attempts, and the procedure duration decreased with the second practice.

En pacientes con infección por SARS-CoV-2 la intubación endotraqueal es un procedimiento con riesgo elevado de contagio. La videolaringoscopia complementa la protección del profesional, pero los videolaringoscopios comerciales son caros y no siempre están disponibles en las terapias intensivas pediátricas argentinas. El objetivo fue describir la práctica de intubación en un modelo de cabeza de simulación de lactante con un videolaringoscopio artesanal de bajo costo. Quince pediatras sin experiencia previa con el dispositivo participaron de una práctica de intubación en una cabeza de simulación con un videolaringoscopio artesanal. El tiempo promedio del primer intento fue de 116,4 segundos (intervalo de confianza del 95 % [IC95 %]: 84,8-148,0) y, el del siguiente fue de 44,2 segundos (IC95 %: 27,7­60,6). El tiempo disminuyó de forma significativa en el segundo intento (p : 0,0001). El dispositivo permitió la intubación exitosa en todos los intentos acortando la duración del procedimiento en la segunda práctica.

Comparative evaluation of intubation performances using two different barrier devices used in the COVID-19 era: A manikin based pilot study.

BACKGROUND AND AIMS: Protection of anaesthesiologists from contaminated aerosols of COVID 19 patients during endotracheal intubation has spurred the development of barrier devices like aerosol boxes and clear transparent plastic sheets and usage of videolaryngoscopes in COVID 19 patients. However, the efficiency, feasibility and difficulties faced by anaesthesiologist while performing endotracheal intubations under barrier devices require scientific validation. This manikin-based pilot study aims to assess the laryngoscopic performances of experienced anaesthesiologists under two different barrier enclosures. METHODS AND MATERIALS: 53 anaesthesiologists (14 Consultants and 39 Senior Residents) who were undergoing an airway training module as a part of preparedness for handling the COVID 19 pandemic were recruited. Using an aerosol box over a manikin, the participants attempted intubation using a Glidescope Videolaryngoscope and Macintosh laryngoscopes (GA and MA Groups). Subsequently, intubation was attempted under a transparent plastic sheet using both laryngoscopes (GP and MP groups). Time required for intubation, first pass success rates, subjective ease of intubation and the feedback obtained from the participants were recorded and analysed. RESULTS: Time required for accomplishing successful intubation was 38.55 ± 12.16 seconds, 26.58 ± 5.73 seconds, 46.89 ± 15.23 seconds and 37.26 ± 8.71 seconds for GA, MA, GP and MP groups respectively. Time for intubation and difficulty (VAS) was least for Macintosh group with aerosol box (MA) and maximum time was taken in Glidescope group with transparent polythene drape (GP). First attempt success rate for Glidescope groups (GP and GA) were 100% and in MA and MP group was 98% and 96% respectively. Restriction in hand movement and stylet removal were the major difficulties reported. CONCLUSION: Longer intubation times were observed while using Glidescope Videolaryngoscopes with either of the two barrier devices in place compared to Macintosh laryngoscopes.