A survey of Canadian respiratory therapists working in the COVID-19 pandemic: The RRT perspective.

Introduction: Registered respiratory therapists (RRTs) are heavily involved in the care of individuals infected with COVID-19. The experiences and challenges specific to the RRT profession during the pandemic have not been qualified and the aim of this study is to bridge that gap. Methods: With institutional ethics approval, a cross-sectional survey was created through the survey software Redcap and made available online from 29 May to 6 July 2020. Any RRT working in Canada during the COVID-19 pandemic was eligible to participate. Responses to yes/no questions were calculated as frequencies and percentages, and free-text responses were summarized. Results: In total, 345 RRTs working in 11/13 of the provinces and territories, with varying years of experience completed the survey. The results reflected impacts of the pandemic that affected RRTs in a variety of ways at work, from being reassigned (30.7%) to caring for COVID-19 positive patients (57.4%) and intubated COVID-19 positive patients (50.7%). RRTs experienced communication issues around guidelines (66.7%) and some departments had run out of personal protective equipment (PPE; 19%). RRTs were personally impacted, including feeling overwhelmed by new and frequently changing guidelines (89.6%) and feeling concerned for themselves or their family members becoming infected because of their proximity to COVID-19 positive patients (89%). Discussion: RRTs reported being required to work more during the pandemic. The unpredictability and constantly changing schedules were sources of stress and anxiety. RRTs were faced with issues of overwhelming amounts of new information and had difficulty in disseminating it in a timely manner. Lack of guidance and lack of confidence in the current protocols added to the confusion, anxiety, and stress. RRTs were at the center of many high-risk moments for contracting the virus (intubation, extubation), and PPE shortages were a major challenge reported. RRTs working during the pandemic have been concerned for their own health and the health of their family members. Conclusion: The COVID-19 pandemic adds another layer of stress for RRT professionals who are working in high-risk situations and feel anxious, overwhelmed, and concerned about their personal safety.

An in vitro assessment of light intensity provided during direct laryngeal visualization by videolaryngoscopes with Macintosh geometry blades.

BACKGROUND: Adequate illumination of the larynx is needed during laryngoscopy to facilitate tracheal intubation. The International Organization for Standardization (ISO) has established a minimum light intensity for direct laryngoscopy (DL) of over 500 lux for at least ten minutes, but no such standard exists for Macintosh geometry videolaryngoscope (Mac-VL) blades, which allow for both direct or indirect (videoscopic) viewing of the larynx. Using in situ bench and in vitro testing in a human cadaver, we determined illumination and luminance values delivered by various Mac-VLs and compared these with published minimum lighting benchmarks as well as a reference direct laryngoscope. METHODS: We tested six Mac-VLs (i-view™, McGRATH™ MAC, GlideScope® Spectrum™ [single-use] DVM S4, GlideScope® Titanium [reusable] Mac T4, C-MAC® S [single-use] Macintosh #4, C-MAC® [reusable] Macintosh #4) together with one direct laryngoscope (Heine LED). Each laryngoscope was assessed with three measurements, as follows: part 1: illuminance (lux) was measured in situ using a purpose-designed benchtop light intensity measurement apparatus; part 2: luminance (light reflected back to the eye) was measured (in candela m-2 [cd·m-2]) during videolaryngoscopy (VL) and DL in a human cadaver using a spot meter pointed at the interarytenoid notch; part 3: illuminance (lux) was measured during VL and DL in a human cadaver using a light meter surgically implanted just proximal to the vocal cords. RESULTS: Illuminance and luminance varied significantly among the Mac-VLs. Mean (standard devitation) illuminance among the six tested Mac-VLs ranged from 117 (11) to 2,626 (42) lux in the measurement apparatus and from 228 (11) to 2,900 (374) lux by the surgically implanted light meter in the cadaver. All values were less than the reference Heine direct laryngoscope and some fell below the published ISO standard of 500 lux for DL. Luminance testing by spot meter had a similarly wide range, varying from 3.78 (0.60) to 49.1 (10.4) cd·m-2, with some Mac-VLs delivering less luminance than the reference Heine direct laryngoscope. CONCLUSIONS: Our results indicate that illuminance and luminance provided by Mac-VLs used for direct laryngeal viewing varies substantially between devices, with some falling below standards previously suggested as the minimum required for DL. While this may have no implications for the quality of image visible on a device's video monitor, the clinician should be aware that when Mac-VLs are used for direct viewing of the larynx, lighting may not be optimal. This might adversely affect ease or success of tracheal intubation.

RéSUMé: CONTEXTE: L'éclairage adéquat du larynx est nécessaire pendant la laryngoscopie pour faciliter l'intubation trachéale. Pour la laryngoscopie directe (LD), l'Organisation internationale de normalisation (ISO) a établi une intensité lumineuse minimale de plus de 500 lux pendant au moins dix minutes. Toutefois, il n'existe aucune norme de ce type pour les lames de vidéolaryngoscope à géométrie Macintosh (VL-Mac), qui permettent une visualisation directe ou indirecte (vidéoscopique) du larynx. Par des études en laboratoire et in vitro sur un cadavre humain, nous avons déterminé les valeurs d'éclairage et de luminance fournies par divers VL-Mac et les avons comparées aux valeurs repères d'éclairage minimal publiées ainsi qu'aux valeurs obtenues avec un laryngoscope direct de référence. MéTHODE: Nous avons testé six VL-Mac (i-view™, McGRATH™ MAC, GlideScope® Spectrum™ [à usage unique] DVM S4, GlideScope® Titanium [réutilisable] Mac T4, C-MAC® S [à usage unique] Macintosh #4, et C-MAC® [réutilisable] Macintosh #4) ainsi qu'un laryngoscope direct (Heine LED). Chaque laryngoscope a été évalué avec trois mesures, comme suit : partie 1: l'éclairage (lux) a été mesuré in situ à l'aide d'un appareil spécialement conçu de mesure de l'intensité lumineuse en laboratoire; partie 2 : la luminance (lumière réfléchie vers l'œil) a été mesurée (en candela m-2 [cd·m-2]) pendant la vidéolaryngoscopie (VL) et la LD sur un cadavre humain, à l'aide d'un posemètre pointé vers la commissure interaryténoïdienne; partie 3: l'éclairage (lux) a été mesuré pendant la VL et la LD sur un cadavre humain à l'aide d'un photomètre implanté chirurgicalement juste en amont des cordes vocales. RéSULTATS: L'éclairage et la luminance variaient considérablement entre les VL-Mac. L'éclairage moyen (écart type) parmi les six VL-Mac testés variait de 117 (11) à 2626 (42) lux avec l'appareil de mesure, et de 228 (11) à 2900 (374) lux lorsque mesuré par le photomètre implanté chirurgicalement dans le cadavre. Toutes les valeurs étaient inférieures au laryngoscope direct Heine de référence, et certaines étaient inférieures à la norme ISO publiée de 500 lux pour la LD. Les essais de luminance par posemètre ont rapporté une plage tout aussi large, variant de 3,78 (0,60) à 49,1 (10,4) cd·m-2, certains VL-Mac offrant moins de luminance que le laryngoscope direct Heine de référence. CONCLUSION: Nos résultats indiquent que l'éclairage et la luminance fournis par les VL-Mac utilisés pour la visualisation directe du larynx varient considérablement d'un appareil à l'autre, certains tombant en dessous des normes précédemment suggérées comme minimalement requises pour la LD. Bien que cela puisse n'avoir aucune incidence sur la qualité de l'image visible sur le moniteur vidéo d'un appareil, le clinicien doit être conscient que lorsqu'un VL-Mac est utilisé pour la visualisation directe du larynx, l'éclairage pourrait ne pas être optimal. Cela pourrait nuire à la facilité ou au succès de l'intubation trachéale.

Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.

BACKGROUND: Rebound pain is a common, yet under-recognised acute increase in pain severity after a peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed. This retrospective cohort study investigated the incidence and factors associated with rebound pain in patients who received a PNB for ambulatory surgery. METHODS: Ambulatory surgery patients who received a preoperative PNB between March 2017 and February 2019 were included. Rebound pain was defined as the transition from well-controlled pain (numerical rating scale [NRS] ≤3) while the block is working to severe pain (NRS ≥7) within 24 h of block performance. Patient, surgical, and anaesthetic factors were analysed for association with rebound pain by univariate, multivariable, and machine learning methods. RESULTS: Four hundred and eighty-two (49.6%) of 972 included patients experienced rebound pain as per the definition. Multivariable analysis showed that the factors independently associated with rebound pain were younger age (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.97-0.99), female gender (OR 1.52 [1.15-2.02]), surgery involving bone (OR 1.82 [1.38-2.40]), and absence of perioperative i.v. dexamethasone (OR 1.78 [1.12-2.83]). Despite a high incidence of rebound pain, there were high rates of patient satisfaction (83.2%) and return to daily activities (96.5%). CONCLUSIONS: Rebound pain occurred in half of the patients and showed independent associations with age, female gender, bone surgery, and absence of intraoperative use of i.v. dexamethasone. Until further research is available, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain.

Factors Associated With Failure of Spinal Anesthetic: An 8-Year Retrospective Analysis of Patients Undergoing Elective Hip and Knee Joint Arthroplasty.

The primary outcome of this 8-year retrospective review was the failure of spinal anesthetic (SA) in elective hip and knee joint arthroplasty surgery. Of 3542 SAs, a total of 135 failures were identified (3.8%). Factors associated with increased odds of failure were younger age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), lower body mass index (BMI; OR, 1.04 [1.01-1.08]), hip arthroplasty (OR, 1.90 [1.28-2.84]) compared to knee arthroplasty, needle insertion at L4-5 (OR, 4.61 [2.02-10.54]) and L5-S1 (OR, 7.66 [2.47-23.7]) compared to L2-3, 22-gauge needle size (OR, 2.17 [1.34-3.52]) compared to 25-gauge needle, and hyperbaric bupivacaine (OR, 1.66 [1.09-2.53]) compared to isobaric bupivacaine.

The incidence, success rate, and complications of awake tracheal intubation in 1,554 patients over 12 years: an historical cohort study.

PURPOSE: Awake tracheal intubation is one recommended option to address select situations in the management of a patient with an anticipated difficult airway. A scarcity of data exists on how often awake intubation is performed or whether its use is changing over time, particularly with the increasingly widespread availability of video laryngoscopy. This retrospective database review was undertaken to determine the incidence, success, and complications of awake intubation and the incidence of other tracheal intubation techniques in the operating room over a 12-yr period (2002-2013) at our institution. METHODS: The Anesthesia Information Management System in use at a Canadian tertiary care centre was searched for all awake intubations that occurred during the years 2002-2013. Records were also searched to identify airway methods other than direct laryngoscopy that may have been used after the induction of general anesthesia. Changes in both the incidence of awake intubation and in the use of video laryngoscopy over the 12 years were analyzed using linear regression modelling. RESULTS: Of 146,252 cases performed under general anesthesia with endotracheal intubation, 1,554 intubations (1.06%) were performed awake. There was no significant change in the rate of awake intubation over the studied years (slope -1.4(-4) incidence·year(-1); 95% confidence interval [CI]: -3.0(-4) to 3.0(-5); P = 0.102). The relatively steady rate of awake intubation occurred despite a significant increase in the use of video laryngoscopy over the same time (slope 0.080 incidence·year(-1); 95% CI: 0.076 to 0.083; P < 0.001), particularly from 2009 onwards. Attempted awake intubation failed in 31 (2%) of the cases. Self-reported complications occurred in 15.7% of successful procedures. In addition, in a convenience sample of three years (2011-2013), the rate at which each of 49 attending staff performed awake intubation varied widely from 0-3.4 awake intubations per 100 cases of general anesthesia with endotracheal intubation. CONCLUSIONS: At our tertiary care centre, we did not find a significant change in the use of awake tracheal intubation over the studied years 2002-2013 despite increasing availability and use of video laryngoscopy. It appears that awake tracheal intubation retains an important and consistent role in the management of the difficult airway.

Illumination of bulb-on-blade laryngoscopes in the out-of-hospital setting.

OBJECTIVES: To determine what percentage of out-of-hospital laryngoscopes meet a predetermined minimal illumination criterion and what factors may be altered to improve illumination. METHODS: This was an observational study of the illumination of laryngoscopes currently in use by the Emergency Health Services of Nova Scotia. Each laryngoscope was measured at baseline. This illumination was compared with the illumination after replacement with new batteries, replacement with a new bulb, replacement with new batteries and a new bulb together, and attachment of a disposable blade. The percentage of laryngoscopes that met a previously defined minimal brightness criterion was determined. RESULTS: Fifty-one laryngoscopes were measured. These laryngoscopes had a mean (+/-SD) illumination of 624 (+/-297) lux at baseline. Laryngoscope illumination increased after replacement with new batteries by 168 lux (95% confidence interval [CI] = 121 to 216), replacement with a new bulb by 679 lux (95% CI = 524 to 834), replacement with new batteries and a new bulb by 937 lux (95% CI = 770 to 1,104), and attachment of a disposable blade by 2,401 lux (95% CI = 2,075 to 2,740). Fourteen percent of laryngoscopes (7/51) at baseline met the minimal illumination criterion. CONCLUSIONS: Only a small percentage of out-of-hospital laryngoscopes met the minimal illumination criterion. There was a statistically significant increase in illumination after replacement with new batteries, replacement with a new bulb, replacement with new batteries and a new bulb, or attachment of a disposable blade. Optimal changing of lightbulbs and batteries in the out-of-hospital setting will have to be more clearly defined.