Comparison of three video laryngoscopy devices to direct laryngoscopy for intubating obese patients: a randomized controlled trial.

STUDY OBJECTIVE: To compare three different video laryngoscope devices (VL) to standard direct laryngoscopy (DL) for tracheal intubation of obese patients undergoing bariatric surgery. HYPOTHESIS: VL (vs DL) would reduce the time required to achieve successful tracheal intubation and improve the glottic view. DESIGN: Prospective, randomized and controlled. SETTING: Preoperative/operating rooms and postanesthesia care unit. PATIENTS: One hundred twenty-one obese patients (ASA physical status I-III), aged 18 to 80 years, body mass index (BMI) >30 kg/m(2) undergoing elective bariatric surgery. INTERVENTION: Patients were prospectively randomized assigned to one of 4 different airway devices for tracheal intubation: standard Macintosh (Mac) blade (DL); Video-Mac VL; Glide Scope VL; or McGrath VL. MEASUREMENTS: After performing a preoperative airway evaluation, patients underwent a standardized induction sequence. The glottic view was graded using the Cormack Lehane and percentage of glottic opening (POGO) scoring systems at the time of tracheal intubation. Times from the blade entering the patient's mouth to obtaining a glottic view, placement of the tracheal tube, and confirmation of an end-tidal CO2 waveform were recorded. In addition, intubation attempts, adjuvant airway devices, hemodynamic changes, adverse events, and any airway-related trauma were recorded. MAIN RESULTS: All three VL devices provided improved glottic views compared to standard DL (p < 0.05). Video-Mac VL and McGrath also significantly reduced the time required to obtain the glottic view. Video-Mac VL significantly reduced the time required for successful placement of the tracheal tube (vs DL and the others VL device groups). The Video-Mac and GlideScope required fewer intubation attempts (P< .05) and less frequent use of ancillary intubating devices compared to DL and the McGrath VL. CONCLUSION: Video-Mac and GlideScope required fewer intubation attempts than standard DL and the McGrath device. The Video-Mac also significantly reduced the time needed to secure the airway and improved the glottic view compared to standard DL.

Autoimmune hemolytic anemia in patients with liver transplants for primary biliary cirrhosis: Three case reports and a review of the literature.

BACKGROUND: Hemolytic anemia is rare after liver transplant and is usually associated with ABO mistmatch, post-transplant lymphoproliferative disorders, or medications. CASE REPORTS: We report three patients who had undergone successful liver transplants for primary biliary cirrhosis (PBC) and developed direct antibody test positive autoimmune hemolytic anemia (AIHA) several years into uncomplicated post-transplant management. For two of the patients, the hemolysis responded to steroids and rituximab. One patient required a surgical splenectomy. DISCUSSION: AIHA is an immune-mediated hemolysis that has been reported in patients with PBC. There are no reports of AIHA in patients following liver transplantation for this disease. AIHA should be considered in stable PBC patients who develop anemia years after liver transplant.

Comparison of direct and video-assisted views of the larynx during routine intubation.

OBJECTIVE: To compare the direct and indirect (video monitor) views of the glottic opening using a new Macintosh blade that is modified to provide a video image of airway structures during laryngoscopy. DESIGN: Prospective multicenter trial. SETTING: 11 university-affiliated hospitals. PATIENTS: 867 adults undergoing elective surgery requiring general anesthesia and tracheal intubation. INTERVENTIONS: Patients received general anesthesia and were paralyzed. Direct laryngoscopy was supervised by one of the investigators at each institution. The best possible view was obtained with a Macintosh video laryngoscope during direct vision using standard techniques such as external laryngeal manipulation and backward, upward, and rightward pressure, if necessary. The laryngoscopist then looked at the video monitor and performed any necessary maneuvers to obtain the best view on the video monitor. Thus, 2 assessments were made during the same laryngoscopy (direct naked-eye view vs video monitor view). Tracheal intubation was then performed using the monitor view. Glottic views were rated according to the Cormack-Lehane scoring system, as modified by Yentis and Lee. A questionnaire was completed for each patient. MEASUREMENTS AND MAIN RESULTS: Data from 865 patients were suitable for analysis. Visualization was considered easy (Cormack-Lehane score<3) in 737 patients and difficult (Cormack-Lehane score=3 or 4) in 21 for both direct and video-assisted views. In 7 patients, the view was considered easy during direct visualization yet difficult on the video monitor view. On the other hand, the view was considered difficult in 100 patients during direct visualization yet easy on the video monitor view (P<0.001). CONCLUSIONS: Video-assisted laryngoscopy provides an improved view of the larynx, as compared with direct visualization. This technique may be useful for cases of difficult intubation and reintubation as well as for teaching laryngoscopy and intubation.

A New Video Laryngoscope - An Aid in Intubation and Teaching.

In recent decades, video techniques have been employed in the majority of endoscopic procedures because of several distinct advantages provided. These include the following: The displayed anatomy is magnified. Recognition of the anatomical structures and anomalies is easier, and manipulation of airway devices is facilitated. When assistance is required, the operator and assistant can coordinate their movements because each sees exactly the same image on the video monitor. As a result, video techniques have become the method of choice in teaching. The Video Macintosh Intubating Laryngoscope System (VMS) was designed employing a standard Macintosh blade and laryngoscope handle. A camera was incorporated into the handle with a short image and light bundle. The magnified anatomy is displayed on an 8-inch monitor, which is attached to a swivel arm on a small cart. Observation and manipulation can be performed in one axis. 235 patients were studied and were divided into two groups: Group A (n=217) where intubation was thought unlikely to be difficult, and Group B (n=18) where difficulty with intubation was anticipated. External laryngeal manipulation (ELM) was required in 22 of the 217 Group A patients (10%). All intubations but one in this group were successful. In the second group (B) of 18 patients who had anatomical conditions that suggested that direct laryngoscopy might be challenging, all 18 cases required ELM but all were successfully intubated using the VMS. The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthesiologist handling the laryngoscope results in a significant advantage over the conventional laryngoscope technique. As a consequence the learning curve is short. In our view, video laryngoscopy will become the method of choice in teaching.

A new video laryngoscope-an aid to intubation and teaching.

In recent decades, video techniques have been employed in the majority of endoscopic procedures because of several distinct advantages provided. These include the following: The displayed anatomy is magnified. Recognition of the anatomical structures and anomalies is easier, and manipulation of airway devices is facilitated. When assistance is required, the operator and assistant can coordinate their movements because each sees exactly the same image on the video monitor. As a result, video techniques have become the method of choice in teaching. The Video Macintosh Intubating Laryngoscope System (VMS) was designed employing a standard Macintosh blade and laryngoscope handle. A camera was incorporated into the handle with a short image and light bundle. The magnified anatomy is displayed on an 8-inch monitor, which is attached to a swivel arm on a small cart. Observation and manipulation can be performed in one axis.A total of 235 patients were studied and were divided into two groups: Group A (n = 217), in whom intubation was thought unlikely to be difficult, and Group B (n = 18), in whom difficulty with intubation was anticipated. External laryngeal manipulation (ELM) was required in 22 of the 217 Group A patients (10%). All intubations but one in this group were successful. In the second group (B) of 18 patients who had anatomical conditions that suggested that direct laryngoscopy might be challenging, all 18 cases required ELM but all were successfully intubated using the VMS. The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthesiologist handling the laryngoscope results in a significant advantage over the conventional laryngoscope technique. As a consequence, the learning curve is short. In our view, video laryngoscopy will become the method of choice in teaching.