Acute Pancreatitis with Intra Abdominal Hypertension- An Airway Issue.

Acute Pancreatitis with acute intra abdominal pressure buildup is an important ICU Airway management issue from time to time. The report below brings this to our attention and while this is primarily a combined Medical / Surgical issue there are many reasons to  rethink the problem.
The recent update of general guidelines are found in the report of the working group IAP/APA Acute Pancreatitis Guidelines.

NB: These Guidelines have been reviewed in 2015

Jiten et.al. reviewed literature and have called for an update of approaches to the problem.

Complications known to occur have been listed and of course include Acute  Respiratory Failure which is approached as indicated with support by ventilation.

The issue of surgical intervention is controversial but the surgery , if done, probably should be carried out when organ failure is beginning to emerge and perhaps less than 6 hours into failure of medical therapeutic options. 

The surgery may be best carried out via a midline incision using mesh and also , importantly , the negative pressure drainage techniques now common. (1.)  This can reduce intra abdominal pressures below the 20 mm Hg level and will permit reduced compliance ventilation. This then will reduce fluid infusions necessary to maintain cardiovascular and renal support.

Conclusion:

In short the Alert from Jiten Jaipura and his team is timely and serves to refocus our attention on the criteria of the Working Group.

1. Plaudis H. et. al. Abdominal Negative Pressure Therapy: a New Method In Countering Abdominal Compartment And Peritonitis- A Prospective Study and Critical Review Of  Literature. Ann. Intensive Care2 Suppl 1 S23, 2012 PMID 23281649

Anesthesia Change Management- Nasal Tse Pap -an example of change resistance psychology

Nasal Tse PAP- The most flexible and effective Nasal Route?

The Airway management world and anesthesia in particular now recognizes the advantages of nasal routes to oxygenation in management of challenging airway management. Change is now happening in spite of the culture of resistance. 

        There are now several strategies and techniques available including:

1. The time honored "NASAL CANNULA" strategy which has been ubiquitous but not used often historically during challenging airway encounters.-this is now being changed as the simplicity and effective use as an adjunct to pre oxygenation becomes recognized.

2. Naso Pharyngeal Cannulae have been recognized as useful to enrich oxygen distal to the nose in the pharynx. The work of Richard Levitan and Scott Weinberg repeatedly pressed the advantages of this strategy.

3. The successful development and commercialization of the " THRIVE " device has added a new strategy that is being shown to be effective by creation of "high flow nasal oxygen" induced CPAP with flow rates up to 70 L/min in adults.

4.  The conception and development of NASAL TSE PAP is , I believe , an example of systematic failure to seriously study and adopt a demonstrated and recognized optimal technology. Dr. James Tse , professor of Rutgers University department of Anesthesiology , has been demonstrating the effectiveness of nasal CPAP ( I call this NASAL TSE PAP in his honour) for perhaps 10 years. Recognition of the pivotal change possible with this teaching has been best recognized by an award from the Anesthesia Patient Safety Foundation a few years ago and by repeated awards at the PGA and ASA.

     The unique value of NASAL TSE PAP is that it is far more effective that ORO-NASAL mask in many situations because of the unique splinting of the airway during ventilation. Also the transition to positive pressure ventilation is at a Medical Student Level of difficulty. The reasons for neglecting this great contribution, that works seamlessly with Video Laryngoscopy in synchronous application, is based I believe on lack of scientific discipline.

    Change management in Anesthesiology is like a popularity contest which reminds me of the adoption of the Hula Hoop in popular culture.

Anesthesia Culture and the Future of Anesthesiology 1 Definition of "Culture" and "Human Factors"

Overview

     The technological changes that have occurred in the last 25 years in delivery of Anesthetics have been paralleled by vast improvements in Education and Culture. The Society for Airway Management , created by Andranik Ovassapian and his friends, is a manifestation of these changes. This Society and all of the other changes have joined to create many improvements in patient safety. The safety of practice improvements have been reflected in some countries , like Canada, by stabilization of growth of Medical Malpractice insurance rates and claims. 

Technological change has been unrelenting and has provided challenges for those learning and teaching management of these changes.

     With these changes we have seen the evolution of a class of caregivers CRNAs who have energetically learned to work in the space , for the most part as  trusted partners of the anesthesiologist. The new technology has increased the ease and safety of using the new class of providers in an Anesthesiology Environment. These new providers are now part of an evolving  new culture. The culture of change developing  is the subject of this series of posts.

Culture Definition:  Merriam Webster Dictionary

• The integrated pattern of human knowledge , belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations.
• The customary beliefs , social forms, and material traits of a racial, religious, or social group.
• The set of shared attitudes, values, goals, and practices that characterizes an institution or organization.
•  The set of Values , conventions, or social practices associated with a particular field, activity, or social characteristic.

Human Factors Engineering Definition:  Britannica

• Human factors Engineering, also called Ergonomics, or Human Engineering Science is application of information on physical and psychological characteristics  to the design of devices and systems for human use. Think aviation culture.
• As a body of knowledge human factors is a collection of data and principles about human characteristics , capabilities, and limitations in relation to machines , jobs, and environments.
• As a profession , human factors engineering includes a range of scientists and engineers from several disciplines that are concerned with individuals and small groups at work.

     The culture we now have in Anesthesiology is amazing in its power and reflects the enormous  output of the University systems and Industry output.  There is a complex intertwining of private medicine with new Government Care funding and all of this has a large bureaucracy attached.

What would be the feature set of a new culture  created to provide a path to the future:

• The new culture must have a strong central theme benefiting from "Enlightened Management ".
• The new culture must not be centrally micromanaged but must allow "islands of change that are locally inspired and controlled". Think of the hospital group , ICU level or the stand alone OR as examples of scale of the agents of change.
• The culture of change should weld into its DNA the benefits of Telemedicine that enables shared Electronic Medical Record , practice guidelines, inter hospital and inter service coordination while remaining decentralized in many ways.
• The culture of change should be viewed as a continuous process that engages all players.
• The culture of change should embrace the science of change management and the disciplines of Human Factors Engineering.

The Medical Professional of the future should be educated and enabled to be able to lead in local change initiatives in a role change that exploits the intellect and history of our profession.

To do this refocussing the training and preparation for change must be embraced and incorporated in Medical Training as a sub specialty. Medical schools should spend valuable teaching time serving this need.

Anesthesiologists can become the visionaries and agents of change in developing this new culture by reinventing them selves and learning to create " a new Personal Brand " as a change agent. 

The great technical development we have experienced now makes us the weak link in the " quality of care" equation. The way we behave leaves great opportunity for us to measure and improve our contributions to the great " Hippocratic Tradition".

Post Operative Continuous Positive Airway Pressure : ( New Book Reference)

The critical Postoperative period is different for those with risk of hypoventilation , subsequent respiratory failure, atelectasis, pneumonia, acute illness factors, and exacerbation of underlying lung disease or OSA than for those with short surgery with no risk factors.
         As an aside that corresponds with my intense interest in Nasal Tse Pap:
The provision of CPAP (preferably from the nasal route a la Rutgers Professor Dr. James Tse "Nasal Tse Pap" ) is a superior way of managing those at risk. The benefits , arguably ,  should be provided more liberally as opposed to the current practice where use is indicated " as required for problem solving".  This is an evolving topic which parallels a similar discussion around the 2013 ASA minimal requirement for "pre oxygenation" during intubation .  Nasal CPAP can provide extra preop benefits (next post). Dr Tse has received numerous awards from ASA Patient safety poster competitions for creative demonstrations of Nasal CPAP applications at Rutger's University Medical School.

Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care

Springer
Editor  : Antonio M. Esquinas
ISBN  978-3-319-04258-9 Print
           978-3-319-04259-6 Online

The Physiologically Difficult Airway

Jarrod M. Mosier, MD , Raj Joshi, MD , Cameron Hypes, MD, Garrett Pacheco MD, Terrence Valenzuela, MD, John Sakles MD.
                                      University of Arizona ICU and ED Departments.
                                   Published, Western Journal of Emergency Medicine 2015

Full text available via open access http: escholarship.org/uc/uciem_westjem 

DOI 10.5811/westjem/ 2015

With recognition that many tools ( DL, VL, FOB, Surgical neck access),  are now available for the placement of endotracheal tubes and that CPAP , BIPAP also make a powerful contribution to oxygenation and ventilation ,  there remains another dimension of the airway management problem that needs to be addressed. 

Physiological Factors:

This important contribution to the teaching of Airway strategy underlines the four physiological states that add a complexity and risk to the Difficult Airway patient management. The special problems in the ICU and the ED are often coloured by the complex physiology of people who are suffering from profound general disorders. It is therefore fitting that this new look at the difficult Airway should come from Mosier (ICU) and Sakles (ED). Separation of these factors for special education and acute care consideration will surely make care safer in critical care areas.

1. Hypoxemia - with a patient at an unfavourable point on the oxygen dissociation curve leaving reduced margin for rapid deterioration. The pre oxygenation process becomes important prior to attempts at intubation. The use of Nasal approaches to provision of procedural oxygen are currently attracting more attention and study. These include the Thrive Hi Flo Nasal oxygen strategy, the simple use of nasal prongs (less effective but still added value) and nasal TSE PAP which uses the nose as a conduit for CPAP with a modified #2 Childrens mask.

    2. Hypotension- addressed  with standard volume optimization support  and pressor use as indicated. 

    3. Severe Metabolic acidosis - treated with disease specific therapy (i.e. Diabetic Keto-acidosis) and or other cause specific therapy such as septic state therapy.

    4. Right Ventricular failure - firstly awareness of the diagnosis is key followed by excellent strategies defined by truly expert care. The following are considered to be of value by Mosier and his team 1. Available bedside cardiac echo to assess right heart reserve allowing fluid use, 2. pre oxygenation (see above) 3. consider etomidate induction, 4. consider Norepinephrine to increase systemic pressure, and low mean airway pressure ventilation. To obtain a discussion of these outline points consult the original detail embodied in the paper itself.

Abstract

Video Laryngoscopy Improves Odds of First Attempt Success at Intubation in the ICU: A Propensity-Matched Analysis

Cameron D Hypes, Uwe Stolz, John C Sakles, Raj R Joshi, Bhupinder Natt, Josh Malo, John W Bloom, and Jarrod M Mosier

Jarrod Mosier and John Sakles continue to be among leaders in clinical evaluation of airway management in ICU and ED areas. This article reinforces the growing understanding that in ICU , where most caregivers are no longer from an anesthesiology training base but from various other disciplines, the Video Laryngoscope is easier to learn and use. The skill retention is also superior using VL so overall performance for first pass success is superior to DL.
The Abstract for ICU application is as follows:

Abstract

 Rationale: Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however existing comparative data on outcomes are limited. 

Objectives: To compare first attempt success and complication rates during intubation when using video laryngoscopy compared to traditional direct laryngoscopy in a tertiary academic medical intensive care unit. Methods: We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1st, 2012 and December 31st 2014. Propensity-matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding.

 Measurements and Main Results: A total of 885 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 

136 (16.8%) using direct laryngoscopy. 

First attempt success with video laryngoscopy was 80.4% (95% CI 77.2 to 83.3%) compared and 65.4% (95% CI: 56.8 to 73.4%) for intubations performed with direct laryngoscopy, p=<0.001. In a propensity-matched analysis, the odds ratio for first attempt success with video laryngoscopy vs. direct laryngoscopy was 2.81 (95% CI 2.27 to 3.59). The rate of arterial oxygen saturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%, p=0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%, p=0.008). 

Conclusions: Video laryngoscopy was associated with significantly improved odds of first attempt success at tracheal intubation by non-anesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation complicating intubation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

Read More: http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201508-505OC#.VniHCTa0GfM   

   

Ventrain- A novel approach to ventilation through small bore cannulas by Professor Dietmar Enk

The Ventrain device is designed to take advantage of the Bernoulli Principle to 

create a control that will use the pressure of an Oxygen source to create 

positive pressure inflow and when the appropriate orifice is blocked a negative pressure for expiration is created by the passage of air over the entrance to the endotracheal tube. This is explained in the Text.

This substantially improves the potential to ventilate through small caliber cannulas. 

The simplicity and brilliance of the design suggests an important role that will improve difficult airway management and also possibly a number of other situations.