Telemedicine Strategies Advancing

The world is leading toward more and more connectedness and the potential to extend the footprint of very knowledgeable people is great as tele systems gather strength. The use of commercially available I Phones and FaceTime for Medical consultation was first reported for Airway Management by Dr John Sakles and Dr Jarrod Mosier from the University of Arizona . (Telebation : Next-Generation telemedicine in remote airway management using current wireless technologies. Telemed J E health 2013,Feb 19,(2): 95-8.)

This new study from Japan extends this theme

A pilot study of tele-anaesthesia by virtual private network between an island hospital and a mainland hospital in Japan

1. Tetsuya Miyashita, Yusuke Mizuno,Yo Sugawara, Yusuka Nagamine, Yukihide Koyama
2. Tomoyuki Miyazaki, Kazuhiro Uchimoto, Yasuhiro Iketani, Kentaro Tojo, Takahisa Goto.

1. Department of Anesthesiology, Yokohama City University Hospital, Japan

1. Dr Tetsuya Miyashita, Department of Anesthesiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa 236-0004, Japan. Email: yushukyo@gmail.com

We studied the use of tele-anaesthesia between Sado General Hospital (SGH) located on Sado Island and Yokohama City University Hospital (YCUH) located in mainland Japan. The two sites were connected via a virtual private network (VPN). We investigated the relationship between the bandwidth of the VPN and both the frame rate and the delay time of the tele-anaesthesia monitoring system. The tool used for communication between the two hospitals was free videoconferencing software (FaceTime), which can be used over Wi-Fi connections. We also investigated the accuracy of the commands given during teleanaesthesia: any commands from the anaesthetist at the YCUH that were not carried out for any reason, were recorded in the anaesthetic records at the SGH. The original frame rate and data rate at the SGH were 5 fps and approximately 18 Mbit/s, respectively. The frame rate at the transmission speeds of 1, 5 and 20 Mbit/s was 0.6, 1.6 and 5.0 fps, respectively. The corresponding delay time was 12.2, 4.9 and 0.7 s. Twenty-five adult patients were enrolled in the study and tele-anaesthesia was performed. The total duration of anaesthesia was 37 hours. All 888 anaesthetic commands were completed. There were 7 FaceTime disconnections, which lasted for 10 min altogether. Because no commands needed to be given during the FaceTime disconnection, the telephone was not used. The anaesthesia assistance system might form part of the solution to medical resource shortages.

• Accepted September 26, 2014.

GlideScope use in ICU Teaching Environment produces Superior results.

There is an interesting development in the use of video laryngoscopy in ICU settings that is associated with modern trends in training:

1. When Anesthesiologists administer care in adult ICU the incidence of difficult airways is 22% so that one could argue that intubation attempts should begin with the most effective available device which I suggest is a Video laryngoscope. Florian Heuer  2012 :40 Anesthesia Intensive Care .

2. When the ICU trainees and Fellows come from a Medical background where intubation skills are dramatically less developed than anesthesiologists , then it is not possible to obtain DL skills quickly enough to have an experience of 100 cases that could bring the rates of success to 90%. Thus the trainees would almost always be operating at an unacceptable level. It is however to have VL skills after many fewer cases , perhaps 10 , and then function better. The paper by Silverberg suggests that VL is much more effective in an ICU for obtaining higher success levels.

Comparison of Video Laryngoscopy Versus Direct Laryngoscopy During Urgent Endotracheal Intubation: A Randomized Controlled Trial.

Silverberg, Michael J. MD; Li, Nan MD; Acquah, Samuel O. MD; Kory, Pierre D. MD, MPA 

Objectives: In the critically ill undergoing urgent endotracheal intubation by direct laryngoscopy, multiple attempts are often required with a higher complication rate due to the urgency, uncontrolled setting, comorbidities, and variability in expertise of operators. We hypothesized that Glidescope video laryngoscopy would be superior to direct laryngoscopy during urgent endotracheal intubation.

Design: Single-center prospective randomized controlled trial.

Setting: Beth Israel Medical Center, an 856-bed urban teaching hospital with a 16-bed closed medical ICU.

Patients: Of 153 consecutive patients undergoing urgent endotracheal intubation by pulmonary and critical care medicine fellows, 117 met inclusion criteria.

Interventions: Patients undergoing urgent endotracheal intubation were randomized to Glidescope video laryngoscopy or direct laryngoscopy as the primary intubation device.

Measurements and Main Results: The primary outcome measure was the rate of first-attempt success. Acute Physiology and Chronic Health Evaluation II scores were similar between groups (20.9 +/- 8.2 vs 19.9 +/- 7.9). First-attempt success was achieved in 74% of the Glidescope video laryngoscopy group compared with 40% in the direct laryngoscopy group (p < 0.001). All unsuccessful direct laryngoscopy patients were successfully intubated with Glidescope video laryngoscopy, 82% on the first attempt. There was no significant difference in rates of complications between direct laryngoscopy and Glidescope video laryngoscopy: esophageal intubations (7% vs 0%; p = 0.05), aspiration events (7% vs 9%; p = 0.69), desaturation (8% vs 4%; p = 0.27), and hypotension (13% vs 11%; p = 0.64).

Conclusions: Glidescope video laryngoscopy improves the first-attempt success rate during urgent endotracheal intubation performed by pulmonary and critical care medicine fellows when compared with direct laryngoscopy.