Correspondence
Tom G. Hansen1,2 Department of Anaesthesia and Intensive Care – Pediatric Section, Odense University Hospital, Odense C, Denmark 2 Clinical Institute – Anesthesiology, University of Southern Denmark, Odense C, Denmark Email: [email protected]
Conflicts of interest
1
No conflicts of interest declared.
doi:10.1111/pan.12632
References 1 Hansen TG, Pedersen JK, Henneberg SW et al. Academic performance in adolescence after inguinal hernia repair in infancy: a nationwide cohort study. Anesthesiology 2011; 114: 1076–1085. 2 Hansen TG, Pedersen JK, Henneberg SW et al. Educational outcome following pyloric stenosis repair before 3 months of age: a
nationwide cohort study. Pediatr Anesth 2013; 23: 883–890. 3 Hansen TG. Anesthesia-related neurotoxicity and the developing animal brain is not a significant problem in children. Pediatr Anesth 2015; 25: 65–72. 4 Warner DO, Flick RP. Effects of anesthesia and surgery on the developing brain: prob-
lem solved? Pediatr Anesth 2015; 25: 435– 436. 5 Hansen TG, Pedersen JK, Henneberg SW et al. Neurosurgical conditions and procedures in infancy are associated with mortality and academic performances in adolescence: a nationwide cohort study. Pediatr Anesth 2015; 25: 186–192.
It’s not about the endotracheal tube: reply to editorial on our paper “Endotracheal intubation in the pediatric emergency department” SIR—We thank Lerman, Sharma, and Heard for their valuable comments on our article, and agree that nonoperating room intubations, both in adults and in children, are in need of CPR (1). We also agree that minimum thresholds for proficiency at tracheal intubation should be established as a standard of care, and that a mean first pass success rate of 90% is too low. Furthermore, we feel that the aim of nonoperating room intubations should be zero iatrogenic harm. In response to the suggestion that the primary problem resulting in a high rate of adverse events during Emergency Department (ED) intubations relates to nonanesthetic trainees deficits in knowledge and procedural proficiency, we would like to highlight two points. Firstly, the adverse event rate observed in our study was independent of the specialty or seniority of the intubator. Anesthetic trainees had the same adverse event rate as nonanesthetic trainees. Secondly, none of the patients intubated in our ED over a 1-year period had difficult Cormack and Lehane grade laryngoscopy. The requirement for multiple intubation attempts and the high adverse event rate were due critical illness, not difficult airways. As such, we believe that improving the safety of nonoperating room intubations cannot be addressed entirely by focussing on the knowledge and procedural proficiency of the intubator, as suggested by Lerman et al. The “nontechnical” factors, such as teamwork, leadership and followership, communication, and avoid© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
ance of fixation are equally important, and require different training modalities. We have introduced a quality improvement program to improve the safety of nonoperating room intubations that includes a hospital-wide difficult intubation algorithm, clear pathways for airway escalation, standardized hospital-wide equipment available in all critical care areas using identical airway carts, and multidisciplinary education and training to address both the technical and nontechnical aspects of nonoperating room airway management. We recognize that no single educational tool has been shown to improve patient-centered airway outcomes (2). We aim to monitor our first pass success and adverse event rates to see if the afore-mentioned interventions improve the safety of nonoperating room intubations in our institution. Ethics approval Not applicable. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. 437
Correspondence
Elliot Long1,2,3, Stefan Sabato2,4 & Franz E. Babl1,2,3 Department of Emergency Medicine, Royal Children’s Hospital, Parkville, Vic., Australia 2 Murdoch Children’s Research Institute, Parkville, Vic., Australia 3 Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia 1
4
Department of Anaesthesia and Pain Management, The Royal Children’s Hospital, Parkville, Vic., Australia Email: [email protected] doi:10.1111/pan.12630
References 1 Lerman J, Sharma S, Heard C. Pediatric airway management in the emergency department: in urgent need of CPR. Pediatr Anesth 2014; 24: 1199–1203.
2 Kennedy CC, Cannon EK, Warner DO et al. Advanced airway management simulation training in medical education: a systematic
review and meta-analysis. Crit Care Med 2014; 42: 169–178.
Pediatric endobronchial blockers in infants: a refinement in technique SIR—The Arndt endobronchial blocker (AEB) (Cook Medical, Bloomington, IN) is commonly used to facilitate one-lung ventilation in pediatric patients (1–5). Extraluminal AEB placement is used in infants and small children because endotracheal tubes (ETT) with internal diameters less than 4.5 mm cannot simultaneously accommodate a pediatric fiber-optic bronchoscope (FOB) and 5 French AEB. Extraluminal placement has the added advantage of increasing the endotracheal cross-sectional area available for ventilation. Four strategies have been previously described for positioning of the extraluminal AEB into the desired mainstem bronchus. First, Hammer, et al. proposed intubating the desired mainstem bronchus with an ETT, placing a guidewire into the bronchus, exchanging the
(a)
(b)
(c)
(d)
Figure 1 (a) 5 French Arndt endobronchial blocker (AEB); (b) The AEB is prepared by making a sharp bend at the base of the monofilament guide loop; (c) for added rigidity, the bend may be made in the AEB itself; (d) An illustration of the fiber-optic view during placement
438
ETT for an AEB, reintubating the trachea, and checking final AEB position using a FOB through the ETT (1). Second, Bastien, et al. describe simultaneous intubation with AEB and ETT such that the AEB’s guide loop encircles the tip of the ETT, guidance of the FOB into the mainstem bronchus of choice, and deployment of the AEB and guide loop over the FOB (4). Third, Stephenson et al. describe tracheal intubation with AEB and ETT, threading the FOB through the AEB guide loop in situ, advancing the FOB into the desired mainstem bronchus, and deploying the AEB and guide loop over the FOB (5). Fourth, after intubating the trachea with AEB and ETT, Stephenson et al. describe their preferred method of using head movements and twisting the cuffed ETT to direct the AEB into the desired
of the endobronchial blocker into the left mainstem bronchus. The guide loop directs the AEB to the left side of the carina as it is advanced into position. For right mainstem placement, the loop is turned toward the right prior to advancement (not shown). © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
Copyright of Pediatric Anesthesia is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Tom G. Hansen1,2 Department of Anaesthesia and Intensive Care – Pediatric Section, Odense University Hospital, Odense C, Denmark 2 Clinical Institute – Anesthesiology, University of Southern Denmark, Odense C, Denmark Email: [email protected]
Conflicts of interest
1
No conflicts of interest declared.
doi:10.1111/pan.12632
References 1 Hansen TG, Pedersen JK, Henneberg SW et al. Academic performance in adolescence after inguinal hernia repair in infancy: a nationwide cohort study. Anesthesiology 2011; 114: 1076–1085. 2 Hansen TG, Pedersen JK, Henneberg SW et al. Educational outcome following pyloric stenosis repair before 3 months of age: a
nationwide cohort study. Pediatr Anesth 2013; 23: 883–890. 3 Hansen TG. Anesthesia-related neurotoxicity and the developing animal brain is not a significant problem in children. Pediatr Anesth 2015; 25: 65–72. 4 Warner DO, Flick RP. Effects of anesthesia and surgery on the developing brain: prob-
lem solved? Pediatr Anesth 2015; 25: 435– 436. 5 Hansen TG, Pedersen JK, Henneberg SW et al. Neurosurgical conditions and procedures in infancy are associated with mortality and academic performances in adolescence: a nationwide cohort study. Pediatr Anesth 2015; 25: 186–192.
It’s not about the endotracheal tube: reply to editorial on our paper “Endotracheal intubation in the pediatric emergency department” SIR—We thank Lerman, Sharma, and Heard for their valuable comments on our article, and agree that nonoperating room intubations, both in adults and in children, are in need of CPR (1). We also agree that minimum thresholds for proficiency at tracheal intubation should be established as a standard of care, and that a mean first pass success rate of 90% is too low. Furthermore, we feel that the aim of nonoperating room intubations should be zero iatrogenic harm. In response to the suggestion that the primary problem resulting in a high rate of adverse events during Emergency Department (ED) intubations relates to nonanesthetic trainees deficits in knowledge and procedural proficiency, we would like to highlight two points. Firstly, the adverse event rate observed in our study was independent of the specialty or seniority of the intubator. Anesthetic trainees had the same adverse event rate as nonanesthetic trainees. Secondly, none of the patients intubated in our ED over a 1-year period had difficult Cormack and Lehane grade laryngoscopy. The requirement for multiple intubation attempts and the high adverse event rate were due critical illness, not difficult airways. As such, we believe that improving the safety of nonoperating room intubations cannot be addressed entirely by focussing on the knowledge and procedural proficiency of the intubator, as suggested by Lerman et al. The “nontechnical” factors, such as teamwork, leadership and followership, communication, and avoid© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
ance of fixation are equally important, and require different training modalities. We have introduced a quality improvement program to improve the safety of nonoperating room intubations that includes a hospital-wide difficult intubation algorithm, clear pathways for airway escalation, standardized hospital-wide equipment available in all critical care areas using identical airway carts, and multidisciplinary education and training to address both the technical and nontechnical aspects of nonoperating room airway management. We recognize that no single educational tool has been shown to improve patient-centered airway outcomes (2). We aim to monitor our first pass success and adverse event rates to see if the afore-mentioned interventions improve the safety of nonoperating room intubations in our institution. Ethics approval Not applicable. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. 437
Correspondence
Elliot Long1,2,3, Stefan Sabato2,4 & Franz E. Babl1,2,3 Department of Emergency Medicine, Royal Children’s Hospital, Parkville, Vic., Australia 2 Murdoch Children’s Research Institute, Parkville, Vic., Australia 3 Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia 1
4
Department of Anaesthesia and Pain Management, The Royal Children’s Hospital, Parkville, Vic., Australia Email: [email protected] doi:10.1111/pan.12630
References 1 Lerman J, Sharma S, Heard C. Pediatric airway management in the emergency department: in urgent need of CPR. Pediatr Anesth 2014; 24: 1199–1203.
2 Kennedy CC, Cannon EK, Warner DO et al. Advanced airway management simulation training in medical education: a systematic
review and meta-analysis. Crit Care Med 2014; 42: 169–178.
Pediatric endobronchial blockers in infants: a refinement in technique SIR—The Arndt endobronchial blocker (AEB) (Cook Medical, Bloomington, IN) is commonly used to facilitate one-lung ventilation in pediatric patients (1–5). Extraluminal AEB placement is used in infants and small children because endotracheal tubes (ETT) with internal diameters less than 4.5 mm cannot simultaneously accommodate a pediatric fiber-optic bronchoscope (FOB) and 5 French AEB. Extraluminal placement has the added advantage of increasing the endotracheal cross-sectional area available for ventilation. Four strategies have been previously described for positioning of the extraluminal AEB into the desired mainstem bronchus. First, Hammer, et al. proposed intubating the desired mainstem bronchus with an ETT, placing a guidewire into the bronchus, exchanging the
(a)
(b)
(c)
(d)
Figure 1 (a) 5 French Arndt endobronchial blocker (AEB); (b) The AEB is prepared by making a sharp bend at the base of the monofilament guide loop; (c) for added rigidity, the bend may be made in the AEB itself; (d) An illustration of the fiber-optic view during placement
438
ETT for an AEB, reintubating the trachea, and checking final AEB position using a FOB through the ETT (1). Second, Bastien, et al. describe simultaneous intubation with AEB and ETT such that the AEB’s guide loop encircles the tip of the ETT, guidance of the FOB into the mainstem bronchus of choice, and deployment of the AEB and guide loop over the FOB (4). Third, Stephenson et al. describe tracheal intubation with AEB and ETT, threading the FOB through the AEB guide loop in situ, advancing the FOB into the desired mainstem bronchus, and deploying the AEB and guide loop over the FOB (5). Fourth, after intubating the trachea with AEB and ETT, Stephenson et al. describe their preferred method of using head movements and twisting the cuffed ETT to direct the AEB into the desired
of the endobronchial blocker into the left mainstem bronchus. The guide loop directs the AEB to the left side of the carina as it is advanced into position. For right mainstem placement, the loop is turned toward the right prior to advancement (not shown). © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 431–439
Copyright of Pediatric Anesthesia is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
