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Item Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position(Springer, 2016) Turner, Joseph S.; Ellender, Timothy J.; Okonkwo, Enola R.; Stepsis, Tyler M.; Stevens, Andrew C.; Eddy, Christopher S.; Sembroski, Erik G.; Perkins, Anthony J.; Cooper, Dylan D.; Department of Emergency Medicine, IU School of MedicineThere are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack–Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack–Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.Item Difficult Airway Algorithm in a Patient with Stridor and Significant Airway Edema Upon Extubating(2022-09-17) Garcia, Jennifer; Conrad, David J.INTRODUCTION: The difficult airway algorithm established by the American Society of Anesthesiologists (ASA) provides a set of guidelines for anesthesiologists to follow even before a patient is brought into the operating room. It begins with a physical exam evaluation of the airway in the preoperative period and the performance of a risk assessment with the available patient information. Although adequate preoperative evaluation can be presented and a difficult airway may not be expected, there are cases where an unanticipated difficult airway is encountered. Being prepared for such cases with the difficult airway algorithm in mind is crucial. The algorithm suggests beginning with bag mask ventilation and if failed, attempting placement and ventilation with a supraglottic airway. If this attempt fails, intubation can be attempted and lastly an emergency airway such as a cricothyrotomy or tracheotomy.1 CASE DESCRIPTION: A 60-year-old male ASA class 3 with a past medical history of a cerebellopontine angle (CPA) tumor, post-resection, presented for a palatoplasty for residual dysphonia and aspiration. After his initial CPA tumor resection, the patient had difficulty with airway management and a tracheotomy was performed. The tracheotomy had been removed prior to presentation for this procedure. On pre-operative assessment, the patient was a Mallampati class 2, and his airway exam was unremarkable. On induction, the patient received 200mg propofol and 100mg rocuronium for paralysis. The patient was an easy bag mask ventilation. A McGrath Mac 3 was used and with a Cormack-Lehane grade 2b view, a size 6.0 endotracheal tube (ETT) was placed. Anesthesia was maintained with sevoflurane. The patient remained hemodynamically stable throughout the case and no issues with extubation were expected; however, the patient was stridorous after extubation. Transnasal laryngoscopy revealed an edematous airway with significant supraglottic edema. The supraglottic obstruction was caused by manipulation during the surgery. The patient’s oxygen saturation began dropping. Bag mask ventilation with placement of an oral airway was unsuccessful. Laryngeal mask airway placement was attempted and unsuccessful. Video laryngoscopy was then attempted and showed edema and bleeding, leading to an unsuccessful reintubation. The decision was then made to perform an emergent tracheostomy to secure the airway. DISCUSSION: Maintaining a secure airway to assure adequate oxygenation and ventilation of a patient is of utmost importance. Anticipating difficulties with airway management is critical before bringing a patient back in to the operating room. Keeping the difficult airway algorithm in mind, even when a patient’s pre-operative airway assessment does not have features indicative of a difficult bag mask ventilation or intubation, is crucial. REFERENCES: 1. Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O’Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung; 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 2. Rosenberg MB, Phero JC. Airway Assessment for Office Sedation/Anesthesia. Anesth Prog. 2015 Summer;62(2):74-80; quiz 80-1. doi: 10.2344/0003-3006-62.2.74. PMID: 26061578; PMCID: PMC4462705.Item A Simulation Case of Cricothyrotomy in an Acute Upper GI Bleed(2022-04-28) Yu, Corinna; Rigueiro, Frank; Backfish-White, Kevin; Boyer, TannaIntroduction: Although difficult airway management is an expected skill of anesthesiologists, there is no mandatory training focused on this skill set in anesthesiology residency programs. Difficult airways are taught when the clinical situation arises, leading to variable resident expertise. Formal instruction in cricothyrotomy is lacking and the procedure is clinically rare. This lack of training has led to a rise in fellowship programs in airway management, demonstrating the need for greater attention to this skill set. Procedural times for cricothyrotomy improve after educational interventions, providing further evidence to support formal instruction in invasive airway management training. Patients presenting for upper endoscopies are considered full stomach due to the bleeding, and endotracheal intubation is preferred over sedation to prevent aspiration. These airways can be challenging to manage and may require surgical intervention as a last resort. We created a difficult airway simulation scenario to teach residents cricothyrotomy. Objective: To teach anesthesiology residents how to perform a cricothyrotomy and improve their confidence in difficult airway management. Methods: A patient presents with an acute gastrointestinal bleed for an upper endoscopy. A pressurized bag of red fluid was hidden out of view with tubing placed into the SimMan’s posterior oropharynx. Anesthesiology residents obtain the history from the patient when the patient coughs vigorously and its mouth fills with simulated blood. Residents attempt intubation, which is difficult if not impossible on this SimMan. When they communicate their decision for surgical intervention, a secondary mannequin was provided to perform the actual cricothyrotomy. At the end of the simulation, a behavior checklist is used for evaluation and the residents are asked to complete a simulation feedback form. Results: 26 PGY-4 anesthesiology residents completed the simulation from April-May in 2019 with 25 residents providing feedback with a 5-point Likert scale of agreement. Most residents quickly recognized the patient’s need for emergency intubation. 16 residents had prior experience managing the airway in an acute upper GI bleed (average 3 patients) whereas 9 residents reported no prior experience. 88% of participants strongly agreed that the simulation was a valuable learning experience with 92% stating it increased their confidence and clinical decision making in handling similar scenarios in the future. In addition, there were no negative scores to any of the survey questions. Discussion: Difficult airway skills include management of a patient with an upper gastrointestinal bleed requiring surgical cricothyrotomy. This is a valuable skill that can be taught with simulation. Our simulation led to an increase in resident confidence in the procedure, but it would be useful to follow up with the cohort and see if these skills prepared them for patient encounters afterwards and if the learning was sustainable. Conclusion: Our simulation case was a valuable learning experience for residents and provided critical surgical skills for future anesthesiologists in difficult airway management. It is worthwhile to include this simulation in the anesthesiology resident curriculum.Item Unanticipated Difficult Intubation In An Adult Patient(StatPearls Publishing, 2022) Traylor, Beth Ann; McCutchan, Amy; Anesthesia, School of Medicine