Intern Seminar – A 45 y/o male with PONV and sore throat history
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Intern Seminar – A 45 y/o male with PONV and sore throat history
Ri 林孟暐 , Ri 林蔚鑫
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Patient data
Age: 45 y/o Gender: male Chart number: 3988096 Ward: 11D-05-1
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Past history
Denied any systemic disease Denied any drug or food allergy Operation history: TUR-BT
(2002/07/26) (Difficult intubation, sore throat,
and PONV was noted at that time.) ASA class 2
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Diagnosis and operation method
Diagnosis: bladder cancer Operation method: radical
cystectomy
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Anesthesia course
Induction Robinul 0.3 mg Fentanyl 100 mg Pentothol 375 mg Tracrium 50 mg Intubation by “light wand” method
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Anesthesia course
Maintenance Isoflurane Tracrium Vitacal Lasix Operation time: 11:35~20:30
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Post-anethesia course PONV: grade 0 Sore throat: 0 Headache: 0 Post operation pain score: 7~8 Pain control by PCA
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Discussion: postoperative nausea and vomiting
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The emetic center is an ill-defined area located in the lateral reticular formation of the medulla.
It receives input from the chemoreceptor trigger zone, vestibular apparatus, cerebellum, solitary tract nucleus, and higher cortical center.
The receptor types include: dopamine, acetylcholine (muscarine), histamine, and serotonin receptors.
Anatomy and Physiology of Vomiting
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Anatomy and Physiology of Vomiting
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Incidence The incidence of PONV ranged from
75~80% during the ether era to approximately 9~43% over the past 40 years.
Presently, the overall incidence of PONV for all surgeries and patient populations is estimated to be 25~30%.
0.18% of all patients may experience intractable PONV.
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Risk Factors for PONV
Patient-related factors Factors related to anesthesia Factors related to surgery Factors
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Patient-related factors Young age Female gender Body weight History of PONV History of motion sickness Non-smoking Underlying disease: metabolic abnormalities (renal failure, uremia, DM…),
CNS pathology Psychological concerns and
preoperative anxiety
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Factors related to anesthesia (1)
Premedication opioids (morphine, fentanyl, alfentanil) Anesthetic gases N2O, halothane, enflurane, isoflurane, desflurane, s
evoflurane Intravenous anesthetic agents etomidate, ketamine
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Factors related to anesthesia (2)
Reversal of muscle relaxation Preoperative fasting Others long anesthesia, regional anesthesia,
postoperative pain, orthostatic hypotension
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Factors related to surgery
Strabismus surgery Ear surgery Laparoscopy Orchiopexy Ovum retrieval tonsillectomy
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Anesthesia method: IVG Difficult intubation -> face mask Anesthesia drugs: propofol, fentanyl 1
50mg, ketamine 25mg Operation time: am 8:30~ am 8:55 Operation method: TUR-BT
Previous anesthesia course of this patient
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Risk factor of this patient
Patient-related factors nonsmoker Factors related to anesthesia opioid, ketamine Factors related to surgery TUR-BT induced electrolyte imbalance
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Dopamine antagonists: droperidol Anticholinergics: scopolamine Antihistamines: cyclizine Serotonin antagonists: ondansetron,
dolasetron, granisetron
Antiemetic medications
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Guiedlines for prophylactic antiemetic therapyPost operative nausea and vomiting – can it be
eliminated? JAMA, March 13, 2002-Vol 287, No. 10
Patient FactorsFemale Sex
History of PONV or Motion Sickness
NonsmokerPostoperative Opoid Use
Surgical FactorsLaparoscopyLaparotomy
Plastic SurgeryMajor Breast Surgery
CraniotomyOtolaryngologic Procedures
Strabismus Surgery
Mild to Moderate Risk (20~40%)1~2 Factors Present
Any 1 of the Following:Droperidol, Dexamethasone
Scopolamine, Serotonin Antagonist
Moderate to High Risk (40~80%)3~4 Factors Present
Droperidol Plus Serotonin Antagonist
OrDexamethasone PlusSerotonin Antagonist
Very High Risk (>80%)4 Factors Present
Combination AntiemeticsPlus
Total IV Anesthesia With Propofol
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Difficult airway: algorithm
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Lighted Stylet Tracheal Intubation: A Review
Anesthesia and analgesia Volume 90(3)
March 2000 pp 745-756
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The upper “glow” shows a well defined circle of light just below the hyoid and above the thyroid cartilage in the midline indicating an ideal position for passing the tip of the endotracheal tube between the vocal cords. From this point, the tube should be advanced easily off the stylet and into the trachea where its position will be confirmed by a cone-shaped light above the suprasternal notch (lower “glow).
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The glow demonstrated just as the lighted stylet passes the vocal cords. The initial circle of light just above the thyroid cartilage may change to a cone of light projecting caudally toward the suprasternal notch.
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Learning the techniques (1)
Lighted stylet tracheal intubation requires practice, but is easily learned
Ellis et al: first 25 attempts: 42 seconds 2nd 25 attempts: 32 seconds all were successful by the 3rd attempt
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Learning the techniques (2)
Fisher and Tunkel :- 125 children (mean age three years)- intubated by anesthesia residents with little or
no lighted stylet experience- overall success rate of 83% and a 76% success
rate in infants weighing <10 kg- Failures: 1. too large a tracheal tube was chosen 2. persistent vallecular or esophageal entry
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Prediction of Ease of Intubation Ainsworth and Howells : 200 patients 87.5% : successfully intubated on the first attempt by using a lighted stylet 99%: tracheally intubated within three attempts Hung et al: 950 patients no correlation between the time to intubate and a
ny of the airway prediction variables, such as the Mallampati score and the circumference of the neck
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Sympathetic Stimulation During Intubation Laryngoscopy and endotracheal intubation are bot
h intensely stimulating procedures and are associated with varying degrees of sympathetic activity which may be detrimental in patients with coexisting conditions, such as coronary artery disease, elevated intracranial pressure, and asthma.
Results from 3 studies: No significant difference bewteen DL and lightwa
nt lighted stylet tracheal intubation, if performed in the same time as direct laryngoscopy, should not incur greater hemodynamic instability
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Complications and Safety Friedman et al. : - The lightwand group had a significantly lower incidence of sore throat, hoarseness, and dysphagia. - Also, hoarseness and sore throat are less severe.• Hung et al.’s large comparative trial: A significantly lower incidence of traumatic events and
fewer postoperative sore throats in the lighted stylet group
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The Possibility of Heat Damage Nishiyama et al. : a cat model - Temperature at the tip of the Trachlight™ : 55° ± 6°C at the time of the first blink 103° ± 10°C after 10 blinks (250 seconds in total.) - No macroscopic signs of burn injuries in any of the cats. - Histologically: moderate neutrophil and lymphocyte infiltration in both the Trachlight™ and the control specimens, but no significant differences between the two sides. - These findings suggest that there is little risk of burn injury from the clinical use of the Trachlight™
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Lighted Stylet Compared with Direct Laryngoscopy
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Indications (1) The difficult airway is possibly the most common in
dication for the use of the lighted stylet Reasons: (1) the ability of a lighted stylet to negotiate acute oropharynx-tracheal angles, particularly in situations in which neck mobility is limited or contraindicated (2) secretions are not an impedance as they can be in direct or fiberoptic laryngoscopy
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Indications (2) Difficult or impossible direct laryngoscopic intubation in cases of: - Congenital abnormalities of upper airway( Treacher-Collins syndrome, Pierre-Robin syndrome, etc) - Acquired abnormalities of the upper airway( trauma, etc) - Limited mandubular protusion - Short thyromental distance - Short neck - High Mallampati grade - secretions or blood in the oropharynx Patients with fixed dental appliances
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Adult Difficult Airways Hung et al : 265 patients anticipated difficulty unexpected difficult intubations - In all but two patients, tracheal intubation w
as successful with the Trachlight™, the vast majority on the first attempt.
- The failures were patients who were grossly obese.
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Pediatric Difficult Airways
Holzman et al. : 31 patients with either known or anticipated difficult endotracheal intubations
27/31 : aged 5–17 years. In all but one case, the trachea was in
tubated by using a lighted stylet in an average of 30–60 seconds
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The Emergency Setting (1) Cervical spine injuries present a particular c
hallenge for airway management, for the airway is likely to be obscured with blood and secretions, and the neck cannot be flexed nor the head extended to aid laryngoscopy. Lighted stylets may be useful under these circumstances, but should not be used if there is suspicion of a fracture of the larynx
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The Emergency Setting (2) Weis claimed a 100% success rate in securing
the airway by using lighted stylet intubation in 28 cervical spine cases
the use of lighted stylet intubation: (1) not influenced by blood in the airway (2) allowed administration of cricoid pressure (3) kept the cervical spine in the neutral position
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Limitations
No visualization of pharyngeal and laryngeal structures
Suboptimal transillumination in grossly obese patients or in patients with limited neck extension
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Difficulties Difficulties in controlling the tip of the devic
e in case of accidental partial withdrawal of the stylet
Unintentional switching off of the light while withdrawing the mental stylet
Difficulties in withdrawing the mental stylet Disturbing effects of the blinking light after
30 seconds from switching on
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Contraindications few absolute contraindications : the presence of an upper airway
foreign body, tumor, polyp, retropharyngeal abscess, or other friable tissue along the intubation course
A trauma victim who may have sustained laryngeal injury should have direct visualization rather than blind intubation
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Relative contraindications Some consider a known difficult airway and
a planned fiberoptic approach to be a relative contraindication, because a blind lightwand intubation attempt might cause bleeding which could make subsequent fiberoptic visualization of the larynx difficult
Obesity Short neck Limited neck extension Awake and/or uncooperative patients
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Complications there have been very few reported complic
ations two reported incidents of instrument disar
ticulation Trauma to the upper airway after lighted st
ylet intubation is generally of a minor nature and includes bleeding, sore throat, hoarseness, and dysphagia
two reported cases of arytenoid cartilage dislocation
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Conclusion (1) Useful in both oral and nasal intubation fort
patients with difficult airways. Also useful in emergency sitautions or when
direct laryngoscopy and fiberoptic endoscopy is not effective
Can be used in conjunction with other devices (LMA, intubating LMA, DL)
Should be avoided in patients with tumors, infections, trauma or foreign body in the upper airway
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Conclusion (2) a simple technique that is easily learned valuable if tracheal intubation by using direct
laryngoscopy is impossible. At worst, the technique is as good as tradition
al laryngoscopy; at best and in experienced hands, it is quicker, more reliable, and better tolerated by the patient.
With the right choice of stylet, it can be used for all sizes of patients and will not significantly increase department costs. It should be available in all anesthetic departments and taught to all trainees.
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Thanks for your attention!!