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SCOTT BEATTIE Toronto, Ontario, Canada TIMOTHY ANGELOTTI Alto,C. California SPalo IMON BODY Boston, Massachusetts ALAIN BORGEAT Switzerland RZurich, ICHARD BRULL Toronto, Ontario, Canada RICHARD BRULL JOHNToronto, F. BUTTERWORTH Ontario, Canada , IV Richmond, Virginia JOHN F. BUTTERWORTH, IV Richmond, Virginia KUMAR BUVANENDRAN Chicago, Illinois KUMAR BUVANENDRAN Chicago,C Illinois WILLIAM AMANN Boston, Massachusetts WILLIAM CAMANN Boston, MARKMassachusetts CHANEY Chicago, Illinois MARK CHANEY Chicago, Illinois JOSEPH P. C RAVERO Lebanon, New Hampshire MAY L. CHIN Washington, District of Columbia KENNETH DRASNER San Francisco, California

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GUEST EDITORS 2012 GUEST EDITORS 2014 STACIE DEINER JONAS JOHANSSON RNew ICHARD P. D UTTON GEORGEPennsylvania M. HALL York, New York Philadelphia,

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2014

ANESTHESIA & ANALGESIA

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The “Gold Standard” in Anesthesiology

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Abstracts of Posters Presented at the International Anesthesia Research Society IARS 2014 Annual Meeting Montréal, Canada May 17-20, 2014 Abstracts (by category): Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-1 – S-21 Ambulatory Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-22 – S-29 Anesthetic Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-30 – S-50 Cardiovascular Anesthesiology . . . . . . . . . . . . . . . . . . . . . . . .S-51 – S-79 Critical Care, Trauma and Resuscitation. . . . . . . . . . . . . . . . S-80 – S100 Economics, Education and Policy . . . . . . . . . . . . . . . . . . . .S-101 – S-127 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-128 – S-132 Neuroscience in Anesthesiology and Perioperative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-133 – S-181 Obstetric Anesthesiology. . . . . . . . . . . . . . . . . . . . . . . . . . .S-183 – S-194 Pain Mechanisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-195 – S-202 Pain Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-203 – S-215 Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-216 – S-254 Pediatric Anesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . .S-255 – S-273 Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-274 – S-297 Sleep Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S-298 – S-302 Technology, Computing and Simulation . . . . . . . . . . . . . . .S-303 – S-319 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-320

obtained, or if animal research is reported, the usual standards and guidelines for animal care have been followed. Material published in this supplement has not undergone review by the Editorial Board of Anesthesia and Analgesia. Any of the abstracts in this supplement may have been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive and format electronic submissions for publication in this supplement but has not reviewed each abstract for the purpose of textual error correction and is not liable in any way for any formatting, textual or grammatical error or inaccuracy.

©2014 by the International Anesthesia Research Society

Airway Management

ABSTRACTS

S-1

ANESTH ANALG 2014; 118; S-1 – S-319

S-1. EMERGENCY INTUBATION WITH VIDEOLARYNGOSCOPY: PRELIMINARY DATA OF A PROSPECTIVE, RANDOMIZED, MULTICENTER OUT-OFHOSPITAL TRIAL AUTHORS: S. Janssen1, F. Reifferscheid1, V. Doerges1, P. Knacke2, A. Callies3, E. Cavus1 AFFILIATION:1Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany, 2 Anaesthesiology and Intensive Care Medicine, Sana Clinics OstHolstein, Eutin, Germany, 3Anaesthesiology and Intensive Care Medicine, Klinikum Links der Weser, Bremen, Germany INTRODUCTION: Videolaryngoscopy may be a valuable technique for pre-hospital endotracheal intubation1. However, the performance of different videolaryngoscopic systems in this setting is unclear. The aim of the present study was to compare three new portable videolaryngoscopes, the A.P. Advance® (APA; VENNER Medical, Kiel, Germany), the C-MAC® PM (CM; Karl Storz, Tuttlingen, Germany), and the channeled-blade King Vision® (KV; King Systems, Noblesville, USA) for pre-hospital emergency endotracheal intubation (ClinicalTrials.gov NCT01635660). METHODS: Approval of the institutional review board was obtained. We report of 45 matched patients (15 for each device; age, median [range]: 65 [18-87]; 24 female), that had the need for prehospital emergency intubation, and that were treated by a physician introduced in the use of the devices. RESULTS: Most frequent indications for pre-hospital intubation were cardiopulmonary resuscitation in 9 cases, and trauma in 20 cases (including maxillo-facial trauma in 4 cases), respectively. Glottic visualization was comparable with all 3 devices (Best achievable Cormack-Lehane classes: I: APA 8, CM 7, KV 8; II: APA 5, CM 8, KV 4; III: APA 1, KV1; IV: APA 1). Median [range] time to successful intubation for the APA was 30 [10-135] seconds, for the CM 45 [20-90] seconds, and for the KV 70 [20-140] seconds. 73%, 67%, and 47%, respectively. Overall success for APA, CM, and KV was 100%, 100%, and 60%, respectively. Direct laryngoscopy for successful intubation after failed videolaryngoscopic attempts was necessary with the APA in 2 patients, and with the CM in 1 patient. In the KV group, 6 patients were intubated with a conventional Macintosh laryngoscope. CONCLUSION: A.P. Advance, C-MAC PM, and King Vision® showed comparable glottis visualization during pre-hospital emergency endotracheal intubation; however, intubation success rates in non-standardized, challenging conditions may vary between the different videolaryngoscopic devices. REFERENCE: Cavus E, et al. Emerg Med J. 2011;28:650-3.

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ABSTRACTS

S-2

ANESTH ANALG 2014; 118; S-1 – S-319

S-2. “THE PATIENT ACTUALLY LIKES IT!!”: A SIMPLE AND NO-EXTRA-COST TSE-ALLOTEH NASAL CPAP MASK/CIRCUIT FOR A MORBDLY OBESE PATIENT WITH OBSTRUCTIVE SLEEP APNEA UNDER MAC FOR IRRIGATION AND DEBRIDEMENT OF ANKLE ULCER AUTHORS: H. Skiff, C. W. Hunter, E. Pantin, R. Alloteh, S. Barsoum, C. Kloepping, J. Tse AFFILIATION: Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ INTRODUCTION: Patients under monitored anesthesia care (MAC) routinely receive intravenous (IV) sedation and O2. Oversedation or airway obstruction may cause severe desaturation, especially in obese patients with obstructive sleep apnea (OSA). These patients may use nocturnal continuous positive airway pressure (CPAP) or bi-level continuous positive airway pressure (BiPAP) machine. Under sedation, they may require frequent chinlift, jaw-thrust or insertion of a nasal airway. To avoid the risk of epistaxis when inserting a nasal airway, the TSE-Alloteh nasal CPAP mask/circuit has recently been shown to improve oxygenation in sedated OSA patients using existing anesthesia equipment1-4. We report a challenging case using this simple technique to improve oxygenation and comfort in a morbidly obese OSA patient under MAC. CASE REPORT: A 48 y/o morbidly obese man (5’10”, 141 kgs, Body Mass Index: 45 kg/m2) presented for irrigation and endotracheal intubation, status post tracheostomy several year prior, not restricted his mobility until recently, and OSA. He used a home BiPAP mask/machine (16/7 cm H2O). Because of his multiple comorbidities and severe peripheral neuropathy that made his wound insensible to pain, it was decided to proceed without local anesthesia or IV sedation. He was on nasal cannula (NC) O2 (2 L/ min) and his O2 saturation (Sat) was 95% while sitting upright. His oropharynx was pretreated with 5% lidocaine cream for possible while lying down with a foam wedge (30 degree incline). His O2 Sat decreased to 92% even with NC O2 (5L/min). He requested a BiPAP adult anesthesia breathing circuit, but felt more comfortable when his nose and secured with head straps to obtain a tight seal (Photo 1-3)1-4. It was connected to an adult breathing circuit attached to the anesthesia machine. Pressure-relief valve was adjusted to deliver CPAP (5 cm H2O) with a mixture (0.75 FiO2) of fresh O2 (5 L/min) and fresh air (2 L/min). The patient was happy with this nasal CPAP mask and gave consent for photography. He maintained spontaneous respiration and 100% O2 saturation throughout the procedure. He tolerated the procedure well without complication. CONCLUSION: This simple nasal CPAP mask/circuit takes 2-3 min to assemble using existing anesthesia equipment and machine. This patient actually liked this nasal CPAP mask much better than a facial CPAP mask. It improves oxygenation and proactively prevents desaturation in sedated obese patients with OSA1-4. It can also be used to deliver assisted nasal mask ventilation without interrupting the procedure1-4. This simple technique may improve patient safety at no extra cost. REFERENCES: 1. www.TSEMask.com; 2. SASM 3rd AM: P27, 35 & 43, Oct 10-11, 2013 3. ASA AM:MC536 & MC1100, Oct 12-16, 2013 4. NYSSA 67th PGA:MCC-7094, 7115, 7120, 7189, 7199 & 7203 Dec13-17, 2013

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ABSTRACTS

S-3

ANESTH ANALG 2014; 118; S-1 – S-319

S-3. DIVERSITY OF OUT-OF-OPERATING-ROOM INTUBATIONS AMONG RESIDENCY PROGRAMS IN THE UNITED STATES AUTHORS: P. Upadya, M. Conopio, J. Spaliaras, A. Padover, A. Krottapalli, S. Shodhan AFFILIATION:Anesthesiology, St. Joseph’s Regional Medical Center, Paterson, NJ INTRODUCTION: Preparation is vital for intubation. After anecdotal complaints of lack of adequate equipment and resident dissatisfaction with out-of-operating-room intubations, we sought to investigate resident concerns for patient safety. The unavailability situations. This study was undertaken to investigate the standard of equipment, medications and monitors available during out-ofoperating-room intubations. To understand how other anesthesia programs handle these situations, a survey was created to compare protocols from other hospitals. METHODS: An IRB approved survey was sent out to all ACGME Program coordinators were requested to forward the survey link to each anesthesia resident. This survey was created using the software, Survey Monkey (SurveyMonkey Inc., Portland, OR). software. The questionnaire consisted of 19 questions designed to evaluate how emergency out-of-operating-room intubations were logistically handled in each hospitals’ setting. RESULTS: Over a span of four months, 414 responses were collected. The majority of respondents (79.95%) were from a level 1 trauma center. The anesthesia department was primarily responsible for out-of-operating-room intubations (93.24%). Variations were noted among residents in the following categories: 1) Equipment: 70% bring their own equipment to the bedside versus bedside equipment available; 2) Emergency and Intubation Medications: 43% bring their own medications versus 43% available at bedside; 3) Bedside Monitoring Availability: EKG - 65.74%, BP 80.15%, SpO2 - 85.28%, ETCO2 - 21.02%; and 4) Maintenance of Intubation Equipment Responsibility: Floor RN - 10.53%, Anesthesia resident on call - 45.43%, Anesthesia attending - 2.22%, Central Supply - 16.34%, Other (anesthesia technician/CRNA/RT/ pharmacy) - 31.86%. Most importantly, respondents noted that lack of supplies was the cause of preventable morbidity in 13.47% of out-of-operating-room intubations. DISCUSSION: From this survey, it is evident that there is diversity among anesthesia programs in the United States, on how each handles out-of-operating-room intubations. This includes but is no limited to personnel responding to the intubation and bedside availability of equipment, medication and monitoring. Diversity is acceptable until patient safety is compromised. Therefore, it is feasible to consider establishing a universal airway management operating-room intubations.

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ABSTRACTS

S-4

ANESTH ANALG 2014; 118; S-1 – S-319

S-4.

METHODS: We enrolled 28 patients undergoing elective surgery

A PILOT STUDY TO EVALUATE A NOVEL TECHNIQUE FOR BAG MASK VENTILATION IN A PATIENT WITH ESTABLISHED CRITERIA FOR DIFFICULT MASK VENTILATION

Obstructive sleep apnea (OSA), mallampati 3 or 4, and mallampati 1 or 2 serving as controls. After the induction of general anesthesia but before intubation, the provider would ventilate the patient using an adult sized facemask. A preset tidal volume of 8cc/kg was delivered for 8 breaths for each technique. TV, peak airway pressures, HR and O2 saturation were recorded after each breath. The anesthesia providers were demonstrated the NS grip prior to induction.

AUTHORS: D. Grech, S. Patel, H. Israel, A. Bekker AFFILIATION: Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ INTRODUCTION: Masked ventilation is an essential skill that is practiced by virtually all medical professionals. It is a skill that when used correctly can save many lives. Traditionally, there are two main styles of mask ventilation, the one handed (the “C and

RESULTS: All the groups, except OSA, showed improvement, the novel technique when compared to the traditional C&E onehanded grip. The two handed technique, as expected, provided the largest tidal volumes when compared to the other two technqiues.

grip. With the one handed grip, there is a risk of air leak on the side opposite to the stabilizing hand. The two handed grip provides better protection against an air leak but requires another provider to actually deliver the tidal volumes. We are proposing a novel sub-

CONCLUSION: Our results show that the novel submandibular technique can prove to be a useful complement or alternative to the traditional one and two-handed techniques. Future studies can be undertaken to stratify the effectiveness of these techniques based on provider’s hand size, grip strength, gender, and training level.

adequate pressure on both sides of the mask and deliver adequate tidal volume using the other hand. The anesthesia provider (AP) will stand perpendicular to the long axis of the patient’s body, aligning the AP’s umbilicus to the patient’s mentum. Next, the AP will place

REFERENCES:

will be placed along the body of the right mandible. The AP will rotate clockwise at the hip while keeping their elbow against their body to lift the patient’s chin to 45 degrees. This rotational force adds strength to the chin lift maneuver. The AP will avoid pressing

Yentis SM: Predicting trouble in airway management. Anesthesiology 2006; 105:871-2.

to apply pressure to the left border of the facemask while the second and third digits will be used to apply pressure to the right border of the facemask.

Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly ventilation. Anesthesiology 2006; 105: 885-91

Danielle Hart, Robert Reardon, Christopher Ward, James Miner, Face Mask Ventilation: A Comparison of Three Techniques, The Journal of Emergency Medicine, Volume 44, Issue 5, May 2013, Pages 1028-1033

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ABSTRACTS

S-5

ANESTH ANALG 2014; 118; S-1 – S-319

S-5. WITHDRAWN.

©International Anesthesia Research Society. Unauthorized Use Prohibited.

ABSTRACTS

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S-6. NO-COST TSE “MASK” FOR PRE-OXYGENATION PRIOR TO RAPID SEQUENCE INDUCTION OF GENERAL ANESTHESIA IN A PATIENT WITH LARGE BOWEL OBSTRUCTION, PAINFUL NASOGASTRIC TUBE, ANXIETY AND CLAUSTROPHOBIA AUTHORS: J. Kim, S. Barsoum, N. Kumar, T. Mehta, S. Shah, C. W. Hunter, J. Tse AFFILIATION: Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ INTRODUCTION: Rapid sequence induction (RSI) of general anesthesia (GA) is routinely performed after preoxygenation in a patient who is claustrophobic and irritated by a nasogastric tube (NGT) with a face mask. A simple plastic bag was shown to improve oxygenation by transforming a nasal cannula (NC) to a face tent (TSE “Mask”) in sedated patients during various procedures1-3 and to improve oxygenation prior to perform RSI of GA for endotracheal intubation (ETI) in a combative trauma patient4. We report its use in improving preoxygenation in a patient with large bowel obstruction and claustrophobia. CASE REPORT: A 65 y/o, 5’2”, 128 lb, woman presented with large bowel obstruction for colonoscopy and subsequently for exploratory laparotomy 2 days later. She had diverticulosis, HTN, depression, anxiety and claustrophobia. GA with ETI was planned for colonoscopy due to distended abdomen with large bowel obstruction. She had pain and was very uncomfortable even with gentle manipulation of NGT during NGT suctioning. She anxiously requested not to use a face mask for preoxygenation because of extreme claustrophobia. After discussing the risks of inadequate preoxygenation, she agreed to preoxygenation with a NC and a clear plastic bag (TSE “Mask”) as described1-3. Her O2 saturation (Sat) increased from 98% to 100% after 4-5 min with TSE “Mask” and NC O2 4 L/min (Photo 1). RSI (with cricoid pressure) of GA was performed with 100 mg lidocaine, 150 mg propofol and 100 mg succinylcholine. ETI was quickly and easily accomplished with a video-laryngoscope (Photo 2-3). Her O2 Sat was 100% throughout. Anesthesia was maintained recovered without problem. Two days later, she was brought to OR for urgent exploratory laparotomy and Hartmann’s procedure. She was pleased to see the same attending anesthesiologist and requested to have a TSE “Mask” for preoxygenation and gave consent for photography. Her O2 Sat increased from 95% to 100% after 4-5 min preoxygenation with NC O2 with 100 mcg fentanyl, 80 mg lidocaine, 150 mg propofol and 60 mg recuronium. ETI was again quickly and easily accomplished with a video-laryngoscope (Photo 2-3). Her O2 Sat was 100% throughout. completed without complication. She was extubated awake in PACU without problem. She was discharged home after an uncomplicated postoperative course. CONCLUSIONS: This patient might not gain adequate preoxygenation with a face mask prior to RSI of GA due to extreme claustrophobia and an irritating NGT. She was very pleased and comfortable with a TSE “Mask” for preoxygenation. After preoxygenation with this technique for a few minutes, GA with RSI and ETI can be accomplished without desaturation. This simple face tent can be prepared in a few sec without additional cost and may improve patient comfort and safety. REFERENCES: 1. Anesth 107:A922, 2007 2. Anesth 102:484, 2005 3. www.TSEMask.com 4. IARS 2013 AM: CC141

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S-7. RANDOMIZED CONTROLLED TRIAL OF THE RIGID AND FLEXING LARYNGOSCOPE VERSUS THE FIBEROPTIC BRONCHOSCOPE FOR DIFFICULT AIRWAY MANAGEMENT AUTHORS: A.B. King1, B. D. Alvis2, C. Hughes1, M. Higgins3, D. Hester4 AFFILIATION: 1Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, 2Vanderbilt Medical Center, Nashville, TN, 3Anesthesiology, VUMC, Nashville, TN, 4 Anesthesiology, Vanderbilt University, Nashville, TN INTRODUCTION: endotracheal intubation. A comparative trial of these devices has not been performed.Methods: Adult surgical patients requiring with previous intubation were randomized to undergo endotracheal intubation with either the Rigid and Flexing Laryngoscope (RIFL) or the Flexible Fiberoptic Bronchoscope (FOB). Induction was performed in usual manner by anesthesiologists, and intubation The primary outcomes measured were successful intubation, time to successful intubation, and number of attempts requiring additional airway assist maneuvers. The lowest observed oxygen saturation and airway trauma were also recorded. Results: A total of 41 patients were enrolled, with 20 randomized to each group and 1 withdrawal. Intubation was successful in all patients with both shorter in the RIFL group compared to the FOB group (49 vs. 64 seconds; p=0.048). Airway assist maneuvers were required in 2 (10%) intubations with the RIFL compared to 16 (80%) intubations lowest oxygen saturation or airway trauma. CONCLUSION: airway assist maneuvers for successful endotracheal intubation compared to FOB when utilized by experienced providers in

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S-9.

A NOVEL AIRWAY RESCUE TECHNIQUE: CAMERA IN TUBE INTUBATION THROUGH A SUPRAGLOTTIC AIRWAY

WITHDRAWN.

AUTHORS: A. Craenen1, E. Koopman1, N. Eipe2, J. Huitink1 AFFILIATION: 1Anesthesiology, VU Medical Center, Amsterdam, Netherlands, 2Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada INTRODUCTION: Airway rescue techniques are of vital intubate- cannot oxygenate scenario1. Tracheal intubation with a camera in tube intubation (CITI) technique through a supraglottic device may offer easier and faster intubation2,3. Aim of the current study was to compare this novel technique with direct laryngoscopy METHODS: Review Board approval was obtained for this study in the simulation lab. A Laerdal SimMan™ manikin was placed in the lateral decubitus on a bean bag mattress - left- and subsequently participants- two 4th year registrars, two experienced consultants and one experienced nurse anesthetist were divided into sequential with a laryngoscope Macintosh blade 3 and this was followed by the second operator’s attempt with CITI- Igel [a VivaSight™ (ET View) 7.0 through an I-gel 5.0]. Times were recorded until visual the same VivaSight™ tube was used. Maximal time for intubation was set at 40 seconds. If the intubation took longer the intubation was scored as failed attempt. The intubation times were compared with a Mann-Whitney test (IBM SPSS 20.0). RESULTS: A total of 120 intubations (60 with a laryngoscope and 60 with the CITI I-gel technique) were performed. With laryngoscopy 56 attempts (93%) were successful within 40 s with the CITI I-gel technique we observed the same overall success rate (93%). The mean (SD) time to intubation with a laryngoscope was 10.1 (4.2) s and with the CITI I-gel combination 10.6 (4.1) s (p=0.243). In contrast to the consultants and nurse anesthetist, the registrars had a higher success rate using the CITI I-gel technique (100%) than with the conventional method (83%). Their intubation vs 12.8 (4.9) s (p=0.041). DISCUSSION: The use of a supraglottic airway is recommended as an adjunct to bag mask ventilation and it may be used to facilitate tracheal intubation4. This concept has not been previously formally evaluated or compared to laryngoscopy. Our study suggests that the I-gel may be a suitable conduit for intubation in the lateral position. Further the use of the tracheal tube with the embedded camera may increase the success of this technique. The difference between the trainees and the experienced with regards to success with the intubation through the I-gel both in time and attempts is also noteworthy. In conclusion, camera in tube intubation through a supraglottic airway is a fast technique for tracheal intubation of a REFERENCES: 1. Br J Anaesth. 2011;106:617-31. 2. Anaesthesia. 2013;68:74-8. 3. Br J Anaesth. 2005;95:715-8. 4. Emerg Med J. 2010; 27:860-3. 5. Anesth Analg. 2004;99:279-83.

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S-10. A NOVEL LARYNGOSCOPE MODIFICATION FOR FASCILITATING DIRECT LARNYGOSCOPY IN THE SMALL LAB RODENT AUTHORS: S. K. Puri, J. LI, J. Reyes, V. Le, M. Xiong, J. H. Ye, A. Bekker AFFILIATION: Department of Anesthesiology, Rutgers – New Jersey Medical School, Newark, NJ Introduction: Endotracheal intubation of the laboratory rat is for the small rodents’ airway. The standard Miller blade 0 is wider than maximum mouth opening for the rat. We have developed a custom made laryngoscope modeled from a Miller 0 blade. This instrument is more suitable for direct visualization of the cords in small animals. Moreover it causes minimal trauma to the airway. All animals intubated using this technique have recovered and were extubated uneventfully with no complications of airway trauma. METHODS: We used a standard pediatric Miller blade 0 with attached light source as a basis for this design. We then utilized a metal cutting saw to cut out one half of the width of the blade extending from the distal tip for approximately 2/3 of the entire length of the blade (Figure 1). The light source and the attachment site for the handle remained intact. The sides were sanded with sandpaper until no sharp fragments were felt and a smooth uniformed surface was present.

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Prior to intubation a peripheral IV was placed in the lateral tail vein. A bolus of IV medication was then given for anesthesia induction. The animal was then placed on a custom made adjustable intubating stand fashioned from a metal book holder. The rat was secured with clear tape wrapped around the extremities and the mouth was secured open with rubber bands that maintained gentle pressure on the incisors. Once the animal was secured and connected to BP and pulse ox the rat was positioned in a 45 angle. The tongue was gently retracted using forceps. The operator then performed direct laryngoscopy from behind head looking directly into the into the oropharynx and lift the epiglottis to allow for direct visualization of the vocal cords. Once intubation was complete, the blade was easily removed from the mouth. RESULTS: We successfully intubated 20 of 20 rats on the successfully extubated and recovered uneventfully with no evidence CONCLUSIONS: an effective tool for performing direct laryngoscopy and intubation in the small laboratory rat. This blade allows direct visualization of the vocal cords in small rodents. We were able to achieve 100% Miller 0 blade can help improve success of intubation for the lab rat and decrease the overall trauma associated with this procedure.

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S-11. LARYNGEAL MASK AIRWAY USE IN PATIENTS WITH ELEVATED BODY MASS INDEX, A RETROSPECTIVE REVIEW AUTHORS: C. Effertz, C. Burkle, M. Walsh AFFILIATION: Anesthesiology, Mayo Clinic, Rochester, MN Introduction: The laryngeal mask airway (LMA) was introduced in the early 1980’s, and has since become a mainstay in ambulatory anesthesia care. The LMA Unique™ is sized by weight with a maximum suggested limit of 100kg (size 5 LMA Unique™ package instructions). However, with additional provider experience and rising patient weights, the device has been pressed into use among an increasingly heavier group of individuals. Recent studies have also documented this trend.1,2,3 our retrospective study set out to analyze the success of LMA use among patients with elevated body mass index (BMI). We compared individuals with elevated BMI (>30kg/m2, >40kg/m2) with those of lower mass who were cared for in our ambulatory surgery center. METHODS: Following Institutional Review Board approval, electronic medical records of patients having LMAs (LMA Unique™) placed in our ASC between 7/07 and 11/12 were analyzed. The total number of LMAs placed over the study period, the weight (kg) and height (m) of each patient, whether the device required intra-operative exchange to EI, and rates of elevated end tidal CO2 (ETCO2), inspiratory airway pressure (PIP), decreased SpO2, aspiration and bronchospasm were measured. When assessing event marker differences between patient populations 2 2 vs >30kg/m2 vs >40kg/m2), p30kg/m2 m2); 583 (>40kg/m2)). (Tables 1, 2) Rates of exchange of LMA to EI were higher in the >30kg/m2 and >40kg/m2 cohorts (1.4% vs 0.6%; 2.2% vs 0.8% respectively p30kg/m2 and >40kg/m2 patient cohorts. (Tables 1, 2) Very few episodes of aspiration (n=3) and no episodes of bronchospasm were reported in any group. CONCLUSIONS: and effective use of the LMA in outpatient settings. Nearly 13,000 LMAs were placed in a 5 year period with less than a 1% requiring exchange to EI. Our results suggest that oxygenation and ventilation m2. Our study has the limitation of utilizing surrogate markers to would be required to establish whether these surrogate markers effective airway tool in the outpatient setting and that it may be used safely in larger patients when vigilantly monitored. REFERENCES: 1. Doyle DJ, et al. Airway management in a 980-lb patient: use of the Aintree intubation catheter. J Clin Anesth. 2007;19:367-369. 2. Natalini G, et al. Comparison of the standard laryngeal mask airway and ProSeal laryngeal mask airway in obese patients. Br J Anaesth. 2003;90(3):323-326. 3. Zoremba M, et al. Comparison between intubation and the laryngeal mask airway in moderately obese adults. Acta Anaesthesiol Scand. 2009;53:436-442.

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S-12. 3-DIMENSIONAL DIRECT LARYNGOSCOPY – A FEASIBILITY STUDY AUTHORS: J. M. Watkins-Pitchford AFFILIATION: Anesthesiology, Richmond VAMC, Richmond, VA INTRODUCTION: Conventional direct or video laryngoscopy depth. The normal inter-occular stereoscopic base is too wide for commercially available camera allows still and video stereoscopic layngoscopy, giving realistic images with true depth perception to aid instrumentation and diagnosis in the upper airway. METHODS: (Cyclopital3D Inc), and a +2D close-up meniscus (Neewer). The camera zoom was adjusted for minimal vignetting, and the camera stereo image offset was centered for subjectively easy viewing. rescuscitation training manikin, to view the vocal cords. The camera was then moved in place of the laryngoscopist’s eye, the Stereoscopic still or video images are captured easily. The camera “.mpo”-format (Multi Picture Object) images are displayed by the camera or a 3-D capable TV. The .mpo images are also split into left and right images of stereo pairs by software such as mposplit, or the author’s splitmpo.sh (International Stereoscopic Union). These split and generate stereo pairs from a single or for Holmes-type, cross-eyed, over-under, or red-cyan anaglyph RESULTS: Example images are a red-cyan anaglyph to be viewed with red-cyan glasses, and the same image presented as a “crooseye” stereo pair, best viewed without special equipment using a cross-eyed gaze to the opposite images until they perceptually fuse Proprotionate example geometry for a laryngoscope blade-mounted camera (see Conclusions): stereo base 10mm, stereo angle of convergence 8 degrees: Working distance - 0.5mm tan8 = 35mm or 1.4” CONCLUSIONS: Direct laryngoscopy and intubation requires manipulation in 3 dimensions, usually with only one eye, or a single video-laryngoscope camera. Stereoscopy restores visual depth. The Cyclopital prism reduces the stereoscopic optical base from a normal interoccular distance of 70mm to 25mm, allowing binoccular stereoscopy at short working distances from outside the mouth. However, if the stereo camera were to be placed in a conventional video laryngoscope blade, proportionate calculations of the geometry indicate a suitable optical base of only 10mm or less for the decreased wortking distance. We suggest this should make the construction of a practical stereo video laryngoscope enterely feasible, with commercially available 3D displays as found on current cell phones and game devices. REFERENCES: 1. International Stereo Union. (http://www.stereoscopy.com/isu/) for image processing software and stereoscopic geometry. 2. (http://cstein.kings.cam.ac.uk/~chris/mposplit/) An mpo splitting software.

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S-13. SIMULATION AS A SET-UP FOR TECHNICAL MASTERY: CAN A HIGH-FIDELITY VIRTUAL WARM-UP IMPROVE RESIDENT PERFORMANCE OF FIBEROPTIC INTUBATION? AUTHORS: S. T. Samuelson AFFILIATION: Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY BACKGROUND: Fiberoptic intubation (FOI) is an essential procedure for anesthesiology residents to master during training. However, FOI is an advanced technical skill with a steep learning curve, and traditional training may not enable novice practitioners to safely perform this procedure under pressure. Recently in the surgical literature, a virtual “warm-up” has been described to prime a practitioner’s skillset immediately before performing challenging procedures.1,2 This study examines whether a similar warm-up can improve resident performance of FOI in the operating room using speed and graded technical performance as benchmarks. METHODS: CA1 and CA2 anesthesiology residents were recruited to perform elective asleep oral FOI in the operating room. Residents in a warm-up cohort underwent a 5-minute guided exercise immediately prior to live FOI using a virtual bronchoscopy simulator, while those in the control cohort performed FOI without the warm-up. All subjects were timed achieving FOI and were graded on a 45-point validated skills scale by blinded observers. Previous resident FOI experience was determined by total number of FOI completed prior to sampling and time elapsed since the most recent attempt. To control for factors intrinsic to individuals (e.g. hand-eye coordination), all subjects completed a second FOI after a two-week washout period as a member of the opposite cohort. Mean scaled scores and times were calculated and multivariate analysis was performed to determine the effect of warm-up on time to achieve FOI and cumulative global skills score. RESULTS: 33 anesthesiology residents were recruited, of which 22 were CA1 residents and 11 were CA2s. On univariate analysis, warmup was associated with a 43% decrease in time to achieve FOI in CA1 residents (mean 60 vs. 34 sec) and a 17% decrease for CA2s (32 vs. 26 sec), and was associated with a 9-point increase in global skills score for CA1 residents (mean 31 vs. 40) and a 3-point increase for CA2s (mean 39 vs. 42). Controlling for experience and intrinsic factors, virtual warm-up conferred a 37% reduction in time to achieve FOI for CA1s (mean 35 vs. 57 sec, p3) and thyromental distance (

Abstracts of Posters presented at the 2014 Annual Meeting of the International Anesthesia Research Society Montréal, Canada May 17-20, 2014.

Abstracts of Posters presented at the 2014 Annual Meeting of the International Anesthesia Research Society Montréal, Canada May 17-20, 2014. - PDF Download Free
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