Correspondence
New pediatric airway devices, friends or foes? SIR—We commend Slinn et al. (1) for their recent article reviewing device cost-effectiveness in pediatric airway management. Although their title indicated a review of cost-effectiveness, it read more like a review of new devices with little discussion on actual comparative costs. The authors contend that mastery of Supraglottic Airway Devices (SADs) inevitably takes away from the maintenance of facemask ventilation. We disagree, and feel that achieving expertise in facemask ventilation and SAD use are not mutually exclusive. Facemask ventilation is a core foundation of airway management which can almost always be performed prior to SAD insertion. Many pediatric inductions are inhalational. Inhalational induction provides the ideal conditions to teach the skill and art of facemask ventilation as the patient transitions through the predictable stages of anesthesia. Learning expert facemask ventilation can occur while mastering SAD placement and troubleshooting. In summarizing the evidence supporting SAD use, the authors state, ‘the evidence for a SAD providing a better airway compared to a facemask is equivocal.’ This statement downplays the critical role SADs have played in saving the lives of infants and children who fail facemask ventilation. We would do a disservice to our patients if we neglected to teach SAD insertion and troubleshooting in favor of just facemask ventilation. If an anesthetist graduates from a training program without expert skill in facemask ventilation, this represents a failure in education and not a reflection of the use of SADs. Although the authors describe conventional direct laryngoscopy (DL) as ‘an easy psychomotor skill,’ our experience with teaching this technique and the published literature are not consistent with this statement. Conventional DL is difficult to learn and master; some studies demonstrate that it takes more than 50 attempts to become proficient (2). It is clear that clinicians with rare opportunities to practice DL perform it poorly which may result in complications. Combination videolaryngoscopes (videolaryngoscopes which mimic the shape of conventional laryngoscopes and allow conventional laryngoscopy as well), are the best tools for routine tracheal intubation, particularly in training institutions. They require fewer attempts to learn and allow conventional laryngoscopy with the option to use video if needed. In addition, they allow an instructor to guide a novice more effectively. One study showed that
648
video laryngoscopy improved subsequent conventional laryngoscopy when used by medical students (3). Another showed a decrease in the occurrence of esophageal intubation (4). An adult study in the emergency department demonstrated higher success with a videolaryngoscope with a Macintosh style blade than a conventional Macintosh laryngoscope (5). Although these were adult studies, our clinical experience also suggests that these combination videolaryngoscopes may be a better way to teach conventional laryngoscopy in children. The case may be even stronger for neonates and infants who have a narrow margin for error with imperfect technique. Decreasing tracheal intubation attempts and increasing safety is cost effective. As acquisition costs plummet, these devices are becoming more affordable and cost effective. The age of routine videolaryngoscopy is now upon us; the conventional laryngoscope may NOT rest easy as videolaryngoscopy is looming as the new standard. Ethics approval Not applicable. Funding The study was funded by departmental resources. Conflict of interest Narasimhan Jagannathan serves on the advisory board for Teleflex Medical. John E. Fiadjoe1, Narasimhan Jagannathan2, Patrick Olomu3 & Pete Kovatsis4 1 Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA 2 Department of Pediatric Anesthesia, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA 3 Department of Anesthesiology and Pain Management, Children’s Medical Center & University of Texas Southwestern Medical Center, Dallas, TX, USA 4 Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA Email: [email protected] doi:10.1111/pan.12651
© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 642–650
Correspondence
References 1 Slinn SJ, Froom SR, Stacey MRW et al. Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective? Pediatr Anesth 2015; 25: 20–26. 2 Konrad C, Sch€ upfer G, Wietlisbach M et al. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86: 635–659.
3 Herbstreit F, Fassbender P, Haberl H et al. Learning Endotracheal Intubation Using a Novel Videolaryngoscope Improves Intubation Skills of Medical Students. Anesth Analg 2011; 113: 586–590. 4 Howard-Quijano KJ, Huang YM, Matevosian R et al. Video-assisted instruction improves the success rate for tracheal intubation by novices. Br J Anaesth 2008; 101: 568–572.
5 Sakles JC, Mosier J, Chiu S et al. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med 2012; 60: 739–748.
The effect of prophylactic methylprednisolone need more evidences on postoperative outcomes SIR—We have read with respect the article by Theroux et al. (1) focusing on prophylactic methylprednisolone during one lung ventilation (OLV) to reduce inflammation and improve outcomes. This paper raises some interesting questions about the relationship between prophylactic methylprednisolone during OLV and the outcomes. We acknowledge this interesting and well-designed study, but from the point of surgery, also express our thoughts and concerns, especially about the potential effect of prophylactic methylprednisolone on postoperative outcomes. We indeed agree that glucocorticoids (GC), a class of steroid hormones, possess strong immunosuppressive and anti-inflammatory activity. GCs exert their effects by binding to the glucocorticoid receptor; ligand–receptor complexes, once inside the nucleus, modulate several DNA transcription factors. This leads to the upregulation of anti-inflammatory protein production and to a concomitant down-regulation of pro-inflammatory protein production (2). However, the decrease in inflammatory cytokines described in the article, such as IL-6, TNF-a, and IL-10, does not necessarily mean the improvement of clinical outcomes for the children, because many inflammatory cytokines, including IL-1 and IL-6, and TNF-a play important roles in wound healing and rehabilitation after acute injury (3). On the other hand, GCs are associated with many side effects, especially immunosuppression (and hence the increased risk of infection), growth suppression in children, and decelerated wound healing (2). In a randomized clinical trial, 40 neonates undergoing open-heart surgery, Keski-Nisula et al. (4) found that methylprednisolone significantly lowered concentrations of pro-inflammatory cytokines IL-6 and IL-8, and raised levels of anti-inflammatory IL-10, but no significant differences were observed in other clinical or physiological outcome © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 642–650
measurements. In a large cohort study on perioperative corticosteroids, the investigators evaluated outcomes across methylprednisolone regimens vs no steroids, and found no mortality or length-of-stay benefit associated with any regimen, but that there was a significant association between methylprednisolone use and postoperative infection consistent across all methylprednisolone regimens (5). Theroux et al. (1) focused mainly on inflammatory markers but failed to provide data on clinical outcomes between methylprednisolone and placebo group, including mortality, postoperative infection, length of stay, and wound healing. We would really appreciate if the investigators could provide information on this issue. We agree that the role of methylprednisolone in the reduction in inflammation needs to be investigated in larger prognostic data that are adequately powered to answer this important question. We suggested more attention be paid on clinical outcomes in related studies. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. 1
Yibo Li1, Yabing Zhang2, Yin Zhou1 & Yuan Li1 Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China 2 Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China Email: [email protected] doi:10.1111/pan.12662
649
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.
New pediatric airway devices, friends or foes? SIR—We commend Slinn et al. (1) for their recent article reviewing device cost-effectiveness in pediatric airway management. Although their title indicated a review of cost-effectiveness, it read more like a review of new devices with little discussion on actual comparative costs. The authors contend that mastery of Supraglottic Airway Devices (SADs) inevitably takes away from the maintenance of facemask ventilation. We disagree, and feel that achieving expertise in facemask ventilation and SAD use are not mutually exclusive. Facemask ventilation is a core foundation of airway management which can almost always be performed prior to SAD insertion. Many pediatric inductions are inhalational. Inhalational induction provides the ideal conditions to teach the skill and art of facemask ventilation as the patient transitions through the predictable stages of anesthesia. Learning expert facemask ventilation can occur while mastering SAD placement and troubleshooting. In summarizing the evidence supporting SAD use, the authors state, ‘the evidence for a SAD providing a better airway compared to a facemask is equivocal.’ This statement downplays the critical role SADs have played in saving the lives of infants and children who fail facemask ventilation. We would do a disservice to our patients if we neglected to teach SAD insertion and troubleshooting in favor of just facemask ventilation. If an anesthetist graduates from a training program without expert skill in facemask ventilation, this represents a failure in education and not a reflection of the use of SADs. Although the authors describe conventional direct laryngoscopy (DL) as ‘an easy psychomotor skill,’ our experience with teaching this technique and the published literature are not consistent with this statement. Conventional DL is difficult to learn and master; some studies demonstrate that it takes more than 50 attempts to become proficient (2). It is clear that clinicians with rare opportunities to practice DL perform it poorly which may result in complications. Combination videolaryngoscopes (videolaryngoscopes which mimic the shape of conventional laryngoscopes and allow conventional laryngoscopy as well), are the best tools for routine tracheal intubation, particularly in training institutions. They require fewer attempts to learn and allow conventional laryngoscopy with the option to use video if needed. In addition, they allow an instructor to guide a novice more effectively. One study showed that
648
video laryngoscopy improved subsequent conventional laryngoscopy when used by medical students (3). Another showed a decrease in the occurrence of esophageal intubation (4). An adult study in the emergency department demonstrated higher success with a videolaryngoscope with a Macintosh style blade than a conventional Macintosh laryngoscope (5). Although these were adult studies, our clinical experience also suggests that these combination videolaryngoscopes may be a better way to teach conventional laryngoscopy in children. The case may be even stronger for neonates and infants who have a narrow margin for error with imperfect technique. Decreasing tracheal intubation attempts and increasing safety is cost effective. As acquisition costs plummet, these devices are becoming more affordable and cost effective. The age of routine videolaryngoscopy is now upon us; the conventional laryngoscope may NOT rest easy as videolaryngoscopy is looming as the new standard. Ethics approval Not applicable. Funding The study was funded by departmental resources. Conflict of interest Narasimhan Jagannathan serves on the advisory board for Teleflex Medical. John E. Fiadjoe1, Narasimhan Jagannathan2, Patrick Olomu3 & Pete Kovatsis4 1 Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA 2 Department of Pediatric Anesthesia, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA 3 Department of Anesthesiology and Pain Management, Children’s Medical Center & University of Texas Southwestern Medical Center, Dallas, TX, USA 4 Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA Email: [email protected] doi:10.1111/pan.12651
© 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 642–650
Correspondence
References 1 Slinn SJ, Froom SR, Stacey MRW et al. Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective? Pediatr Anesth 2015; 25: 20–26. 2 Konrad C, Sch€ upfer G, Wietlisbach M et al. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86: 635–659.
3 Herbstreit F, Fassbender P, Haberl H et al. Learning Endotracheal Intubation Using a Novel Videolaryngoscope Improves Intubation Skills of Medical Students. Anesth Analg 2011; 113: 586–590. 4 Howard-Quijano KJ, Huang YM, Matevosian R et al. Video-assisted instruction improves the success rate for tracheal intubation by novices. Br J Anaesth 2008; 101: 568–572.
5 Sakles JC, Mosier J, Chiu S et al. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med 2012; 60: 739–748.
The effect of prophylactic methylprednisolone need more evidences on postoperative outcomes SIR—We have read with respect the article by Theroux et al. (1) focusing on prophylactic methylprednisolone during one lung ventilation (OLV) to reduce inflammation and improve outcomes. This paper raises some interesting questions about the relationship between prophylactic methylprednisolone during OLV and the outcomes. We acknowledge this interesting and well-designed study, but from the point of surgery, also express our thoughts and concerns, especially about the potential effect of prophylactic methylprednisolone on postoperative outcomes. We indeed agree that glucocorticoids (GC), a class of steroid hormones, possess strong immunosuppressive and anti-inflammatory activity. GCs exert their effects by binding to the glucocorticoid receptor; ligand–receptor complexes, once inside the nucleus, modulate several DNA transcription factors. This leads to the upregulation of anti-inflammatory protein production and to a concomitant down-regulation of pro-inflammatory protein production (2). However, the decrease in inflammatory cytokines described in the article, such as IL-6, TNF-a, and IL-10, does not necessarily mean the improvement of clinical outcomes for the children, because many inflammatory cytokines, including IL-1 and IL-6, and TNF-a play important roles in wound healing and rehabilitation after acute injury (3). On the other hand, GCs are associated with many side effects, especially immunosuppression (and hence the increased risk of infection), growth suppression in children, and decelerated wound healing (2). In a randomized clinical trial, 40 neonates undergoing open-heart surgery, Keski-Nisula et al. (4) found that methylprednisolone significantly lowered concentrations of pro-inflammatory cytokines IL-6 and IL-8, and raised levels of anti-inflammatory IL-10, but no significant differences were observed in other clinical or physiological outcome © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 642–650
measurements. In a large cohort study on perioperative corticosteroids, the investigators evaluated outcomes across methylprednisolone regimens vs no steroids, and found no mortality or length-of-stay benefit associated with any regimen, but that there was a significant association between methylprednisolone use and postoperative infection consistent across all methylprednisolone regimens (5). Theroux et al. (1) focused mainly on inflammatory markers but failed to provide data on clinical outcomes between methylprednisolone and placebo group, including mortality, postoperative infection, length of stay, and wound healing. We would really appreciate if the investigators could provide information on this issue. We agree that the role of methylprednisolone in the reduction in inflammation needs to be investigated in larger prognostic data that are adequately powered to answer this important question. We suggested more attention be paid on clinical outcomes in related studies. Funding The study received no external funding. Conflict of interest The authors report no conflict of interest. 1
Yibo Li1, Yabing Zhang2, Yin Zhou1 & Yuan Li1 Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China 2 Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China Email: [email protected] doi:10.1111/pan.12662
649
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.
