A & A Should Stay!

am the technical director of the anesthesia simulation lab at University Hospitals of Cleveland, and I read with interest Dr. Bacon’s recent “From the Crows Nest” (December 2007) regarding “ …ending a long-term relation with Anesthesia & Analgesia…” For what it is worth, I think that is silly! While perhaps narrow and selfish, I value the journal because it tends to feature material, more so than other journals, that I can use in creating high-fidelity crisis management scenarios in the lab (with SimMan and SimBaby). As a “Clinical Ph.D.,” I cannot “vote” on the issue, but I think that dissociation is silly!

Ronald L. Cechner, Clin. Ph.D.
Russell, Ohio

Algorithm ‘Help Box’

irway management is a major responsibility for the anesthesiologist. Difficulty with intubation and/or ventilation significantly contributes to morbidity and mortality with anesthesia. According to the ASA Closed Claims Project database, difficult intubation is the second most frequent primary damaging event leading to malpractice claims, with obesity representing 31 percent of the claims.¹ Furthermore, airway management issues account for more than 17 percent of precipitating events in obstetric malpractice issues.²

Practice guidelines systematically develop recommendations that assist the practioner in making health care decisions. Since the first “Practice Guidelines for Management of the Difficult Airway” adopted by ASA in 1992, the 2003 revisions provide a wider range of management techniques.^3,4

Emergency room and intensive care units also have difficult airway algorithms and emphasize the value of calling for early assistance and the importance of proper head position for ventilation and intubation.^5,6 However, the ASA Difficult Airway Algorithm does not rigorously address the need for either early calls for help or the value of optimal head position during difficult airway management.

Several articles in the general anesthesia literature promote the use of the head-elevated laryngoscopy position (HELP) to facilitate intubation in the obese patient.^7-9 Brodsky and others suggest that this position should be further defined in an effort to optimize successful intubation.^7-8 Placing the patient in a ramped position so that the pinna of the ear and the sternum are in the same horizontal plane (P-S line) has led to high rates of successful intubations and improved ventilation.¹⁰

Finally, the ASA algorithm states “...the anesthesiologist should have a pre-formulated strategy for extubation of the difficult airway.”4 The addition of blankets and other devices, such as an inflatable patient adjustment device,¹¹ can provide the proper head position for intubation as well as optimize airway management during and after extubation.

For the patient without serious neck injury, the aforementioned considerations suggest that the ASA Difficult Airway Algorithm should include a “Help Box” [see next page]. Prior to following the Difficult Airway Algorithm, the “Help Box” would serve as the entering focal point to the algorithmic cascade and encourage the search for early assistance and promote proper head position.

James M. Gayes, M.D.
Minnetonka, Minnesota

References:
1. Miller CG. Management of the difficult intubation in closed claims. ASA Newsl. 2000; 64(6):13-16,19.
2. Ross BK. ASA closed claims in obstetrics: Lessons learned. Anesth Clin N Am. 2003; 21:183-197.
3. Berry FA, et al. Practice Guidelines for Management of the Difficult Airway. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 1993; 78:597-602.
4. Practice Guidelines for Management of the Difficult Airway. Updated report by the ASA Task Force on Management of the Difficult Airway. Anesthesiology. 2003; 98:1269-1277.
5. Sakles JC, Laurin, FG, Rantapaa AA, et al. Airway management in the emergency department: One year study of 610 tracheal intubations. Ann Emerg Med. 1998, 31:325-332.
6. Lim MST, Hunt-Smith JJ. Difficult airway management in the intensive care unit: Practical guidelines. Crit Care and Resus. 2003; 5:43-52.
7. Brodsky JB. Physiological and anesthetic considerations in morbidly obese patients. Curr Rev Clin Anesth. 2006; 26(18):237-248.
8. Brodsky JB, Lemmens HJ, Brock, Utne JG. Anesthetic considerations for bariatric surgery: Proper positioning is important for laryngoscopy. Anesth & Alalg. 2002; 95:4793.
9. Levitan RM, Mechem CC, Ochroch EA, et al. Head elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003; 41:322-330.
10. Collins JS, Lemmons HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: A comparison of the “sniff” and “ramped” positions. Obes Surg. 2004; 14:1171-1175.
11. Nissen MD, Gayes JM. An inflatable multichambered upper body support for placement of the obese patient in the head-elevated laryngoscopy position: Anesth & Analg. 2007; 104: 1305-1306.

The views and opinions expressed in the “Letters to the Editor” are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. The Editor has the authority to accept or reject any letter submitted for publication. Personal correspondence to the Editor by letter or e-mail must be clearly indicated as “Not for Publication” by the sender. Letters must be signed (although name may be withheld on request) and are subject to editing and abridgment.