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Intubation with the Glidescope Cobalt AVL Intubation with the GlideScope Cobalt AVL Agnes Hunyady, MD Assistant Professor of Anesthesiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA Cheryl Gooden, MD, FAAP Associate Professor of Anesthesiology and Pediatrics Mount Sinai School of Medicine, New York, NY Choose baton and stat size per manual • Cobalt AVL Baton 1-2 (neonates and infants) – GVL 0 Stat: <1.5 kg – GVL 1 Stat: 1.5-3.6 kg – GVL 2 Stat: 3.6-10 kg • Cobalt AVL Baton 3-4 (children and adolescents) – GVL 3 Stat: 10 kg- adults – GVL 4 Stat: 40 kg- morbidly obese Get GlideScope Cobalt ready by Connecting video baton to monitor Turning the device on Inserting baton into stat GlideScope intubation 4-step technique 1. 1. MOUTH Looking directly into the patient’s mouth, with the device in the left hand, introduce the blade of the video laryngoscope into the oropharynx, gliding down along the midline of the tongue, without displacing it. GlideScope intubation 4-step technique 2. 2. SCREEN With the laryngoscope inserted, look at the monitor to identify the epiglottis, then manipulate the scope to get the best view of the glottis. GlideScope intubation 4-step technique 3. 3. MOUTH Look directly into the patient’s mouth – not at the screen – as you guide the distal tip of the ETT into position next to the tip of the blade, following the curve of the blade as close as possible GlideScope intubation 4-step technique 4. 4. SCREEN Look at the monitor to complete the intubation. Advance ETT and remove stylet • To aid the passage of the ETT, withdraw the stylet carefully while gently advancing the ETT. Slight withdrawal of the laryngoscope may be beneficial to allow a glottis to drop and reduce the viewing angle. Complications of videolaryngoscopy Complications of videolaryngoscopy • Most data from the use of GlideScope • Incidence was 1% (21/2004) in a large series of GS intubations1 • Case reports2,3,4 1. Aziz et al. Anesthesiology 2011 2. Hsu et al ActaAnesthesiol Taiwan 2008 3. Cooper Can J Anaesth 2007 4. Leong et al Anaesth Intensive Care 2008 Complications of videolaryngoscopy • Minor lip and gum laceration • Vocal cord trauma • Tracheal injury • Hypopharyngeal injury • Dental trauma • Tonsillar perforation • Palatoglossal arch injury • Palatopharyngeal wall perforation • Possible lingual nerve injury Maneuvers to avoid injury • Stylet (and ETT) should reproduce blade’s course • Keep ETT parallel and as close as possible to the blade • Visual control of ETT advancement 1. 2. 3. 4. 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' +8 %,,2&,@-&, @,)--@@ ,%, @,*0@C0,-+'=0-11-90 -+.0'1-,2:,2& 0<,%*1)'0:<G,'/8,2&'0G ,283,% 0<,%* '0:<',&'*0,C CQOPQAQQHQIBPUPGVC %,,2&,@-&, @:0)0@&&@<, @ %,,2&,@,01-, C 0,-+'1-+.0'1-,-2&'0G, ,'/8L',&'*0,G GQOPQ .AUVHXIBXVRGX %,,2&,@-&, @:0)0@-0-, @&&@-2&@8)&0(' @801&C 0,-+'=-+.0'1-,2:,2&+880G',2&'0G ,283,% 0<,%*'0:< -020&*',283-,',&'*0,C CQOPQAQQHPQIBPPXVGQOSC -921'1@'(- @20')0C'+.*@0*'*0.*+,2-.'*-2**--,1-0 90'2<-*','*1'283-,1C'20,12&CQOPO 8,AQOHUIBSXOGSC.8QOPO0PPC ! From: Heaf, D.P., Helms, P, Gordon, I., Turner, M., Postural Effects of Gas Exchange In Infants, NEJM; 1983 ' ' % Adapted From: Hammer, G.B., Fitzmaurice, B.G., Brodsky, J.B., Methods for Single Lung Ventilation in Pediatric Patients, Anesth Analg, 1999;89:1426-9 Hammer, G.B., Peditaric Thoracic Anesthesia, Anesthesia and Analgesia, 2001;92:6, 1449 #$ ! ! From: Lammers, C.R., Hammer, G.B., Brodsky, J.B., Cannon, W.B., Anesthesia and Analgesia, 1997;85:944-9 Pediatric Anesthesia 2005 15: 204–208 " ! From: Yun, E.S., Saulys, A., Popic, P.M., Arndt, G.A., Single-lung ventilation in a pediatric patient using a pediatric fibreoptically-directed wire-guided endobronchial blocker, Can J Anesth, 2002;49:3, 256-61 Selective Lobar Block Espi C, et. al., Arch Bronconeumol, 2007 Schmidt et. al. A and A 2005 This patient is a 4-year-old male who was transferred to your hospital because of persistent pneumonia and fever. Chest x-ray demonstrated a 7 cm opacification with an air-fluid level in the left posterior lung in the area of the left upper lobe. The cystic lesion was drained by a CT-guided aspiration, which was minimally therapeutic. The patient has been persistently febrile and is now scheduled for video assisted thoracic surgical decortication on the left side with left pleurodesis. Key Question: What are the options for intubation at this point including risks and benefits of each? The patient is intubated with a #5.0 uncuffed endotracheal tube. The surgeon then reminds you that he has requested single lung ventilation of the right lung for this case. Key Questions: Describe the various techniques for single lung ventilation that are available for this age group. What are the pros and cons for each? Is there any specific advantage to any given technique in this patient? Single lung ventilation is established with a bronchial blocker and confirmed by auscultation and by fiberoptic visualization. The patient is turned to the right lateral decubitus position. The surgeon inserts the thoracoscope through an incision on the left side of the chest at the 5th intercostal space and confirms absence of ventilation and proceeds with the decortication and pleurodesis. Shortly thereafter (within 10 minutes), the oxygen saturations drop to 92% with an inspired oxygen level of 50%. Key Questions: Describe the approach to hypoxia during single lung ventilation in children. What are the treatment options? Approximately 1 hour into the procedure with the chosen anesthetic technique and mechanical ventilation, the capnograph low CO2 alarm sounds. The oxygen saturation, blood pressure and pulse are all unchanged. The peak-inspiratory pressure has increased by 10 cmH2O and the tidal volumes have decreased significantly. Key Questions: What is the differential diagnosis? What is a reasonable plan of action? After you stabilize the patient the surgeon is able to complete the procedure with a total blood loss of 50ml. Key Questions: Describe a plan for emergence including analgesia and an approach to extubation. Would it differ if the patient required a thoracotomy? Fiberoptic intubation David M.
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