j p mulier md phd silent aspiration prevention in bariatric surgery j p mulier md phd sint jan...
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Silent aspiration prevention in bariatric surgery
J P Mulier MD PhDJ P Mulier MD PhD
Sint Jan Brugge-OostendeSint Jan Brugge-Oostende
www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier
1150 1850 1947 1977 2010
Sint Jan Brugge-OostendeSint Jan Brugge-Oostende
www.publicationslist.org/jan.mulierwww.publicationslist.org/jan.mulier
1150 1850 1947 1977 2010
The Negative Impact ofPost-Intubation Pulmonary
ComplicationsJ P Mulier MD PhDJ P Mulier MD PhD
JPMulier New York 13 dec 2009 3
The Negative Impact ofPost-Intubation Pulmonary
ComplicationsDoes it begin in the Operating Room?Does it begin in the Operating Room?
Silent aspiration prevention in bariatric surgery:A pilot study of new endotracheal tube technology
Jan-Paul Mulier, MD, PhD, Anesthesiologist, Critical Care Physician Chairman Anesthesiology, Sint Jan Brugge-Oostende President, European Society for Periopertive Care of the Obese
Patient Affiliated Researcher, Katholieke Universiteit Leuven
This program is not associated with or part of the 63rd PostGraduate Assembly in Anesthesiology.
Jan P Mulier received support from Covidien for giving this lecture.
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What are the What are the complications?complications?
Intubation trauma during insertionIntubation trauma during insertion Laryngeal trauma by tube or cuff Laryngeal trauma by tube or cuff Ventilation trauma by the ventilatorVentilation trauma by the ventilator
VILI: Ventilation induced lung injuryVILI: Ventilation induced lung injury BarotraumaBarotrauma VolutraumaVolutrauma
Ventilation induced lung diseaseVentilation induced lung disease VAP: Ventilation associated pneumoniaVAP: Ventilation associated pneumonia Long term changes in post op lung functionLong term changes in post op lung function
Surgery induced lung injurySurgery induced lung injury Anesthesia induced lung injuryAnesthesia induced lung injury Fluid therapy induced lung oedemaFluid therapy induced lung oedema
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> 60 years of intubation > 60 years of intubation expertiseexpertise
Improvements in intubation Improvements in intubation technology brought each time new technology brought each time new complications.complications. Use of an endotracheal tubeUse of an endotracheal tube Use of anesthesia and muscle relaxants Use of anesthesia and muscle relaxants
to intubateto intubate Use of an inflatable cuffUse of an inflatable cuff Use of a low pressure high volume cuffUse of a low pressure high volume cuff
New safety alerts, vigilance training, New safety alerts, vigilance training, but also inventions were needed but also inventions were needed each time.each time.
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Use of endotracheal Use of endotracheal tubestubes
What size?What size?
•Who to intubate?Who to intubate?
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Use of anesthesia and Use of anesthesia and muscle relaxantsmuscle relaxants
Non traumatic intubation Non traumatic intubation possiblepossiblebutbut
Aspiration risk at inductionAspiration risk at induction Hemodynamic collapsHemodynamic collaps
•Sellick maneuvre ?Sellick maneuvre ?•No food no liquid 24 hNo food no liquid 24 h•Gastric phGastric ph•Fluid therapyFluid therapy•Safer anestheticsSafer anesthetics•……
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Invention of a cuffInvention of a cuff
No leak of air with positive pressure No leak of air with positive pressure ventilationventilation
Size of tube might be smaller and is Size of tube might be smaller and is less criticalless critical
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But post intubation But post intubation stenosis…stenosis…
Question of Question of What tube size?What tube size?
became became What cuff pressure?What cuff pressure?
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Use of a high volume low Use of a high volume low pressure cuffpressure cuff
Low pressure possibleLow pressure possible No N20 or Pressure controlNo N20 or Pressure control Ischemia risk solved, butIschemia risk solved, but
New threatNew threat Silent aspirationSilent aspiration
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Silent aspiration due to leaks Silent aspiration due to leaks around cuffs of endotracheal tubes around cuffs of endotracheal tubes
Petring OUPetring OU Anesth Analg. Anesth Analg. 19861986 Jul;65(7):777 Jul;65(7):777 Methylene blue bronchoscopic test in Methylene blue bronchoscopic test in
patientspatients: Rüsch tube vs Mallinckrodt tube : Rüsch tube vs Mallinckrodt tube AspirationAspiration more frequent with the more frequent with the
Mallinckrodt tube than the Rüsch tubeMallinckrodt tube than the Rüsch tube
0
5
10
15
20
25
30
35
Leak percentage
RushMallinckrodt
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Leakage of fluid around high-Leakage of fluid around high-volume, low-pressure cuffsvolume, low-pressure cuffs
Asai TAsai T, Anaesthesia. , Anaesthesia. 20012001 Jan;56(1):38-42 Jan;56(1):38-42
A comparison of four A comparison of four (high-volume, (high-volume, low-pressure cuffs)low-pressure cuffs) tracheal tubes tracheal tubes in a in a modelmodel trachea and lung. trachea and lung. Large leakLarge leak::
Portex Profile, Mallinckrodt Lo-Contour Portex Profile, Mallinckrodt Lo-Contour Smaller leakSmaller leak::
Portex Soft Seal, and Mallinckrodt Hi-Lo Portex Soft Seal, and Mallinckrodt Hi-Lo tubes tubes
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Fluid leakage past 4 pediatric tube Fluid leakage past 4 pediatric tube cuffs: cuffs:
in in vitrovitro evaluation of the new Microcuff tube evaluation of the new Microcuff tube
Dullenkopf ADullenkopf A, , Intensive Care Med (2003) 29:1849 A: Mallinckrodt B: ICU, Portex Profile Soft Seal, Rusch C: Super Safety Clear, and Sheridan CF. D: HiLo, Microcuff HVLP
A, B, CA, B, C did did leakleak fluid at pressures above fluid at pressures above 1010
D:D: ultra-thin polyurethaneultra-thin polyurethane membrane membrane markedly improved tracheal sealingmarkedly improved tracheal sealing
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Effect of positive expiratory Effect of positive expiratory pressure and type of tracheal pressure and type of tracheal
cuff cuff on the incidence of aspiration in on the incidence of aspiration in
mechanically ventilated patients in mechanically ventilated patients in an intensive care unit. an intensive care unit.
Lucangelo ULucangelo U Crit Care Med. Crit Care Med. 20082008 Feb;36(2):409Feb;36(2):409
Hi-Lo (20 pt), vs SealGuard (20 pt) Hi-Lo (20 pt), vs SealGuard (20 pt) One hour after peep stop: One hour after peep stop:
Hi-Lo 100% leakHi-Lo 100% leak SG 70% leakSG 70% leak
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Silent aspiration Silent aspiration
Fluid in oral cavity can leak along Fluid in oral cavity can leak along tracheal cuff.tracheal cuff. Gastric contentGastric content BloodBlood Leak testLeak test
In vitro and in vivo test with In vitro and in vivo test with methylene blue have frequently methylene blue have frequently been positive: been positive: leakleak through the through the cuff plicacuff plica
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Does it all begin in the OR? Does it all begin in the OR?
InductionInduction Full stomach / gastric fluid pHFull stomach / gastric fluid pH Mask ventilation air in stomachMask ventilation air in stomach Difficult ventilation/intubation/nasal Difficult ventilation/intubation/nasal
intubationintubation Per operativePer operative
Oral blood from operation, nasal bleeding, Oral blood from operation, nasal bleeding, Leak test in RNYLeak test in RNY
Post operativePost operative Residual relaxation, post op sedation, not Residual relaxation, post op sedation, not
coughingcoughing Abdominal surgery risk groupAbdominal surgery risk group
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TaperguardTaperguard
A conical cuff with a large A conical cuff with a large diameter proximal and a small diameter proximal and a small diameter distaldiameter distal
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The obese patient is a challenge The obese patient is a challenge for anaesthesia for anaesthesia
if android shape with intra visceral if android shape with intra visceral fat.fat.
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Android versus Gynoid fat Android versus Gynoid fat distribution has a different distribution has a different
ElastanceElastance
Abdominal pressure volume relation: Android vs Gynoid
0
5
10
15
20
25
0 1 2 3 4
IAV Liter
IAP
mm
Hg
android
gynoid
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Two types of android Two types of android obesityobesity
Intra visceral adiposity Intra visceral adiposity Extra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and
intra abdominal fat is thick and intra abdominal fat is scant.intra abdominal fat is thick and intra abdominal fat is scant.
Subcutaneus FatSubcutaneus Fat Visceral fatVisceral fat
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Pulmonary complications 4x Pulmonary complications 4x higher in morbid obese patientshigher in morbid obese patients
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Clinical study compares cuff Clinical study compares cuff leak leak
Taperguard versus Taperguard versus PolyVinylChloridePolyVinylChloride::
Laparoscopic gastric bypass operationsLaparoscopic gastric bypass operations Orotracheal tube neededOrotracheal tube needed Methylene blue 300 ml in gastric pouch Methylene blue 300 ml in gastric pouch
with overflow in mouth at moment of leak with overflow in mouth at moment of leak testtest
Cuff leak tested with 10 ml methylene blueCuff leak tested with 10 ml methylene blue Ventilation VCV with 5 cm peepVentilation VCV with 5 cm peep
Man 8,0 OTT Woman 7,0 OTTMan 8,0 OTT Woman 7,0 OTT Group A: Hi contour MallinckrodtGroup A: Hi contour Mallinckrodt Group B: TaperGuard MallinckrodtGroup B: TaperGuard Mallinckrodt
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Study on per op preventionStudy on per op preventiontaperguard vs PVC OTT:taperguard vs PVC OTT:
Laparoscopic gastric bypass operationsLaparoscopic gastric bypass operations OTT neededOTT needed Methylene blue 300 ml in gastric pouch with Methylene blue 300 ml in gastric pouch with
overflow in mouth at moment of leak testoverflow in mouth at moment of leak test Risk for silent aspiration pneumonia?Risk for silent aspiration pneumonia? Ventilation VCV with 5 peepVentilation VCV with 5 peep
Man 8,0 OTT Woman 7,0 OTTMan 8,0 OTT Woman 7,0 OTT Group A: Hi contour Mallinckrodt dryGroup A: Hi contour Mallinckrodt dry Group B: Hi contour Mallinckrodt with gelGroup B: Hi contour Mallinckrodt with gel Group C: TaperGuard Mallinckrodt dryGroup C: TaperGuard Mallinckrodt dry
Black line above and below cuffBlack line above and below cuff
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Group A B CGroup A B C
A B CA B C
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Methods Methods
Automatic cuff pressure control.Automatic cuff pressure control. Set at 25 cmH20Set at 25 cmH20
2 ml methylene blue + 8 ml H20 2 ml methylene blue + 8 ml H20 injected above cuff.injected above cuff.
Bronchsocopic control after 5 Bronchsocopic control after 5 minutes.minutes. Blue fluid must be visible above cuff.Blue fluid must be visible above cuff. Blue visible below cuff, between Blue visible below cuff, between
trachea and tube?trachea and tube?
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In vitro testsIn vitro tests
A A B CB C
Runs throughRuns through stop on top stop on top runs & runs & stopstop
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Methylene blue testMethylene blue test
PVC 7,0 vs taperguard 7,0 at PVC 7,0 vs taperguard 7,0 at lower end cuff. Look upsidelower end cuff. Look upside
PVCPVCTaperguardTaperguard
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Impact of OTT size Impact of OTT size
Larger OTT more plica, deeper Larger OTT more plica, deeper run in run in
taperguard 7,0taperguard 7,0 taperguar 8,0taperguar 8,0
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PGA PGA posterposter
Total Number Total Number of patients: of patients: 4040
Human Methylene blue leakHuman Methylene blue leakObese patients, CMV 5 peep after 5 minutes when blue is Obese patients, CMV 5 peep after 5 minutes when blue is
visible above cuff 81 patientsvisible above cuff 81 patients
Bronchoscopic visualized methylene blue leak
0
5
10
15
20
25
30
35
Hi contour Mallinckrodt Hi contour Mallinckrodtwith KY gel
TaperGuard Mallinckrodt
nu
mb
er
of
pa
tie
nts
leakno leak
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Still a lot of QuestionsStill a lot of Questions
Is post operative pneumonia caused by Is post operative pneumonia caused by silent leakage?silent leakage?
Is fluid leakage dangerous?Is fluid leakage dangerous? Amount of fluid leak over what time?Amount of fluid leak over what time? Fluid type impact?Fluid type impact?
Gastric contentGastric content Oral bloodOral blood Leak test fluidsLeak test fluids
How long is gel protecting? Not possible How long is gel protecting? Not possible with NTT?with NTT? Impact of peep not sufficient?Impact of peep not sufficient?
Impact of tube movement?Impact of tube movement?
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Where can we reduce Where can we reduce silent aspiration?silent aspiration?
Oral bloodOral blood Oral pharyngeal surgery ( maxillo facial)Oral pharyngeal surgery ( maxillo facial) Nasal surgery ( septum surgery)Nasal surgery ( septum surgery) Naso gastric tube, oro trcheal tube, naso Naso gastric tube, oro trcheal tube, naso
tracheal tube inserted with bleedingtracheal tube inserted with bleeding Patient under heparines ( cardiac, vascular)Patient under heparines ( cardiac, vascular)
Gastric fluid in oral cavityGastric fluid in oral cavity Post induction regurgitation (urgent, obstruction)Post induction regurgitation (urgent, obstruction) Bad gastric drainage, gastroscopy, laparoscopy, Bad gastric drainage, gastroscopy, laparoscopy,
trendelenburgtrendelenburg Water/air injection for leakage testWater/air injection for leakage test
Esophagus, stomach, ( gastric bypass)Esophagus, stomach, ( gastric bypass)
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Attractiveness in WHR from 4000 BC until 2000 Attractiveness in WHR from 4000 BC until 2000 ACAC
1,5 1,1 1,5 0,5 0,7 1,5 1,1 1,5 0,5 0,7
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Intubation trauma during Intubation trauma during insertioninsertion
Teeth damage is one of the most freq Teeth damage is one of the most freq complications for anesthesiacomplications for anesthesia Broken teeth due to gaatjesBroken teeth due to gaatjes Loose teeth due to peridontitisLoose teeth due to peridontitis Glazuur damage of the front teethGlazuur damage of the front teeth
Teeth protection takes placeTeeth protection takes place Improving patient positioningImproving patient positioning bronchoscopic intubationbronchoscopic intubation
Nasal bleedingNasal bleeding Dyslocation of arytenoidsDyslocation of arytenoids Lip, tongue, eye contusion, cornea Lip, tongue, eye contusion, cornea
abrasionabrasion
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Foto of teeth in lungsFoto of teeth in lungs
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Laryngeal trauma by cuffLaryngeal trauma by cuff
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Laryngeal trauma by cuffLaryngeal trauma by cuff
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Ventilation trauma by the Ventilation trauma by the ventilatorventilator
Large tidal volume Large tidal volume overstretching of the lungsoverstretching of the lungs
Foto of rats lung traumaFoto of rats lung trauma
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Ventilation induced lung Ventilation induced lung diseasedisease
VAP: Ventilation associated VAP: Ventilation associated pneumoniapneumonia
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Long term changes in post Long term changes in post op lung functionop lung function
Decreased lung capacity and Decreased lung capacity and ESW after CABG has been provenESW after CABG has been proven
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Surgery induced lung Surgery induced lung injuryinjury
Stress reactionStress reaction
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Anesthesia induced lung Anesthesia induced lung injuryinjury
Fluid therapy induced lung Fluid therapy induced lung edemaedema
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What preventive What preventive measures?measures?
Correct tube, size and cuff designCorrect tube, size and cuff design Cuff pressure monitorCuff pressure monitor Video assisted laryngoscopyVideo assisted laryngoscopy Protective lung ventilationProtective lung ventilation Anti volutrauma valveAnti volutrauma valve Anti barotrauma O2 therapyAnti barotrauma O2 therapy Prevent silent aspiration pre per Prevent silent aspiration pre per
postpost Correct extubation technique and Correct extubation technique and
momentmoment
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Why do we not apply this Why do we not apply this knowledge every time?knowledge every time?
Do we think this does not happen Do we think this does not happen with my patient?with my patient?
This is too expensive to be worth?This is too expensive to be worth?
Other problems are still bigger?Other problems are still bigger?
Not evidence based?Not evidence based?
Always studies that tell opposite?Always studies that tell opposite?
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Does it begin in the OR?Does it begin in the OR?
YES becauseYES because you choose the product, you choose the product,
techniquetechnique Yes even Yes even if damage comes laterif damage comes later We do not notice it becauseWe do not notice it because different physician at the ICU, different physician at the ICU,
ward, is part of surgery, is normal…ward, is part of surgery, is normal… listen to them with an open mindlisten to them with an open mind
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President President
Jan P MulierJan P Mulier
Vice-President Vice-President
Yigal LeykinYigal Leykin
Secretary Secretary
Luc De baerdemaekerLuc De baerdemaekerTreasurer Treasurer
Nick KennedyNick Kennedy
www.publicationslsit.org/www.publicationslsit.org/ESPCOPESPCOP
www.espcop.org
ESPCOP ESPCOP founded feb founded feb
2009 2009
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Attend first ESPCOP meetingAttend first ESPCOP meeting14 nov 2009 Ostend Belgium14 nov 2009 Ostend Belgium
““The sea” from Georges GrardThe sea” from Georges Grard
Better known as Better known as
““fat Mathilde of Ostend”fat Mathilde of Ostend”