Faculty Bibliography

BACKGROUND:The use of intraoperative carbon dioxide (CO(2)) colonoscopy during a laparoscopic colon operation is becoming more common. Simultaneous intracolonic and intraabdominal CO(2) insufflation may result in significant physiologic changes, but in-depth physiologic effects have not been studied to date. This study aimed to evaluate the physiologic changes and the overall safety of simultaneous CO(2) laparoscopy and colonoscopy. METHODS:A prospective pilot study was performed with 26 subjects (17 men and 9 women) undergoing laparoscopic surgical treatment for colorectal conditions adjunctively managed with CO(2) intraoperative colonoscopy. Surgery proceeded with CO(2) insufflation to a maximum pressure of 12 mmHg by laparoscopy and with a maximum CO(2) flow of 5 l/min via colonoscopy. Serial intra- and postoperative arterial blood gases, end-tidal CO(2), and minute ventilation were recorded during predetermined periods: during initial laparoscopy, during simultaneous colonoscopy and laparoscopy, during laparoscopy after colonoscopy, and after desufflation. RESULTS:No significant morbidity resulted from simultaneous CO(2) insufflation. Three patients had a CO(2) partial pressure (PaCO(2)) greater than 50, and one patient with a body mass index (BMI) higher than 42 kg/m(2) had a PaCO(2) greater than 50 for more than 30 min and was compensated by increasing minute ventilation. The mean pH was 7.36 in the recovery room. Postoperatively, no patient had a pH lower than 7.3, prolonged intubation, or reintubation. CONCLUSION/CONCLUSIONS:Simultaneous CO(2) colonoscopy and laparoscopy lead only to transient alterations in respiratory parameters that can be compensated. Based on these findings, simultaneous insufflation of CO(2) into the peritoneal cavity and the large bowel lumen during complex endoscopic procedures may be considered safe for most patients.

OBJECTIVE: To assess the skills of anesthesiologists in the interpretation of chest radiographs. DESIGN: Randomized evaluation conducted among anesthesiologists and radiologists. SETTING: Postgraduate Assembly of the New York State Society of Anesthesiologists in 1999, and the Department of Radiology, New York University Medical Center. PARTICIPANTS: A total of 61 anesthesiologists (48 attending physicians; 13 residents); control group of 8 radiology residents (all participants volunteered). INTERVENTIONS: After completing a demographic survey, participants were asked to review a series of 10 chest radiographs. A brief clinical scenario accompanied each radiograph. No time limit was set for these interpretations. Measurements and Main Results: The demographic characteristics of the anesthesiology participants included university faculty (46%), private group practitioners (41%), independent practitioners (11%), and 1 participant with an unspecified type of practice. Additional training among the participants included internal medicine (31%), surgery (19%), and pediatrics (3%); 34% did not specify any additional training. Of the participants, 92% were involved in cases requiring general anesthesia; 96% managed patients in the recovery room; and 34% managed patients in the intensive care unit. Of participants, 80% usually order chest radiographs, but only 42% interpret the films themselves. Misdiagnosed radiographs included pneumothorax by 11% of participants, free air under the diaphragm by 41%, bronchial perforation from a nasogastric tube by 28%, right mainstem intubation by 20%, superior vena cava perforation from a central venous catheter by 31%, normal film by 75%, negative pressure pulmonary edema by 16%, left lower lobe collapse by 80%, pulmonary infarction from a pulmonary artery catheter by 29%, and tension pneumothorax by 41%. Overall scores of the attending physicians were not significantly different from that of residents (p > 0.05). The control group of radiology residents scored significantly better (mean, 83.7; p = 0.009) than the anesthesia residents (mean, 62.8) and anesthesia attending physicians (mean, 62.5). CONCLUSION: Anesthesiologists are deficient in skills for the interpretation of chest radiographs. The skill level of university-based physicians is not greater than physicians in private practice, and skill level does not improve with level of training or experience. Most anesthesiologists rely on radiologists for interpretative results. Further training during the residency years may help improve diagnostic skills

In a randomized, prospective pilot study, we compared awake blind orotracheal intubation using the intubating laryngeal mask airway (blind-ILM) with awake fibreoptic-guided orotracheal intubation using an Ovassapian airway (FOS-OA). Fifty-four patients (ASA 1 to 3, aged 18 to 85 years) requiring awake intubation for elective surgery were randomly allocated by coin toss into two groups: 31 patients were intubated blindly through the ILM (blind-ILM) and 23 were intubated using fibreoptic guidance through the Ovassapian airway (FOS-OA). Sedation to a target clinical end-point (spontaneous eye-closing, but responsive to verbal command) was obtained with fentanyl/midazolam and a cricothyroid puncture was performed with 3 ml lignocaine 4%. The oropharynx was then topicalized until tolerance of a Guedel airway was achieved. The number of failed attempts (maximum of three allowed), overall success rates, the time from insertion of the airway to capnographic (blind-ILM) or fibreoptic (FOS-OA) confirmation of intubation or until three failed attempts, and cardiovascular responses before and during intubation, were recorded. The first time (blind-ILM, 25/31 [81%]; FOS-OA, 20/23 [87%], P = 0.6) and overall (blind-ILM, 26/31 [84%]; FOS-OA, 22/23 [96%], P = 0.2) intubation success rates were similar. The mean +/- SD time to intubation was shorter for the blind-ILM group (104 +/- 65 vs 158 +/- 115 sec, P = 0.05). There were no clinically significant differences in blood pressure or heart rate between groups. Compared with baseline values, there was no cardiovascular response to intubation in either group. We conclude that the blind-ILM and FOS-OA techniques have similar success rates and cardiovascular responses, but intubation is slightly quicker with the blind-ILM technique

The mortality of the acute respiratory distress syndrome (ARDS) remains high despite advances in supportive care of ARDS and in the understanding of the pathogenesis. Numerous inflammatory mediators including reactive oxygen species, arachidonic acid metabolites, and growth factors, are present in the circulation of patients with or at risk for developing this syndrome and play a key pathophysiologic role in the development of lung injury. Pharmacologic therapy is being evaluated to: 1) support the failing lung by improving gas exchange; 2) interrupt the mediator-induced mechanisms of inflammation and injury. Although none of these experimental therapies has yet been proven to improve survival in well conducted prospective, randomized, double-blind, controlled clinical trials, many have demonstrated improvement in physiologic function. These results have helped lay the groundwork for future advances in this field