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Silent aspiration prevention in bariatric surgery J P Mulier MD PhD

1150 1850 1947 1977 2010 . Silent aspiration prevention in bariatric surgery J P Mulier MD PhD. Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier.

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Silent aspiration prevention in bariatric surgery J P Mulier MD PhD

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  1. 1150 1850 1947 1977 2010 Silent aspiration prevention in bariatric surgeryJ P Mulier MD PhD Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier

  2. 1150 1850 1947 1977 2010 The Negative Impact ofPost-Intubation Pulmonary ComplicationsJ P Mulier MD PhD Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier

  3. The Negative Impact ofPost-Intubation Pulmonary Complications 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. JPMulier New York 13 dec 2009

  4. What are the complications? • Intubation trauma during insertion • Laryngeal trauma by tube or cuff • Ventilation trauma by the ventilator • VILI: Ventilation induced lung injury • Barotrauma • Volutrauma • Ventilation induced lung disease • VAP: Ventilation associated pneumonia • Long term changes in post op lung function • Surgery induced lung injury • Anesthesia induced lung injury • Fluid therapy induced lung oedema JPMulier New York 13 dec 2009

  5. > 60 years of intubation expertise • Improvements in intubation technology brought each time new complications. • Use of an endotracheal tube • Use of anesthesia and muscle relaxants to intubate • Use of an inflatable cuff • Use of a low pressure high volume cuff • New safety alerts, vigilance training, but also inventions were needed each time. JPMulier New York 13 dec 2009

  6. Use of endotracheal tubes • Who to intubate? • What size? JPMulier New York 13 dec 2009

  7. Use of anesthesia and muscle relaxants • Non traumatic intubation possible but • Aspiration risk at induction • Hemodynamic collaps • Sellick maneuvre ? • No food no liquid 24 h • Gastric ph • Fluid therapy • Safer anesthetics • … JPMulier New York 13 dec 2009

  8. Invention of a cuff • No leak of air with positive pressure ventilation • Size of tube might be smaller and is less critical JPMulier New York 13 dec 2009

  9. But post intubation stenosis… • Question of • What tube size? • became • What cuff pressure? JPMulier New York 13 dec 2009

  10. Use of a high volume low pressure cuff • Low pressure possible • No N20 or Pressure control • Ischemia risk solved, but • New threat • Silent aspiration JPMulier New York 13 dec 2009

  11. Silent aspiration due to leaks around cuffs of endotracheal tubes • Petring OUAnesth Analg. 1986 Jul;65(7):777 • Methylene blue bronchoscopic test in patients: Rüsch tube vs Mallinckrodt tube • Aspiration more frequent with the Mallinckrodt tube than the Rüsch tube JPMulier New York 13 dec 2009

  12. Leakage of fluid around high-volume, low-pressure cuffs • Asai T, Anaesthesia. 2001 Jan;56(1):38-42 • A comparison of four (high-volume, low-pressure cuffs) tracheal tubes in a model trachea and lung. • Large leak: • Portex Profile, Mallinckrodt Lo-Contour • Smaller leak: • Portex Soft Seal, and Mallinckrodt Hi-Lo tubes JPMulier New York 13 dec 2009

  13. Fluid leakage past 4 pediatric tube cuffs: in vitro evaluation of the new Microcuff tube • Dullenkopf 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, C did leak fluid at pressures above 10 • D:ultra-thin polyurethane membrane markedly improved tracheal sealing JPMulier New York 13 dec 2009

  14. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. • Lucangelo UCrit Care Med. 2008 Feb;36(2):409 • Hi-Lo (20 pt), vs SealGuard (20 pt) • One hour after peep stop: • Hi-Lo 100% leak • SG 70% leak JPMulier New York 13 dec 2009 • At the fifth hour, two patients of the HL group failed the test. One hour after positive expiratory pressure removal, all subjects in group HL exhibited a dyed lower trachea. On the other hand, one patient in group SG presented a leak at the eighth hour, and at the 12th hour three of them were still sealed

  15. Silent aspiration • Fluid in oral cavity can leak along tracheal cuff. • Gastric content • Blood • Leak test • In vitro and in vivo test with methylene blue have frequently been positive: leak through the cuff plica JPMulier New York 13 dec 2009

  16. Does it all begin in the OR? • Induction • Full stomach / gastric fluid pH • Mask ventilation air in stomach • Difficult ventilation/intubation/nasal intubation • Per operative • Oral blood from operation, nasal bleeding, • Leak test in RNY • Post operative • Residual relaxation, post op sedation, not coughing • Abdominal surgery risk group JPMulier New York 13 dec 2009

  17. Taperguard • A conical cuff with a large diameter proximal and a small diameter distal JPMulier New York 13 dec 2009

  18. The obese patient is a challenge for anaesthesia if android shape with intra visceral fat. JPMulier New York 13 dec 2009

  19. Android versus Gynoid fat distribution has a different Elastance JPMulier New York 13 dec 2009

  20. Two types of android obesity Subcutaneus FatVisceral fat Intra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and intra abdominal fat is thick and intra abdominal fat is scant. JPMulier New York 13 dec 2009

  21. Pulmonary complications 4x higher in morbid obese patients JPMulier New York 13 dec 2009

  22. Clinical study compares cuff leak Taperguard versus PolyVinylChloride: • Laparoscopic gastric bypass operations • Orotracheal tube needed • Methylene blue 300 ml in gastric pouch with overflow in mouth at moment of leak test • Cuff leak tested with 10 ml methylene blue • Ventilation VCV with 5 cm peep • Man 8,0 OTT Woman 7,0 OTT • Group A: Hi contour Mallinckrodt • Group B: TaperGuard Mallinckrodt JPMulier New York 13 dec 2009

  23. Study on per op preventiontaperguard vs PVC OTT: • Laparoscopic gastric bypass operations • OTT needed • Methylene blue 300 ml in gastric pouch with overflow in mouth at moment of leak test • Risk for silent aspiration pneumonia? • Ventilation VCV with 5 peep • Man 8,0 OTT Woman 7,0 OTT • Group A: Hi contour Mallinckrodt dry • Group B: Hi contour Mallinckrodt with gel • Group C: TaperGuard Mallinckrodt dry • Black line above and below cuff JPMulier New York 13 dec 2009

  24. Group A B C • A B C JPMulier New York 13 dec 2009

  25. Methods • Automatic cuff pressure control. • Set at 25 cmH20 • 2 ml methylene blue + 8 ml H20 injected above cuff. • Bronchsocopic control after 5 minutes. • Blue fluid must be visible above cuff. • Blue visible below cuff, between trachea and tube? JPMulier New York 13 dec 2009

  26. In vitro tests A B C Runs through stop on top runs & stop JPMulier New York 13 dec 2009

  27. Methylene blue test • PVC 7,0 vs taperguard 7,0 at lower end cuff. Look upside PVC Taperguard JPMulier New York 13 dec 2009

  28. Impact of OTT size • Larger OTT more plica, deeper run in taperguard 7,0 taperguar 8,0 JPMulier New York 13 dec 2009

  29. PGA poster • Total Number of patients: 40 JPMulier New York 13 dec 2009

  30. Human Methylene blue leakObese patients, CMV 5 peep after 5 minutes when blue is visible above cuff 81 patients

  31. Still a lot of Questions • Is post operative pneumonia caused by silent leakage? • Is fluid leakage dangerous? • Amount of fluid leak over what time? • Fluid type impact? • Gastric content • Oral blood • Leak test fluids • How long is gel protecting? Not possible with NTT? • Impact of peep not sufficient? • Impact of tube movement? JPMulier New York 13 dec 2009

  32. Where can we reduce silent aspiration? • Oral blood • Oral pharyngeal surgery ( maxillo facial) • Nasal surgery ( septum surgery) • Naso gastric tube, oro trcheal tube, naso tracheal tube inserted with bleeding • Patient under heparines ( cardiac, vascular) • Gastric fluid in oral cavity • Post induction regurgitation (urgent, obstruction) • Bad gastric drainage, gastroscopy, laparoscopy, trendelenburg • Water/air injection for leakage test • Esophagus, stomach, ( gastric bypass) JPMulier New York 13 dec 2009

  33. Attractiveness in WHR from 4000 BC until 2000 AC 1,5 1,1 1,5 0,5 0,7 JPMulier New York 13 dec 2009

  34. JPMulier New York 13 dec 2009

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  36. JPMulier New York 13 dec 2009

  37. Intubation trauma during insertion • Teeth damage is one of the most freq complications for anesthesia • Broken teeth due to gaatjes • Loose teeth due to peridontitis • Glazuur damage of the front teeth • Teeth protection takes place • Improving patient positioning • bronchoscopic intubation • Nasal bleeding • Dyslocation of arytenoids • Lip, tongue, eye contusion, cornea abrasion JPMulier New York 13 dec 2009

  38. Foto of teeth in lungs JPMulier New York 13 dec 2009

  39. Laryngeal trauma by cuff JPMulier New York 13 dec 2009

  40. Laryngeal trauma by cuff JPMulier New York 13 dec 2009

  41. Ventilation trauma by the ventilator • Large tidal volume overstretching of the lungs • Foto of rats lung trauma JPMulier New York 13 dec 2009

  42. Ventilation induced lung disease • VAP: Ventilation associated pneumonia JPMulier New York 13 dec 2009

  43. Long term changes in post op lung function • Decreased lung capacity and ESW after CABG has been proven JPMulier New York 13 dec 2009

  44. Surgery induced lung injury • Stress reaction JPMulier New York 13 dec 2009

  45. Anesthesia induced lung injury • Fluid therapy induced lung edema JPMulier New York 13 dec 2009

  46. What preventive measures? • Correct tube, size and cuff design • Cuff pressure monitor • Video assisted laryngoscopy • Protective lung ventilation • Anti volutrauma valve • Anti barotrauma O2 therapy • Prevent silent aspiration pre per post • Correct extubation technique and moment JPMulier New York 13 dec 2009

  47. Why do we not apply this knowledge every time? Do we think this does not happen with my patient? This is too expensive to be worth? Other problems are still bigger? Not evidence based? Always studies that tell opposite? JPMulier New York 13 dec 2009

  48. Does it begin in the OR? • YES because • you choose the product, technique • Yes even • if damage comes later • We do not notice it because • different physician at the ICU, ward, is part of surgery, is normal… • listen to them with an open mind JPMulier New York 13 dec 2009

  49. ESPCOP founded feb 2009 President Jan P Mulier Secretary Luc De baerdemaeker Treasurer Nick Kennedy Vice-President Yigal Leykin www.publicationslsit.org/ESPCOP www.espcop.org JPMulier New York 13 dec 2009

  50. Attend first ESPCOP meeting14 nov 2009 Ostend Belgium • “The sea” from Georges Grard • Better known as “fat Mathilde of Ostend” JPMulier New York 13 dec 2009

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