Julia Dixon-Ernst RN, BSN, SRNA University of Pittsburgh Gliding Past Video Assisted Intubation Complications Identification, Treatment and Prevention of GlideScope-Associated Injury Julia Dixon-Ernst RN, BSN, SRNA University of Pittsburgh
Upper teeth tongue Lower teeth
Glidescope Laryngoscopy Improved glottic view anterior displacement of lower jaw manipulation of cervical spine lifting force traction on soft tissue success with difficult airway
Case 1 Scheduled teeth extraction and alveoplasty Airway Assessment MP 3 Small oral opening Slightly limited A/O extension Loose teeth Glidescope intubation!
Case 2 Elective nasal valve reconstruction Airway MP 2 Glidescope attempts X2 2nd attempt impaled right soft palate Procedure aborted Transfer to ICU Intubated overnight Steroids and antibiotics Extubated without primary closure 1cm full thickness defect 2 week follow up in clinic: mucosa healing and no deficits
Case 3 Upper teeth Airway: MP 1 Induction Blood noted in oropharynx. Glidescope attempts x2 Placed LMA Blood noted in oropharynx. ENT consulted 2cm deep laceration closed with sutures Well healed laceration with no functional impairment Tongue Lower teeth
Oropharyngeal injuries are more likely to occur while using the Glidescope
Trends in the literature Primary Location of Injury: Tongue base Palate Tonsils
Site of Surgery
Trends in the literature Only 30% of injuries were recognized during intubation Injury was seen more often in women than men
Mechanism of Injury Attention on monitor during oral insertion Rigid stylet Increased flexion to accommodate stylet Anatomic strains Blind spot
Identification is Key As blade is withdrawn assess the path of the ETT and the oral cavity for injury
Management of Palatal Injury
Prevention Look in the Mouth Look at the Screen
Clinical Pearls for Prevention Insert blade midline under direct vision Introduce ETT close to the blade Visualize tip during any advancement Other strategies for prevention of injury include: Inserting the blade midline to the tongue and epiglottis under direct vision You can use the blade in the vallecula like a MAC blade or to pin up the epiglottis like a miller blade Introduce ETT close to the blade to avoid blind, traumatic insertion as the space created by the blade will allow for improved visualization of ETT until it I sable to be seen on the monitor Using a stylet is recommended to enhance control of the ETT. A malleable stylet can be used bent to a 60-90 degree angle Glidescope rigid stylet is also acceptable Evidence shows there is no difference in intubation success between the stylets however increased risk is seen with the ridgid stylet Visualize tip during any advancement either by direct visualization or on the monitor advancement of ETT and blade should always be midline, gentle and under direct vision It is important to insert the ETT with beveled tip facing against the blade of glidescope to avoid cutting of the soft tissues in the oropharynx
Clinical Pearls for Prevention Insert ETT with beveled tip facing against the blade of GlideScope
Clinical Pearls for Prevention
Clinical Pearls for Prevention Soft tip EET may avoid trauma As blade is withdrawn assess for tissue injury
What About the Novice? Pro Con Better intubation instruction Improved visualization of anatomy Higher success rate for successful intubation for difficult airway Higher trainee satisfaction rates No change in performance between VAL and DL with normal airway Higher incidence of injury Large percent of case studies have involved students
What about the novice Review the basics prior to induction Look in the Mouth Look at the Screen Bevel front and center! Moves always gentle
In Summary The Glidescope is a great tool that has the potential to cause injury Patient and User factors may contribute to increased risk of injury Providers can reduce injury incidence with increase vigilance Provider should always have visualization of blade/ETT tip while advancing Glidescope is a good educational tool for trainees when they are instructed to avoid injury
Questions?