Female Jockey Wins Melbourne Cup on KIWI HORSE

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Annis Bradley
5 years ago
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1 Female Jockey Wins Melbourne Cup on KIWI HORSE

2 Research in CICO Transtracheal jet oxygenation and ventilation Colin Marsland ANZCA NZ ASM Wellington 2015

3 Experimental Airway Obstruction, TTJV and Fatality Neff et al J Trauma 1983;23:84-90 Paxian et al BJA 2015;115: Constant Flow 15L/min via 15G cannula Paw 260cm H2O at 15 sec Death at 18 sec Intermittent Jets 15L/min 3:5 sec I:E Paw 254cm H2O at 64 sec Death at 65 sec Intermittent jets 0.5 bar manujet 1:4 sec I:E Paw 50cm H2O for 6 min 30% mortality in pigs

4 Whale Sharks and WAAG

5 Manujet Complete Obstruction

6 Physiology in Play V/Q, V/P, O 2 Shunt Lung Compliance O2 transport Physiologic Dead Space Auto-PEEP

7 Berry M, Tzeng Y, Marsland C Percutaneous transtracheal ventilation in an obstructed airway model in post-apnoeic sheep. Br J Anaesth 2014;113:

automatic shut off Flow regulated, EVA 15Lmin -1 O 2

8 Manujet vs Ventrain Pressure regulated 0-4 bar 50 psi O 2 source 250ml O 2 sec -1 2mm TTC 1 bar Manual operation No automatic shut off Flow regulated, EVA 15Lmin -1 O 2 flowmeter 250ml O 2 sec -1 2mm TTC Manual operation Triphasic ventilation

9 Ventrain (manufacturer s graphic) INSP EXP EQ

10 Ventrain Complete Obstruction

11 Manujet Complete Obstruction 5 minute oxygenation window after single breath Median time to secondary breath 7m20s

12 SaO 2 and Airway Pressure VO Ventrain Obstructed VP Ventrain Partial Obstruction MO Manujet Obstructed MP Manujet Partial Obstruction

13 Table of Results

14 Ventrain The ideal device for TTJV?? INSP EXP NO. TOO COMPLICATED FOR CRISIS USE EQUIL

15 Rapid-O 2 Concept developed by A.Heard et al RPH Flow regulated 15L/min delivers 250ml/sec O2 via 14G TTC No flow to TTC if T not occluded Feedback at occlusion site Passive expiration Simple, Cheap, Effective

16 Proximal Leak and TTJO

17 Big Proximal Leak and TTJO

18 CICO Kits in Wgtn

19 Local Training Heard Algorithm Dry Lab Skills Simulation Anaesthetised Sheep Initial Emphasis Senior staff and Technicians Trainees

20 Whale Sharks and WAAG with credit to Dr A.Heard et al

21 CICO Emphasis Oxygenation not Ventilation Temporising oxygenation to allow definitive airway management Minimize barotrauma risk with minimal breath frequency (peak sat falls 5% = trigger) Hypercarbia not the issue in the short term

22 Cannula Indicated?? Cannulation improbable: Non-palpable anatomy No end-point e.g blood or vomit on aspiration PTO ineffective/dangerous: Big leak e.g perforated airway Barotrauma Lung injury

23 Scalpel Best First Choice Environment Military/Field Crises/Specialty culture Airway trauma / Barotrauma Low lung compliance Lung injury, soiling with blood / vomit Anatomy

24 Pre-emptive Ultrasound CTM Correct ID of CTM by palpation in Obese patients: <10% ID BMI >30 Aslani et al Anesth Analg 2012;114: Time to ID CTM with USS 30 seconds Nicholls et al Am J Emerg Med 2008;26:852-6 Portex Kit in cadavers with difficult or impalpable landmarks: Success: 8% vs 46% with USS Moderate to severe injury:100% vs 33% with USS Siddiqui et al Anesthesiology 2015;123:

25 Questions?

26 Examine Front of Neck in Potentially Difficult Airways Consider pre-emptive USS definition of CTM and trachea if anatomy is impalpable

27 Simulated Obesity and Burn Howes et al BJA 2015;114:1:136-42

28 Complete Airway Obstruction in CICO Good Bad Lung inflation with flowcontrolled devices Auto-PEEP maintains lung volume Breath Stacking Barotrauma Pulmonary flow impairment

29 Large Proximal Leak and PTV Bad Good Lung inflation difficult with flow-controlled devices No PEEP to maintain lung volume Unimpeded gas egress Minimal Barotrauma Risk Low intra-thoracic pressure

30 Oxygenate Safely Minimise Ventilation in CICO Paxian et al BJA 2015;115:2: % mortality (pigs) with fixed ventilation, complete obstruction and Manujet

31 Emergency PTV TC position confirmed - long axis tracheal lumen High pressure O2 source - cannula resistance Proximal airway obstruction - gas egress lung inflation limited if escapes too much barotrauma if escapes too little minute ventilation affected with each

32 Hypothesis Post-apnoeic transtracheal oxygenation with critical and complete proximal airway obstruction will be achievable with both Ventrain and Manujet devices, but airway pressures lower with Ventrain. Test Compare primary outcome measures (oxygenation, airway pressure and CO 2 clearance) following PTV in a large animal obstructed airway model.

VENTILATION STRATEGIES FOR THE CRITICALLY UNWELL

VENTILATION STRATEGIES FOR THE CRITICALLY UNWELL Dr Nick Taylor Visiting Emergency Specialist Teaching Hospital Karapitiya Senior Specialist and Director ED Training Clinical Lecturer, Australian National