Critical Evaluation and Application for the Anaesthesia and Post Anaesthesia Practice - Assignment Example

Critical Evaluation of the Efficacy of Bonfils Fiberscope Introduction The aim of this assignment is to provide a critical analysis of primary research article. For this assignment, the review shall concentrate on Jost Kaufmann, Michael Laschat, Martin Hellmich and Frank Wappler’s article Pediatric Anesthesia. Notably, the importance of anaesthesia practices will be determined in the review of the same article. The methodological strategies will follow the source and identify primary research for this paper. The research questions are formulated as provided in the Appendix1 (Lehabe 2004, p. 1109) The topic under study has been analysed carefully. The article was selected from the PubMed data base. The search was limited to article that was published within the last five years in order to obtain latest study that have been done on anaesthesia practices. Moreover, the research settled on articles that was published in English because the language is easy and convenience to understand. From 102 articles, 6 articles were analyzed in relation to the study of anaesthesia (Halligan 2003, p. 671) Additionally, the literature reviews help in determining how these two clinical instruments may influence the performance of all the involved experts, particularly anaesthetist among other clinical technicians. The framework by Moule et al. (2003, p. 201) for critical appraisal of the article will be used to follow logical guidance process towards critical review (Appendix3). The paper is completed by analysing the Kauffman et al (2013, p. 302) study on paediatric anaesthesia (Appendix 2). The research also reviews other secondary data with the intention of understanding other author’s ideas on paediatric anaesthesia. Research Rigour Applied The study population selected for this study consisted of 100 paediatric patients who were less than seven years of age. These children were to undergo elective surgery with endotracheal intubation (Rosed 2009, p. 665). The study excluded patients having previous history of mask ventilation or intubation since these sets of patients are usually exposed to anaesthesia medical practices. Other exclusion criteria included a Cormack and Lehane grade of >2 during the direct laryngoscopy DL with the main aim of determining e quality of visualization particularly of the larynx. Similarly, patients who had higher risk classification more than ASA II were also excluded from the research (Divatia and Bhowmick, 2005, p. 315). Therefore, the study requires the application of the technique on paediatric and infant cases which show difficulty in intubation, or that show deviance from normal laryngeal anatomy (Divatia and Bhowmick, 2005, p. 89). Visualization in such cases is crucial, and methodology suggested in this study can be of extreme benefit in clinical practice. Emergency cases such as trauma, infections and pulmonary distress, asthma and congenital anomalies, can require prompt intubation (Charters 2003, 1090). It should be noted that the same treatments can be accorded to ethical issues associated with trialling novel equipment in emergency situations. Nonetheless, the period to carry out these intubations is usually lesser than the duration needed to carry out elective procedures on healthy patients since the latter requires the use of ethical requirement (Divatia and Bhowmick, 2005, p. 123). The study was carried out by two investigators; however, both were paediatric anaesthesiologists. Anaesthesiology techniques and abilities vary from consultant to consultant (Divatia and Bhowmick, 2005, p 51). Therefore, the use of the technique in such cases is dependent on the skill of the anaesthesiologist himself. Skills of anaesthetists come into light under high pressure and difficult cases. While the researcher must be efficient and capable to do so, the actual assessment skill should take place in acute or critical care situation (Divatia and Bhowmick, 2005, p. 36). Notably, the evaluation of one anaesthetist is not enough; thus, there should be more anaesthetists involved in studying both methods. A large population will create a large pool from which to ascertain the efficacy of the anaesthetic process involved in studying process (Divatia and Bhowmick, 2005, p. 89). The children who were selected belonged to a broad age range group of less than seven years of age. Smaller children of less than two years of age usually have a significantly different laryngeal shape than children above two years of age (Knudsen and Rasmussen, 2005,p. 839). Therefore, their inclusion in the study may have affected the method of intubation. It would have been better to choose a set of children with extremely close age ranges according to the anticipated anatomical variations (Knudsen and Rasmussen, 2005, p. 840). Similarly, the presence of any lung diseases or pathologies can also contribute to airway difficulties consequently leading to difficulties in intubation. The healthier children are likely to recover from various intubation methods relatively easily (Knudsen and Rasmussen, 2005, p. 841). The study by Kauffman et al (2013, p. 89) found that visualization with BF and consequent intubation was significantly better and easier to carry out compared to the use of DL especially when applying intubation methods or principles (Kaufmann et al. 2013, p. 83). With factors including selection of patient and administrative procedures among remaining constant others, the study provided results. However, poorer visibility in the DL cases lead to longer intubation times compared to cases that Glidescope could have been used (Kaufmann, 2013, p 67). Potential Physiological and Physical Implications Endotracheal intubation is a process carried out in patients with difficulty in maintaining airway patency. The process is also indicated in patients who cannot protect their airway against aspiration (Lafferty et al. 2012, p. 102). Other indications include ventilator compromise, any difficulty or inability to oxygenate pulmonary capillary blood, and any event that indicates further deterioration of the condition; therefore, the entire process usually necessitates the maintenance of airway patency (Lafferty et al. 2012, p. 90) during the process execution unlike when the general anaesthesia is recommended for the same treatment. The BF is a good option for intubation due to its particular location of the camera, allowing visualization of the entire laryngeal pathway (Kaufmann et al. 2013, p. 73). This instrument allows identifying anatomical restrictions and how to manoeuvre around them to attain the intubation (Kaufmann et al. 2013, p. 72). However, this study must be compared to previous studies, which found BF method to be inferior to GL. The use of a laryngoscope has been recommended when using BF. However, it would be better if it becomes a mandatory practice, to allow for better intubation with fewer chances of injury. The infant epiglottis is larger than adults; thus, making them more prone to damage (Walker 2001, p 87). ET Tubes utilised also shows certain limitations as they may present negative effects on the patients. There can be a limitation in a viewing quality due to the presence of blood, secretions, fogging or any type of tissue contact (Thong and Wong 2012, p. 857). This limitation is found in usually most fiberoptic instruments. This method is highly dependent on the operator and his skills (Thong and Wong 2012, p. 56). This was the same concern shown in the beginning of the analysis that the quality of intubation and ease of it may vary from one practitioner to another; particularly in the kind of urgency called for in the particular clinical situation. The study did not study the impact and effect of fibre optic intubation on the arterial blood pressure. Study carried out by (Xu et al., 2007, p. 284) compared the increase or changes in the arterial blood pressures after nasotracheal or tracheal intubation of fibre-optic instrument. This study was carried out on children ranging from 3 to 9 years. The study results demonstrated a significant increase in the arterial pressure through fibre-optic intubation via oral or nasal routes (Xu et al., 2007, p. 123). While this finding may not be of much significance in healthy children, it may result into significant outcomes when the children are patients of heart conditions, are being treated in emergency departments or are syndromic in nature (Xu et al., 2007, p. 89). The article has a physiological relevance as it equips anaesthetic technicians with the fundamental concepts that underpin the management and delivery of safe practices in any operating department. With such fundamental concepts, an anaesthetic technician will be able to develop specialist skills and knowledge needed by practitioners for post-anaesthetic safe practices (Hung 2007, p. 725). The article helps the reader to promote optimum patients care immediately after undergoing a range of anaesthetic interventions and techniques. It also helps in addressing the patient’s physiological, physiological and socio cultural needs as well as contextualizes practices in the contemporary social and health care provision. In doing so, the article facilitates the exploration of how perioperative service and practice provision may be developed through post anaesthetic care practitioner contribution in any care team (Bonfils 2005, p.56) Management and Introduction to Change on my Practice The implications for anaesthetic technicians are as valuable as they are for any other health professional involved in intubation procedures, whether in elective surgical settings or acute, emergency conditions. Intubation in children is extremely difficult maneuverer since it requires high levels of dexterity and care. While this procedure is not difficult for a seasoned anaesthesiologist, the problem emerges when handling cases of infants (Walker 2001, p. 342). The challenge also emerges in emergencies where paramedical staff and nursing staff may have to take decisions in managing airway patency (Walker 2001, p. 345). The assistance of the anaesthetic technicians’ in providing intubation makes the intubation process an indispensable technique. In fact, intubation is a critical aspect of care and all those operating in the emergency units should be well versed with techniques that handling the situation effectively (Maier 2005, p. 36). Although legal and medical ethics may not allow this form of treatment by lower medical staff, there can be official courses and trainings carried out for medical practitioners as well as the medical students to allow improvement and expertise to develop. The study by Erb, et al. (1997, p 1038) noted that paramedic and student can learn intubation in healthy children of the ages between 2 and 9 years.) The article plays a vital role when it comes to the management as it equips one with necessary skills and knowledge in managing potential and actual problems that may arise during post anaesthetic period (Cormack and Lehane 2000, p. 1108). An anaesthetic technician will be in a position to address and differentiate the patient’s needs as well as patients with co-existing health requirements. The technician will also be better placed to understand the factors that influence pain and have the ability to manage and asses the pain of patients according to their respective needs. Any technician or practitioner will be in a better position to provide care accurately and care chart the progress of a patient during the surgical encounter, the preop stage through PACU (Erb et al. 1997, p. 1043). Conclusions The study carried out by Kauffmann et al (2013, p. 302) has been a significant contributor in evaluating the efficacy of BF technique in children. The proper use of this technique with a laryngoscope can help in smooth intubation without complications and better recovery outcomes. However, this study requires a renewed research based on children entering the emergency department. Other sample must include cases of children suffering from various syndromes affecting the jaw and mouth as well as the nature of mouth. These cases should be learnt to be managed more effectively. Intubation is a life-saving procedure; therefore, every medical institution should have a staff trained on the same. Creating this procedure as part of the life saving techniques in the health care policy can help significantly reduce lives and improve the quality of health care delivery (Redick 2009, p. 675) The article is relevant especially to an anaesthetic technician as it will vast him or her with enough expertise in monitoring and administration of anaesthetic as well as extensive knowledge in the required instruments, technology and supplies (Mirakhurr 2006, p. 946). The technician will be in a position to prepare all the facilities needed by anaesthetists for intravenous therapies, airway management, invasive physiological monitoring and environmental temperature monitoring and control. The technicians will also be in a position to assist during emergency resuscitation and procedures Kauffmann et al (2013, p. 307). Bibliography Divatia J V and Bhowmick K, 2005. ‘Complications of Endotracheal Intubation and Other Airway Management Procedures’. Indian J. Anaesth 49(4):308-318 Erb T, Marsch S C, Hampl K F and Frei F J, 1997. ‘Teaching the Use of Fiberoptic Intubation for Children Older Than Two Years of Age’. Anesthesia and Analgesia Vol. 85, No. 5, 1037-1041. Kaufmann J, Laschat M, Hellmich M and Wappler F, 2013. ‘A Randomized Controlled Comparison of the Bonfils Fiberscope and the GlideScope Cobalt AVL Video Laryngoscope for Visualization of the Larynx and Intubation of the Trachea in Infants and Small Children with Normal Airways’. Pediatric Anesthesia ISSN 1155-5645. Knudsen RH, Eriksen K and Rasmussen L S, 2005. ‘Using a Nasopharyngeal Airway During Fiberoptic Intubation in Small Children with a Difficult Airway’. Pediatric Anesthesia 2005 Vol. 15: 839-845. Lafferty K A, Kulkarni R and Filbin M R, 2012. ‘Rapid Sequence Intubation’. Medscape Reference Drugs, Diseases and Procedures. Site last accessed on March 20th, 2013. Available at http://emedicine.medscape.com/article/80222-overview#a01 Moule, P. Pontin, D. Gilchirist. M. and Ingram, R. 2003. Critical appraisal framework. Bristol: University of the West of England. Thong SY and Wong TG, 2012. ‘Clinical Uses of the Bonfils Retromolar Intubation Fiberscope: A Review’. Anesth Analg 115(4):855-66. Walker R W M, 2001. ‘Management of the Difficult Airway in Children’. Journal of the Royal Society of Medicine 94(7):341-344. Xu FS, Li CW, Sun HT, Zhang GH, Xu YC and Liu Y, 2007. ‘Circulatory Responses to Fiberoptic Intubation in Anesthesized Children: A Comparison of Oral and Nasal Routes’. Anesth Analg2007 Feb; 104(2): 283-8. Redick, L.,2009. “The temporomandibular joint and tracheal intubation”, Anesth Analg, 66:675-76 Cormack, R& Lehane, J. 2004. “Difficult tracheal intubation in obstetrics”, Anaesthesia. 39: 1105-11 Bonfils, P., 2005. “Fiberoptic intubation”, Intensivbehandlung. 8:53-60 Hung, O., 2007. “Understanding homodynamic responses to tracheal intubation,” Can J Anesth. 48: 723-726 Rosed, K., 2009. “The intubating laryngeal mask airway with and without fiberoptic guidance”. Anesth Analg. 88:662-6 Lehabe, J., 2004. “Difficult trachela intubation in obstetrics,” Anaesthesia. 39:1105-11 Halligan, M., 2003. “Learning curve for the Bonfils intubation fiberscope,” Br J. Anaesth. 90:826 Halligan, M., 2003. “A Clinical appraisal of the Bonfils intubating fiberscope,” Br J. Anaesth. 89:671-2 Charters, P., 2003. “A Clinical appraisal of the Bonfils intubating fiberscope,” Anaesthesia. 58:1087-91 Mirakhurr, K. 2006. “ A comparison of the stress response to larynscopy,” Anaesthesia. 50:943-946 Maier, S., 2005. “ An unexpected difficult intubation: Bonfils rigid fiberscope,” Anaesthetist. 54:35-40 Appindex1 Research question 1. What is the benefit of the Bonfils fiberscope and the GlideScope Cobalt AVL video laryngoscope for visualization of the larynx and intubation of the trachea in infants and small children with normal airways? Appendix2 Original Article A randomized controlled comparison of the Bonfils fiberscope and the GlideScope Cobalt AVL video laryngoscope for visualization of the larynx and intubation of the trachea in infants and small children with normal airways Jost Kaufmann1,2, Michael Laschat1, Martin Hellmich3 & Frank Wappler1,2 Appendix 3 UWE Framework for Critically Appraising Research Articles The Introduction Is there a clear statement about the topic being investigated? Is there a clear rationale for the research? Is there a clear statement about the limitations of the research? The Literature Review Do the researchers use contemporary material about the topic being investigated? Do the researchers link their work to a wider body of knowledge through the references cited? Do the researchers link the topic to the questions about theory? Is there a clear link between the literature and the formulation of the research question(s)? Is the research question clearly stated? The Methods Section Is the research design clearly described? Are the research methods appropriate for the topic being investigated? Are any advantages or disadvantages of the design acknowledged by the researchers? Is there a clear statement about who participated in the research? Is there a clear statement about how the participants were selected? Is the selection of participants appropriate to the design? Is there a clear statement about the number of people taking part in the research? Data Collection and Analysis Is there a clear description about how the data was collected? Was the data collected by appropriate people? Is the approach to data analysis appropriate to the type of data collected? Quantitative Is there any explanation of sample size used? Is the level of significance of the tests (alpha) used indicated, or implied to be the customary 5%? If Pearson correlation coefficients are being calculated, is there any evidence of a check for a linear relationship? If t-tests or analysis of variance (ANOVA) are to be performed, is there any evidence of check(s) to demonstrate that the data follows a normal distribution, or of assumptions made? Are reasons/assumptions re the level of measurement of the data given? (This affects the appropriateness of the descriptive statistics given and the tests used.) Is there a clear statement describing how valid and reliable the measures are? Are the types of statistical tests used appropriate for the sorts of data collected? Is the use of any statistical analysis package, such as SPSS discussed? Is there evidence of a statistician's input to the analysis? Ethics Is there a clear statement about ethical committee approval? Is there a clear description about gaining consent, maintaining anonymity and or confidentiality? The Results/ Findings Are the results related back to the literature review? Are the weaknesses in research design acknowledged? Quantitative Is the presentation of results clear and unambiguous? Are all the results presented? Do the tables and charts used give a clear picture of the sample data and results? Are the charts used appropriate? Are the tables easy to use? If percentages are recorded, are actual numbers also clearly shown? Are results of tests interpreted rightly? The Conclusions Are the implications for further research acknowledged? Are areas for further research identified? Are further recommendations made for practice that comes from the results/discussion? (Moule et al. 2003) Read More