BEELDVORMING VOOR DE ANESTHESIST Inleiding

BEELDVORMING VOOR DE
ANESTHESIST
L. BIESEMANS
AVU 2008-2009
Inleiding
• Belang beeldvorming
– Diagnose
– Behandeling
– Follow up
• Wat je ziet is beter dan iedere blinde
techniek, maar niet altijd een toegevoegde
waarde…
– Epiduraal???
– Neuraxiaal???

• Referentiepunten voor centraal veneuze
catheters
– Jugulair
– Subclaviculair
– Femoraal
Eigen zicht
• Conventionele laryngoscoop
– Klassiek beeld in de diepte
• Videolaryngoscoop
Laryngoscopie
– Het einde van de klassieke laryngoscopie in
zicht???
• Glidescope® / Airtraq®
– Enkel in bepaalde gevallen
– Niet altijd eenvoudig toe te passen
– Disposable / kost

Glidescope
Glidescope: characteristics (1)
• Designed to assist airway management by
application of video cameras to a
redesigned classical rigid laryngoscope to
provide an improved view.
• Design is similar to that of conventional
laryngoscope, making it easy for
“conventional laryngoscope users” to use.

Glidescope: characteristics (2)
• Antifogging mechanism
• 60° angle blade provides
– a minimal distorted view of supraglottic anatomy
– access by reducing the need to remove the tongue
from the line of sight to the larynx
• Provides a view of the glottis without alignment
of the oral, pharyngeal and tracheal axes
Glidescope: use
• Placement of endothacheal tubes
• Removal of foreign bodies
• Tube exchanging
• Managing difficult airways
• Positioning of tracheal tubes during
percutaneous tracheostomy

Glidescope: literature (1)
• The Glidescope Video Laryngoscope:
randomized clinical trial in 200 patients.
Sun, British Journal of Anaesthesia 94 (3): 381–4 (2005)
– Conclusion:
• In most patients, the GlideScope provided a laryngoscopic
view equal to or better than that of direct laryngoscopy, but it
took an additional 16 s (average) for tracheal intubation.
• It has potential advantages over standard direct laryngoscopy
for difficult intubations.
Glidescope: literature (2)
• Early clinical experience with a new videolaryngoscope
(GlideScope®) in 728 patients. Cooper, Can J Anesth 2005 /
52: 2 / pp 191–198
• GS laryngoscopy consistently yielded a comparable or
superior glottic view compared with DL despite the limited
or lack of prior experience with the device. Successful
intubation was generally achieved even when DL was
predicted to be moderately or considerably difficult.
• GS was abandoned in 3.7% of patients. This may reflect
the lack of a formal protocol defining failure, limited prior
experience or difficulty manipulating the endotracheal tube
while viewing a monitor.

Glidescope literature (3)
• Case report: “Complications associated with the
use of the Glidescope® videolaryngoscope.”
Cooper, Can J Anesth 54:1 jan 2007
– Perforation palatopharyngeal arch
• R/ suturing / electrocautery
Glidescope literature (4)
• Case report: “Glidescope video laryngoscope is usefuf in
exchanging endotracheal tubes.”
Peral, Anesth Analg 2006;103:1043-1044
– Man, 34j, vocal cord tumor, Malampati 2
– Classic laryngosopy: Cormack 3, ET n° 5,5
– Postoperative
• deterioration of ventilation, ↑ mean inspir. pressure
– R/ Exchanging ET under direct visual control with
Glidescope: larger ET
– Air leak: rupture cuff
• R/ Exchanging ET with airway exchange catheter /
glidescope

Glidescope Literature (5)
• The use of the Glidescope® for tracheal intubation in
patients with ankylosing spondylitis.
Lai, British J Anesth 97 (3): 419-22 (2006)
– Conclusions:
• Glidescope provides a better laryngosopic view
than that of direct laryngoscopy
• Elective patients with ankylosing spondylitis:
– awake fiberoptic intubation is superior: spontaneous
breathing
– Glidescope®: alternative option: general anesthesia
The use of the Glidescope® for tracheal intubation in
patients with ankylosing spondylitis.
Lai, British J Anesth 97 (3): 419-22 (2006)
Pre operative
Malampati
Glidescope
succesful 8/8
Laryngoscopie
Cormack
Glidescope
failure 3/11
Glidescope
succesful 8/11
Glidescope
succesful 1/1

AIRTRAQ®
Airtraq®: advantages
• Provides a magnified angular view of the larynx
and adjacent structures
• No hyperextension of the neck required
• Allows intubation in any position, (e.g., sitting)???
• Easy to use
• Short learning cycle
• Removes potential problems of multi-use
intubation devices???
• Guides the tube (we hope) just before the
entrance to the larynx / no additional separate
manipulation of the tube required

Airtraq®: characteristics (1)
• The Airtraq is an anatomically shaped
laryngoscope with two separate channels:
– Optical channel: contains a high definition
optical system.
– Guiding channel: holds the endotracheal
tube (ETT) and guides it through the vocal
cords.
• It has a built-in Anti-fog system and a low
temperature light.
Airtraq®: characteristics (2)
• It is a very affordable??? SINGLE USE
device: ±80 €
• Set up time between 30-60 seconds
• It can be used with any standard
endotracheal tube

Airtraq®: other applications
• Emergency settings
• Cervical spine immobilization
• Nasal intubations
• Fiberscope Gastroscope guidance
• Double lumen ETT intubation
• Vocal cords visualization
• Foreign body removal
Film Airtraq®

Airtraq ®
Airtraq® Literature (1)
• A comparison of tracheal intubation using
the Aitraq® or the Macintosh laryngoscope
in routine airway management: a
randomised controlled trial.
(Maharaj, Anesthesia, 2006, 61: 1093-1099)
• Randomised controlled trial
– Airtraq (n=30) vs laryngoscope (n=30)
– Only pts at low risk for difficult intubation
– Experienced anesthetists

Airtraq Literature (2)
• All but one pt were succesfully intubated
on the first attempt.
• No difference between groups in duration
of intubation attempts.
• Less alterations in haert rate with airtraq.
• Conclusion: utility of airtraq for tracheal
intubation in low risk patients.
Airtraq® Literature (3)
• Case report: Emergency use of the Airtraq
laryngoscope in traumatic asphyxia.
(Black, Emerg Med J 2007;24:685)
– Bleeding into upper airway
– Rapid sequence intubation with cricoid
pressure prehospital
– Minimal manipulation
• Future???

Fiber (1)
• Intubatie: moeilijke luchtweg
• Onder narcose: spontaan AH/ beademend
• Wakker met sedatie
– Goed lokaal verdoven
» LA spray in de keel / LA thv neus
» Eventueel epidurale catheter door suctiekanaal voor
extra LA in de diepte
Difficult airway

Te verwachten “diffucult airway”
Fiber via nasale route

• Controle positie ET
Fiber (2)
– “gouden standaard” voor plaatsing dubbel
lumen ET
– Ook bij single lumen ET / tracheo
• Vb.: problemen bij beademen, ↑luchtwegdrukken
dr plug, ET op carina, pt. gaat niet bilateraal op,…
• Tracheascheur
• stembandverlamming
Film fiber controle positie
dubbel lumen ET

• Bronchoscopie
Fiber (3)
– Vb. op PAZA na majeure thoracale heelkunde
• Aspiratie secreties
• Controle sutuur bronchiale stomp
• Evaluatie oedeem, roodheid luchtwegen
• Afname sputum / BAL
Casus P.D.
• Vrouw, 61j, thuis onwel geworden, ↓ BWZ
• Bijstand MUG
– GCS: 4/15, extensie bij pijnprikkel, anisocoor
re>li
– Bilat. VAG, sat. 97% met masker 15 l zuurstof
– SR, bradycardie 45/’, BD 201/112 mmHg
– R/ sedatie en curarisatie voor intubatie
– Tijdens transport: bradycardie tot 25/’
– Dringende CT schedel

CT hersenen
Massieve intraventiculaire bloeding, basilaris -
aneurysma? Transtentoriële inklemming
• Consult NCH
CASUS P.D.
– Anisocoor (re>li), niet reactief
– Afwezige hogere stamreflexen
– Intacte lagere stamreflexen (reactie op ET)
– Endorotatie op pijn
– Plaatsen bilat. VED met drukmeting aan 1
kant

RX thorax
Bronchoscopie PAZA

RX na bronchoscopie
Bronchoscopie
• Verwijderen vreemd lichaam
– Rigiede bronchoscoop
• Verwijderen vreemd lichaam onder AA
– Vb.: nootje verwijderen uit luchtweg bij kind
– Flexibele bronchoscoop
• Casus: jongen, 14j., kopspeld ingeslikt…
• Gastroscopie: … niets te vinden
• RX thorax toont vreemd voorwerp

Film casus verwijderen
kopspeld uit luchtweg kind
RX / scopie
• Plaatsen dubbel lumen ET
• Rewiring CVC
• Plaatsen PICC’s (controle positie guide wire)
• Diagnostiek:
• Controle atelectase na “one lung ventilation”
• Positie CVC / uitsluiten pneumothorax na CVC

Dubbel lumen ET: plaatsing
Controle: linker diafragma

Controle: rechter diafragma
Pneumothorax na punctie CVC

Casus S.J.
• Man, 81j, 71kg
• 1° AA voor CABG voor drietakslijden
• Medische antecedenten
– Tabagisme (rookstop 25j)
– Hypercholesterolemie
– Polyneuropathie OL
Casus SJ
• Inductie
– Vasculair acces voor inductie:14G IV / 20G art
– Sufentanil 50µg / midazolam 6mg / etomimidate 20mg /
cisatracurium 20mg
• Vlotte plaatsing ET en beademing
• Verder oplijnen
– 3-L CVC via li v.jug.int.: vlot
– Thermodilutie via re v.jug.int.
• Vlotte punctie
• Catheter schuift moeilijk op
• Blijvend ventriculaire curve: opgeschoven tot 60cm!!!
• Uiteindelijk weerstand bij terugtrekken van catheter

Wat nu gedaan???
Beeldvorming!!!
Scopie peroperatoir

Casus S.J.
• Poging tot “ontknoping”
– Verhogen rigiditeit catheter d.m.v. koude
infusievloeistof
– Guidewire opschuiven door catheter
→ geen succes
– Chirugische verwijdering catheter via
sternotomie
• Tachy-aritmie bij plaatsen klem op hartoortje
– Beta-blokkade, defibrillatie
– ST-afwijkingen
RX: diagnostiek

Echo (1)
• Regionale Anesthesie: peri,… cfr. infra
• Vasculaire acces (cfr. Les AVU: perifere
echo)
–CVC
– PICC’S
– (art.)
• Perifeer zenuwblock (cfr. Les AVU:
zenuwblocks)

Echo (2)
• Cardiac imaging (3-D)
– Inschatten cardiale functie tijdens cardiale
heelkunde
• Contractiliteit, RWMA,…
• Status kleppen
– Stenose
– Insuffuciëntie
– Diagnostiek: uitsluiten tamponade, enz. …
– Optimalisatie vullingsstatus

echocardio
Echo (3)
• Heartport: Mitral valve
• Echocardio:
– Uitsluiten contraindicaties:
• AI en/of “zieke Ao” → cardioplegie in ventrikel i.p.v. in
coronairen: geen bescherming hart
– 1° veneuze canule: v. jug. int. dr ane
• Controle positie / heparinisatie
– 2° veneuze canule: v. femoralis dr chirurg
• Controle positie: VCI, begin atrium
– Arteriële canule: a. femoralis dr chirug
• Controle positie seldinger in arterie
• Uitsluiten dissectie
• Controle positie ballon
– 3 cm boven AoK en onder tr.brachioceph. re
• Insufflatie ballon: vervangt AoX

• Transthoracaal
Echo (4)
– Uitsluiten pneumothorax
– Evaluatie pleurauitstorting
• bladderscan
Literatuur echo (1)
• Britisch Journal of Anaethesia, vol 94,
Number 1, jan 2005, Editorial 1
– Location, location, location! Ultrasound
imaging in regional anaesthesia
• Ultrasound imaging in pediatric regional
anesthesia, Rapp, Canadian Journal of An 51: 277-278
(2004)

Literatuur echo (2)
• Ultrasound imaging improves learning curves in obstetric
epidural anesthesia: a preliminary study.
Grau, Canadian J of ane 50: 1047-1050 (2003)
– Purpose:
• evaluate teaching possibilities of US as a diagnostic
approach to the epidural region
– Methods
• 2 groups of residents performed their first 60
obstetric epidurals under supervision
• Control group (CG): LOR technique
• Ultrasound group (UG): Prepuncture US followed by
LOR
Literatuur echo (3)
• Results: success rate
–CG:
• 60%±16%: peri 1 to 10
• 84%: peri 11 to 50
–UG:
• 86%±15%: peri 1 to 10
• 94%: peri 11 to 50
• Prepuncture ultrasound
– Location optimal puncture point
–Depth
– angle

Monitoring
• Oesophagale doppler
– Flow Aorta
– Volume optimalisatie bij majeure gastrointestinale
heelkunde
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