14. • Time (& timing) is of the essence
• First attempt ≈ best attempt
• Waking is (often) not an option
• “If at first you don’t succeed...” (?)
ICU intubations
20. In short:
•ICU patients requiring intubation are sick
•Your first device should be the best device
•Macintosh = old, low-tech and out-of-spec
A videolaryngoscope - with a standard
geometry blade - should be the ICU device
of choice for critically ill airways
21. Any questions or comments?
(I have no C.O.I. to declare)
THANKYOU
Editor's Notes
Hello - Liam Scott, Anaesthetic Reg from Severn Deanery
I’m going to show you exactly what ICM can do without
This is my presentation - VKTMS
Hello - Liam Scott, Anaesthetic Reg from Severn Deanery
I’m going to show you exactly what ICM can do without
This is my presentation - VKTMS
Welcome to ICU - the sharpest of sharp ends in hospital medicine
A state of the art forum - use the best staff, the latest technology, cutting edge science
to help the sickest patients in their darkest hour
And yet... modern ICU remains stuck in the past in one respect
Up and down the country, around the world, we find ourselves beholden to an archaic piece of airway equipment
Reach for it when our patients at most vulnerable, most in need all ICU has to offer
It is of course the Mac laryngoscope, the so-called “gold standard” airway device
This low tech tool, this relic of resuscitation that has become a WMD on the ICU.
A history lesson to frame this
It’s 1888 and Alfred Kirstein from Germany performed the first DL with his modified oesophascope. He was inspired / motivated by the recent death of Emperor Frederick III, who died after reigning for just 99 days with a large larnygeal tumour.
After some early refinements - Janeway laryngscope - (i.e. a handle, a curved blade, an integral battery) there have been essentially no improvements for the last 100 years. Macintosh weighed into the fray in 1943 with what has essentially become the go-to DL blade of choice around the world. It’s smart, small, simple and effective.
SO what’s my problem with the humble, old fashioned Mac in ICU...?
Who cares as long as the plastic get between the vocal cords, right? tried and tested? WRONG!
This is not theatre. These are not healthy, staffed, stable patients in elective situations.
Videolaryngoscopes have revolutionised airway management in the last few years
Now numerous devices on the market, in many shapes and forms
But crucially, they get us into the larnyx of these sickest of patients.
VL has been shown to have many positive effects
Just to be clear on terminology - not arguing against DIRECT laryngoscopy itself
This is NOT about DL vs VL
VL simply means camera on blade. The best VL blades are standard geometry, and capable of indirect and direct views
The problem with Mac blades are that they are only capable of DL.
Reduced spec compared to VL devices with standard geometry blades. Best of both world
Intubating in ICU is not like in theatre!!
Unwell patients - hypoxic, CVS and resp unstable, compromised airways
They are not starved, pre-screened, elective patients in controlled environment
Your first device should be your best device
If you can get a direct view - great. Shove that tube in.
But if you can’t see diddly on direct, then without changing device you have a camera in the larynx
Your primary device needs to be idiot proof
Your opinions about this topic will depend heavily upon which of two camps camps you fall into,
whether you consider novel technological innovations either something to be embraced and championed, or feared and mistrusted, whether you are attracted to or repulsed by this typewriter.
The other people likely to be offended by this are of course - anaesthetists, and anyone working in theatre
Robert Reynolds Macintosh, I salute you.
May your invention forever continue to be used in theatres around the land for slim, fasted, elective, stable patients with straightforward airways...
But please don’t bring it on to my ICU, where it is wheeled as an antiquated implement of death and destruction in inexperienced hands. It is no longer needed. We have VL devices with standard geometry blades. For these patients your device is now obsolete
