 There we go. Thank you. So thank you Dr. Papa for the introduction and I'd like to thank you and the organizing committee for the invitation for this very important symposium. So I'll be here today talking about point of care uh Utterson for Error Management. Sorry just a second let me there we go and uh as my conflict of interest disclosure I just want to inform that I was granted with the 2022 Society of Error Management Research Award in a study that were performing a related area with the presentation. So as learning objectives we're going to discuss area protocols for four main points identification of the criteria of membrane confirmation of endotracheal intubation, Utterson guided percutaneous stratostomy and the ability to predict difficult area with area Utterson. So the first topic identification of the cricotyled membrane and I would say that the point of the start for growing interest with that was once the airway guidelines start to make it a little bit shorter to reach front of neck access. This is the Default Airway Society guideline that was published in 2015 as you can see the plan D that's emerging front of neck access when you reach a situation of cannot intubate cannot oxygenate is much closer to your first plan that's plan A if you compare with other guidelines that were published before that notably the ASA American Society of Anesthesiologists guidelines. Another point that these guidelines highlighted that cricotyledotomy would be the technique of choice for front of neck access. So once these start to be established there was more interested in studying the cricotyledotomy and studying as well how to find the cricotyled membrane. So first a few studies were published about the at that point the common sense technique that was identifying the cricotyled membrane by palpation. So you can see on this slide on the top and on the right bottom two studies that look into what was the accuracy of palpation of the neck landmarks and the cricotyled membrane and they show that amongst several professionals in different specialties like anesthesiologists, immersion department physicians and trauma surgeons the accuracy was only around 50 percent and one study from our group that cited that you can see at the bottom left in even like specific populations like obese woman parturians in labor this accuracy could go as low as 39 percent. At this point people got interested as well what other devices could use to help on this subject and in 2015 Dr. Christensen from Denmark and Dr. Teo from Singapore they published this they published this article highlighting all the details about the ultrasonographic identification of the cricotyled membrane and after that more interesting research about using ultrason for identification the cricotyled membrane they start to show up and then we have like at our site we we had several studies about this subject and we are able to not only show that ultrason was superior to the palpation technique for defining cricotyled membrane in patients with poorly defined neck landmarks but also that using ultrason will make it easier to perform cricotyled autonomy. So just to show you guys the technique for identify the cricotyled membrane for biultrason here we have a neck of a person and then we have a draw of the structures of interest and you can see that the the structure with the letter C is the tyroid membrane you have the cricoid cartilage with the letter E and in between you have a letter D the cricotyled membrane so this is what we want to find and here I can I'm going to show you there are two approaches that we can use for identify the cricotyled membrane by ultrason we have the transverse and the longitudinal approach the transverse is always also called taka and I'm going to explain why why is that and the the longitudinal is called the strings of purse so this is the taka technique the first the upper line you can see the tyroid cartilage so on the left you can see the probe on the neck of a patient in the middle you can see the ultrasonographic image in the right you have like the structures highlighted by a blue blue lines so you can see at the top that you have the tyroid that's a structure in a v inverted v shape when you scroll down a little bit your your your probe you're going to see like a small right line that's actually air interface when you reach your cricot cartilage membrane so we have like a very bright line a small bright line then once you push your probe a little bit lower on your neck you're going to start to see a structure that's in form of a c and this is your cricot cartilage once you have this image you know that you pass already your cricot tyroid membrane so then you can go up again on your probe and find the second image again and then you know that you're in the the correct level for the cricot tyroid membrane for this approach sometimes it's a little bit challenging to find the structure so if you're having difficulty you can just go to your supra sternum notch and then place the probe there find the trachea first and then you go up and find the other structures the other approach would be the longitudinal approach or the longitudinal approach and then in here you start from this sternum notch you find the trachea you move your probe to the side as you would be cutting your trachea so you can see these on the second line the trachea is the the big rounded shadow in the upper line but in the second line you go and move your probe and then you cut your trachea in half and then you turn your probe 90 degrees and then you should see this image on the third line when you have several small rounded structures that are hypercoic so they are black and these are the trachea rings just below the trachea rings you are going to have a bright line again that's just the air interface that you have from the air in the trachea once you find this image you can just move your probe a little bit cephalic and then in after a little bit of movement you are going to find a big rounded structure that you can see at the bottom line as the highlighted in in green and as you move the probe a little bit and this structure will be a little bit higher on your image and this will be the cricoid cartilage then if you move a little bit higher you're going to have another bigger structure similar size of the cricoid that will be the thyroid cartilage and this is highlighted by the purple circle in the last line and between these two structures you're going to have the cricoid thyroid membrane you can use a needle can be an epidural needle or like a an IV catheter needle and then create a shadow to make sure that you are into the cricoid thyroid membrane and you can mark after you remove your probe mark your cricoid thyroid membrane so we have two techniques in general the longitudinal technique is more accurate but is ideal to have proficiency in both because there are a few situations that you're not going to be able to use the longitudinal one and that will be when you have a really short neck this might be a problem and the other situation will be if you have a little bit like of your your midline distorted from the center you might be difficult to find in the longitudinal approach so in these situations the tacca that stands for thyroid air cricoid air the tacca the approach will be the best one to use so once the technique was described and I just described it for you guys here as well is it difficult to learn so another study from our group at Sinai we are able to to evaluate it how trainees will will do trying to identify the cricoid thyroid membrane after two hours of training and actually our group find that they are they were able to achieve competency after only 20 attempts and they were able to keep these competencies after three months and off note for this study after the meantime for finding the cricoid thyroid membrane was around 36 seconds just after they train the first time however after this primary study showing that the the identification of the cricoid thyroid membrane by uterus one was more accurate than that by palpation more studies show that the time for this identification would be around 30 seconds and some studies up to 60 seconds so we start to have a conversation and discussion among the among error experts this is this feasible when you have like a situation that you have a canteen to bake can oxygenate situation when you are passing from the plan c to the plan d on your difficult error algorithm and even in this time was after your uterus one was ready to go and turn on so most likely when your patients it is the setting and going south is not the best moment to do this procedure however what's going what's being advocated right now that will be that we should move and use the cricoid thyroid membrane identification as a prep procedure evaluation part of our error evaluation before we start the error management on the patients this should be done in in in patients that we identify that we might have any any difficult during the error management and this could be done when we go see the patient in the the prep procedure area just a few minutes before the before the the the surgery starts and I would say that maximum two minutes we need after you have competencies in this technique sorry so this is the second topic that we're going to talk is the confirmation of endotrache intubation by uterus so we have we have a really good literature support on this technique to the point that we have at least three systematic reviews and meta-analysis on the topic and this meta-analysis where they were they made sorry they were made in the emergency department and ICU setting and I would say that this technique maybe will not be so interesting for anesthesiologists because we have the majority of our patients in a controlled environment and they are most of the time stable but when you look into the position that our colleagues that ED and ICU they are when they manage every the things are not so white and black so I believe that this will be a technique that they could certainly use to confirm that the patients are we have endotrache intubation and all this meta-analysis with a good number of patients even one more 2500 they show that the for this technique we have a sensitivity above 90% and a specificity above 84% so it's a really really reliable technique so I just want to show you what we could see on this technique so if you look first to the image on the left you're going to see an image and the bigger rounded area with the air interface again so that will be the upper yellow arrow you have the trachea and on the lower yellow arrow you can see the esophagus with the outside and inside wires and you can see that is a a collapsed structure so this is a very good image it's always challenging to see the esophagus but here is really clear that's there when you look into the the middle image you can sometimes are going to have the bullet sign when you have the endotracheal tube into the trachea so that means that you're going to have a really firm shadow because the endotracheal tube is there and you have this bullet sign but the most important image here will be the one on the right side because here we have an image from for esophageal intubation okay and this is what we call the double track image the double track sign so what you have here on the left part you actually have like your bigger rounded structure that's the trachea with the air area sorry the air interface so you have the bright lines but you have another image a little bit lower in the center also with air interface so that means this is the esophagus with the endotracheal tube inside and because you have air inside the endotracheal tube you have air interface there so that means that you have the double track sign and this is an esophageal intubation this this technique despite have a high accuracy as we see in the systematic reviews there is a pivot there is a backlash if your esophagus is below the trachea then you're not going to be able to use this technique however we have confirmation from other studies a few studies actually on the how cryoid pressure changed the positions but doing MRIs in healthy patients without cryoid pressure you can see that majority of times esophagus is actually on the left of the trachea left the posterior part of the trachea and only a few percentage of them will be just posteriorly to the trachea the next technique that I would like to talk about and in this presentation I'm doing like from the the one that we have more literature to support is more well documented in literature the one that's last the next one will be the use the uterus on guided percutaneous tracheostomy despite this technique also would be a technique that will be maybe use it probably use it more from our ic colleagues but I would say that would be a technique that anesthesiologist will have like facility to use because it mainly reproduces what we do when we're doing like a central line or when we're doing a regional anesthesia block so on the top two images this is what they call the out of plane technique so in the middle of the image you can see again around the structure that's the trachea and if you look into the image on the top left letter c you're going to see above the trachea a dot a white dot and this is actually the tip of your needle so what you need to do you just follow the tip of your needle until it reaches the trachea with your trusson beam at the bottom both images you can see actually all your needle because you're doing an in-plane approach and then again you can see on the left bottom the image under letter e you can see a line that comes from the top left end of the image and goes all the way until it touches the trachea so these are both techniques that you can use for percutaneous tracheostomy guided by ultrasound and the thing that we want need to be in mind the the limitation of this technique is that once you enter the trachea because you have air interface and you cannot look into the air with the ultrasound what happens is you cannot see the tip of the needle you cannot see the wire that introduced because normally we use like a silicon technique and you cannot see even like the tracheostomy tube balloon so this is a limitation of technique in terms of literature we have first the first study on the top left is a comparison about like doing it with by palpation with ultrasound and it showed that these students show lower peroperative complications with ultrasound guided technique 7.82 percent to 15 percent however it was a small study so there was no statistical significance but there was a lower number of multiple attempts in the ultrasound group and these was like 4 percent to 13 percent and was statistically significant. The second study at the bottom is a comparison of three techniques the in-plane out-plane out-of-plane and palpation techniques and the out-of-plane technique had fewer punctures lower complications and higher first entry success. This is another study comparing then ultrasound to bronchoscopy guided percutaneous tracheostomy and it showed that the rate of air was this equal between both groups despite the number of minor complications being a little bit higher in the ultrasound guided technique 32 percent to 20 percent but also was not statistically significant so ultrasound guided percutaneous might be as safe as bronchoscopy one. And now I just want to spare a few minutes talking about prediction of difficult airway by ultrasound that's the topic that was like this is the hot topic right now and there are many many studies that came out in the last years about how to predict the difficult langoscopy difficult intubation or difficult bag mass ventilation by ultrasound and there are many many parameters that had been studied above around 28 actually so this is mainly how we do is in the submanibular space that we're going to do the measurements you can do also or as you can see on the left longitudinal approach and here you can see a few parameters like a high elemental distance, tone thickness, the height of your your tongue as well and the other side you can use like the transverse approach to see how the tone concessional area for example so this will be the true approach and there are so many so many small studies on there this is a limitation several small studies that actually had like two systematic reviews a meta-analysis published on this topic already one in 2021 and one now in April 2022 and these these two systematic reviews they showed that the the parameter that was most studied and seems more promising right now will be the distance from a skin to a big lotus however all these these both meta-analysis agreed that the studies are low to very low quality of evidence and there is a high journey between the studies and why is that because we have so many parameters and the way that the studies are done they check the parameters by ultrasound they they make the error in management then they divided the patients into the easy category and difficult category by the error management and then they review the parameters so the number of the difficult areas of course are much smaller in these meta-analysis from analgesia analgesia they went a little bit further and they said that because the cutting off measurements they are not well-defined so this is a barrier to understand how this can be used but they went on this systematic review above and they said from the distance from skin to epiglottis maybe two to above two or two point five centimeters might be an indication of difficult lineroscopy so more studies will definitely come on that I think is promising but we need to wait a little bit more to have more precise indications on that and that's all that I have to talk about thank you very much again for the opportunity and I'm open to any questions at the end of the session I'm going to stop sharing now