Article The patient was the only person blinded to the intervention group. We recommend that ET cuff pressure be set and monitored with a manometer. 1984, 288: 965-968. CRNAs (n = 72), anesthesia residents (n = 15), and anesthesia faculty (n = 6) performed the intubations. Precaution was taken to avoid premature detachment of the loss of resistance syringe in this study. This is used to present users with ads that are relevant to them according to the user profile. Copyright 2017 Fred Bulamba et al. 10911095, 1999. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, http://www.biomedcentral.com/1471-2253/4/8/prepub. Accuracy 2cmH. This however was not statistically significant ( value 0.053) (Table 3). Figure 2. Frontiers | Evaluation of Endotracheal Tube Cuff Pressure and the Use Currently, in critical care settings, patients are intubated with ETT comprising high-volume low-pressure cuffs. Collects anonymous data about how visitors use our site and how it performs. The allocation sequence was generated by an Internet-based application with the following input: nine sets of unsorted sequences, each containing twenty unique allocation numbers (120). This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. There are data regarding the use of the LOR syringe method for administering ETT cuff pressures [21, 23, 24], but studies on a perioperative population are scanty. Most manometers are calibrated in? If an air leak is present, add just enough air to seal the airway and measure cuff pressure again. Young, and K. K. Duk, Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation, Korean Journal of Anesthesiology, vol. We did not collect data on the readjustment by the providers after intubation during this hour. 31. Kim and coworkers, who evaluated this method in the emergency department, found an even higher percentage of cuff pressures in the normal range (2232cmH2O) in their study. Anesth Analg. Compliance of the cuff system was evaluated by linear regression of measured cuff pressure vs. measured cuff volume. Uncommon complication of Carlens tube. 101, no. Endotracheal tube (ETT) insertion (intubation) What are the . This type of aneroid manometer is nearly as accurate as a mercury manometer, but easier to use [23]. JD conceived of the study and participated in its design. ETTs were placed in a tracheal model, and mechanical ventilation was performed. This category only includes cookies that ensures basic functionalities and security features of the website. 2003, 38: 59-61. 617631, 2011. The cuff is inflated with air via a one-way valve attached to the cuff through a separate tube that runs the length of the endotracheal tube. The distribution of cuff pressures achieved by the different levels of providers. H. Jin, G. Y. Tae, K. K. Won, J. LOR group (experimental): in this group, the research assistant attached a 7ml plastic, luer slip loss of resistance syringe (BD Epilor, USA) containing air onto the pilot balloon. ETT cuff pressure estimation by the PBP and LOR methods. The cookie is used to allow the paid version of the plugin to connect entries by the same user and is used for some additional features like the Form Abandonment addon. chin anteriorly), no lateral deviation, Open mouth and inspect: remove any dentures/debris, suction any secretions, Holding laryngoscope in left hand, insert it looking down its length, Slide down right side of mouth until the tonsils are seen, Now move it to the left to push the tongue centrally until the uvula is seen, Advance over the base of the tongue until the epiglottis is seen, Apply traction to the long axis of the laryngoscope handle (this lifts the epiglottis so that the V-shaped glottis can be seen), Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords, Remove laryngoscope and inflate the cuff of the tube with 15ml air from a 20ml syringe, Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning, Consider applying CO2 detector or end-tidal CO2 monitor to confirm placement, if it takes more than 30 seconds, remove all equipment and ventilate patient with a bag and mask until ready to retry intubation. Pelc P, Prigogine T, Bisschop P, Jortay A: Tracheoesophageal fistula: case report and review of literature. 5, pp. CAS This is a standard practice at these hospitals. This was statistically significant. Curiel Garcia JA, Guerrero-Romero F, Rodriguez-Moran M: [Cuff pressure in endotracheal intubation: should it be routinely measured?]. LOR = loss of resistance syringe method; PBP = pilot balloon palpation method. Anesthetists were blinded to study purpose. The difference in the number of intubations performed by the different level of providers is huge with anesthesia residents and anesthetic officers performing almost all intubation and initial cuff pressure estimations. The complaints sought in this study included sore throat, dysphagia, dysphonia, and cough. Consecutive available patients were enrolled until we had recruited at least 10 patients for each endotracheal tube size at each participating hospital. Nordin U, Lindholm CE, Wolgast M: Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation. Development of appropriate procedures for inflation of endotracheal The groups were not equal for the three different types of practitioners; however, determining differences of practice between different anesthesia providers was not the primary purpose of our study. Fernandez et al. A research assistant (different from the anesthesia care provider) read out the patients group, and one of the following procedures was followed. Volume + 2.7, r2 = 0.39. ismanagement of endotracheal (ET) tube cuff pressure (CP), defined as a CP that falls outside the recommended range of 20 to 30 cm H 2 O, is a frequent occur-rence during general anesthetics, with study findings ranging from 55% to 80%.1-4 Endotra-cheal tube cuffs are typically filled with air to a safe and adequate pressure of 20 to 30 cm H 2 The end of the cuff must not impinge the opening of the Murphy eye; it must not herniate over the tube tip under normal conditions; and the cuff must inflate symmetrically around the ETT.1 All cuffs are part of a cuff system consisting of the cuff itself plus . muscle or joint pains. Animal data indicate that a cuff pressure of only 20 cm H2O may significantly reduce tracheal blood flow with normal blood pressure and critically reduces it during severe hypotension [15]. Bunegin L, Albin MS, Smith RB: Canine tracheal blood flow after endotracheal tube cuff inflation during normotension and hypotension. This cookies is set by Youtube and is used to track the views of embedded videos. Endotracheal tubes are widely used in pediatric patients in emergency department and surgical operations [1]. 70, no. 21, no. If the tracheal lumen is in the appropriate position (i.e., it has not been placed too deeply), bilateral breath sounds will. This was a randomized clinical trial. distance from the tip of the tube to the end of the cuff, which varies with tube size. Google Scholar. For the secondary outcome, incidence of complaints was calculated for those with cuff pressures from 20 to 30cmH2O range and those from 31 to 40cmH2O. Inflation of the cuff of . A. Secrest, B. R. Norwood, and R. Zachary, A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement, American Journal of Nurse Anesthestists, vol. Independent anesthesia groups at the three participating hospitals provided anesthesia to the participating patients. PDF Endotracheal Tube Pressure Monitor - University of Wisconsin-Madison Mandoe H, Nikolajsen L, Lintrup U, Jepsen D, Molgaard J: Sore throat after endotracheal intubation. V. Foroughi and R. Sripada, Sensitivity of tactile examination of endotracheal tube intra-cuff pressure, Anesthesiology, vol. After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH2O. 2, pp. Air Leak in a Pediatric CaseDont Forget to Check the Mask! N. Lomholt, A device for measuring the lateral wall cuff pressure of endotracheal tubes, Acta Anaesthesiologica Scandinavica, vol. Our results thus fail to support the theory that increased training improves cuff management. Endotracheal Tube: Purpose, What to Expert, and Risks - Verywell Health (Supplementary Materials). Study participants were randomized to have their endotracheal cuff pressures estimated by either loss of resistance syringe or pilot balloon palpation. We evaluated three different types of anesthesia provider in three different practice settings. Does that cuff on the trach tube get inflated with air or water? This adds to the growing evidence to support the use of the LOR syringe for ETT cuff pressure estimation. A) Dye instilled into the normal endotracheal tube travels all the way to the cuff. 1990, 18: 1423-1426. M. H. Bennett, P. R. Isert, and R. G. Cumming, Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuffa randomized controlled trial, Anesthesia and Analgesia, vol. Cuff pressures less than 20 cmH2O have been shown to predispose to aspiration which is still a major cause of morbidity, mortality, length of stay, and cost of hospital care as revealed by the NAP4 UK study. Cuff pressure in tube sizes 7.0 to 8.5 mm was evaluated 60 min after induction of general anesthesia using a manometer connected to the cuff pilot balloon. Ninety-three patients were randomly assigned to the study. 12, pp. Measure 5 to 10 mL of air into syringe to inflate cuff. If the patient is able to talk, the cuff is not inflated adequately (air is vibrating the vocal cords). This cookie is set by Youtube and registers a unique ID for tracking users based on their geographical location. laryngeal mask airway [LMA], i-Gel), How to insert a nasopharyngeal airway (NPA), Common hypertensive emergencyexam questions for medical finals, OSCEs and MRCP PACES, Guedel Airway Insertion Initial Assessment of a Trauma Patient, Haemoptysis case study with questions and answers, A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway the gold standard of airway management), Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required), Patient cant protect their airway (e.g. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. It does not correspond to any user ID in the web application and does not store any personally identifiable information. Endotracheal Tube Cuff Leaks: Causes, Consequences, and Mana - LWW P. Biro, B. Seifert, and T. Pasch, Complaints of sore throat after tracheal intubation: a prospective evaluation, European Journal of Anaesthesiology, vol. Low pressure high volume cuff. Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques. Pediatr Pathol Lab Med. The distribution of cuff pressures (unadjusted) achieved by the different care providers is shown in Figure 2. Measured cuff volume averaged 4.4 1.8 ml. 1992, 74: 897-900. 2003, 29: 1849-1853. Numbers 110 were labeled LOR, and numbers 1120 were labeled PBP. C. Stein, G. Berkowitz, and E. Kramer, Assessment of safe endotracheal tube cuff pressures in emergency care - time for change? South African Medical Journal, vol. The intracuff pressure, volume of air needed to fill the cuff and seal the airway, number of tube changes required for a poor fit, number with intracuff pressure 20 cm H 2 O, and intracuff pressure 30 cm H 2 O are listed in Table 4. 2, pp. In addition, acquired laryngeal stenosis may be caused by mechanical abrasion or pressure necrosis of the laryngeal mucosa secondary to high cuff pressure [13, 14]. At this point the anesthesiology team decided to proceed with exchanging the ETT, which was successful. We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. Decrease the cuff pressure to 30 cm H2O by withdrawing a small amount of air from the balloon with a 10 mL syringe. 1996-2023, The Anesthesia Patient Safety Foundation, APSF Patient Safety Priorities Advisory Groups, Pulse Oximetry and the Legacy of Dr. Takuo Aoyagi, APSF Prevencin y Manejo de Fuegos Quirrgicos, APSF Prvention et gestion des incendies dans les blocs opratoires, Monitoring for Opioid-Induced Ventilatory Impairment (OIVI), Perioperative Visual Loss (POVL) Informed Consent, ASA/APSF Ellison C. Pierce, Jr., MD Memorial Lecturers, The APSF: Ten Patient Safety Issues Weve Learned from the COVID Pandemic, APSF Technology Education Initiative (TEI), Emergency Manuals Implementation Collaborative (EMIC), Perioperative Multi-Center Handoff Collaborative (MHC), APSF/FAER Mentored Research Training Grant, Investigator Initiated Research (IIR) Grants, Past APSF Consensus Conferences and Recommendations, Conflict in the Operating Room: Impact on Patient Safety Report from the ASA 2016 Annual Meetings APSF Workshop, Distractions in the Anesthesia Work Environment: Impact on Patient Safety. The ASA recommends checking all ETT cuffs prior to their use.1 While rare, endotracheal tube cuff defects are a known cause of endotracheal tube leaks which often necessitate endotracheal tube exchange. 1999, 117: 243-247. In low- and middle-income countries, the cost of acquiring ($ 250300) and maintaining a cuff manometer is still prohibitive. 111, no. It is used to either assist with breathing during surgery or support breathing in people with lung disease, heart failure, chest trauma, or an airway obstruction. At the time of the intervention, the study investigator retrieved the next available envelope, which indicated the intervention group, from the next available block envelope and handed it to the research assistant. This single-blinded, parallel-group, randomized control study was performed at Mulago National Referral Hospital, Uganda. Daniel I Sessler. [21] found that the volume of air required to inflate the endotracheal tube cuff varies as a function of tube size and type. Distractions in the Operating Room: An Anesthesia Professionals Liability? A wide-bore intravenous cannula (16- or 18-G) was placed for administration of drugs and fluids. Reed MF, Mathisen DJ: Tracheoesophageal fistula. Inflate the cuff with 5-10 mL of air. Both under- and overinflation of endotracheal tube cuffs can result in significant harm to the patient. 443447, 2003. Anesthetists were blinded to study purpose. Categorical data are presented in tabular, graphical, and text forms and categorized into PBP and LOR groups. Therefore, anesthesia providers commonly rely on subjective methods to estimate safe endotracheal cuff pressure. The compliance of the tube was determined from the measured cuff pressure (cmH2O) and the volume of air (ml) retrieved at complete deflation of the cuff; this showed a linear pressure-volume relationship: Pressure= 7.5. C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. Our first goal was thus to determine if cuff pressure was within the recommended range of 2030 cmH2O, when inflated using the palpation method. You also have the option to opt-out of these cookies. Ann Chir. However, less serious complications like dysphagia, hoarseness, and sore throat are more prevalent [911]. The patients were followed up and interviewed only once at 24 hours after intubation for presence of cough, sore throat, dysphagia, and/or dysphonia. An anesthesia provider inserted the endotracheal tubes, and the intubator or the circulating registered nurse inflated the cuff. 36, no. The exact volume of air will vary, but should be just enough to prevent air leaks around the tube. The tube will remain unstable until secured; therefore, it must be held firmly until then. Spay/Neuter Patient Care: Inflating an Endotracheal Tube Cuff protects the lung from contamination from gastric contents and nasopharyngeal matter such as blood. It does not store any personal data. Perhaps the LOR syringe method needs to be evaluated against the no air leak on auscultation method. C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. Step 10: Inflate cuff - Elentra Chest Surg Clin N Am. Alternatively, cheaper, reproducible methods, like the minimum leak test that limit overly high cuff pressures should be sought and evaluated. Privacy The cookie is used to store information of how visitors use a website and helps in creating an analytics report of how the website is doing. Data are presented as means (SD) or medians [interquartile ranges] unless otherwise noted; P < 0.05 was considered statistically significant. Catastrophic consequences of endotracheal tube cuff over-inflation such as rupture of the trachea [46], tracheo-carotid artery erosion [7], and tracheal innominate artery fistulas are rare now that low-pressure, high-volume cuffs are used routinely. (States: would deflate the cuff, pull tube back slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air entry). C. K. Cho, H. U. Kwon, M. J. Lee, S. S. Park, and W. J. Jeong, Application of perifix(R) LOR (loss of resistance) syringe for obtaining adequate intracuff pressures of endotracheal tubes, Journal of Korean Society of Emergency Medicine, vol. 18, no. We use this to improve our products, services and user experience. Outcomes were compared by tube size, provider, and hospital with either an ANOVA (if the values were normally distributed) or the Kruskal-Wallis statistic (if the values were skewed). This method has been achieved with a modified epidural pulsator syringe [13, 18], a 20ml disposable syringe, and more recently, a loss of resistance (LOR) syringe [21, 23, 24]. Volume+2.7, r2 = 0.39 (Fig. Endotracheal intubation in the dog | Lab Animal - Nature The tube is kept in place by a small cuff of air that inflates around the tube after it is inserted. In the absence of clear guidelines, many clinicians consider 20 cm H2O a reasonable lower limit for cuff pressure in adults. 2013 Aug;117(2):428-34. doi: 10.1213/ANE.0b013e318292ee21. Measured cuff pressures averaged 35.3(21.6)cmH2O; only 27% of the patients had measured pressures within the recommended range of 2030 cmH2O. Students were under the supervision of a senior anesthetic officer or an anesthesiologist. volume4, Articlenumber:8 (2004) SP oversaw day-to-day study mechanics, collected data on many of the patients, and wrote an initial draft of manuscript. This point was observed by the research assistant and witnessed by the anesthesia care provider. Seegobin and Hasselt reached similar conclusions in an in vitro study and recommended cuff inflation pressure not exceed 30 cm H2O [20]. B) Dye instilled into the defective endotracheal tube stops at the entrance of the pilot balloon tubing into the main tubing (arrow in Figure 2A and 2B). In addition, over 90% of anesthesia care at this hospital was provided by anesthetic officers and anesthesia residents during the study period. PDF ENDOTRACHEAL INTUBATION ADULT PERFORMANCE CRITERIA EMS Policy No. 2545 We tested the hypothesis that the tube cuff is inadequately inflated when manometers are not used. This cookie is set by Google analytics and is used to store the traffic source or campaign through which the visitor reached your site. Anaesthesist. The study was approved by the School of Medicine Research and Ethics Committee, Makerere University, and registered with http://www.clinicaltrials.gov (NCT02294422). We recognize that people other than the anesthesia provider who actually conducted the case often inflated the cuffs. Previous studies suggest that the cuff pressure is usually under-estimated by manual palpation. Article Although this was a single-blinded, single-centre study, results suggest that the LOR syringe method was superior to PBP at administering pressures in the optimal range. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs. 10, no. U. Nordin, The trachea and cuff-induced tracheal injury: an experimental study on causative factors and prevention, Acta Oto-Laryngologica, vol. Also, at the end of the pressure measurement in both groups, the manometer was detached, breathing circuit was attached to the ETT, and ventilation was started. Hahnel J, Treiber H, Konrad F, Eifert B, Hahn R, Maier B, Georgieff M: [A comparison of different endotracheal tubes. . Tube positioning within patient can be verified. Necessary cookies are absolutely essential for the website to function properly. Vet Anaesth Analg. We enrolled adult patients scheduled to undergo general anesthesia for elective surgery at Mulago Hospital, Uganda. Endotracheal Tube Cuff Inflation Pressure Varieties and Response to if GCS <8, high aspiration risk or given muscle relaxation), Potential airway obstruction (airway burns, epiglottitis, neck haematoma), Inadequate ventilation/oxygenation (e.g. Aire cuffs are "mid-range" high volume, low pressure cuffs. Morphometric and demographic characteristics of the patients were similar at each participating hospital (Table 1). Lomholt et al. These were adopted from a review on postoperative airway problems [26] and were defined as follows: sore throat, continuous throat pain (which could be mild, moderate, or severe), dysphagia, uncoordinated swallowing or inability to swallow or eat, dysphonia, hoarseness or voice changes, and cough (identified by a discomforting, dry irritation in the upper airway leading to a cough). PDF Tracheostomy Tube Reference Guide - UC Davis Previous studies suggest that this approach is unreliable [21, 22]. 6, pp. Endotracheal tubes | Anesthesia Airway Management (AAM) 10, pp. These included an intravenous induction agent, an opioid, and a muscle relaxant. Airway 'protection' refers to preventing the lower airway, i.e. The integrity of the entire breathing circuit and correct positioning of the ETT between the vocal cords with direct laryngoscopy were confirmed. 3, p. 965A, 1997. When this point was reached, the 10ml syringe was then detached from the pilot balloon, and a cuff manometer (VBM, Medicintechnik Germany. The optimal technique for establishing and maintaining safe cuff pressures (2030cmH2O) is the cuff pressure manometer, but this is not widely available, especially in resource-limited settings where its use is limited by cost of acquisition and maintenance. studied the relationship between cuff pressure and capillary perfusion of the rabbit tracheal mucosa and recommended that cuff pressure be kept below 27 cm H2O (20 mmHg) [19]. One such approach entails beginning at the patient and following the circuit to the machine. 3, pp. Accuracy 2cmH2O) was attached. Novel ETT cuffs made of polyurethane,158 silicone, 159 and latex 160 have been developed and . Anesth Analg. However, a full hour was plenty of time for the provider to have checked and adjusted cuff pressure to a suitable level. 9, no. Used by Google DoubleClick and stores information about how the user uses the website and any other advertisement before visiting the website. This is an open access article distributed under the, PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient. Male patients were intubated with an 8 or 8.5 mm internal diameter endotracheal tube, and female patients were intubated with a 7 or 7.5 mm internal diameter endotracheal tube. The study would be discontinued if 5% of study subjects in one study group experienced an adverse event associated with the study interventions as determined by the DSMB, or if a value of <0.001 was obtained on an interim analysis performed halfway through patient accrual. Nitrous oxide and medical air were not used as these agents are unavailable at this hospital. At the University of Louisville Hospital, at least 10 patients were evaluated with each endotracheal tube size (7, 7.5, 8, or 8.5 mm inner diameter [Intermediate Hi-Lo Tracheal Tube, Mallinckrodt, St. Louis, MO]); at Jewish Hospital, at least 10 patients each were evaluated with size 7, 7.5, and 8 mm Mallinckrodt Intermediate Hi-Lo Tracheal Tubes; and at Norton Hospital, 10 patients each were evaluated with size 7 and 8-mm Mallinckrodt Intermediate Hi-Lo Tracheal Tubes. Even with a 'good' cuff seal, there is still a risk of micro-aspiration (Hamilton & Grap, 2012), especially with long-term ventilation in the . trachea, bronchial tree and lung, from aspiration. Heart Lung. Support breathing in certain illnesses, such . Cuff pressure is essential in endotracheal tube management. . Compared with the cuff manometer, it would be cheaper to acquire and maintain a loss of resistance syringe especially in low-resource settings. 7 It has been shown that the best way to ensure adequate sealing and avoid underinflation (or overinflation) is to monitor the intracuff pressure periodically and maintain the intracuff pressure within All patients with any of the following conditions were excluded: known or anticipated laryngeal tracheal abnormalities or airway trauma, preexisting airway symptoms, laparoscopic and maxillofacial surgery patients, and those expected to remain intubated beyond the operative room period. The manual method used a pressure manometer to adjust pressure at cruising altitude and after landing. Cite this article. El-Orbany M, Salem MR. Endotracheal tube cuff leaks: causes, consequences, and management. How to insert an endotracheal tube (ETT) Equipment required for ET tube insertion Laryngoscope (check size - the blade should reach between the lips and larynx - size 3 for most patients), turn on light Cuffed endotracheal tube Syringe for cuff inflation Monitoring: end-tidal CO2 monitor, pulse oximeter, cardiac monitor, blood pressure Tape Suction Because cuff inflation practices are likely to differ among clinical environments, we evaluated cuff pressure in three different practice settings: an academic university hospital and two private hospitals. Cuff pressure can be easily measured with a small aneroid manometer [23], but this device is not widely available in the United States. 1mmHg equals how much cmH2O? In our study, 66.3% of ETT cuff pressures estimated by the LOR syringe method were in the optimal range. This outcome was compared between patients with cuff pressures from 20 to 30cmH2O range and those from 31 to 40cmH2O following the initial correction of cuff pressures. Cuff pressure should be maintained between 15-30 cm H 2 O (up to 22 mm Hg) . Although it varied considerably, the amount of air required to achieve a cuff pressure of 20 cmH2O was similar with each tube size. Inject 0.5 cc of air at a time until air cannot be felt or heard escaping from the nose or mouth (usually 5 to 8 cc). Anesth Analg. Comparison of distance traveled by dye instilled into cuff. S. Stewart, J. 1, p. 8, 2004. Springer Nature. Manage cookies/Do not sell my data we use in the preference centre. If the silicone cuff is overinflated air will diffuse out. The high incidence of postextubation airway complaints in this study is most likely a site-specific problem but one that other resource-limited settings might identify with. There was no correlation between the measured cuff pressure and the age, sex, height, or weight of the patients. 10.1007/s001010050146. Clear tubing. The anesthesia providers were either physician anesthetists (anesthesiologists or residents) or nonphysicians (anesthetic officer or anesthetic officer student).

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