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[The summarization of clinical experience of difficult tracheal intubation].

OBJECTIVE: To summarize our experiences and lessons of difficult tracheal intubation for clinical anesthesia reference. METHODS: We had done a retrospective analysis of clinical data on difficult tracheal intubation in 2,825 patients undergoing elective plastic surgery with anesthesia. The main causes of difficult tracheal intubation were the limitations of neck extension (n = 1,169), mouth opening (n = 889), both neck extension and mouth opening (n = 698), and micromaxillary deformity (n = 69). By the Cormack's classification, all the patients had the laryngeal exposure of grade II or more. The tracheal intubations were done under neuroleptanalgesia combined with topical spray of local anesthetic in 439 patients, intravenous anesthesia of sedative drugs and nondepolarizing relaxants of subnormal doses in 629 subjects, and total intravenous or inhaled anesthesia in 1,757 cases, respectively. RESULTS: The difficult tracheal intubations were completed using blind nasal intubations in 142 patients, blind oral intubations with direct laryngoscope in 2,377 patients, oral intubations with fiberoptic stylet rigid laryngoscope in 186 patients, and oral or nasal intubations with flexible fiberoptic bronchoscope in 72 patients. The incidence of successful intubation was 99.7%. The common complication of intubation was airway trauma and its incidence was 19.3% in all the patients. Anesthetic techniques could affect significantly the intubation time and the incidences of complications in the patients with difficult intubation. CONCLUSIONS: By the improvement of anesthetic methods and common intubation techniques, the intubation time and the incidence of complications in the patients with difficult intubations were reduced.

Adolescent↗

Management of tracheal intubation in the respiratory intensive care unit by pulmonary physicians.

BACKGROUND: Expert management of tracheal intubation has become fundamental to the routine practice of pulmonary physicians who work in respiratory intensive care units (ICUs). In Italy, tracheal intubation is not included as part of the training in respiratory medicine, and pulmonary physicians are usually dissuaded from managing intubations. METHODS: We prospectively studied the intubation success rate in 46 consecutive respiratory ICU patients who required either emergency or urgent intubation, conducted by 3 intubation-trained pulmonary physicians in our respiratory ICU. Intubation success was defined as successful tracheal intubation without any of 7 pre-defined complications. RESULTS: There were 17 emergency intubations and 29 urgent intubations. Intubation was successful in 43 of the 46 intubation attempts. Complications occurred in 3 cases: 2 patients needed to be intubated by an anesthesiologist, and 1 patient received fiberoptic intubation. CONCLUSIONS: Pulmonary physicians trained in tracheal intubation can have a high success rate in performing intubation in the respiratory ICU. Collaborative efforts between anesthesiologists and pulmonary physicians are necessary to optimize the training, skill-retention, and back-up for advanced airway management in the respiratory ICU.

Aged↗

Rocuronium versus succinylcholine for rapid sequence induction intubation.

BACKGROUND: Patients requiring emergent endotracheal intubation often require a rapid sequence induction intubation (RSI) technique to protect against gastric aspiration, to facilitate intubation, or to protect against increased intracranial pressure. Succinylcholine is the most common muscle relaxant used because it has a fast onset and a short duration. Unfortunately it can have serious side effects as a result of it's membrane depolarizing effect and release of potassium. Rocuronium has been suggested to create intubating conditions similar to succinylcholine. Previous studies have been underpowered to determine equivalence and there has been no previous meta-analysis performed. OBJECTIVES: To determine if rocuronium creates comparable intubating conditions to succinylcholine during RSI intubation. Comparisons were made with succinylcholine based on the dose of rocuronium, use of a narcotic, emergent versus elective intubation, age group and the induction agent used. The primary outcome was excellent intubation conditions. A secondary outcome of clinically acceptable conditions was also performed. These were all dichotomous outcomes using cutpoints from a four point scale by Goldberg to evaluate intubation conditions. SEARCH STRATEGY: We searched MEDLINE (1966-March 2000), EMBASE (1988-March 2000) and the Cochrane Central Register of Controlled Trials (CENRAL) (March 2000) for randomized controlled trials (RCT) or controlled clinical trials (CCT) relating to the use of rocuronium and succinylcholine. Foreign language journals were included. References of identified studies were hand-searched for citations missed by the electronic searches. SELECTION CRITERIA: All trials meeting the inclusion criteria (comparison of rocuronium and succinylcholine, one of study's main outcomes was scoring of intubation conditions) were included. DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers for allocation concealment. The outcomes were combined using MetaView 4.1 with risk differences for all categories and RR for the excellent outcomes with a random effects model. MAIN RESULTS: 40 studies were identified; 26 were combined for analysis. Overall, rocuronium was inferior to succinylcholine, with a RR=0.87 (95%CI = 0.81 to 0.94) (N=1606). In the group that used propofol for induction of anaesthesia, the intubation conditions were similar, with a RR=0.96 (95%CI = 0.87 to 1.06) (N=640). No major adverse events were reported. REVIEWER'S CONCLUSIONS: Succinylcholine created superior intubation conditions to rocuronium when comparing excellent intubation conditions. Using the less stringent outcome, clinically acceptable intubation conditions, the two agents were not statistically different. Intubation conditions were not statistically different between succinylcholine and rocuronium when propofol was used.

Androstanols↗

[The laryngeal mask airway in the difficult intubation. The results of a prospective study].

OBJECTIVE: The laryngeal mask airway (LMA) was prospectively used in patients who were difficult to intubate to evaluate whether it improves ventilation compared to a face mask, facilitates fibreoptic intubation, and how often blind intubation would be possible. METHODS: In a university hospital, 30 patients who were difficult to intubate (35 operative procedures) and 50 normal subjects were investigated; 23 patients had had radical resection of a facial tumor with irradiation at a previous time and 7 could not be intubated conventionally (grade 3 and 4 visibility of the larynx according to Cormack [14]). Blind intubation was attempted with a bent bougie, a 6.0-mm uncuffed tube, or a straight bougie. RESULTS: Insertion of the LMA was possible in all except 1 patient with a mouth opening of 1 cm. Ventilation via the LMA was always excellent and, for tumor patients, superior to a face mask. In tumor patients, leak pressure was higher than in patients with normal cervical anatomy either with or without difficult intubation conditions (25.2 +/- 7.9, P < 0.05, vs. 20.8 +/- 4.4 vs. 20.6 +/- 4.9 cmH2O; n.s.; Fig. 2). Fibreoptic intubation through the LMA was successful in all cases and easier than via a nasal or oral route. Blind intubation was successful in 22% of difficult to intubate patients and 19% of normals, mainly using a 6.0 mm uncuffed endotracheal tube. Substitution of an uncuffed oral tube inserted via the LMA by a nasal endotrachel tube using a reinforced stomach tube is described (Fig. 4). CONCLUSION: The LMA improves ventilation, facilitates fibreoptic intubation, and offers the possibility for blind endotracheal intubation in difficult to intubate patients. Blind intubation though the LMA has to be practised extensively to have a high success rate. The LMA represents an additional aid for the anaesthetic management of patients who are difficult to intubate.

Anesthesia↗

Out-of-hospital endotracheal intubation and outcome after traumatic brain injury.

STUDY OBJECTIVE: Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury. METHODS: From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage). RESULTS: There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52). CONCLUSION: Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.

Adolescent↗

The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation.

One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic rapid sequence intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after intubation (post-intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-intubation aspiration, peri-RSI aspiration, and post-intubation regurgitation of vomitus or blood were determined. Patients with and without pre-intubation aspiration were compared with regard to pre- and post-intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-intubation aspiration and various demographic and clinical factors. The results showed that pre-intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-intubation regurgitation of vomitus or blood. Patients in the pre-intubation aspiration group required more intubation attempts, had a higher incidence of desaturations and lower pre- and post-intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.

Abbreviated Injury Scale↗

Airway management in the emergency department: a one-year study of 610 tracheal intubations.

STUDY OBJECTIVE: To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital. METHODS: This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record. RESULTS: A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest. CONCLUSION: At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications.

Adolescent↗

Effect of paramedic experience on orotracheal intubation success rates.

This study's objective was to determine the effect of paramedic experience on orotracheal intubation success in prehospital adult nontraumatic cardiac arrest patients. This retrospective study analyzed all attempted intubations of prehospital adult nontraumatic cardiac arrest patients between January 1, 1997 and April 30, 1997 in an urban, all ALS service. Data were abstracted from EMS reports and intubation data forms. Variables included months of experience, number of patients in whom intubation was attempted, number of intubation attempts, success per attempt, and success per patient. Ninety-eight paramedics performed 909 intubations on 1066 cardiac arrest patients, yielding an intubation success rate of 85.3%. The median months of experience was 59.5 (Range 5-223). The median number of patients in whom intubation was attempted per paramedic was 10 (Range 1-36). The mean intubation success rate per paramedic was 80.6% (+/- 22.4, 95% CI 76.1, 85.1). There was significant correlation between total number of patients in whom intubation was attempted and intubation success rate (p <.001, R = 0.32). There was no correlation between months of experience and intubation success rate. In conclusion, the number of patients in whom intubation was attempted per paramedic was significantly correlated with the intubation success rate. Months of experience per paramedic had no significant correlation with intubation success rate.

Clinical Competence↗

[Anesthesia induction with sevoflurane in adult patients with predictive signs of difficult intubation].

OBJECTIVE: This work was carried out to study induction with sevoflurane in adult patients with predictive signs of difficult intubation. STUDY DESIGN: Randomised prospective study. PATIENTS AND METHODS: The study had two parts. Part I: 15 patients without predictive signs of difficult intubation but with a cervical collar. Eight patients were anaesthetised with propofol 3 mg.kg-1 and fentanyl 2 micrograms.kg-1, seven with sevoflurane 8%. Part II: 20 patients with predictive signs of difficult intubation anaesthetised with sevoflurane 8%. RESULTS: In part I, all patients were intubated, the time for intubation was longer with sevoflurane, 6 vs 4 min. They were apneic only in the propofol group. After intubation, 7 cases of coughing (4 severe) occurred in the propofol group and 3 moderate coughing in the sevoflurane group. In part II, one patient experienced considerable agitation after oral airway insertion and was excluded. Other patients were intubated with sevoflurane. Seven patients were intubated with a bougie, three patients through an intubating LMA and one patient with a rigid bronchoscope. The other patients were intubated with a Macintosh blade. The mean time for intubation was 10 +/- 7 min and end tidal sevoflurane concentration after intubation was 4 +/- 0.6%. After intubation, 7 cases of coughing (3 severe) occurred but no desaturation < 95%. No significant haemodynamic variations occurred. CONCLUSION: Induction with sevoflurane 8% allowed tracheal intubation without major incidents. All patients breathed spontaneously. Sevoflurane can be recommended for induction in cases of predictive difficult intubation.

Adult↗

Clinical trial of a new lightwand device (Trachlight) to intubate the trachea.

BACKGROUND: Transillumination of the soft tissue of the neck using a lighted stylet (lightwand) is an effective and safe intubating technique. A newly designed lightwand (Trachlight) incorporates modifications to improve the brightness of the light source as well as flexibility. The goal of this study was to determine the effectiveness and safety of this device in intubating the trachea of elective surgical patients. METHODS: Healthy surgical patients were studied. Patients with known or potential problems with intubation were excluded. During general anesthesia, the tracheas were intubated randomly using either the Trachlight or the laryngoscope. Failure to intubate was defined as lack of successful intubation after three attempts. The duration of each attempt was recorded as the time from insertion of the device into the oropharynx to the time of its removal. The total time to intubation (TTI), an overall measure of the ease of intubation, was defined as the sum of the durations of all (as many as three) intubation attempts. Complications, such as mucosal bleeding, lacerations, dental injury, and sore throat, were recorded. RESULTS: Nine hundred fifty patients (479 in the Trachlight group and 471 in the laryngoscope group) were studied. There was a 1% failure rate with the Trachlight, and 92% of intubations were successful on the first attempt, compared with a 3% failure rate and an 89% success rate on the first attempt with the laryngoscope (P not significant). All failures were followed by successful intubation using the alternate device. The TTI was significantly less with the Trachlight compared with the laryngoscope (15.7 +/- 10.8 vs. 19.6 +/- 23.7 s). For laryngoscopic intubation, the TTI was longer for patients with limited mandibular protrusion and mentohyoid distance, with a larger circumference of the neck, and with a high classification according to Mallampatti et al. However, there was no relation between the TTI and any of the airway parameters for Trachlight. There were significantly fewer traumatic events in the Trachlight group than in the laryngoscope group (10 vs. 37). More patients complained of sore throat in the laryngoscope group than in the Trachlight group (25.3% vs. 17.1%). CONCLUSIONS: In contrast to laryngoscopy, the ease of intubation using the Trachlight does not appear to be influenced by anatomic variations of the upper airway. Intubation occasionally failed with the Trachlight but in all cases was resolved with direct laryngoscopy. The failures of direct laryngoscopy were resolved with Trachlight. Thus the combined technique was 100% successful in intubating the tracheas of all patients.

Adult↗

Facilitation of neonatal endotracheal intubation with mivacurium and fentanyl in the neonatal intensive care unit.

BACKGROUND: Endotracheal intubation in the neonate is painful and is associated with adverse physiological effects. Some premedication regimens have been shown to reduce these effects, but the optimal regimen is not yet determined. METHOD: Data on semi-elective intubations were prospectively collected in the neonatal intensive care unit over a six month period. Patients received 20 microg/kg atropine, 200 microg/kg mivacurium (a non-depolarising muscle relaxant) followed by 5 microg/kg fentanyl. RESULTS: Thirty three patients were electively intubated during this time period. The primary reason for intubation was surfactant administration (53%). Median (range) birth weight, gestational age, and age at intubation were 1360 g (675-4200), 29 weeks (25-38), and 33 hours (1-624) respectively. Twenty two of the infants were intubated on the first attempt. Median duration from initial insertion of the laryngoscope to successful intubation was 60 seconds (15 seconds to 20 minutes). In 18 cases, the first attempt was by a trainee with no previous successful intubation experience, 10 of whom intubated within two attempts. Muscle relaxation occurred at a mean (SD) of 94 (51) seconds, and mean (range) time to return of spontaneous movements was 937 seconds (480-1800). Intubation conditions were scored as excellent using a validated intubation scale. CONCLUSION: Effective analgesia can be administered and intubation performed with some brief desaturations, even when junior personnel are being taught their first intubation. In this first report of mivacurium for intubation in the newborn, effective bag and mask ventilation was easily achieved during muscle relaxation and was associated with excellent intubation conditions, permitting a high success rate for inexperienced personnel.

Analgesics, Opioid↗

Evaluation of the Bullard laryngoscope using the new intubating stylet: comparison with conventional laryngoscopy.

The Bullard laryngoscope (BL) is a new device for managing the difficult airway. Previous publications on the BL are primarily descriptive, and fail to use internal controls (i.e., determine the best intubating mechanism) or external controls (i.e., compare the BL to a known standard such as conventional laryngoscopy). Therefore, we attempted to determine the best of four intubating mechanisms described for the BL (independently styletted endotracheal tube [ETT], the Bullard intubating forceps, an ETT with a directional tip or the new dedicated intubating stylet) and to determine whether time to successful intubation with the BL using the best intubating mechanism correlates with conventional grade of laryngoscopic view. The new intubating stylet provided the optimal intubating method; fewer attempts were required (1.1 vs 1.7, P = 0.005), and it took less time to successful tracheal intubation (39 +/- 34 s vs 83 +/- 74 s, P = 0.004) compared to the three other intubating mechanisms. Our results also suggest that the time to successful intubation with the BL using the intubating stylet was not affected by the conventional laryngoscopic grade; it was just as easy (and difficult) to intubate a conventional Grade I laryngoscopic view patient (full glottic view) as it was to intubate a conventional Grade III laryngoscopic view patient (visualization of just the epiglottis) with the BL. There were two failed intubations with the BL (3%) due to an inability to trap the epiglottis.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

Lightwand-assisted intubation of patients in the lateral decubitus position.

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 +/- 13.4 s), left lateral (13.3 +/- 10.2 s), and right lateral positions (15.5 +/- 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.

Adult↗

Proficiency of pediatric residents in performing neonatal endotracheal intubation.

OBJECTIVE: Current guidelines of the Accreditation Council for Graduate Medical Education have restricted the amount of intensive care experience obtained during pediatric residency. The impact on performing procedures has not been evaluated. To determine the current level of competency in 1 common procedure, we investigated the proficiency of pediatric residents in performing neonatal endotracheal intubation during the academic years 1998-1999 and 2000-2001. METHODS: Indication for intubation, number of attempts, and achievement of success were recorded by the respiratory therapist present for the procedure. Each intubation was scored according to the attempt on which intubation was successful. Indications for intubation were categorized as respiratory failure, delivery room resuscitation, and meconium-stained amniotic fluid. Competency was defined as a successful intubation occurring on the first or second attempt >or=80% of the time. Intubation scores were compared between residents at various stages of training and analyzed by multivariate logistic regression analysis for significance. Comparisons were then performed to determine percentage success with confidence intervals. We also surveyed previous graduates of the training program not included in the observations for this study and asked them to indicate how frequently they perform intubation in current practice and to assess their own competence in the procedure. RESULTS: A total of 449 resident procedures were observed during the study periods: 192 by postgraduate year 1 (PGY-1) residents, 126 by PGY-2 residents, and 131 by PGY-3 residents. A total of 35% (160 of 449) of intubation procedures were never successful by pediatric house officers. Intubation was successful on the first or second attempt for 50% of PGY-1 residents (95% confidence interval [CI]: 42.6-56.8), 55% of PGY-2 residents (95% CI: 46-63.5), and 62% of PGY-3 residents (95% CI: 53.9-70.7). The third-year residents exhibited a significantly higher likelihood of performing a successful intubation compared with first-year residents. The first-year residents in 1998-1999 showed no improvement by their third year in 2000-2001. Surveys were sent to 56 graduates of our residency program (1998-2000). Completed surveys were received from 31 (66%) of 47. A total of 71% of the respondents are practicing general pediatrics, and 36% attend deliveries or perform intubations. A total of 87% reported that their level of confidence with endotracheal intubation was good or excellent after completion of residency training. CONCLUSIONS: We provide objective and subjective data concerning the proficiency of pediatric residents in performing neonatal endotracheal intubation. None of our resident groups met the specified definition of technical competence, although there was improvement with advancing training level in bivariate analyses. However, graduates of our training program felt confident with their intubation skills in contrast to our objective findings. As exposure to these important skills becomes limited, methods to ensure attainment of technical competency during training may need to be redefined.

Clinical Competence↗

The incidence of bacteremia associated with emergent intubation: relevance to prophylaxis against bacterial endocarditis.

STUDY OBJECTIVE: To examine the incidence of bacteremia associated with emergent nasotracheal intubation. STUDY DESIGN: Non-randomized, controlled cohort trial during 30 minutes post-intubation with limited in-hospital follow-up. SETTING: Emergency care unit and inpatient setting of a tertiary care facility. PATIENTS: Emergency care unit patients with acute respiratory distress necessitating non-elective emergency airway placement. MEASUREMENTS AND MAIN RESULTS: We studied 84 blood cultures obtained from 21 patients intubated emergently. Fourteen patients were intubated by the nasotracheal (NT) route and seven patients were intubated orotracheally (OT) for comparison. Pre-intubation and post-intubation blood cultures were obtained at two to five, 10 to 15 and 30 minutes after intubation. Patients were excluded if they had strong clinical evidence of pre-existing bacterial infection, had received antibiotics within 48 hours of presentation or were less than 16 years of age. Of the patients that were NT intubated, 29% (4/14) of patients became bacteremic after intubation. All had negative pre-intubation cultures. Organisms isolated were nasopharyngeal florae and included: Streptococcus viridans, Veillonellae sp., aerobic diphtheroids, and other mouth florae. Of the seven patients with OT intubation, six were culture negative. One was excluded because of positive preintubation cultures secondary to urosepsis. No patients in our study developed complications that could be directly attributed to these organisms or to intubation alone. CONCLUSIONS: The risk of bacteremia associated with emergency nasotracheal intubation is substantial and is accompanied by organisms that may produce serious morbidity in the patient with valvular heart disease or compromised immunity. Our findings suggest that, whenever possible, the nasotracheal route should be avoided for emergency intubation in patients with valvular heart disease and if used, prophylactic antibiotics should be strongly considered.

Aged↗

Field trial of endotracheal intubation by basic EMTs.

STUDY OBJECTIVE: The 1994 basic-EMT (EMT-B) curriculum recommended teaching EMT-Bs the skill of endotracheal intubation. In this study we assessed the success and complication rates of endotracheal intubations in the field by EMT-Bs. METHODS: We conducted a prospective clinical trial over a period of 28 months in an urban out-of-hospital EMS system. Four first-responder EMT-B engine companies with paramedic backup received 10 hours; intubation training in three sessions spread over at least 2 weeks. The training module was similar to that of the 1994 EMT-B curriculum and included at least 10 intubations on manikins. The EMTs used manikins with closed chest cavities to learn assessment of endotracheal-tube placement. Patients were eligible for intubation by the EMTs if they were apneic and older than 15 years. We calculated 95% confidence interval (CIs) for intubation success rates. RESULTS: Sixty-six EMT-Bs passed the training examinations and were authorized to perform intubation in the field. Endotracheal intubation was attempted by EMTs in 103 patients; the attempt was successful in 53 (95% CI, 42% to 61%). All patients who were not intubated by EMT-Bs were intubated by paramedics, with the exception of six cases. One attempt at intubation was made in 52 patients, two attempts in 44, and three in 7. Three unrecognized esophageal intubations occurred. CONCLUSION: EMT-Bs trained in a short course successfully intubated about half the patients they encountered in this study. This low intubation success rate calls into question the validity of the endotracheal-intubation training module in the 1994 EMT-B national curriculum.

Aged↗

[Intubation conditions and the development of neuromuscular blockade with rocuronium in endoscopic ORL surgery].

UNLABELLED: Rocuronium is a new nondepolarizing muscle relaxant for which a fast onset has been described. The goal of this study was to examine whether the characteristics of rocuronium could make it an appropriate relaxant for the anaesthetic management of operations of intermediate duration such as endoscopic upper airway surgery. These operations, which require the anaesthesiologist and surgeon to "share" the patient's airway, require good muscle relaxation for endotracheal intubation and placement of endoscopic instruments. In addition, the time course of neuromuscular blockade and its relation to the quality of intubating conditions were analysed. METHODS: The study was approved by the local ethics committee; 30 patients (ASA status 1-3) scheduled for elective endoscopic upper airway surgery were included after written informed consent. Exclusion criteria were suspected difficult intubating conditions, neuromuscular disease, or antibiotic therapy with aminoglycosides during the last 24 h. Anaesthesia was induced by propofol 2 mg/kg and alfentanil 1 mg after volume loading with 500 ml Ringer's lactate and preoxygenation, and was maintained by propofol infusion 5-8 mg/kg/h and repetitive alfentanil injections according to clinical needs. Endotracheal intubation was performed by a senior anaesthesiologist 90 s after injection of rocuronium 0.6 mg/kg (2 x ED95). Intubating conditions were graded 1 to 4 (1 = excellent, 2 = good, 3 = sufficient, 4 = inadequate). Acceleromyography was used for neuromuscular monitoring by means of the TOF-guard (organon Teknika/Biometer). The adduction movement of the thumb was measured by an acceleration transducer while stimulating the ulnar nerve at the wrist via surface electrodes in a supramaximal train-of-four (TOF) mode (2 Hz every 15 s). Twitch height and TOF ratio were documented during the course of neuromuscular blockade. Data are presented as mean +/- standard deviation. RESULTS: Patients were aged 37 to 64 years (mean 54 +/- 7). Intubating conditions were excellent in 17 cases and good in 7. In 2 cases intubating conditions were graded sufficient, as patients could be easily intubated but showed clear diaphragmatic movements at intubation. In 4 patients intubating conditions could not be judged, as a laryngoscopic view of the glottic structures was impossible for anatomic reasons. Neuromuscular block at intubation was 78 +/- 22%, onset time 152 +/- 62 s, clinical duration 30 +/- 8 min, and recovery index 11 +/- 4 min. The TOF ratio required 51 +/- 14 min to return to 0.7. CONCLUSIONS: Good to excellent intubating conditions can be expected 90 s after injection of rocuronium 0.6 mg/kg. Diaphragmatic reactions cannot be excluded. Complete relaxation of the adductor pollicis muscle is not necessary for endotracheal intubation. Intubation at a certain time interval, for example, 90 s after injection of rocuronium 0.6 mg/kg, can be recommended. Onset and recovery characteristics of rocuronium make it an appropriate relaxant for the anaesthetic management of operations of intermediate duration such as endoscopic upper airway surgery. Care should be given, however, to detect inadequate recovery of neuromuscular transmission, as there are considerable interindividual differences in recovery.

Adult↗

Comparative chronic toxicity and carcinogenicity of acrylonitrile by drinking water and oral intubation to Spartan Sprague-Dawley rats.

Groups of 100 male and 100 female Spartan Sprague-Dawley rats were administered lifetime oral doses of Acrylonitrile (AN) by one of two routes of dosing, either at 0.1 or 10 mg/kg per day, 7 day per week by intubation or continually at 1 or 100 ppm AN in their drinking water. The doses selected were designed to approximate the same daily intake of AN in each of two separate studies, whether by a single bolus dose (intubation) or a more continuous dosing regimen in drinking water. Each study had its own untreated control group of 100 rats per sex. In the drinking water study, the equivalent mean dosage of AN administered to males and females were 0, 0.09, and 0.15 mg/kg per day, respectively, at the 1 ppm level, and 0, 8.0 and 10.7 mg/kg per day, respectively, for 100 ppm dose groups. In both studies, groups of ten rats per sex were sacrificed at 6, 12 and 18 months and at study term. Ophthalmoscopic, hematological, clinical biochemistry, urinalysis and full histopathological exams were performed on control and high dose groups of rats in each study. Similar tests were done in lower dose groups, as required, to define dose-responses of observed effects. All animals were necropsied and underwent microscopic examination of target tissues, including brain, ear canal, stomach, spinal cord and any observable tissue masses. High dose male and female rats in both studies exhibited statistically decreased body weights. Food consumption and water intake were reduced only in the drinking water study. Due to increased deaths in groups of high dose rats of both studies receiving AN, all intubation test groups were terminated after 20 months of treatment. Surviving males and females in the drinking water study were terminated after 22 and 19 months, respectively. Small, sometimes statistically significant, reductions in hemoglobin, hematocrit and erythrocyte count were observed in male and female rats in both high dose (10 mg/kg per day intubation and 100 ppm drinking water) groups from both studies. There were increases in absolute or relative organ weight ratios for liver and adrenal in the high dose intubation study groups, but could not be correlated with AN toxicity in the absence of adverse clinical biochemistry or microscopic findings. Similar organ weight findings were not observed in the drinking water study. Again, there were no changes in clinical biochemistry or microscopic findings in these tissues. Absolute kidney weights were increased in high dose male and female rats in the intubation study and high dose female rats only in the drinking water study. Male and female rats from high dose groups in each study had a higher incidence of palpable masses of the head and the nonglandular stomach and, in females only, the mammary region. In both sexes, treatment-related tumors of the central nervous system (brain, spinal cord), ear canal, and gastrointestinal tract, and in females only, the mammary gland (intubation only) were observed in rats administered either 10 mg/kg per day by intubation or 100 ppm in drinking water. Animals from the intubation study had a substantially higher incidence of AN-related site-specific tumors than did their drinking water study counterparts. While a similar spectrum of tumors was produced by both oral dosing regimens, there were some notable differences in organ-specific incidence of tumors. Astrocytomas of the brain and spinal cord were found at a higher incidence in those rats exposed continuously to AN administered in the drinking water versus bolus dosing by intubation. Conversely, a higher incidence of squamous cell carcinomas/papillomas of the forestomach and adenocarcinomas of the intestine and, in females only, carcinomas of the mammary gland were observed in high dose rats receiving AN by intubation. An increase in the degree of severity of forestomach hyperplasia was observed in all high dose groups of animals, irrespective of mode of administration. These effects were more pronounced, were correlated with a much higher incidence of forestomach tumors, and were identified earlier (12 months) in the intubation study in which there was direct tissue contact with a more concentrated AN solution. Elevations in epidermal cysts in high dose males and females in the intubation study and renal hyperplasia in high dose animals of both sexes in both studies may have a treatment relationship. All other clinical and microscopic findings were considered unremarkable. There were no discernable non-neoplastic effects attributable to treatment in groups of low dose male and female rats given AN by intubation at 0.1 mg/kg per day or 1 ppm in drinking water. The results of this study indicate a consistent spectrum of neoplastic and non-neoplastic effects produced by AN in the same rat strain, whether administered orally by bolus or by continuous dosing in the drinking water. While the spectrum of tumors and target organ toxicity produced was similar, bolus dosing clearly increased tumors associated with the gastrointestinal tract. Neoplasms found in several other tissues were most prominently displayed in groups of more continuously dosed rats.

Acrylonitrile↗