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PubMedDate not supplied

Failed prehospital intubations: an analysis of emergency department courses and outcomes.

OBJECTIVE: To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). METHODS: Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. RESULTS: During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of "truly difficult" intubation in this system is approximately 0.8-1.6%. CONCLUSIONS: Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were "truly difficult" and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

Adolescent↗
PubMedDate not supplied

Comparison of times to intubate a simulated trauma patient in two positions.

BACKGROUND: The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients. OBJECTIVES: The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient. METHODS: Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27 degrees, resulting in 7 degrees of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with chi2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position. RESULTS: Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 +/- 19.0 seconds vs 27.9 +/- 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007). CONCLUSIONS: Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.

Airway Obstruction↗
PubMed1998

Nasotracheal intubation in patients with immobilized cervical spine: a comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy.

UNLABELLED: Tracheal intubation may pose problems in patients with cervical spine injury (CSI). In patients without CSI, the success rate of blind nasotracheal intubation is increased by endotracheal tube (ETT) cuff inflation in the pharynx. The purpose of this study was to assess the efficacy of ETT cuff inflation in the pharynx as an aid to blind nasotracheal intubation in patients with an immobilized cervical spine. The technique was compared with fiberoptic bronchoscopy. Twenty ASA physical status I and II patients undergoing elective surgery in which the trachea was to be intubated nasally were enrolled in this prospective, randomized study. The cervical spine of each patient was immobilized. The trachea of each patient was intubated twice, once using fiberoptic bronchoscopy and once blindly using the technique of ETT cuff inflation in the pharynx. A maximum of three attempts was allowed for intubation using ETT cuff inflation. A maximum of 3 min was allowed for intubation using fiberoptic bronchoscopy. When ETT cuff inflation was used, intubation was successful in 19 of 20 patients (95%); the first attempt at intubation was successful in 14 of 20 patients (70%). Intubation was successful in 19 of 20 patients (95%) when using fiberoptic bronchoscopy. Mean times to intubate were 20.8 +/- 23 s when the ETT cuff was inflated in the pharynx and 60.1 +/- 56 s when using fiberoptic laryngoscopy (P < 0.01). We conclude that both ETT cuff inflation in the pharynx and fiberoptic bronchoscopy are valuable for nasotracheal intubation in patients with an immobilized cervical spine and that ETT cuff inflation can be used as an alternative to fiberoptic bronchoscopy in patients with CSI. IMPLICATIONS: We compared the technique of endotracheal tube cuff inflation in the pharynx for blind nasotracheal intubation in patients with an immobilized cervical spine with fiberoptic bronchoscopy. There was no significant difference between the success rates of the techniques.

Adolescent↗
PubMed2001

Effect of cricoid pressure on the success of endotracheal intubation with a lightwand.

BACKGROUND: The lightwand may be useful as an alternative for tracheal intubation during a rapid-sequence induction of anesthesia in the presence of a full stomach. This study was undertaken to assess the effect of application of cricoid pressure on the success of lightwand intubation. METHODS: Sixty adult female patients presenting for abdominal hysterectomy were randomly allocated to lightwand intubation with and without cricoid pressure. The time to successful intubation and number of attempts were recorded. RESULTS: All 30 patients allocated to intubation without cricoid pressure were intubated successfully at the first attempt within a median time of 28 s (95% confidence interval, 18-77 s). Lightwand intubation with cricoid pressure was successful in 26 of 30 patients at the first attempt, but the median time to successful intubation was significantly longer at 48.5 s (95% confidence interval, 36-78 s; P = 0.001). Three patients required two attempts for successful intubation, and one could not be intubated with the lightwand while cricoid pressure was being applied. CONCLUSIONS: The lightwand cannot be recommended for the first attempt at intubation where cricoid pressure is being applied because the time to successful intubation is significantly prolonged, and the failure rate for the first attempt at lightwand intubation is 13%.

Adult↗
PubMed2005

Cricoid pressure does not increase the rate of failed intubation by direct laryngoscopy in adults.

BACKGROUND: Cricoid pressure (CP) is applied during induction of anesthesia to prevent regurgitation of gastric content and pulmonary aspiration. However, it has been suggested that CP makes tracheal intubation more difficult. This double-blind randomized study evaluated the effect of CP on orotracheal intubation by direct laryngoscopy in adults. METHODS: Seven hundred adult patients undergoing general anesthesia for elective surgery were randomly assigned to have a standardized CP (n = 344) or a sham CP (n = 356) during laryngoscopy and intubation. After anesthesia induction and complete muscle relaxation, a 30-s period was allowed to complete intubation with a Macintosh No. 3 laryngoscope blade. The primary endpoint was the rate of failed intubation at 30 s. The secondary endpoints included the intubation time, the Cormack and Lehane grade of laryngoscopic view, and the Intubation Difficulty Scale score. RESULTS: Groups were similar for demographic data and risk factors for difficult intubation. The rates of failed intubation at 30 s were comparable for the two groups: 15 of 344 (4.4%) and 13 of 356 (3.7%) in the CP and sham CP groups, respectively (P = 0.70). The grades of laryngoscopic view and the Intubation Difficulty Scale score were also comparable. Median intubation time was slightly longer in the CP group than in the sham CP group (11.3 and 10.4 s, respectively, P = 0.001). CONCLUSIONS: CP applied by trained personnel does not increase the rate of failed intubation. Hence CP should not be avoided for fear of increasing the difficulty of intubation when its use is indicated.

Adult↗
PubMed2006

Lightwand tracheal intubation with and without muscle relaxation.

BACKGROUND: Lightwand tracheal intubation is a suitable technique for patients who are difficult to intubate but who are receiving effective ventilation. The effect of muscle relaxants on the efficacy of lightwand intubation has not yet been evaluated. The authors conducted a prospective, double-blind, placebo-controlled study to assess the effectiveness and incidence of complications of lightwand tracheal intubation performed during general anesthesia with and without the use of a muscle relaxant in patients with apparently normal airway anatomy. METHODS: One hundred seventy-six patients who required orotracheal intubation were prospectively included. Anesthesia was administered using propofol (2 mg/kg, then 3 mg . kg (-1). h(-1)) and remifentanil (1 microg/kg, then 0.3 microg . kg(-1) . min(-1)). Patients were randomly assigned to one of two groups (n = 88 for each) to receive rocuronium 0.6 mg/kg or saline intravenously. Lightwand orotracheal intubation (Trachlight; Laerdal Medical Inc., Armonk, NY) was attempted after 3 min. The authors recorded the number of successful intubations, the number of attempts and their duration, and events during the procedure. RESULTS: The failure rate of lightwand intubation was 12% in the placebo group and 2% in the rocuronium group (P = 0.021). Patients in the placebo group received more multiple intubation attempts (P < 0.001), required a greater intubation time (77 +/- 65 vs. 52 +/- 31 s; P = 0.002) and experienced a greater incidence of events during intubation (61 vs. 0%; P < 0.001) than patients in the rocuronium group. CONCLUSIONS: The use of muscle relaxants in patients with apparently normal airways is associated with a lower failure rate, decreased intubation time, and fewer attempts when performing lightwand orotracheal intubation.

Adult↗
PubMed1994

Women are at greater risk than men for malpositioning of the endotracheal tube after emergent intubation.

OBJECTIVES: To investigate the occurrence of endotracheal tube malpositioning after emergent intubation in critically ill adults and to determine the need for a routine postintubation chest radiography to assess endotracheal tube position. DESIGN: Prospective study. SETTING: All adult critical care and acute care units of a 560-bed university teaching hospital. PATIENTS: Study of 297 consecutive intubations (185 intubations in males and 112 intubations in females) in 238 adult patients. METHODS: Emergent endotracheal intubations were performed by resident physicians with supervision from an intensive care unit (ICU) or anesthesia attending physician or an anesthesia resident. After intubation, proper positioning of the endotracheal tube was verified by the intubating physician using clinical criteria, including auscultation of bilateral breath sounds, symmetric chest expansion, and palpation of the endotracheal tube cuff in the suprasternal notch. The endotracheal tube position relative to the lower anterior incisors or alveolar ridge was recorded using the centimeter markings printed on the endotracheal tube. A chest radiograph was obtained after intubation to verify endotracheal tube position. Appropriate endotracheal tube position on chest radiograph was defined as between > 2 and < or = 6 cm above the carina. MEASUREMENTS AND MAIN RESULTS: Of the 297 intubations, 26 were excluded from analysis because a chest radiograph was not obtained or the patient was not of normal stature. For the remaining 271 intubations, 42 (15.5%) endotracheal tubes were inappropriately placed, according to the radiographic assessment. The percentage of malpositioned endotracheal tubes was significantly higher in women than in men (61.9% vs. 38.1%, respectively; chi-square: p < .001). Thirty-three (78.6%) of 42 malpositioned endotracheal tubes were placed < 2 cm from the carina, with the highest occurrence (24/33) of proximal malposition occurring in women. Positioning of endotracheal tubes using the centimeter markings printed on the tube referenced to the lower incisors did not accurately identify malposition as documented by chest radiograph. CONCLUSIONS: Emergent endotracheal intubations result in a significant occurrence of malpositioned endotracheal tubes that are undetected by clinical evaluation. Malpositioning is not detected by routine clinical assessment, but only by chest radiograph. Women are at greater risk than men for endotracheal tube malpositioning after emergent intubation; in women, the endotracheal tube is more likely to be positioned too close to the carina. A chest radiograph for confirmation of endotracheal tube position after emergent intubation should remain the standard of practice.

Adult↗
PubMed1999

Fiberoptic intubation in 327 neurosurgical patients with lesions of the cervical spine.

In patients with lesions of the cervical spine, direct laryngoscopy for endotracheal intubation entails the risk of injuring the spinal cord. In an attempt to avoid this complication, the authors used flexible fiberoptic nasal intubation in a series of 327 patients with cervical lesions undergoing elective neurosurgical procedures. The nasal route was preferred for laryngeal intubation because it is easier than the oral route and a restraining collar or halo device does not impair the intubating maneuver. Bronchoscopic intubation was possible in all patients. In 12 patients (3.6%), anatomic abnormalities prevented transnasal insertion of the endotracheal tube, and transoral fiberoptic intubation was necessary. Endotracheal intubation was graded as slightly difficult in 85 patients (26%). The minimal peripheral oxygen saturation during intubation exceeded 90% in 289 patients (88%). In the other 38 patients, the mean O2 saturation was 84.2+/-4.3% (range, 72-89%). Intubation was well tolerated by all patients and none had recall of the procedure. Cervical stabilizers did not have to be removed for intubation in any patient. None of the patients had postoperative neurologic deficits attributable to the intubation procedure. The authors consider fiberoptic transnasal intubation to be a useful alternative to direct laryngoscopic tracheal intubation in patients undergoing elective surgical procedures on the cervical spine to avoid potential injury to the cervical spinal cord.

Adolescent↗
PubMed2001

A prospective study of tracheal intubation in an emergency department in Hong Kong.

Emergency department (ED) doctors often intubate patients, however no data was available in Hong Kong on this aspect. Our study was to assess the competency of ED doctors in intubating critical patients in a typical ED in Hong Kong. Between March and August 1999, in an urban hospital with an emergency physician training programme, all doctors, after performing any tracheal intubation, were required to fill in a pro forma designed for the study. Data collected included the training status of the intubator, the number of intubation attempts, intubation methods and complications. A total of 214 ED patients required advanced airway management including 87 (41%) patients in cardiopulmonary arrest; 207 (97%) of them were successfully intubated by ED doctors (76 by specialists, 61 by trainees, 70 by residents) and 90% were successful in the first attempt. The remaining seven patients' airway control was eventually managed by anaesthetists who successfully intubated six patients and performed cricothyrotomy for one patient. Rapid sequence intubation was performed in 70 (33%) patients by ED doctors and specialists. There were 30 (14%) patients successfully intubated using sedative agents alone. Twenty-two (10%) patients were found to have a total of 32 complications including 13 patients with oesophageal intubation, seven with soft tissue damage, four with desaturation, three with bronchial intubation, three with hypotension, one with dental trauma, one with dysrhythmia. The majority of ED intubations for critically ill patients were performed by ED doctors with high success rate and few major complications.

Adolescent↗
PubMed1990

Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation.

We evaluated a colorimetric end-tidal carbon dioxide (ETCO2) detector (FEF end-tidal carbon dioxide detector, Fenem, New York, N.Y.) during 62 intubations in anesthetized patients who were hemodynamically stable. The intubations were performed during a drill that simulates difficult tracheal intubation and therefore is associated with an increased risk of esophageal intubation. Each intubation attempt was monitored by two anesthesiologists and a research assistant who together used chest auscultation, colorimetric ETCO2, and capnography to confirm tracheal intubation and detect esophageal intubation. The reliability of the monitors was compared with capnography. Colorimetric ETCO2 confirmed tracheal intubations and detected esophageal intubations 100% of the time, as judged by capnography. There were no false-positive or false-negative decisions based on endotracheal tube position; however, one equivocal color change occurred, which was caused by failure to inflate the endotracheal tube cuff. Colorimetric ETCO2 monitoring confirmed tracheal intubation more rapidly than did chest auscultation (P less than 0.001) or capnography (P less than 0.05), and detected esophageal intubation more rapidly than did chest auscultation (P less than 0.05) and as rapidly as capnography did. Confirmation of tracheal intubation was achieved earlier than detection of esophageal intubation with all three monitors (P less than 0.05). We conclude that colorimetric ETCO2 monitoring is a safe, reliable, rapid, simple, and portable method for determining endotracheal tube position for patients who are hemodynamically stable and should be recommended where capnography is not available.

Carbon Dioxide↗
PubMed2003

Hemodynamic responses among three tracheal intubation devices in normotensive and hypertensive patients.

UNLABELLED: We compare hemodynamic responses in normotensive and hypertensive anesthetized paralyzed patients among three intubation devices: the Macintosh laryngoscope (LS), the Trachlight lightwand (LW), and the intubating laryngeal mask airway Fastrach (ILM). Seventy-five normotensive and 75 hypertensive patients were randomly assigned to each intubation device (n = 25). Noninvasive systolic blood pressure (SBP) and diastolic blood pressure (DBP) and heart rate (HR) were recorded immediately preinduction, immediately preintubation, and every minute for the first 5 min after the successful intubation. The number of intubation attempts, the time to successful intubation, and any airway injuries were recorded. Pharyngolaryngeal morbidity was assessed 18-24 h after surgery by a blinded investigator. In all groups, there was a reduction in SBP and DBP but no change in HR immediately preintubation compared with baseline values. In all groups, HR increased, but there were no increases in SBP and DBP other than in DBP in the LS/hypertensive group after intubation compared with baseline values. In normotensive patients, there were no differences in any hemodynamic variables among the three devices. In hypertensive patients, SBP and DBP in the LS group were significantly higher than the ILM and LW groups for 2 min after intubation, but there were no differences in HR among the devices. The number of intubation attempts was similar among groups, but intubation time was longer for the ILM group. The incidence of airway injury was more frequent for the ILM than the LS and LW groups (16% versus 0% versus 0%). There were no differences in pharyngolaryngeal morbidity among groups. We conclude that both the ILM and the LW attenuated the hemodynamic stress response to tracheal intubation compared with the LS in hypertensive, but not in normotensive, anesthetized paralyzed patients. IMPLICATIONS: Both the intubating laryngeal mask airway Fastrach and the Trachlight lightwand attenuate the hemodynamic stress response to tracheal intubation compared with the Macintosh laryngoscope in hypertensive, but not in normotensive, anesthetized paralyzed patients.

Aged↗
PubMed2003

Difficult tracheal intubation is more common in obese than in lean patients.

UNLABELLED: Whether tracheal intubation is more difficult in obese patients is debatable. We compared the incidence of difficult tracheal intubation in obese and lean patients by using a recently validated objective scale, the intubation difficulty scale (IDS). We studied 134 lean (body mass index, <30 kg/m2) and 129 obese (body mass index, >or=35 kg/m2) consecutive patients. The IDS scores, categorized as difficult intubation (IDS >or=>5) or not (IDS <5), and the patient data, including oxygen saturation (SpO2) while breathing oxygen, were compared between lean and obese patients. In addition, risk factors for difficult intubation were determined in obese patients. The IDS score was >or=5 in 3 lean and 20 obese patients (P = 0.0001). A Mallampati score of III-IV was the only independent risk factor for difficult intubation in obese patients (odds ratio, 12.51; 95% confidence interval, 2.01-77.81), but its specificity and positive predictive value were 62% and 29%, respectively. SpO2 values noted during intubation were (mean +/- SD) 99% +/- 1% (range, 91%-100%) and 95% +/- 8% (range, 50%-100%) in lean and obese patients, respectively (P < 0.0001). We conclude that difficult intubation is more common among obese than nonobese patients. None of the classic risk factors for difficult intubation was satisfactory in obese patients. The high risk of desaturation warrants studies to identify new predictors of difficult intubation in the obese. IMPLICATIONS: We report a difficult intubation rate of 15.5% in obese patients and 2.2% in lean patients. None of the risk factors for difficult intubation described in the lean population was satisfactory in the obese patients. We also report a high risk of desaturation in obese patients with difficult intubation.

Adolescent↗
PubMed1993

Analysis of an endotracheal intubation service provided by respiratory care practitioners.

UNLABELLED: Our Respiratory Care Services Department provides an endotracheal intubation service that responds to all intubation requests. Intubation is performed by registered respiratory therapists who complete an 8-hour training program, advanced cardiac life support (ACLS) training and certification, and clinical performance of intubation with supervision. The goals of this service are (1) to provide competent persons for performing this service, (2) to assure a rapid response time, and (3) to be cost-effective. EVALUATION METHODS: A retrospective analysis of our service was conducted over a 1-year period (7/90 to 6/91), and calculations were made of the intubation success rate and complication rate. RESULTS: Of the 833 total intubations, 791 were successfully performed by respiratory care practitioners; 730 of those successful intubations (92.3%) were accomplished in fewer than 3 attempts. Recognized complications occurred in 96 intubations (12.1%) and included oral bleeding, vomiting, and short periods of oxygen desaturation. In the 5.1% (42) of the patients not intubated by our service, 22 required heavy sedation, and an anesthesiologist was consulted; 17 patients were intubated by other physicians; and 3 tracheotomies were performed. Multiple intubation attempts were a result of secretions, induced bradycardia, blade-light malfunction, damaged cuff, and esophageal intubations. CONCLUSION: Respiratory Care Services can provide an effective intubation service. Cost savings were realized by centralizing equipment.

Academic Medical Centers↗
PubMedDate not supplied

Intubation with transillumination: nasal or oral?

Transillumination-guided intubation is a useful back-up method when laryngoscopic intubation proves to be difficult or impossible. The Trachlight (Laerdal, N-4001 Stavanger, Norway) is suited for both nasal and oral use. Intubation times (IT) and success rates (SR) for nasal and oral intubation with the Trachlight were compared. Twenty-four medical students, inexperienced in intubation were instructed in the use of the Trachlight. A demonstration also was performed. Subsequently, they were asked to intubate a Laerdal Airway Management Trainer (Laerdal, Stavanger, Norway) using the Trachlight. Each student intubated 10 times orally and 10 times nasally (five times through the right and five times through the left nostril). The succession of the students was randomized. The intubation times were measured and the position of the tube noted. Nasal and oral intubation times for the tenth trial (steady state conditions) were compared using the rank-order test for paired observations. Oral and nasal success rates were compared using the sign test for paired observations. The differences between nasal and oral intubation concerning intubation time and the success rates were not significant. Nasal intubation with the Trachlight seems to be more difficult than the oral intubation.

Clinical Competence↗
PubMed2005

Intubation conditions with low dose rocuronium under sevoflurane induction for children.

BACKGROUND: During short surgical procedures and when there is a need to avoid the use of anticholinesterase at the end of surgery, the use of a smaller intubation dose of neuromuscular blocking drug is preferred. The aim of this study was to evaluate tracheal intubation conditions using smaller doses of rocuronium for children under sevoflurane induction. METHODS: Eighty American Society of Anesthesiologists classification physical status I or II children were enrolled. After mask induction with sevoflurane with nitrous oxide for 3 minutes, 0.3 mg/kg of rocuronium was given. Intubation was performed 60 or 90 seconds thereafter. Study group A included children aged 1 to 3 years and 90 seconds between rocuronium injection and intubation. Group B included children aged 1 to 3 years who had 60 seconds between rocuronium injection and intubation. Group C included children aged 4 to 6 years who had 90 seconds between rocuronium injection and intubation. Group D included children aged 4 to 6 years who had 60 seconds between rocuronium injection and intubation. Intubation conditions were judged based on the scoring of ease of jaw opening and laryngoscopy, position of the vocal cords, and degree of straining after tracheal intubation. RESULTS: All 80 children underwent successful tracheal intubation without laryngospasm or any complications. Intubation conditions were judged as optimal in all children in group A, 95% in group B, 80% in group C, and 65% in group D. CONCLUSIONS: A total of 0.3 mg/kg of rocuronium was sufficient for tracheal intubation for children 1 to 6 years old under sevoflurane induction. To guarantee optimal intubation conditions for elder children, allow 90 seconds waiting time after rocuronium administration was recommended.

Androstanols↗
PubMed1992

Intraocular pressure changes in response to endotracheal intubation facilitated by atracurium or succinylcholine with or without lidocaine.

Changes in intraocular pressure (IOP) and hemodynamics (SP, DP and HR) were measured in 105 patients ASA I and II randomly assigned into seven equal and comparable groups (A to G) during induction of anesthesia and endotracheal intubation facilitated either by succinylcholine or atracurium with or without lidocaine. IOP decreased significantly (p less than 0.01) after induction of anesthesia with thiopentone in all the groups. While atracurium with or without lidocaine did not affect IOP following complete suppression of train-of-four (groups A, B, and C), succinylcholine per se or in combination with lidocaine (groups F and G) significantly (p less than 0.01) increased IOP after induction with thiopentone but not exceeding the baseline IOP level. IOP was significantly elevated (p less than 0.01) immediately after endotracheal intubation in all the groups when compared to IOP following thiopentone administration. In those patients given atracurium (groups A to E), IOP increased (p less than 0.05) in response to endotracheal intubation above the baseline level only in group B where atracurium was divided into a priming and intubating doses. However, the priming dose did not have any significant effect on the onset time of complete twitch suppression of train-of-four and did not affect the intubation conditions compared with the uniformly excellent conditions found with atracurium over an equivalent bolus dose of the relaxant. In patients who received succinylcholine only (group F), IOP immediately after endotracheal intubation was significantly greater (p less than 0.01) as compared to the baseline and did not return to the baseline level until 3 minutes after endotracheal intubation. The use of lidocaine in combination with atracurium (group D) or succinylcholine (group G) for a rapid sequence intubation did not affect IOP following endotracheal intubation. However, atracurium when used in a rapid sequence intubation could not produce similar intubation conditions when compared with succinylcholine. Consequently, we cannot endorse atracurium as an alternative to succinylcholine for patients with penetrated eye injuries and full stomach requiring rapid sequence intubations. In this context, the role of IV lidocaine in mitigating or preventing the systemic and ocular reactions and especially the acute increase in IOP associated with endotracheal intubation should be emphasized.

Anesthesia, Endotracheal↗
PubMed2005

[Hemodynamic responses to orotracheal intubation with fiberoptic bronchoscope and direct laryngoscope in children].

OBJECTIVE: To compare the hemodynamic responses to orotracheal intubation via fiberoptic bronchoscope (FOB) with conventional orotracheal intubation via direct laryngoscope (DLS) in children under general anesthesia. METHODS: Forty-three American Society of Anesthesiologist grade I-II children undergoing the elective plastic surgery and requiring orotracheal intubation were randomly allocated to either the DLS group (n = 20)or the FOB group (n = 23). After standard intravenous anesthetic induction, orotracheal intubation was performed using a DLS or a FOB. Noninvasive systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and rate-pressure product (RPP) were recorded before and after anesthetic induction, at intubation, and 5 minutes after intubation with 1 minute interval. RESULTS: In the DLS group, SBP, HR, and RPP at intubation increased significantly compared to their postinduction values (P < 0.05),but blood pressure, HR and RPP at intubation didn't differ from their preinduction values. The maximal values of SBP, HR and RPP during the observation (from the beginning of intravenous anesthetic induction to 5 minutes after intubation) were significantly higher than their preinduction values (P < 0.05). In the FOB group, blood pressure, HR and RPP at intubation increased significantly compared to their preinduction and postinduction values (P < 0.05), and the maximal values of blood pressure, HR and RPP during the observation were significantly higher than their preinduction values (P < 0.05). There were no significant differences in blood pressure and RPP at each time point during the observation between the two groups. The HR at intubation were significantly higher in the FOB group than in the DLS group (P < 0.05), but no significant difference was observed in the HR values at other time points during the observation between the two groups. There were also no significant differences in the maximal values of blood pressure, HR and RPP or the times to reach their maximal values between the two groups. CONCLUSION: General anesthesia of clinical standard depth can not effectively inhibit the pressor and tachycardiac responses caused by fiberoptic orotracheal intubation in children. As compared with DLS, FOB has no special advantages in preventing the cardiovascular stress responses to orotracheal intubation in children.

Anesthesia, General↗
PubMed1996

[Light-guided intubation using Trachlight].

BACKGROUND: A new intubating transilluminated device (Trachlight) has been recently proposed as an alternative to tracheal intubation with direct laryngoscopy. OBJECTIVE: 1) To evaluate Trachlight device in orotracheal intubation and to assess its operation and complications. 2) To compare the time consumption of transillumination intubation in respect to direct laryngoscopy on the same patients. METHODS: The first study was performed on 50 patients undergoing elective surgery and submitted to Trachlight intubation alone; speed of intubation, number of attempts and all complications were recorded and related to Mallampati classes. In the second study 16 patients undergoing to elective surgery were enrolled. Each patient was classified according to both the Mallampati classes and the Cormack classes. Each patient was submitted to two tracheal intubations: the first with the Trachlight and the second with conventional direct laryngoscopy performed by the same anesthesiologist. The time to intubation and the number of attempts were recorded and related to the Mallampati and Cormack classes. RESULTS: In the first study time of intubation with Trachlight was 20.93 +/- 13.02s (mean +/- SD) without statistical differences in respect to the Mallampati classes. In the second study the times to intubation were without any statistical difference independently of the technique of intubation and of the Mallampati or Cormack classes. CONCLUSIONS: Orotracheal intubation using Trachlight appears to be an effective and easy to learn technique, being also easy, safe and fast to carry out. The comparison with direct laryngoscopy showed the same speed and effectiveness even on patients with difficult intubation.

Adolescent↗