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PubMed2002

Endotracheal intubation with a gum-elastic bougie in unanticipated difficult direct laryngoscopy: comparison of a blind technique versus indirect laryngoscopy with a laryngeal mirror.

UNLABELLED: We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or indirect laryngoscopy with a laryngeal mirror in patients with unexpected difficult direct laryngoscopy. In a prospective study, 60 consecutive patients with an unexpected Grade III or IV direct laryngoscopy were randomly allocated for intubation with a gum-elastic bougie either blindly (Group 1) or by indirect laryngoscopy with a laryngeal mirror (Group 2). We evaluated the failure rate of each method of intubation, complications related to either method, and the time required for intubation. Out of 725 patients evaluated over a 2-mo period, 60 patients (8.3%) had a Grade III laryngoscopy, and 30 of these were randomized into each group. There were 8 failed intubations in Group 1 compared with 1 failed intubation in Group 2 (P < 0.05). All eight failures in the blind intubation group ended with esophageal intubation. No additional complications were noted in either group. The time required for endotracheal intubation with each group was not significantly different (45 +/- 10 s versus 44 +/- 11 s). We conclude that intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror than a traditional blind technique. IMPLICATIONS: We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or a laryngeal mirror. Intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror (P < 0.05) than a traditional blind technique.

Aged↗
PubMed1999

Evaluation of tracheal intubation difficulty in patients with cervical spine immobilization: fiberoptic (WuScope) versus conventional laryngoscopy.

BACKGROUND: The WuScope is a rigid, fiberoptic laryngoscope designed to facilitate tracheal intubation without the need for head extension. The study evaluated the WuScope in anesthetized patients with neck immobilization. METHODS: Patients were randomized to one of two groups: those receiving fiberoptic laryngoscopy (WuScope, n = 43) and those receiving conventional laryngoscopy (Macintosh blade, n = 44). Manual in-line stablization of the cervical spine was done during intubation. Seven parameters of intubation difficulty were measured (providing an intubation difficulty scale score): number of operators, number of attempts, number of techniques, Cormack view, lifting force, laryngeal pressure, and vocal cord position. RESULTS: Successful intubation occurred in 95% of patients in the fiberoptic group and in 93% of patients in the conventional group. There were no differences in number of attempts. In the fiberoptic group, 79% of patients had an intubation difficulty scale score of 0, representing an ideal intubation: that is, one performed by the first operator on the first attempt using the first technique with full glottic visualization. Only 18% of patients in the conventional group had an intubation difficulty scale score of 0 (P < 0.001). More patients had Cormack grade 3 or 4 views with conventional than with fiberoptic laryngoscopy (39 vs. 2%, P < 0.001). Intubation times in patients with one attempt were slightly longer in the fiberoptic (median, 25th-75th percentiles: 30, 23-53 s) compared with the conventional group (24, 17-30 s, P < 0.05). Corresponding times in patients requiring > one attempt were 155 (range, 112-201) s and 141 (range, 95-186) s in the fiberoptic and conventional groups, respectively (P value not significant). CONCLUSIONS: Compared with conventional laryngoscopy, tracheal intubation using the fiberoptic laryngoscope was associated with lower intubation difficulty scale scores and better views of the laryngeal aperture in patients with cervical imnmobilization. However, there were no differences in success rates or number of intubation attempts.

Adult↗
PubMed1986

Indications for intubation in blunt chest trauma.

The value of endotracheal intubation and internal stabilization in severe chest injuries is well known. Recent reports have proposed that many such patients can be managed without intubation. To determine which patients need intubation we reviewed 140 patients with three or more rib fractures who presented to our hospitals from 1 January 1979 through 31 December 1983: 119 nonintubated patients (Group A); 13 patients intubated on admission (Group B); five patients intubated after hospital day 1 (Group C); and three patients intubated questionably on admission (Group D). The purpose of this report was to identify the factors which indicated severe pulmonary injury necessitating intubation. The need for intubation was correlated with five risk factors: 1) initial respiratory rate of over 25 min; 2) pulse greater than 100 min; 3) systolic blood pressure less than 100 mm Hg; 4) poor initial arterial blood gas; 5) the presence of other injuries. There was no correlation between severity of pulmonary injury and number of fractures, bilateral and/or segmental fractures, flail chest, contusion of lung, or age of patient. There was a greater percentage of complications and deaths in intubated patients (Groups B, C, and D). Group C patients all had poor initial blood gases and were erroneously not intubated early, even though 60% of them had three or more risk factors, as did Group B patients. Only 4% of patients who did not need intubation (Group A) had three or more risk factors. Group D patients were intubated without apparent indication. They had good initial blood gas levels and only one risk factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed2000

Intubation and survival in severe paediatric blunt head injury.

The majority of severe childhood injuries are due to head injuries. We studied the impact of emergency intubation in a cohort of children suffering severe blunt head trauma. A 10-year retrospective case note analysis was performed on 176 children (age < 16 years) with severe blunt head trauma (abbreviated injury scale > or =4) in Southern Finland, who required intensive care in a level 1 trauma centre, or who died despite initiation of life supporting measures at the scene. Children in whom emergency intubation was performed either at the scene, or in the emergency room (ER) were analysed. Of the 59 children who fulfilled the study criteria, 20 had an isolated head injury. Most injuries (56/59) were caused by road traffic accidents. Field-intubation was performed in 24 children, and emergency intubation in the ERs of regional hospitals or the level 1 trauma centre, in 13 and 22 children respectively. Mortality was 54.2% (32/59), and was highest in children intubated in regional hospital ERs or in the field. Children intubated at the scene or in the ER of regional hospitals, had significantly worse AIS (head/neck), injury severity score (ISS), and Glasgow coma (GCS) scores than those children intubated in the ER of the level 1 trauma centre. Survival was better in field-intubated children compared with those intubated in regional hospital ERs, despite similar trauma scores (p = 0.05). It is concluded that although children with severe (AIS > or =4) head injury who require emergency intubation have a high overall mortality, field-intubation may improve survival, compared with 'scoop and run' with BLS airway management and deferred emergency intubation.

Abbreviated Injury Scale↗
PubMed2004

Premedication for tracheal intubation: a prospective survey in 75 neonatal and pediatric intensive care units.

OBJECTIVE: In children, like in adults, tracheal intubation is a painful procedure that may induce hypertension, tachycardia, and other undesirable hemodynamic disorders. Although premature neonates are very sensitive to pain and vulnerable to its long-term effects, the need for sedation before tracheal intubation is still discussed in neonatal units. Our objective was to investigate the practice of premedication before tracheal intubation in neonatal and pediatric units and determine the influence of premedication on intubating conditions. DESIGN: We performed a 10-day prospective survey in 75 neonatal and pediatric intensive care units among the 98 licensed in France. A questionnaire was completed for each intubation performed in each surveyed unit. SUBJECTS: A total of 204 patients were studied: 140 neonates, 52 infants, and 12 children. MAIN RESULTS: Data on 204 tracheal intubations were collected from 223 that were performed during the study period (participation rate, 91.4%). Premedication was used before intubation for 37.1%, 67.3%, and 91.7% of neonates, infants, and children, respectively (p <.0001). In the subgroup of neonates, premedication was particularly rare for the youngest and the smallest infants. Midazolam was the principle hypnotic used in neonates, whereas propofol was mainly used in children. Opioids or muscle relaxants were used in 16.2% and 4.4% of the patients, respectively. A low success rate and a high incidence of hypoxemia and bradycardia were correlated with the inexperience of the operator. Premedication did not significantly influence either the success rate or the undesirable events associated with tracheal intubation. CONCLUSION: Use of premedication before tracheal intubation is limited in neonates and increases according to the age of the patient. Midazolam does not seem to be an accurate choice to improve intubating conditions in neonates and infants. Because tracheal intubation is a technique that requires a skill only developed by regular practice, operators who have limited experience with intubating children should be supported by senior operators.

Anesthesia↗
PubMed2003

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury.

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.

Abbreviated Injury Scale↗
PubMed2005

The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury.

BACKGROUND: Several studies have demonstrated that the success rate of prehospital intubation is improved by the use of neuromuscular blocking agents (NMBAs). However, a recent study has reported that prehospital intubation with NMBAs worsens outcome after traumatic brain injury (TBI). We sought to determine the effect of the use of NMBAs to facilitate prehospital intubation on outcome after TBI. METHODS: All patients admitted to our Level I trauma center with a head Abbreviated Injury Scale score >/= 3 were identified by the trauma registry (January 1998-June 2003). Patient records were matched with prehospital databases. Patients were further stratified on the basis of prehospital Glasgow Coma Scale (GCS) score into mild (GCS score of 14/15), moderate (GCS score of 9-13), and severe (GCS score < 9) TBI. Outcome included mortality and good outcome (survival to discharge with a GCS score of 14/15). RESULTS: There were 3,052 patients who were identified as having been transported directly from the field. Complete prehospital data were available for 2,012 patients (66%). Of these, 920 were mild TBI (intubation rate, 17.4%), 293 moderate TBI (intubation rate, 57.7%), and 799 severe TBI (intubation rate, 95%). Overall, 72% of intubated patients received NMBAs. There were no significant differences in demographics or injury severity between the groups. Patients not receiving NMBAs were more likely to be hypotensive and have prehospital cardiopulmonary resuscitation (p = 0.001). The unadjusted mortality for the patients intubated with NMBAs was 25% versus 37% for those not receiving NMBAs (p < 0.001). When adjusted for confounding variables, patients intubated with NMBAs were more likely to survive (odds ratio, 0.63; 95% confidence interval, 0.41-0.97; p = 0.04) and have a good outcome (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; p = 0.006) than those in the no-NMBA group. CONCLUSION: The use of NMBAs to facilitate prehospital intubation improves outcome for patients with TBI. The value of prehospital intubation for TBI remains to be determined; however, any trial evaluating nonintubation for TBI must be compared with NMBA-facilitated intubation to be valid.

Abbreviated Injury Scale↗
PubMed2005

Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification.

BACKGROUND: Recently, evidence has shown that intubation in the field may not improve or may even adversely affect outcomes. Our objective was to analyze outcomes in pediatric intubated trauma patients using a large national pediatric trauma registry. METHODS: The patient population was derived from the last phase of the National Pediatric Trauma Registry, comprising admissions from 1994 through 2002. Intubated patients were identified, as was their place of intubation: in the field, at a hospital that was not a trauma center, and at a trauma center. Risk stratification was performed for mortality using logistic regression models and variables available at presentation to the emergency room. Odds ratio and variable significance were calculated from the logistic regression model. The percentage of patients discharged to home and an abnormal Functional Independence Measure at hospital discharge examined functional outcome of survivors. RESULTS: There were a total of 50,199 patients, 5460 (11.6%) of whom were intubated (1,930 in the field, 1,654 in the hospital, and 1,876 in a trauma center). Unadjusted mortality rates for intubated patients were as follows: field, 38.5%; hospital, 16.7%; and trauma center, 13.2% (all different, p < 0.05). The developed logistic regression model had an area under the receiver operating characteristic curve of 0.98. Compared with nonintubated patients, the odds ratio for field intubation, for non-trauma center, and for trauma center intubation was 14.4, 5.8, and 4.8, respectively (significantly different field vs. either hospital). The actual (observed) death rate was significantly higher than predicted in those intubated in the field. Stratification of injury by New Injury Severity Score or degree of head injury showed that this difference extended from mild to severe (e.g., odds ratio for New Injury Severity Score < 15 field vs. trauma center intubation, 12.3; odds ratio for none or moderate head injury, 5.1). Similar results were obtained for functional outcome in the survivors. CONCLUSION: Field intubation is an independent strong negative predictor of survival or good functional outcome despite adjustment for severity of injury. Although not causal, the magnitude of these differences should lead to future controlled studies of pediatric trauma field intubations.

Abbreviated Injury Scale↗
PubMed1998

Intubation difficulty in poisoned patients: association with initial Glasgow Coma Scale score.

OBJECTIVE: To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out-of-hospital airway management of poisoned patients. METHODS: A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician-based out-of-hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out-of-hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1-page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival. RESULTS: Forms were completed for all 394 consecutive out-of-hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7 < or = GCS < or = 9 (36%) than in patients with GCS < 7 (15%) or > 9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid-sequence intubation rather than administration of sedation alone. CONCLUSION: Maximum difficulty of intubation is encountered in poisoned patients with 7 < or = GCS < or = 9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.

Adolescent↗
PubMed2003

Does the sedative agent facilitate emergency rapid sequence intubation?

OBJECTIVES: To ascertain whether the sedative agent administered during neuromuscular-blocking agent-facilitated intubation (rapid sequence intubation [RSI]) influences the number of attempts and overall success at RSI. METHODS: Records were drawn from an ongoing, prospective multicenter registry of emergency department intubations. Conditional logistic regression stratified by institution was used to identify factors associated with multiple intubation attempts and unsuccessful RSI. RESULTS: Of 3,407 intubations over 33 months in 22 institutions, 2,380 involved RSI. After correcting for the specialty and experience of the intubator and for the presence of airway aberrancy, the sedative agent was significantly associated with the number of attempts at intubation (p = 0.002). Specifically, the use of etomidate (adjusted odds ratio [OR] 0.35 [95% CI = 0.17 to 0.72]), ketamine (OR 0.27 [95% CI = 0.11 to 0.65]), a benzodiazepine (OR 0.47 [95% CI = 0.23 to 0.95]), or no sedative agent (OR 0.51 [95% CI = 0.23 to 1.13]) prior to neuromuscular blockade was associated with a lower likelihood of successful intubation on the first attempt, as compared with thiopental, methohexital, or propofol. The adjusted odds ratios for the likelihood of overall success had similar point estimates, but did not reach statistical significance due to lack of power (p = 0.2, with 36 unsuccessful intubations). Among patients receiving etomidate, intubation was more likely to be successful on the first attempt with increasing doses of either etomidate or succinylcholine. CONCLUSIONS: Thiopental, methohexital, and propofol appear to facilitate RSI in emergency department patients, independent of patient characteristics or intubator training. A deeper plane of anesthesia may improve intubating conditions in emergency patients undergoing RSI by complementing incomplete muscle paralysis.

Adolescent↗
PubMed1999

[Light-guided tracheal intubation using a Trachlight: causes of difficulty and skill acquisition].

We studied the reasons why tracheal intubation using a lighted stylet (Trachlight) was sometimes difficult for unexperienced intubators. We also examined light-guided intubation skill acquisition in inexperienced anesthesiologists. Two anesthesiologists, with no prior experience in using a Trachlight, performed orotracheal intubation using a Trachlight in 60 anesthetized patients (30 patients each). During intubation, an assistant observed the advancement of the tracheal tube using a fiberscope passed nasally and recorded the reason for difficulty in intubation. The time to successful intubation was also measured. Data were divided into epochs of 10 cases, and the intubation time and the incidence of difficult cases were compared between the groups. Tracheal intubation was successful using the Trachlight in 59 of 60 patients. The incidence of difficult cases, defined as cases requiring two or more attempts, was 31.7%. Fiberscopy showed that when the tube tip was located in the vallecula or in the esophagus, it was sometimes difficult to determine the position of the tube tip by transillumination of the soft tissues of the neck, and this results in the need for multiple attempts. Both the intubation time and the incidence of difficult cases decreased significantly between the first and last epoch. The present study confirms that light-guided intubation is sometimes difficult when the tube tip is advanced to the vallecula or to the esophagus. An acceptable level of skill in light-guided intubation is achieved within 30 uses.

Adult↗
PubMed2003

Randomized evaluation of the performance of single-use laryngoscopes in simulated easy and difficult intubation.

BACKGROUND: Single-use laryngoscopes are becoming used more widely. METHODS: We compared six types of single-use laryngoscope with the standard Macintosh laryngoscope using the Laerdal SimMan patient simulator. Twenty anaesthetists attempted to intubate the simulator with standardized airway settings allowing a full view of the vocal cords ('easy intubation'). The airway settings were then changed so that only the posterior part of the glottis was visible ('difficult intubation') and the anaesthetists were asked to intubate the simulator again. RESULTS: The time to intubate with the standard laryngoscope was less in both easy (P<0.05) and difficult (P<0.01) intubations. The performance of five laryngoscopes during easy intubation (P<0.01) and four during difficult intubation (P<0.001) was significantly worse than that of the Macintosh. There was a significant difference in Cormack and Lehane grading between the laryngoscopes tested in both easy (P<0.05) and difficult (P<0.05) intubation. The percentage of glottic opening visible (POGO score) also differed between laryngoscopes in both the easy (P<0.01) and difficult (P<0.001) groups. The highest POGO scores were obtained with the Macintosh laryngoscope. During the difficult intubation simulation, the reusable Macintosh laryngoscope needed less use of a bougie and had fewer failed intubations than the single-use laryngoscopes, but these differences did not reach statistical significance. CONCLUSIONS: Of the laryngoscopes tested, the standard reusable Macintosh laryngoscope performed best. The Europa was the best single-use laryngoscope. Some single-use laryngoscopes tested were significantly inferior to the Macintosh. This raises concern over their use in clinical practice, particularly if intubation is difficult.

Disposable Equipment↗
PubMed2004

Frequent use of alternative airway techniques makes difficult intubations less and easier.

BACKGROUND: This study is to evaluate how alternative airway techniques work at different scenarios of difficult airways in our department where those techniques are popularized in daily practice. METHODS: This is an open and observational study. Ten thousand two hundred and twenty nine adult patients were included in the 7-month period of investigation. When a difficult intubation was recognized, the responsible anesthesiologist would complete a questionnaire that was designed to explore the possible causes relative to the difficulty, i.e. the laryngoscopic view grade, the muscle relaxant administered during induction, any difficulty of mask ventilation, the eventually successful intubation technique, and the recommendation on the next intubation to the same patient. RESULTS: About 22% of the patients received various airway techniques for intubation other than laryngoscopic technique in general anesthesia. Laryngoscopic intubation was planned firstly on 8,058 cases; the incidence of difficult intubation was 0.44% (36/8058). Laryngoscopic view was found to be grade 2 in 10 patients, grade 3 in 24, and grade 4 in 2 patients, respectively. In these difficult airway intubations were accomplished ultimately with a conventional laryngoscope in 13 patients, a lighting stylet in 20 patients, a laryngeal mask airway (LMA) in 2 patients, and surface tactile oral intubation (STOI) in 1 patient. As to these patients with difficult airways who would undergo general anesthesia with endotracheal intubation next time awake intubation was suggested only to 4 patients. CONCLUSIONS: In elective general anesthesia, frequent use of the alternative airway techniques, such as LMA for a surgical procedure of short duration and lighting stylet for a possibly difficult airway, will decrease the events of difficult intubations. Lighting stylet seems more advantageous than laryngoscope in management of difficult intubation caused by poor laryngoscopic view.

Adult↗
PubMed2004

[Tracheal intubation under general anesthesia in patients with difficult laryngoscopy].

OBJECTIVE: To evaluate the safety and efficacy of oral endotracheal intubation in the patients with difficult laryngoscopy undergoing general anesthesia. METHODS: A total of 1 683 patients with difficult laryngoscopy, aged 1.5-67 yr, and scheduled for the elective plastic surgery were observed in this study from 1989-1997. All these patients were at American Society of Anesthesiologist physical status I. According to the preoperative predictive results for difficult laryngoscopy, we classified these patients into two groups: Group I included 1 375 patients, whose epiglottis could be viewed (laryngoscopic view grades II and III); and Group II, included 308 patients, whose epiglottis could not be viewed (laryngoscopic view grade IV). For group I, anesthesia was induced with thiopentone 4-5 mg/kg and succinylcholine 1 mg/kg; Laryngoscopy was carried out using modified Macintosh method. For Group II, anesthesia was induced with a total intravenous anesthesia or inhaled anesthesia; anesthetic depth was required to effectively inhibit laryngeal reflexes with reservation of spontaneous breathing. Tracheal intubation was performed by fiberoptic stylet laryngoscope (FOSL). During anesthesia induction and tracheal intubation procedures, electrocardiogram, arterial pressure, heart rate and pulse oxygen saturation (SpO2) were continuously monitored. Complications of intubation (arrhythmia, and so on) were observed and recorded. Immediately after laryngoscopy and successful intubation, patients were examined for any traumatic injuries at teeth, lips, tongue, and oropharyngeal tissues. RESULTS: In group I, tracheal intubation was accomplished by the first attempt in 1 279 cases (93.0%) and the intubation time was less than 3 min in 1 304 cases (94.8%). In group II, tracheal intubation was accomplished by the first attempt in 114 patients (37.0%), and 123 patients (39.9%) had the intubation time of less than 3 min. Tracheal intubation was successful by the second or third attempt in 96 patients of group I and 156 patients of group II, respectively. Thirty-eight patients required four or more attempts, which only occurred in group II. Of all the complications of tracheal intubation, the traumatic complications were most common. The incidences of traumatic complications in the patients with laryngoscopic view grade II, III (group I ) and IV (group II) were 0.7%, 3.9% and 14.3%, respectively. Other complications such as respiratory depression were only seen in group II. A pooled incidence of the intubation complications was 6.7% (113/1 683). CONCLUSION: An anesthesiologist who is skillful in difficult airway management may safely manage the airway in the patients with difficult laryngoscopy under general anesthesia.

Adolescent↗
PubMed1989

[The effect of nifedipine and fentanyl on changes in the circulatory reaction to endotracheal intubation].

UNLABELLED: Recommendations for prevention of hypertension and tachycardia during the induction of anesthesia include the use of fentanyl and antihypertensive drugs and superficial anesthesia of the throat. Nifedipine has been used to treat acute hypertension and in many cases it has proved superior to other antihypertensive drugs. The present study was designed to find whether prophylactic injection of nifedipine alone or in combination with fentanyl can prevent cardiovascular responses during endotracheal intubation. METHODS: A total of 140 female patients (ASA groups I or II) with no history of arterial hypertension were randomly allocated to 7 groups: group K was the control group, in which patients received only saline solution; patients in groups 0,1F; 0,2F; 0,3F received 0.1, 0.2 or 0.3 mg fentanyl, respectively; those in group 1,0N, 1 mg nifedipine; those in group 0,5N + 0,1F, 0.5 mg nifedipine, plus 0.1 mg fentanyl; and those in group 1,0N + 0,1F 1 mg nifedipine plus 0.1 mg fentanyl. Blood pressure and heart rate were measured at 1 min intervals. After estimation of control values the prophylactic drug or combination of drugs was injected. Anesthesia was induced in the conventional manner. Plasma concentrations of epinephrine and norepinephrine were analyzed before intubation and at 5, 30 and 60 min intervals after intubation. Side-effects, especially respiratory depression and arrhythmia, were carefully recorded. RESULTS: In group K only systolic BP increased significantly after intubation. In the other groups the peak systolic blood pressure was not statistically different from the preinjection values. Diastolic BP increased significantly after intubation in all but two groups: in group 0,3F and in group 1,0N + 0,1F there was no significant difference in diastolic BP compared with the control values. The heart rate increased significantly in the control group after intubation as well as in groups 0,1F and 0,2F. In patients receiving 0.3 mg fentanyl there was no change in HR after intubation. Administration of 1 mg nifedipine alone (group 1,0N) or in combination with 0.1 mg fentanyl (group 1,0N + 0,1F) caused tachycardia even before intubation, whereas the combination of 0.5 mg nifedipine and 0.1 mg fentanyl did not result in a significant increase of HR following intubation. In all groups, epinephrine concentrations were significantly lower 5 min after intubation. A return to the control values was observed after 60 min in all groups except group 0,1F. Serum concentrations of norepinephrine were lower 5 min after intubation in all groups and were still low in groups 0,1F , 0,2F, 0,5N+0,1F and 1,0N+0,1F up to 60 min after intubation. Side-effects and adverse effects were checked for in the present study. An increase in heart rate was observed during induction in almost every group. More pronounced changes were recorded in groups 1,0N and 1,0N+ 0,1F receiving 1 mg nifedipine.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1999

[Propofol for intubation of infants after halothane induction].

UNLABELLED: The unwanted side effects of muscle relaxants used for anaesthesia in the newborn and infants resulted in a search for alternatives to atraumatic intubation (IN). The study was aimed to investigate conditions of intubation, time of intubation as well as changes in systolic, mean and diastolic blood pressure (RRs/RRm/RRd) and heart rate (HR) under the use of propofol (P) after narcosis induction by mask. PATIENTS AND METHODS: The study was approved by the local ethics committee. The data was analysed from 100 infants aged between 4 days and 56 weeks (weight 2110-9230 g) in the ASA I and II groups (Group [Gr] A and B both with 50 patients). In both groups induction was performed inhalationally with halothane (1.5-2.0 vol%) and pure oxygen. After that propofol for intubation was applied in a dose of 2 mg/kg i.v. In Gr A blood pressure and heart rate were registered at three measuring points (MP): MP 1 = before P administration, MP 2 = after P, MP 3 = following intubation; in Gr B at MP 1 and MP 3. Additionally in Gr B the intubation time was recorded in seconds (t1 = time after P administration to beginning of IN, t2 = time after P administration to the end of the IN, t3 = t2-t1). In both groups the conditions of intubation were assessed (score 1--excellent, 2--good, 3--bad, 4--impossible intubation). RESULTS: The means of RRs/RRm/RRd/HR varied in Gr A at MP 2 by -11.20*/-9.18*/-8.58*/-3.52 mmHg/bpm and at MP 3 by -2.74/-2.26/-2.04/+5.46 mmHg/bpm in comparison to MP 1 (p < 0.05 = significant*). Compared to MP 1 in Gr B the mean values of RRs/RRm/RRd/HR varied at MP 3 by -0.89/+0.50/-0.80/+4.20* mmHg/bpm. T1 (mean, SD) was 10.88 +/- 3.52 seconds (s), t2 26.22 +/- 6.12 s, and t3 was therefore 15.78 +/- 6.28 s. Conditions of intubation were found to be excellent or good in both groups (Gr A and B [100 patients]: score 1 = 95x = 95%, score 2 = 5x = 5%). CONCLUSION: In the observation period, changes in heart rate stayed in the range of reference. In our opinion the excellent and good conditions for intubation, as well as the ultrashort drug-onset and intubation time demonstrate the good characteristics afforded by propofol to perform intubation in infancy.

Anesthesia, General↗
PubMed2000

Nasal versus oral intubation for mechanical ventilation of newborn infants.

BACKGROUND: This section is under preparation and will be included in the next issue. OBJECTIVES: The purpose of the review was to compare the complications associated with intubation by the nasal route with those associated with intubation by the oral route for mechanical ventilation in newborn infants. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials, MEDLINE and CINAHL. A call was placed on the list servers, NICU-NET and Neonatal Talk for unpublished trials, conference presentations and current trials. SELECTION CRITERIA: All trials using random or quasi-random allocation of patients to either the nasal or oral route of intubation were included. Study quality and eligibility were assessed independently by each author. DATA COLLECTION AND ANALYSIS: The standard method of the Cochrane Collaboration and the Neonatal Review Group was used to assess the methodological quality of the included studies. The methodological quality of each study was reviewed by the second author blinded to study authors and institutions. Each reviewer extracted data separately before comparison and resolution of differences. The standard method of the Neonatal Review Group was used to measure the effect of the different routes of intubation, using Relative Risk (RR) and 95% Confidence Intervals (CI). MAIN RESULTS: Only two eligible randomized trials were found. Data from these two trials failed to show significant differences between the oral and nasal route of intubation for mechanically ventilated neonates. The rate of failure to intubate using the nasal route was higher in one study. One study found post extubation atelectasis occurred more frequently in nasally intubated infants who weighed less than 1500 grams. The rates of malposition of the tube at the initial intubation, accidental extubation, tube blockage, re-intubation after extubation, septicaemia, clinical infection and local trauma (nasal erosion or palatal groove) were not significantly different for the two groups. REVIEWER'S CONCLUSIONS: Post extubation atelectasis may be more frequent after nasal intubation, particularly in very low birth weight infants. One route of intubation does not seem to be preferable to the other. There is a need for further randomized controlled trials containing larger numbers of infants.

Humans↗
PubMedDate not supplied

Sevoflurane with remifentanil allows rapid tracheal intubation without neuromuscular blocking agents.

PURPOSE: After inhalational induction with sevoflurane, we compared the effects of adding remifentanil 1 microg x kg(-1) or remifentanil 2 microg x kg(-1) on conditions for tracheal intubation without neuromuscular blocking agents. METHODS: Before anesthetic induction, all patients were given 0.2 mg of glycopyrrolate iv to counteract the bradycardic effects of remifentanil. Two minutes after inhalational induction with 8% sevoflurane and 50% nitrous oxide, 56 female patients with normal airways scheduled for gynecologic surgery were randomized to receive remifentanil 1 or 2 microg x kg(-1) in a double-blind fashion. One minute later, laryngoscopy was initiated for tracheal intubation. Conditions for tracheal intubation and hemodynamic response to tracheal intubation were assessed. RESULTS: Tracheal intubation was successful in all patients. The incidence of post-intubation coughing was lower in the remifentanil 2 microg x kg(-1) group compared to remifentanil 1 microg x kg(-1) group (11% vs 39%, P <0.02). Optimal intubation conditions were also higher in the remifentanil 2 microg x kg(-1) group at 89% vs 54% (P <0.01). However, the higher dose of remifentanil also resulted in a greater decrease in mean arterial pressure (P <0.05). CONCLUSIONS: The addition of remifentanil after sevoflurane induction allows for rapid tracheal intubation without neuromuscular blocking agents. The higher dose of remifentanil results in improved conditions for tracheal intubation but also caused a greater decrease in mean arterial pressure. Tracheal intubation using sevoflurane and remifentanil may be an alternative to traditional tracheal intubation with neuromuscular blocking agents.

Adjuvants, Anesthesia↗