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PubMed1997

Comparison of intubating conditions related to timed dosages and a nerve stimulator based on the measurement of acceleration using mivacurium.

A quantitative method of monitoring neuromuscular blockade has been recently introduced. It has been suggested, when using mivacurium, that a standardized passage of time be used for induction. The purpose of this study was to determine whether a difference existed in intubating conditions when using mivacurium between a timed-dose technique and the ParaGraph (Vital Signs, Inc., Totowa, New Jersey). In this prospective, experimental, clinical trial, 40 patients were randomized into two groups. Standardized induction sequences were used for both groups. A standardized rating tool was used to grade each intubation. Intubation commenced in the ParaGraph group when the monitor read one twitch. Intubation in the timed-dose group occurred 90 seconds after the first dose of mivacurium. The difference in intubating conditions score and time to intubation was tested by the Mann-Whitney-Wilcoxon lest. The ParaGraph group had superior intubating conditions when compared with the timed dose group (P = .0001). Of the ParaGraph group, 100% had good to excellent intubating conditions, and 85% of the timed-dose group had fair to excellent intubating conditions. Time to intubation was longer in the ParaGraph group, with a mean of 216 seconds compared with 121 seconds in the timed-dose group. The variable time to onset of mivacurium indicates that a timed-dose technique may yield less than optimal intubating conditions despite manufacturer recommendations.

Adult↗
PubMed1995

Speed and ease of tracheal intubation: priming with mivacurium compared with succinylcholine.

This study examined the efficacy of mivacurium priming (0.015 mg.kg-1) with five minutes between the priming and intubating doses by comparing the effects of one, two and three times the ED95 dose (0.075 mg.kg-1) of mivacurium after priming (Groups 1, 2 and 3, respectively), with a saline prime and 2 x ED95 mivacurium (Group 4) or 1 mg.kg-1 dose of succinylcholine (Group 5). The time from the intubating dose injection to intubation was measured and intubating conditions were rated on a five-point scale with 4 being optimal and 0 being failure. Mean times (+/- SEM) in seconds between the administration of the intubating dose and tracheal intubation were: 106.4 +/- 5.1, 89.6 +/- 6.7, 81.9 +/- 2.7, 169.9 +/- 7.8 and 82.9 +/- 3.5 for Groups 1-5 respectively. The times for Group 2 (2 x ED95 with priming), Group 3 (3 x ED95 with priming) and Group 5 (succinylcholine with saline) were shorter than the times of Groups 1 (1 x ED95 with priming) and 4 (2 x ED95 with saline) P < 0.05. Mean intubating condition scores (+/- SD) for the five groups respectively were 3.1 +/- 0.6, 3.4 +/- 0.6, 3.5 +/- 0.5, 3.2 +/- 0.6 and 3.8 +/- 0.4. Scores for Groups 2, 3 and 5 were higher than those of Group 1 (P < 0.05). The data demonstrated that (1) priming with mivacurium shortens the intubation time and is accompanied by good intubating conditions with doses 2x and 3x ED95, and (2) intubating times and conditions similar to those achieved with succinylcholine can be obtained using mivacurium 2x (total dose 0.150 mg.kg-1) or 3 x ED95 (total dose 0.215 mg.kg-1) with a five-minute priming interval. Priming provides an alternative technique in those clinical circumstances where succinylcholine is contraindicated.

Adult↗
PubMed1998

[Assessment of intubation time and conditions under the influence of rocuronium].

PURPOSE: To evaluate the tracheal intubating conditions when intubation time is determined by the onset time of the neuromuscular block either of the adductor pollicis (AP) or of the orbicularis oculi muscle (OO). METHODS: In this prospective, double blind, randomised study, 40 adults ASA I-II undergoing general anaesthesia with tracheal intubation were allocated to two groups (n = 20) according to the reference muscle (AP or OO) used to determine the appropriate intubation time. Induction of anaesthesia was achieved with 5-7 mg.kg-1 thiopentone, 1.5-2.5 micrograms.kg-1 fentanyl and 0.9 mg.kg-1 rocuronium (3 x ED95) for muscular relaxation. Supramaximal train of four stimulation of the ulnar and facial nerve every 10 sec was used to monitor the neuromuscular block. After visual loss of AP or OO contraction, tracheal intubation and quality of intubation assessment were performed by two independent anaesthetists. Data are expressed as mean and standard error of the mean (X +/- SEM). RESULTS: Curarisation time of the OO was shorter (110 +/- 4.9 sec) than that of the AP (144 +/- 5.5 sec; P < 0.0001). Intubation conditions were excellent in 95% and good in 5% of the patients in the AP group whereas in the OO group only 65% of the patients had excellent and 20% good intubation conditions (P < 0.05). Coughing was observed in 15% of patients in the OO group during tracheal intubation. CONCLUSION: Monitoring neuro-muscular activity of the AP using TOF to determine the appropriate tracheal intubation time and conditions in patients paralysed with rocurorium is more clinically relevant than monitoring the OO muscle.

Adult↗
PubMed1996

Determination of end-tidal sevoflurane concentration for tracheal intubation in children with the rapid method.

PURPOSE: Using the conventional method of determining the end-tidal concentration of inhalational anaesthetic for tracheal intubation, a constant end-tidal anaesthetic concentration is maintained for at least 15 min. As sevoflurane has a low tissue/gas partition coefficient, it seems possible in paediatric patients to determine end-tidal concentrations for tracheal intubation more rapidly by using a high inspired concentration. We determined ED50 and ED95 of sevoflurane for tracheal intubation, the end-tidal concentrations that prevented 50% and 95% of patients from coughing and gross purposeful muscular movements after intubation. METHODS: Twenty-nine, ASA 1, unpremedicated patients, aged two to eight years, were enrolled. Anaesthesia was induced using a mask and 5% sevoflurane, inspired, in oxygen. When end-tidal sevoflurane concentration attained a predetermined value, laryngoscopy and tracheal intubation were performed using an uncuffed tracheal tube without neuromuscular relaxants or adjuvants. Each concentration at which laryngoscopy and tracheal intubation were attempted was randomly predetermined (with 0.5% as a step size). When tracheal intubation was accomplished without gross purposeful muscular movements, it was considered a smooth tracheal intubation. RESULTS: The ED50 end-tidal sevoflurane concentration for tracheal intubation was 3.10% (95% confidence limits: 2.43% and 3.78%), and the ED95 was 4.68% (95% confidence limits: 3.91% and 12.74%). The times to end-tidal sevoflurane concentrations of 3.0% and 4.5% were 149 +/- 15 sec (mean +/- SD) and 213 +/- 23 sec. CONCLUSION: In paediatric patients, this method enabled determination of ED50 and ED95 end-tidal sevoflurane concentrations for tracheal intubation without obtaining a long stabilization period.

Anesthetics, Inhalation↗
PubMed1999

Tracheal intubation using Bullard laryngoscope for patients with a simulated difficult airway.

PURPOSE: To evaluate the utility and safety of orotracheal intubation in adult patients with simulated difficult airways using the Bullard Laryngoscope (BL). METHODS: A rigid cervical collar was used to simulate the difficult airway. The study consisted of two phases. Phase I evaluated the BL used in conjunction with an independently styletted endotracheal tube (ISETT) passed freehand into the trachea. Phase II evaluated the new Multifunctional Intubating Stylet (MFIS). Forty patients were studied in each phase. Following induction of anesthesia a rigid cervical collar was applied and the laryngoscopic grade assessed. Tracheal intubation was then performed using the BL with either an ISETT or the MFIS. The total time to intubate, number of attempts, failures, hemodynamic changes during intubation were recorded. RESULTS: The rigid collar effectively simulated a difficult laryngoscopy, 65% of patients had a grade 3 view. The success rates for tracheal intubation using the ISETT and MFIS were 88% and 83% respectively. The average times to intubation were similar for both intubating techniques (45.4 +/- 26.8 sec for the ISETT and 41.2 +/- 25.2 sec for the MFIS). Although there were minor hemodynamic changes, mucosal bleeding and sore throat following intubation, there were no major complications in any of the study patients. CONCLUSIONS: The BL, used with either an ISETT or the MFIS, is an effective and safe intubating device for patients with simulated restricted cervical spine movement. Further studies are needed to compare the effectiveness and safety of these two techniques in managing patients with a difficult airway.

Female↗
PubMed2005

The StyletScope is a better intubation tool than a conventional stylet during simulated cervical spine immobilization.

PURPOSE: We compare the StyletScope fibreoptic stylet (FOS) and the Satin Slip conventional metal stylet (CMS), during simulated difficult airway management with manual-in-line stabilization in terms of ease of intubation and esophageal intubation. METHODS: 193 patients (ASA I-II, 18-80 yr) were studied in a non-crossover, randomized fashion. Manual-in-line stabilization was applied and the best laryngoscopic view obtained. For the CMS, the primed tracheal tube was advanced under direct vision if Cormack-Lehane grade 1/2, placed behind the epiglottis and advanced blindly if grade 3, and intubation was not attempted if grade 4. For the FOS, the primed tracheal tube was advanced under the direct vision if grade 1/2 and under fibreoptic vision if grade 3/4. RESULTS: Intubation was successful more frequently (P = 0.02) and required fewer attempts (P = 0.003) with the FOS than the CMS. Intubation with the FOS was successful more frequently (P = 0.02) and required fewer attempts (P = 0.007) than the CMS if grade 3/4. For both stylets, intubation required fewer attempts (P < 0.007) and was quicker (P <or= 0.0001) for grade 1/2 than 3/4. Esophageal intubation occurred more frequently with the CMS (14 vs 0, P = 0.0001). CONCLUSION: Tracheal intubation is more successful, requires fewer attempts and esophageal intubation is less frequent with the FOS than the CMS during cervical spine immobilization using manual-in-line axial stabilization. The FOS is a more effective intubation instrument compared to the CMS in patients with simulated cervical spine immobilization.

Adolescent↗
PubMed2000

Video-intuboscopic monitoring of tracheal intubation in pediatric patients.

PURPOSE: To evaluate the efficacy of video-intuboscopic monitoring during orotracheal intubation in a pediatric anesthesia teaching unit. METHODS: In 100 pediatric patients direct laryngoscopy performed by residents or nurse anesthetists was monitored on a video display using a flexible, ultralight video-endoscopic system (O.D. 2.8 mm/length 1.8 m) within the endotracheal tube (ETT). Best direct laryngoscopic view was assessed by the intubator. The instructor observed the intubation procedure on the video display and noted number of intubation attempts, best laryngoscopic monitor view, tube passage through the larynx and final tube position. If required he gave instructions or corrections. After removal of the laryngoscope, tracheal tube position was adjusted using the monitor view. Difficulties attributed to the fibreoptic endoscope during intubation and removal from the ETT were recorded. RESULTS: The trachea was successfully intubated at the first attempt in all patients. The supervisor detected one esophageal and 12 endobronchial intubations that were immediately corrected before starting ventilation. Final visualized endotracheal tube adjustment above the carina was possible in all patients except in one with copious tracheal secretions. Compared with direct laryngoscopy the video display provided an improved view of the vocal cords during intubation. In six patients direct laryngoscopy was difficult but the tracheas were intubated using the monitor view. No difficulties with the equipment were encountered except that the black coated endoscope compromised recognition of the black ETT depth-markings in small tubes. CONCLUSIONS: Video-intuboscopic monitoring is a useful monitor of tracheal intubation. "The improved view of the cords may provide assistance during difficult laryngoscopy.

Adolescent↗
PubMed2003

Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema.

OBJECTIVE: Noninvasive ventilation may reduce the endotracheal intubation rate in patients with acute cardiogenic pulmonary edema. However, criteria for selecting candidates for this technique are not well established. We analyzed a cohort of patients with severe acute cardiogenic pulmonary edema managed by conventional therapy to identify risk factors for intubation. These factors were used as guide for indications for noninvasive ventilation. DESIGN AND SETTING: Observational cohort registry in the ICU and emergency and cardiology departments in a community teaching hospital. PATIENTS: . 110 consecutive patients with acute cardiogenic pulmonary edema, 80 of whom received conventional oxygen therapy. INTERVENTIONS: Physiological measurements and blood gas samples registered upon admission. MEASUREMENTS AND RESULTS: Twenty-one patients (26%) treated with conventional oxygen therapy needed intubation. Acute myocardial infarction, pH below 7.25, low ejection fraction (<30%), hypercapnia, and systolic blood pressure below 140 mmHg were independent predictors for intubation. Conversely, systolic blood pressure of 180 mmHg or higher showed to be a protective factor since only two patients with this blood pressure value required intubation (8%)], both presenting with a pH lower than 7.25. Considering systolic blood pressure lower than 180 mmHg, patients who showed hypercapnia presented a high intubation rate (13/21, 62%) whereas the rate of intubation in patients with normocapnia was intermediate (6/23, 26%). All normocapnic patients with pH less than 7.25 required intubation. No patient with hypocapnia was intubated regardless the level of blood pressure. CONCLUSIONS: Patients with pH less than 7.25 or systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for noninvasive ventilation. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation.

APACHE↗
PubMed2003

Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (Trachlight) in elderly patients with hypertension.

PURPOSE: Tracheal intubation using a lightwand device (Trachlight) should minimize hemodynamic change by avoiding direct-vision laryngoscopy. We evaluated hemodynamic and catecholamine responses during tracheal intubation using a Trachlight in elderly patients with hypertension. METHODS: Twenty-six hypertensive patients aged over 65 years undergoing orthopedic surgery were randomly divided into two groups, group L (n = 13) and group T (n = 13). Anesthesia was induced with fentanyl (2 microg x kg(-1)) and propofol (1.5 mg x kg(-1)), and then muscle relaxation was obtained with vecuronium (0.15 mg x kg(-1)). The trachea was intubated with either a Macintosh laryngoscope (group L) or a Trachlight (group T). Hemodynamics, plasma catecholamine concentrations, and arterial blood gases were measured before the induction of anesthesia (T0), before tracheal intubation (T1), immediately after tracheal intubation (T2), and 3 min after tracheal intubation (T3). RESULTS: The intubation time was shorter in group T than in group L (12.6 +/- 1.7 vs 23.5 +/- 2.9 s, mean +/- SE; P < 0.01). Compared with the preinduction (T0) value, systolic blood pressure (SBP) showed a significant decrease at T1 and T3 in group L and at T1, T2, and T3 in group T. The heart rate (HR) and plasma norepinephrine (NE) concentration showed no change in either group throughout the time course, whereas the plasma epinephrine (E) concentration showed a significant decrease at T2 and T3 in both groups. The mean values of the rate-pressure product (RPP: HR x SBP) were less than 15000 after tracheal intubation in both groups. There was no significant difference in hemodynamic or catecholamine responses between groups at any point. No patient had ischemic ST-T changes in either group. CONCLUSION: A lightwand has no advantage over a laryngoscope in terms of hemodynamic and plasma catecholamine responses to tracheal intubation in elderly patients with hypertension, despite a shorter intubation time.

Aged↗
PubMed1995

Use of a Beck Airway Airflow Monitor and controllable-tip endotracheal tube in two cases of nonlaryngoscopic oral intubation.

Alternative techniques and equipment for intubation may be particularly useful in settings such as air-medical transport, prehospital on-scene care, mass casualty incidents, or incidents in which there may be a lack of medications or equipment. Once traditional techniques of endotracheal intubation and tube verification have been mastered, emergency medicine residents and other intubators should be encouraged to learn alternative techniques, such as these, that may be of use in some special situations, even within the ED. Neither of these two techniques of BAAM-assisted blind oral intubation can be considered essential, nor should it be contended that these techniques supplant learning of more conventional methods of endotracheal intubation and tube placement verification. However, particularly in the setting of residency training, multiple methods of endotracheal intubation should be taught in order to allow the clinician alternative methods if unable to intubate by traditional means in a particular setting. Use of a BAAM to assist in blind oral intubation of a spontaneously breathing patient may allow for oral intubation of awake patients without the additional use of paralytic medications. Use of the BAAM with a digital technique during external cardiac massage may facilitate intubation by the digital technique and help to verify endotracheal tube position. These two additional uses for the BAAM should be noted and these two additional methods of airway control be recognized as backup methodologies in the armamentarium for situations in which they may be needed.

Aged↗
PubMed1990

Fiberoptic intubation in the emergency department.

Fiberoptic-aided endotracheal intubation has been shown to be effective in difficult intubation secondary to anatomic abnormalities and traumatic conditions. A retrospective review of emergency airway management in an emergency department during a 30-month period found 35 patients who underwent fiberoptic-aided endotracheal intubation; 31 were treated for medical conditions, and four were trauma patients. Indications in the medical group included failed nasotracheal intubation (ten), anatomic abnormalities (six), and the initial airway maneuver attempted (15). Indications in the trauma group with suspected cervical-spine injury included failed nasotracheal intubation (one) and initial airway maneuver attempted (three). In the medical subgroup, 25 of 31 patients were intubated successfully fiberoptically. All four trauma patients were intubated successfully, and all attempts were done nasally. The limitations of the technique were varied. Twenty of the 25 successful intubations had times recorded for completion (mean time, 1.8 +/- 1.4 minutes [SD]). Four of the six failed attempts had recorded times of 7.8 +/- 1.4 minutes. The mean time of the four trauma cases was 3 +/- 2.2 minutes. The presence of secretions, blood, or vomitus was the cause in five of the six failed intubations. The sixth patient kept swallowing the distal end of the scope. Fiscal restraints may also limit its use. At our institution, the financial commitment has been approximately +17,000 during the past nine years. Repair or replacement of broken equipment appears to be necessary every two or three years. Immediate airway control is often difficult with fiberoptic-aided endotracheal intubation and should be used only in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1987

A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient.

In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.

Adult↗
PubMed1998

Results of a 4-hour endotracheal intubation class for EMT-basics.

STUDY OBJECTIVE: In 1994, the Department of Transportation made endotracheal intubation an optional EMT-Basic skill. To data, there have been no studies addressing the ability of this group to learn or perform this skill. We used a standarized mannequin test to perform a prospective evaluation of this intubation skills of basic EMTs immediately after a 4-hour course on endotracheal intubation. We hypothesized that the intubation success rates would be comparable with those of other types of providers newly trained in this skill. METHODS: Eighty-three EMTS were selected/recruited from four EMS provider agencies. Ninety-six percent of the EMTs were men, and the average age was 38 years; average length of EMT experience was 9.4 years. Training was provided in classes of 6 to 14 persons and included 1 hour of didactic instruction, a 1-hour demonstration of intubation techniques, and 90 minutes of supervised practice with the mannequins in groups of 2 to 4 persons. Testing followed American Heart Association guidelines. Interrater reliability of test criteria was assessed. RESULTS: Ninety-four percent (95% confidence interval 86% to 98%) of the EMTs passed the examination by intubating the mannequin within 35 seconds within 3 attempts. Of the successful EMTs, 94% succeeded on their first attempt, 3% on their second attempt, and 3% on their third. There were three esophageal intubations; all were detected immediately. Interrater agreement was 100% on the pass/fail decision. CONCLUSION: This 4-hour class trained basic EMTs to perform endotracheal intubation on mannequins with a success rate of 94%. Further research should confirm the ability of EMT-Basics to detect esophageal intubation and address the retention of intubation skills, the applicability of these skills to the field, and the components of this course that were responsible for its success.

Adult↗
PubMed2000

The seeing stylet: a new device for tracheal intubation.

A new tracheal intubation device is available. The 'Shikani Seeing Stylet' is a new, inexpensive, reusable high resolution endoscope with a malleable stainless-steel sheath which can be inserted through a tracheal tube allowing intubation to be performed under direct vision. We have assessed this new device on 20 patients (ASA I-II; age 25-67) scheduled to undergo elective surgery with tracheal intubation. We measured heart rate (HR), non invasive blood pressure (NIBP), oxygen saturation (SpO(2)) and end tidal carbon dioxide (ETCO(2)) at three different times: T(0) (induction of anesthesia), T(1) (beginning of intubation procedure), T(2) (end of intubation procedure); we also recorded the time interval between T(1) and T(2). All patients were successfully intubated with the device. Eleven patients were intubated at the first attempt (T(1)-T(2) mean time=8. 65 s); three patients were intubated at the first attempt using cricoid pressure (T(1)-T(2) mean time 11.6 s); four patients were intubated at the second attempt (T(1)-T(2) mean time=36.5 s); two patients were intubated at the third attempt (T(1)-T(2) mean time=54. 5 s). The HR, NIBP, SpO(2) and ETCO(2) remained fairly stable. On the basis of our preliminary experience with 20 patients, the 'Shikani Seeing Stylet' seems to be a promising adjunct for airway management.

Adult↗
PubMedDate not supplied

Incidence of aspiration pneumonia in intubated patients receiving activated charcoal.

Several case reports and animal studies raise concerns over the risk of aspiration pneumonia when administering activated charcoal (AC) to intubated patients. Therefore, we sought to determine the incidence of aspiration pneumonia in intubated overdose patients who then received AC. We conducted a retrospective review from January 1994 to April 1997 of intubated patients who then received AC. Patients were transferred to, or primarily treated at, an 843-bed tertiary medical center with an annual emergency department volume of 100,000 patients. Objective evidence of infiltrate on chest radiograph during initial 48 h of hospitalization was used to determine the incidence of aspiration pneumonia. Patients with known preexisting pneumonia or with administration of AC before intubation were excluded. There were 64 patients identified. Fourteen were excluded for clinical aspiration before intubation, receiving activated charcoal before intubation, or abnormal immediate post-intubation chest radiographs. The remaining 50 patients, ages 1-64 years, 33% male, overdosing on a large variety of substances, required acute intubation and then received AC. Only two patients of these 50 (4%) with initial negative radiographs developed a new infiltrate after intubation and AC. Administration of AC to intubated overdose patients is associated with a low incidence of aspiration pneumonia.

Adolescent↗
PubMed1998

The use of neuromuscular blocking agents in the emergency department to facilitate tracheal intubation in the trauma patient: help or hindrance?

PURPOSE: The purpose of this study is to examine the relationship between the occurrence of a difficult intubation and (1) the use of neuromuscular blocking agents (NMB) and (2) the presence of airway injuries. It is a retrospective analysis of data from a trauma registry. MATERIALS AND METHODS: Registry records of patients (n = 160) who required emergent endotracheal intubation or establishment of a surgical airway over a 3.5-year period in the emergency department were reviewed. Risk factors for difficult intubations were identified and analyzed using multivariate logistic regression analysis. RESULTS: NMB were used in 75% of patients requiring intubation. Fifteen percent of the intubations were considered difficult. No association was found between the presence of airway injuries and difficult intubations; however, the use of succinylcholine was associated with a lower risk of difficult intubations compared with intubations where a nondepolarizing NMB was used. CONCLUSIONS: The use of succinylcholine may result in fewer difficult intubations in the trauma patient than when a nondepolarizing NMB is used. The presence of airway injuries did not appear to predispose to difficult intubations.

Adult↗
PubMed1999

Intraocular pressure changes during rapid sequence induction and intubation: a comparison of rocuronium, atracurium, and succinylcholine.

STUDY OBJECTIVE: To compare changes in intraocular pressure (IOP) during rapid sequence induction and intubation following rocuronium, succinylcholine, and atracurium. DESIGN: Open-label, prospective, randomized study. SETTING: Operating room at the Eye Foundation Hospital (University of Alabama at Birmingham) PATIENTS: 45 ASA physical status I, II, and III patients, aged 18 to 65 years, scheduled for elective eye surgery with general anesthesia. INTERVENTIONS: Anesthesia was rapidly induced in unpremedicated patients with a fixed combination of midazolam 0.025 mg/kg, alfentanil 0.025 mg/kg, and propofol 1.5 mg/kg. Intubation was performed, as clinically indicated, approximately 60 seconds following administration of rocuronium 0.6 mg/kg, atracurium 0.5 mg/kg, or succinylcholine 1 to 1.5 mg/kg. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure was measured before induction of anesthesia (baseline), following anesthesia induction and administration of muscle relaxant (before intubation), and after intubation. The percent change in IOP from baseline was significantly decreased in the rocuronium group compared with the succinylcholine group (p = 0.046) before intubation. This trend continued after intubation, but the difference was no longer significant (p = 0.070). Intubation scores for rocuronium and succinylcholine groups were similar, and both scores were superior to that for the atracurium group (p = 0.002). CONCLUSION: Intraocular pressure can be controlled during emergency induction of anesthesia and intubation with adequate depth of anesthesia and muscle relaxation. Rocuronium, succinylcholine, and atracurium all provided sufficient muscle relaxation to achieve successful intubation and no increase in IOP. However, rocuronium 0.6 mg/kg provided significantly better intubating conditions compared with atracurium, and it resulted in a significantly greater decrease in IOP compared with baseline than succinylcholine.

Adolescent↗
PubMed2004

Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study.

BACKGROUND AND OBJECTIVE: Minimizing cervical vertebrae motion during endotracheal intubation is important in patients with cervical instability. The aim of this study was to compare upper cervical spine extension during endotracheal intubation using three different techniques. METHODS: Duration of intubation and movement of upper cervical vertebrae during endotracheal intubation were compared in 33 patients undergoing lumbar laminectomy. Patients requiring tracheal intubation under general anaesthesia and neuromuscular blockade were randomly allocated into three groups - direct laryngoscopy, intubating laryngeal mask (LM) airway and fibreoptic laryngoscopy. The procedure was recorded by video-fluoroscopy and analysed with computer-assisted measurements. The maximum movement of the C1/C2 and C2/C3 vertebrae during intubation were obtained. Data were analysed using one-way analysis of variance with Bonferroni and Kruskal-Wallis tests. RESULTS: We found statistically significant movement between the first and second, but not between the second and third cervical vertebrae. The mean (+/-SD) movement at C1/C2 was 10.2 +/- 7.3 degrees with direct laryngoscopy, 5.0 +/- 6.3 degrees with LM and 1.6 +/- 3.2 degrees with fibreoptic laryngoscopy. This difference was statistically significant (P = 0.01) between the direct and fibreoptic laryngoscopy groups. The maximum movement at C2/C3 was 2.2 +/- 10.1 degrees with direct laryngoscopy, 3.5 +/- 5.1 degrees with LM and 0.5 +/- 3.2 degrees with fibreoptic laryngoscopy. Duration of intubation was significantly longer in the intubating LM group (P < 0.001). CONCLUSION: We conclude that fibreoptic laryngoscopy is the more suitable intubation technique when cervical spine movement is not desired.

Adult↗