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PubMed2002

Tracheal intubating conditions using propofol and remifentanil target-controlled infusions.

Using target-controlled infusions (TCI) we aimed to determine the most appropriate dose of remifentanil required for intubation, using a steady effect-site concentration of propofol and without the use of neuromuscular blocking drugs. Sixty ASA III patients presenting for elective surgery were randomly allocated to one of three groups. Anaesthesia was induced in all patients using a target-controlled infusion of propofol 6.5 microg x ml(-1). This was reduced to 3 microg x ml(-1) after 1 min. Each group received a different TCI of remifentanil, 19, 15 or 11 ng x ml(-1), which was reduced to 10, 8 or 6 ng x ml(-1), respectively, after 1 min. Laryngoscopy and intubation were attempted at 4 min. Laryngoscopy and ease of intubation were assessed using a standard scoring system. Intubation was considered satisfactory in 75% of patients in groups 1 and 2 and 35% of patients in group 3. Intubation was successful in 20/20, 19/20 and 15/20 patients in groups 1, 2 and 3, respectively. Pulse oximetry, heart rate and noninvasive arterial pressure were measured pre-induction, and at intervals until after laryngoscopy and intubation. Mean arterial pressure (MAP) and heart rate decreased following induction of anaesthesia in all groups, which was statistically significant. Following laryngoscopy, MAP and heart rate increased, but were significantly less than the corresponding baseline values.

Adolescent↗
PubMed2002

Effect of cricoid pressure on the ease of fibrescope-aided tracheal intubation.

We studied the reasons for difficulty with tracheal intubation over a fibrescope, and whether cricoid pressure facilitated intubation, in 50 patients. After induction of anaesthesia and neuromuscular blockade in 10 patients (phase 1), we attempted to clarify the reasons for difficulty in advancing a tracheal tube over an orally-inserted fibrescope, by observing through another fibrescope that was inserted nasally into the pharynx. In the next 40 patients (phase 2), we studied the effect of cricoid pressure on the success rate of tracheal intubation over the fibrescope. After a fibrescope (with a tracheal tube over it) had been inserted orally into the trachea, patients were randomly allocated to receive either criocoid pressure or sham pressure, and the success rate of intubation within 60 s was assessed. In phase 1, the tube was advanced into the trachea without difficulty in three of 10 patients. In the remaining seven patients, the tube impacted on the epiglottis in one patient and on the arytenoid cartilage in another two patients, and the tube migrated into the hypopharynx in the remaining four patients. In phase 2, tracheal intubation was successful within 60 s in seven of 21 patients (33%) without cricoid pressure, compared with 12 of 19 patients (63%) when cricoid pressure was applied (95% CI for difference 2-59%; p = 0.04). We conclude that cricoid pressure facilitates fibrescope-aided tracheal intubation.

Adolescent↗
PubMed1996

Timing of tracheal intubation: monitoring the orbicularis oculi, the adductor pollicis or use a stopwatch?

The most suitable time for tracheal intubation, following vecuronium 0.1 mg kg-1, was estimated in 120 patients. The trachea was intubated at cessation of the visually observed response of the orbicularis oculi muscle to facial nerve stimulation (group 1; n = 30), or of the manually detected response of the adductor pollicis to ulnar nerve stimulation (group 2; n = 30), or after waiting 3 min (group 3; n = 30), or 4 min (group 4; n = 30). There were no significant differences in intubation scores between the four groups of patients. Loss of response to train-of-four stimulation occurred significantly sooner in group 1 (orbicularis oculi) than in group 2 (adductor pollicis) P = 0.021). However, intubating conditions were poor in four patients (14%) in group 1, compared with none in group 2 and one in groups 3 and 4, respectively. Thus, contrary to expectations, the cessation of the response of the orbicularis oculi muscle did not guarantee good or even satisfactory intubating conditions. The results suggest that in fit adult patients it is as good to wait 3 min after injection of vecuronium 0.1 mg kg-1 before tracheal intubation, as to use a nerve stimulator.

Adolescent↗
PubMed1999

Comparison of the effects of topical lignocaine spray applied before or after induction of anaesthesia on the pressor response to direct laryngoscopy and intubation.

In an attempt to attenuate the cardiovascular pressor response to laryngoscopy and intubation, 30 patients presenting for routine ophthalmic surgery were studied and were randomly allocated into two groups: group A (n = 15) received direct laryngeal/tracheal lignocaine spray immediately before intubation; and group B (n = 15) received orolaryngeal lignocaine spray before the induction of anaesthesia. In both groups, general anaesthesia was induced with thiopentone 3-5 mg kg-1, followed by atracurium 0.6 mg kg-1 to facilitate tracheal intubation. Laryngoscopy and endotracheal intubation caused a significant increase in heart rate, by 28% in group A and 23% in group B (P < 0.05 in both), and in diastolic blood pressure, by 28% in group A and 24% in group B (P < 0.05 in both). In group A, the systolic blood pressure also increased significantly (by 18%) after intubation, but there was no significant change in group B. In addition, the plasma lignocaine concentrations remained well below the toxic range in both groups. It was concluded that topical lignocaine administration as an orolaryngeal spray before the induction of anaesthesia is effective in reducing but not abolishing the pressor response to laryngoscopy and endotracheal intubation.

Administration, Topical↗
PubMed2002

The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury.

OBJECTIVE: To determine the effects of rapid sequence intubation in patients with severe head injury performed by paramedics on a helicopter emergency medical service. METHODS: The patient care records for patients with severe head injury who underwent rapid sequence intubation between November 1999 and February 2002 (inclusive) were examined. Data were extracted on the demographics of the patients, as well as the physiological changes before and after rapid sequence intubation. RESULTS: There were 122 patients with severe head injury evaluated at the scene during the study period. Rapid sequence intubation was attempted in 110 patients and was successful in 107 (97%). Intubation was associated with improvements in systolic blood pressure, oxygen saturation and end-tidal carbon dioxide levels, compared with baseline levels. CONCLUSION: Rapid sequence intubation in patients with severe head injury may be safely undertaken by helicopter-based ambulance paramedics and is associated with improvements in oxygenation, ventilation and blood pressure. Further studies of this skill undertaken by road-based paramedics are warranted.

Adult↗
PubMed2001

Post-thyroidectomy sore throat following endotracheal intubation.

BACKGROUND: Sore throat is not an uncommon complaint following general anaesthesia (GA) with endotracheal intubation. It has been a source of considerable discomfort particularly in those patients who had thyroid surgery. Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the contributing factors of sore throat in patients who had thyroid surgery under general anaesthesia. METHODS: A total of 57 consecutive patients who had thyroid surgery from November 1998 to April 1999 was included in this prospective study. Factors such as intubation time, number of intubation attempts, size and type of endotracheal tube (ETT) used, gender and age were recorded. The nature and extent of the surgical procedures were also studied. Postoperative symptoms were assessed by questionnaire on the day after surgery and the different parameters were compared and analysed. RESULTS: The incidence of post-intubation sore throat following thyroid surgery was documented in 39 (68.4%) patients. Twenty-seven (47.4%) patients had a mild complaint of sore throat, which resolved after the third day. The data from the present study show that the size of ETT and extent of surgical procedure were significant contributing factors affecting the postoperative recovery. CONCLUSION: The outcome of the present study demonstrated a substantial increased incidence of sore throat after thyroid surgery under GA. Postoperative sore throat following thyroid surgery under GA may be caused by multiple contributing factors. Nonetheless effort and care should be taken during endotracheal intubation and surgery to reduce this unpleasant complaint arising mainly from pharyngeal irritation or trauma.

Adult↗
PubMed1997

[Use of the laryngeal mask in adenoidectomy in childhood--a comparison with endotracheal intubation].

PURPOSE: Anaesthesia for adenoidectomy is possible during infancy without succinylcholine. One possibility is intubation with vecuronium bromide, whereas another possibility is the use of the laryngeal mask (LMN). The conditions for intubation as well as further details during anaesthesia are listed and compared. METHODS: 200 children are divided into 4 groups. Group A: intubation with thiopental and vecuronium bromide. Group B: LMN with thiopental, Group C and D: as A and B but the thiopental replaced by propofol. The following aspects are compared: the conditions of intubation; circulation conditions; oxygen saturation; the behaviour when coming out of anaesthesia; complications; the assessment by the surgeons. A further control of 100 routine LMN covers the complications which arose. RESULTS: Adenoidectomy can be carried out successfully with both kinds of anaesthesia. Tracheal intubation attained a better assessment by most surgeons and is easier to administer. Brief declines in the saturation of oxygen occur more frequently when using LMN. LMN has its advantages in the low irritation of the respiratory mucous membranes and results in improved behaviour on coming out of the anaesthesia, especially if used with propofol. Problems arise mainly through the use of the mouth clamp which can result in obstructions of the respiratory tract and re-intubation. These problems arise less frequently when the use of this method has become routine. CONCLUSION: LMN takes time to get used to, and places greater demands on the anaesthetist. Success of LMN depends on the cooperation and collaboration to the surgeon to lower the risk of complications. Once specific improvements in the LMN have been made, it may become the standard method for adenoidectomy in future. It is already used by us and in some outpatient departments, as well as in England and America. Our suggestions are as follows: Aims at convincing the surgeons and improving their co-operation; No routine fixation of the laryngeal mask. The laryngeal mask should be kept slightly taut before opening--preferably slowly--the mouth clamp; possible technical modifications of the mouth clamp itself, which produce a wider gap, could be adapted to the new conditions of the wider LM; reaching the necessary depth of anaesthesia through higher doses of propofol or possibly by total intravenous anaesthesia; routine wearing of the LM in the recovery room until it is no longer tolerated by the child.

Adenoidectomy↗
PubMedDate not supplied

Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting.

OBJECTIVE: To prospectively evaluate the effectiveness of the endotracheal tube introducer (ETTI) versus standard orotracheal intubation (SOTI) in the prehospital air medical setting. METHODS: Critically ill patients were randomized to ETTI versus SOTI based on an odd/even day regimen. Data were collected on initial intubation attempt used, success using initial approach, number of intubation attempts until success, and laryngeal view encountered. The 2 approaches then were compared and statistically analyzed. RESULTS: Fifty-one patients were entered into the 10-month study; 20 patients were randomized to the ETTI group and 31 to SOTI. Overall success rate for first intubation attempt was 70% for the ETTI and 65% SOTI (P =.67). Total intubation time was 62 seconds (95% CI = 16-108) for the ETTI versus 62 seconds (95% CI = 38-86) for SOTI (P =.4). The ETTI group had a higher percentage of intubating difficult laryngeal views (grade 3 and 4) on first attempts than SOTI. CONCLUSION: In this study, the authors found the ETTI to be a safe airway adjunct with results equal to SOTI. The ETTI may have a useful role in prehospital airway management.

Chi-Square Distribution↗
PubMedDate not supplied

Rat intubation and ventilation for surgical research.

Effective outcomes in cardiothoracic surgical research using rodents are dependent upon adequate techniques for intubation and mechanical ventilation. Multiple methods are available for intubation of the rat; however, not all techniques are appropriate for survival studies. This article presents a refinement of intubation techniques and a simplified mechanical ventilation setup necessary for intrathoracic surgical procedures using volatile anesthetics. The procedure is defined and complications of the procedure are elucidated that provide a justification for animal numbers needed for initiating new studies. Lewis rats weighing 178-400 g (287 +/- 44) were anesthetized using Enflurane and intubated with a 16-G angiocatheter using transillumination. Mechanical ventilation (85 bpm, 2.5 mL TV, enflurane 1.5-2%) maintained adequate sedation for completion of an intrathoracic procedure. Complications of the intubation and ventilation included mortality from anesthetic overdose, intubation difficulty, pneumothorax, traumatic extubation, and ventilation disconnection. Anesthetic agents and their related effects on the rat heart and reflexes are compared. This article also underscores the importance of refinement, reduction, and replacement in the context of cardiothoracic surgery using rodent models.

Anesthesia↗
PubMed1987

Vecuronium or suxamethonium for rapid sequence intubation: which is better?

The effects of suxamethonium, and of vecuronium given after three subparalyzing (priming) doses, on the time of onset of neuromuscular blockade and on the resultant intubating conditions were compared. This study involved five groups of 10 patients (ASA class I or II) who were premedicated with flunitrazepam 0.015 mg kg-1 i.m. Anaesthesia was induced with thiopentone 6 mg kg-1 and fentanyl 0.003 mg kg-1. In groups 2, 3 and 4 the patients were given a priming dose of vecuronium 0.01, 0.015 and 0.02 mg kg-1, respectively. Three minutes later the intubating dose of vecuronium was given: 0.1 mg kg-1 (group 1), 0.09 mg kg-1 (group 2), 0.085 mg kg-1 (group 3), 0.08 mg kg-1 (group 4). When the electromyographic response was 95% of control, the trachea was intubated. In groups 2, 3 and 4, the onset time was significantly decreased compared with group 1. Increasing the priming dose from 0.01 mg kg-1 did not offer any advantage. The duration of blockade (time from the intubating dose to 15% recovery) was not significantly increased with any priming dose. In group 5, the trachea was intubated after suxamethonium 1.5 mg kg-1. Mean onset time, which was significantly shorter than in the other groups, was half that of the groups that received a priming dose. Intubation conditions were better in group 5 than in the other groups (P less than 0.01).

Adult↗
PubMed1988

Learning fibreoptic intubation: use of simulators v. traditional teaching.

This study compared a graduated training programme with that of a traditional teaching method to facilitate the learning of the technique of fibreoptic nasotracheal intubation. Thirty-two anaesthesia trainees were randomly assigned to two groups. The graduated programme involved: practice on a bronchoscopy teaching model; exposure of the epiglottis and vocal cords in patients recovering from general anaesthesia; performance of fibreoptic nasotracheal intubation in awake sedated patients. The traditional programme involved: demonstration (on a patient) of one fibreoptic nasotracheal intubation by the instructor; performance of fibreoptic nasotracheal intubation (by the trainee) in awake sedated patients. Nasotracheal intubation was accomplished significantly more often by the trainees in the graduated programme (86 out of 96 (89.6%) v. 64 out of 96 (66.5%) (P less than 0.01). The results demonstrate that trainees who undergo a graduated training programme using simulators are initially more successful at awake fibreoptic nasotracheal intubation than those who have learned in the traditional manner, and that the conditions of the investigation were acceptable to the trainees and patients.

Anesthesiology↗
PubMed1989

Pressor and catecholamine response to nasal intubation of the trachea.

The catecholamine and cardiovascular responses to nasal intubation of the trachea with and without laryngoscopy have been compared in 23 patients allocated randomly to each treatment. Arterial pressure, heart rate and plasma concentrations of adrenaline and noradrenaline were measured before and after induction and at 1, 3 and 5 min after intubation of the trachea. There were significant increases in systolic and diastolic pressures after tracheal intubation in both groups. The values at 1 min after intubation were significantly higher in the group undergoing laryngoscopy and intubation compared with the group undergoing blind nasal intubation.

Adult↗
PubMed1991

Effects of trimetaphan on the cardiovascular response to tracheal intubation.

In three groups of 10 patients, we have studied the effect on the cardiovascular responses to laryngoscopy and intubation of bolus doses of saline or trimetaphan 0.05 mg kg-1 or 0.1 mg kg-1 given 1.75 min before the start of laryngoscopy. Anaesthesia was induced with thiopentone 5 mg kg-1 i.v. and tracheal intubation was facilitated with vecuronium 0.2 mg kg-1. During anaesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Patients receiving saline showed a significant increase in mean arterial pressure and rate-pressure product associated with tracheal intubation. These increases following tracheal intubation were less in trimetaphan-treated patients compared with those of the control group (P less than 0.05). There was no significant difference in heart rate following tracheal intubation between the three groups. These data suggest that trimetaphan may be used as a supplement during induction, to attenuate the hypertensive response associated with laryngoscopy and tracheal intubation.

Anesthesia, General↗
PubMed1991

Non-invasive measurement of cardiac output during induction of anaesthesia and tracheal intubation: thiopentone and propofol compared.

We have investigated the haemodynamic changes in response to induction of anaesthesia and tracheal intubation in patients who received either thiopentone 5 mg kg-1 or propofol 3 mg kg-1 followed by atracurium 0.5 mg kg-1 and fentanyl 1.5 micrograms kg-1. Anaesthesia was maintained with 0.6% enflurane and 50% nitrous oxide in oxygen with assisted ventilation. Cardiac output and heart rate (HR) were monitored continuously with a transthoracic impedence monitor. Mean HR did not change after induction in each group, but increased after tracheal intubation in both groups (P less than 0.01). Mean cardiac index (CI) decreased after induction (P less than 0.05) and decreased further after tracheal intubation in both groups (P less than 0.05). There was no difference between the two groups with respect to changes in CI and HR. Mean arterial pressure (MAP) and systemic vascular resistance (SVR) did not change significantly after induction in the thiopentone group. Both variables increased from preinduction values 1 min after tracheal intubation (P less than 0.001). In contrast, both MAP and SVR decreased after induction in the propofol group (P less than 0.001) and did not differ from preinduction values 1 min after tracheal intubation. MAP and SVR were greater in the thiopentone group compared with the propofol group after induction and tracheal intubation (P less than 0.01).

Adult↗
PubMed1993

Tracheal tube cuff inflation as an aid to blind nasotracheal intubation.

We have assessed the efficacy of tracheal tube cuff inflation in the oropharynx as an aid to blind nasotracheal intubation in 20 ASA I and II patients undergoing elective oral surgery. The trachea was intubated once using the technique of tracheal tube cuff inflation in the oropharynx and once keeping the tracheal tube cuff deflated throughout the manoeuvre. With the cuff deflated, intubation was successful in nine of 20 (45%) patients; in eight of 20 (40%) it was successful on the first attempt. With the tracheal tube cuff inflated, intubation was successful in 19 of 20 patients (95%), 15 of 20 (75%) of these on the first attempt. The success rates were significantly different (P < 0.01). Times to intubate were not significantly different (P > 0.05). We conclude that, in normal patients, tracheal tube cuff inflation in the oropharynx increases the success rate of blind nasotracheal intubation.

Adolescent↗
PubMed1993

Teaching fibreoptic nasotracheal intubation with and without closed circuit television.

We have compared the progress of anaesthetists taught fibreoptic nasotracheal intubation with the aid of a closed circuit television (CCTV) system with that of anaesthetists taught by traditional methods. Twenty anaesthetists were allocated randomly to either the video or traditional training group. A graduated training programme was used in which the first stage was an introduction to techniques and apparatus and the second stage was practice on an airway model. During the third stage, rhinoscopy, pharyngoscopy and laryngoscopy were performed on anaesthetized patients whose lungs were ventilated via an orotracheal tube. A maximum time of 6 min was allowed for completion of laryngoscopy. Trainees aimed to perform five endoscopies in less than 60 s before moving on to the next stage. During the fourth stage, they carried out five traditional nasotracheal intubations (plus two video-controlled intubations for the video group) on apnoeic, anaesthetized patients. The mean number of endoscopies required (11.7 vs 21.8), mean total endoscopy time (21.5 vs 63.1 min) and mean number of failed endoscopies (0.8 vs 3.9) were significantly less in the video group. All the video-controlled intubations were successful. There was no significant difference between the number of successful traditional intubations in the two groups (90% video, 92% traditional). CCTV appears to enhance substantially the rate of acquisition of fibreoptic nasotracheal intubation skills.

Adult↗
PubMed1994

Tracheal intubation without neuromuscular block in children.

We have studied 80 healthy children, aged 2-14 yr, undergoing adenotonsillectomy in a double-blind, randomized design. Tracheal intubation facilitated by either suxamethonium 1.5 mg kg-1 or alfentanil 15 micrograms kg-1 was compared after induction of anaesthesia with propofol 3-4 mg kg-1. The quality of tracheal intubation was graded according to the ease of laryngoscopy, position of the vocal cords, coughing, jaw relaxation and movement of limbs. There were no significant differences in the overall assessment of intubating conditions between the two groups, and all children underwent successful tracheal intubation. Fewer patients coughed (P < 0.014) and limb movement was less common (P < 0.007) after tracheal intubation facilitated by suxamethonium. Alfentanil attenuated the haemodynamic responses to tracheal intubation.

Adenoidectomy↗
PubMed1996

Comparison of nicardipine, diltiazem and verapamil for controlling the cardiovascular responses to tracheal intubation.

We have compared the efficacy of three calcium channel blockers, nicardipine, diltiazem and verapamil, in attenuating the cardiovascular responses to laryngoscopy and intubation in 60 normotensive patients (ASA I) undergoing rapid sequence induction of anaesthesia with thiopentone and fentanyl. We also examined whether or not these blockers inhibited catecholamine release induced by intubation. The patients were allocated to one of four groups (n = 15 for each): saline (control), nicardipine 30 micrograms kg-1, diltiazem 0.2 mg kg-1 or verapamil 0.1 mg kg-1. Verapamil and the three other drugs were administered 45 s and 60 s before the start of direct laryngoscopy, respectively, in a double-dummy design. Anaesthesia was induced with thiopentone 4 mg kg-1 i.v. and fentanyl 2 micrograms kg-1 i.v. Tracheal intubation was facilitated with vecuronium 0.2 mg kg-1. During anaesthesia, ventilation was assisted or controlled with 1% isoflurane and 50% nitrous oxide in oxygen. Laryngoscopy lasting 30 s was attempted 2 min after administration of thiopentone and vecuronium. Patients receiving saline exhibited significant increases in systolic and diastolic arterial pressures (AP), heart rate (HR) and plasma concentrations of catecholamines associated with tracheal intubation. The increase in AP was attenuated in patients treated with any calcium channel blocker. The greatest effect was elicited by verapamil, which attenuated the increase in HR, although nicardipine seemed to enhance tachycardia. All three drugs failed to suppress the increase in plasma catecholamine concentrations in response to tracheal intubation. These findings suggest that bolus injection of verapamil 0.1 mg kg-1 was a more effective method of controlling hypertension and tachycardia associated with intubation than diltiazem 0.2 mg kg-1 or nicardipine 30 micrograms kg-1, and that these prophylactic effects were not caused by inhibition of the catecholamine response.

Adult↗