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PubMed1999

The effects of tramadol versus fentanyl in attenuating hemodynamic response following tracheal intubation.

BACKGROUND: Tramadol is a novel central acting analgesic. It has been used as a complement to general anesthesia and an effective agent for postoperative analgesia. However, the influence of tramadol on the hemodynamic response following laryngoscopy and tracheal intubation is less known. METHODS: Forty patients of both sexes, 16-50 year old, ASA physical status I or II, scheduled for elective surgery were randomly divided into equal groups in this prospective, double blind study. After obtaining the baseline data, the patient was given 3 micrograms/kg fentanyl (Group F) or 3 mg/kg tramadol (Group T). Then induction of anesthesia in a uniform and standardized manner was carried out by an anesthesiologist who was blind to the medication. The hemodynamic parameters were measured and recorded immediately after induction but prior to laryngoscopy, 3, 6, and 9 min after intubation, and before incision. We also observed any unusual effect in the postoperative care unit. Chi-square test, Student's t-test and paired t-test were used for statistical comparison. A P less than 0.05 was considered statistically significant. RESULTS: All patients had a successful induction and intubation. Differences in baseline values were not significant, nor were the differences in the values following induction. After laryngoscopy and intubation, heart rate increased significantly above the baseline level in both groups. The increase of heart rate was significantly more at 6 and 9 min (P < 0.05) and lasted longer in the tramadol group. After intubation, systolic, mean and diastolic arterial pressure (SAP, MAP, DAP) increased significantly above baseline in both groups too, except for DAP in fentanyl group. At 6 and 9 min, the MAP and DAP were significantly higher in tramadol than in fentanyl group (P < 0.05). Six patients in tramadol group had mild pain on injection of tramadol. CONCLUSIONS: When administered right before thiopental induction, 3 mg/kg tramadol did not display a better attenuation against the increase of hemodynamic profiles than did 3 micrograms/kg fentanyl following tracheal intubation.

Adolescent↗
PubMed2000

The effect of full protective gear on intubation performance by hospital medical personnel.

OBJECTIVE: To assess the influence of protective gear on intubation performance. DESIGN: Prospective, controlled measurement of duration and quality of intubations performed on mannequins by medical personnel with and without protective gear in a crossover design. PARTICIPANTS: Eight teams each comprising an anesthesiologist and a nurse. RESULTS: Intubation duration with and without chemical warfare gear was 69.2 +/- 7 and 47.3 +/- 6 seconds (mean +/- SEM), respectively (p < 0.05). Moreover, rating of intubation quality as "very good" by the anesthesiologists declined significantly from 62.5% without chemical warfare protective gear to 6.25% with the garment and mask. Tube fixation was the rate-limiting step when performed with protective gear (p < 0.05); it was assessed by 81% of the anesthesiologists as the critical step. A learning curve was not observed during the study. CONCLUSION: Protective gear causes a significant prolongation of intubation duration; however, endotracheal intubation can be performed effectively. Technical improvements are warranted for tube fixation because it is the critical step.

Adult↗
PubMed2000

Out-of-hospital succinylcholine-assisted endotracheal intubation by paramedics.

STUDY OBJECTIVE: To describe the effectiveness and safety of succinylcholine administration by paramedics to out-of-hospital patients requiring endotracheal intubation. METHODS: A consecutive case series was collected by retrospective review of patient care records from a large, private ambulance agency serving an urban and rural county of 600,000 residents over a 40-month period. All patients for whom endotracheal intubation was facilitated by succinylcholine use were identified. Data were systematically collected on demographics, paramedic diagnosis, intubation attempts, and complications. RESULTS: Succinylcholine was used in 150 patients with a mean age (+/-SD) of 50+/-23 years. Paramedic diagnosis was coma in 43% (64/150; 95% confidence interval [CI] 35% to 51%), trauma in 26% (39/150; 95% CI 19% to 33%), and respiratory failure in 31% (47/150; 95% CI 23% to 39%). No patient was in cardiac arrest at the time of succinylcholine use. The intubation success rate was 92% (138/150; 95% CI 88% to 96%), with success achieved on the first attempt in 82% of patients (123/150; 95% CI 76% to 88%). Four patients who received succinylcholine developed cardiac arrest, and 3 others had symptomatic bradycardia. CONCLUSION: The use of succinylcholine by paramedics to assist intubation appears to aid in intubation of patients who are not in cardiac arrest. However, significant cardiac complications can occur.

Adolescent↗
PubMed1998

[Evaluation of the intubating conditions and maintenance doses of rocuronium].

OBJECTIVE: To assess intubating conditions after administration of rocuronium 0.6 mg/kg at 60 or 90 s and neuromuscular blocking effects of rocuronium. METHODS: Thirty-two patients were randomly designated to two groups: 60 s group and 90 s group. Anesthesia consisted of thiopentone, fentanyl, N2O/O2 and enflurane. After a 2 x ED95 dose the trachea was intubated at 60 or 90 s and the intubating conditions were recorded. After intubation was finished, patients were allocated randomly to receive either intravenous infusion or bolus injection of rocuronium to maintain surgical relaxation. RESULTS: Intubating conditions were not different between the two groups and were found to be clinically acceptable (good or excellent) in all patients. The maintenance of surgical relaxation was satisfactory either with repeated bolus and infusion of rocuronium. CONCLUSION: Intubation can be performed under good to excellent conditions within 60-90 seconds after a bolus dose of 0.6 mg/kg rocuronium. This indicates that rocuronium may be a suitable alternative to succinycholine during rapid-sequence induction of anesthesia.

Adjuvants, Anesthesia↗
PubMed2001

[Influence of intubation maneuver with or without premedication for intracranial hemorrhage with unconsciousness].

PURPOSE: To clarify the influence of intubation maneuver with or without premedication for intracranial hemorrhage with unconsciousness. METHODS: Between May 1995 and May 2000, we analyzed retrospectively 46 patients who had received intubation for unconsciousness and were found non-traumatic intracranial hemorrhage by head computer tomography at the Trauma and Critical Care Center, National Defense Medical College. They were divided into two groups, Drug group in which drugs were used before intubation and Control group which were intubated without drugs. Physical findings on admission, head CT findings, Glasgow Outcome Score(GOS) at discharge were analyzed between the groups. RESULTS: There were no significant differences for background of subjects between the groups. In the Drug group, diazepam, pentazocine, lidocaine, nifedipine and nicardipine were used before intubation. GOS in the Control group was significantly greater than in the Drug group(p < 0.01). CONCLUSION: In case of intubation for unconscious patients who may suffer intracranial hemorrhage, using premedication leads to favorable outcome.

Adult↗
PubMed2001

[Light-wand (Trachlight) guided nasotracheal intubation].

We report that Trachlight-guided nasotracheal intubation might be achieved successfully and traumatically without removal of a stiff internal stylet. Endotracheal tube was mounted on a Trachlight with the stylet in position and bent to form a less sharp curvature than a right angle, namely 40-60 degree, at 7 cm proximal to the endotracheal tube tip. Forty-six patients scheduled for nasal intubation were studied to measure the intubation time and the success rate with the use of Trachlight. The tracheas were successfully intubated in 89% of patients. We suggest that Trachlight-guided nasotracheal intubation could be clinically feasible without traumatic complication when applied with a stiff stylet in position and this approach is a useful method for nasal intubation.

Humans↗
PubMed2001

Lack of intravenous lidocaine effects on HRV changes of tracheal intubation during induction of general anesthesia.

BACKGROUND: Intravenous lidocaine has been widely used for suppressing the autonomic activation from tracheal intubation during induction of general anesthesia. Conventionally, researches of its effectiveness through assessment of heart rate and blood pressure changes obtained by common clinical methods result in the conclusions deduced of much controversy. Heart rate variability is a noninvasive measurement of autonomic regulation and is suitable for the study of this subject. METHODS: 36 ASA class I-II patients undergoing general anesthesia were divided into 3 groups. Besides induction agents, intravenous lidocaine was given 5 min before tracheal intubation in group A, 3 min before intubation in group B and nothing in group C. HRV spectral powers were measured at awake state, anesthetized state before tracheal intubation and anesthetized state after tracheal intubation by time frequency spectral analysis method and comparison was made between the three groups. RESULTS: The HRV spectral power in high frequency (HF) and mid-frequency (MF) power bands and their ratios (MF/HF) were not significantly different among the 3 groups during the 3 observation periods. CONCLUSIONS: There was no evidence to indicate the effectiveness of intravenous lidocaine on the autonomic regulation during tracheal intubation under the influence of induction agents used in general anesthesia.

Anesthesia, General↗
PubMed2001

[A clinical evaluation of blind orotracheal intubation using Trachlight in 511 patients].

We used Trachlight for blind orotracheal intubation (ordinary tracheal tube or Portex Blueline in 305 cases, and reinforced tube or Mallinckrodt Safety-Flex in 206 cases) for general anesthetic procedures, and evaluated its technical features along with related complications. With ordinary tubes, 93% of the patients could be intubated successfully at the first attempt. Unsuccessful intubation even at the third attempt occurred in 3 patients (1%). One patient was complicated with a long epiglottis and the cause was unknown in the other patients. With reinforced tubes, 83% of the patients could be intubated at the first attempt but 8 patients (4%) could not. Of them, four patients received too large reinforced tubes straightening the bending of the stylet. Each of the three patients had a narrow larynx, mandibular retraction or obese neck making transillumination difficult. In the remaining one patient, the cause was unknown. Complication found in 30% of the patients was sore throat that seemed severer than that caused by laryngoscope. One patient developed minor tracheal bleeding probably due to injury of the mucosa. The elevation of the blood pressure at intubation with this device was not as high as that by direct laryngoscopy. We conclude that Trachlight leads to intubation with a high success rate, and that care should be taken not to damage the tracheal mucosa by blind insertion.

Adolescent↗
PubMed2002

Self-extubation in intensive care and re-intubation predictors: a retrospective study.

To find out the incidence of self-extubation in intensive care, to evaluate the factors responsible for it and to identify the predictors of need for re-intubation, a retrospective analysis was conducted among 350 patients who were admitted to the intensive care unit over a two-year period and required ventilatory therapy for more than 48 hours. In all patients who self-extubated, the demographic data, ventilatory parameters before self-extubation (mode of ventilation, inspired oxygen concentration, positive end-expiratory pressure), partial pressure of oxygen in arterial blood and inspired oxygen fraction ration (PaO2/FiO2), and the event of re-intubation were noted. These values were compared among patients who were re-intubated and those who were not. Twelve patients out of 350 self-extubated. Of these 12 patients, 7 required re-intubation while 5 did not. Of these 7 patients, 3 died within 48 hours of the episode of self-extubation and one patient's death was directly attributable to self-extubation. Of the remaining 4 patients, 3 died within a span of 7 days. Re-intubation after self-extubation should not be considered mandatory. Patients who required re-intubation had lower PaO2/FiO2 than patients who did not.

Adult↗
PubMed2002

[Fiberoptic tracheal intubation aided by jaw lifting in a patient with an epiglottic cyst].

Epiglottic cyst is known to cause difficult intubation. We report a patient with an epiglottic cyst whose trachea was successfully intubated with the aid of fiberoptic bronchoscopy combined with the jaw lift maneuver. A 29-year-old patient was scheduled for lumbar disk hernia surgery. On the first occasion, surgery was cancelled since the patient was unexpectedly found to have an epiglottic cyst and tracheal intubation was not possible. Two weeks later, nasotracheal intubation guided by fiberoptic bronchoscopy under conscious sedation was planned. On the first attempt of bronchoscopy, the glottic view was obscured by the cyst displacing the epiglottis posteriorly. Next, we applied the jaw lift maneuver in conjunction with bronchoscopy. The maneuver improved the glottic view by clearing the epiglottis from the posterior pharyngeal wall and the patient's trachea was successfully intubated. Jaw lifting could be a useful adjunct to fiberoptic bronchoscopy for tracheal intubation in patients with epiglottic cysts.

Adult↗
PubMedDate not supplied

[Evaluation of the UpsherScope laryngoscope in routine intubation with no expected difficulties].

OBJECTIVES: To evaluate the new rigid, fiberoptic laryngoscope (UpsherScope) in cases with no expectation of intubation difficulty. MATERIAL AND METHODS: We studied 130 ASA I-II patients for whom no difficulty with tracheal intubation was predicted. Intubation attempts were undertaken by three staff anesthesiologists, with up to three tries permitted per patient. Causes of difficulty were recorded. A regression study of the number of tries per patient over the course of the study was used to identify a possible learning effect. Causes related to inexperience were identified by comparing their frequency of appearance between the first and second halves of the study using a chi-squared test. RESULTS: Ninety-nine patients (76%) were intubated, 70 of them (54%) on the first try. A total of 223 attempts at laryngoscopy (1.71 +/- 0.85) per patient) were made. The best relation in the regression analysis was linear, with a significant slope (-0.0193, p < 0.05) and R2 = 0.103 demonstrating a learning effect. The reasons for difficulty were hitting the endotracheal tube (ETT) against the right arytenoids (18), esophageal progression of the ETT (12), blood or secretions (8), vision obstructed by the epiglottis (7), clouding (7), lateral sliding of the stylet (6), hitting the ETT against the epiglottis (4). Only ETT impingement of the right arytenoids was related to inexperience (p < 0.001). We discuss the relation of these factors to the design of the laryngoscope. CONCLUSIONS: Our experience suggests that the UpsheScope does not offer advantages in routine intubations. The low success rate and the need for repeated attempts at intubation may be related to suboptimal design of the laryngoscope.

Equipment Design↗
PubMed2002

Tracheal intubation condition--a comparison between one minute after rocuronium alone, one minute after rocuronium combined with atracurium and one minute after atracurium with rocuronium at one minute priming interval.

BACKGROUND: Rocuronium, a monoquaternary steroid analogue of vecuronium, is designed to provide a rapid onset of action. Experimentally, it has been shown that two non-depolarizing neuromuscular relaxants administered together can produce either a neuromuscular block of a size expected to be the sum of the individual doses (additive effect) or a larger neuromuscular block (synergistic effect). Experimental observations have suggested that during onset rocuronium acts synergistically with other nondepolarizing agents, but that at a steady state the combined action is additive. METHODS: To investigate whether rocuronium can speed up the onset of atracurium for intubation, 120 patients who consented to receive elective surgery requiring tracheal intubation were randomly assigned to 3 equally divided groups to receive one of the following three different combinations of muscle relaxants: twice ED95 of rocuronium (0.6 mg/kg group 1), an equipotent mixture of ED95 of rocuronium and atracurium (0.3 mg/kg and 0.25 mg/kg respectively, group 2), and rocuronium 0.1 mg/kg to prime atracurium 0.42 mg/kg at 1 min interval. Intubation conditions were assessed 1 minute after intravenous muscle relaxant injection, and scored as good, acceptable and poor based on four clinical evaluators: the ease of laryngoscopy (score of 1-3), the relaxation of vocal cord (1-3), the degree of coughing (1-3), and movement of extremity (1-3). Adding up together, intubation condition that scored 4-5 was considered to be good, 6-7 acceptable, and 8-12 poor. RESULTS: The conditions produced in the rocuronium and the mixture groups were similar and both were moderately better than those of the priming group. Good intubation conditions were achieved in 58% patients of the rocuronium group, 63% of the mixture group and 43% of the priming group. By Pearson Chi-square test, the comparisons did not show statistical significance between groups. CONCLUSIONS: Statistically, rocuronium alone, mixture of equipotent atracurium and rocuronium, and using rocuronium to prime atracurium all provided similar onset for satisfactory intubation.

Adult↗
PubMed2003

[Difficult tracheal intubation in a patient suspected of malignant hyperthermia].

We report anesthetic management of a patient suspected of malignant hyperthermia with difficult tracheal intubation. A 64-year-old man was scheduled for a fixation of humerus bone fractures in prone position. He had a history of difficult tracheal intubation due to masseter spasm, and his niece was suspected to be malignant hyperthermia. Anesthesia was induced with propofol using a target controlled infusion. No muscle relaxant was given and spontaneous breathing was maintained. Trials for tracheal intubation failed whenever using a standard laryngoscope, a bronchofiberscope, a laryngeal mask airway or an intubating laryngeal mask airway. Resecting the epiglottic elevating bar of an intubating laryngeal mask airway enabled fiberoptic tracheal intubation. No symptom suggesting malignant hyperthermia developed.

Anesthesia↗
PubMed2003

Nasal vs oral intubation.

Both nasal and oral route for intubation have advantages and disadvantages. Oral intubation is easier to perform, faster and less painful than nasal intubation under direct laryngoscopy, while blind nasal intubation represents a good alternative in conscious patient, without sedation. In trauma patient, oral route should be preferred, with cervical immobilisation. By the contrary, nasal intubation can cause bleeding, retro-pharyngeal and turbinate bones injury, but it seems preferable in preventing laryngeal complications. Moreover nasal intubation seem to increase risk for sinusitis while, there is no clear advantage for any of the two routes, concerning nosocomial pneumonia, bacteriemia and otitis. Nevertheless nasal route increases comfort for the patient and decreases injury and necrosis of tongue and lips; tube fastening is simpler thus reducing accidental extubation.

Humans↗
PubMed1992

[A comparison between nasotracheal and orotracheal intubation in treating chronic obstructive pulmonary disease complicated by respiratory failure].

Endotracheal intubation and mechanical ventilation were given to 100 COPD patients complicated by respiratory failure from Dec. 1977 to May 1990. Among them 42 were intubated through mouth. The tubes were kept from 1 to 6 days. In only 8 cases (19.0%) the tubes could be withdrawn according to the criterion, and 25 patients (59.0%) were tracheostomized. Nasotracheal intubation were given to 58 patients. The tubes were kept from 1 to 220 days and could be withdrawn in 39 cases (81.0%), with an incidence higher than that in patients intubated orotracheally (P < 0.01). Tracheostomy mas given to 6 patients intubated nasotracheally (10.3%), being fewer than in patients intubated through mouth (P < 0.01). Although the tubes have been kept for longer time, the duration of hospitalization was not prolonged.

Adult↗
PubMed1992

Reducing intraocular pressure by intubation elicits precocious development and innervation of the embryonic chick cornea.

Growth of the embryonic chick cornea was directly related to, and coordinated with, overall eye growth. During normal development, the size of the embryonic chick cornea increased in three linear phases of diametric growth. Corneal diameter increased at a rate of 216 microns per day between embryonic day 4 (E4) and E7, 511 microns per day between E7 and E10, and 144 microns per day from E10 until after hatching. After the sustained release of intraocular pressure by intubation on E4, corneal diametric growth was reduced to a single phase of 122 microns per day. After intubation on E4, the mesenchyme surrounding the developing cornea was substantially thicker and the neural crest-derived corneal endothelium was established earlier. The primary corneal stroma of the intubated eye swelled and was precociously populated by neural crest-derived corneal fibroblasts. Thus, the timing of arrival of neural crest cells in the anterior segment and their contribution to the cornea were determined by the growth rate of the eye. Although the diameter of the cornea was substantially reduced after intubation, it was more densely populated by fibroblasts, resulting in a cornea that was substantially thicker than the control by E14. Prospective corneal nerves normally extend into the cornea proper on E11, concomitant with a decrease in its diametric growth rate. After intubation on E4, the perilimbal nerve ring was virtually complete by E5 and numerous nerves had extended throughout the E8 cornea. By E16, the cornea from the intubated eye contained a very high density of nerve fibers, possibly reflecting its reduced size. These data suggest that the primary corneal stroma does not permit nerve fiber extension and demonstrate that the timing of nerve fiber extension into the secondary corneal stroma is specified by the rate of oppositional diametric growth of the cornea.

Animals↗
PubMed2004

Peri-intubation cardiovascular response during low dose remifentanil or sufentanil administration in association with propofol TCI. A double blind comparison.

AIM: The aim of this study was to compare the effects on cardiovascular modifications induced by tracheal intubation when low dose infusion of remifentanil or sufentanil are used in association with propofol target controlled infusion. METHODS: Sixty normotensive, ASA I-II-III, Mallampati Score <3 undergoing general anaesthesia for major elective abdominal surgery, received i.m. midazolam (0.05 mg/kg) and atropine (0.01 mg/kg) 30 min before induction. They were randomly divided in a double-blind fashion into two groups receiving for induction respectively target controlled infusion of propofol (site-effect 3.0 microg/ml) and sufentanil (0.01 microg/kg/min) or remifentanil (0.1 microg/kg/ min) infusion. Rocuronium (0.6 mg/kg) was administered. Following intubation, the lungs were mechanically ventilated with an oxygen/air mixture. RESULTS: Bispectral index score and haemodynamic variables were recorded at baseline, after induction, during intubation and 1-3-5 min after the trachea was intubated. No differences in systolic and diastolic arterial pressure were observed in the sufentanil group, while the remifentanil group showed transient systolic and diastolic variations after intubating manoeuvers. The heart rate and bispectral index score were not affected in either group. CONCLUSION: In healthy normotensive patients the use of a small dose of either remifentanil or sufentanil after standard midazolam premedication, proved to be an effective strategy to blunt the cardiovascular response to intubation.

Anesthetics, Combined↗
PubMed2004

[The efficacy of video intubating laryngoscope for novice residents].

BACKGROUND: The visibility and quality of the tracheal intubation may be improved by the video intubating laryngoscope (VIL). However, the efficacy using VIL among novice residents has not been reported. METHODS: Total of 154 cases of tracheal intubation experienced by 5 novice residents in 8 weeks were divided into VIL (X-Lite: Rüsch, Germany) group (n = 59) and ordinary laryngoscope group (OL: n = 95), retrospectively. Number of attempts, success and failure were recorded in both groups. In VIL group, video image of the entire procedure was recorded. Success rates were compared between OL and VIL. In VIL group, elapsed time for intubation and findings during laryngoscopic procedure were examined retrospectively. RESULTS: In the first attempt, the success rate was significantly higher in VIL (83%) than OL (68%). Including secondary attempt, the rate increased to 85% in OL and 97% in VIL, and the difference was also significant. In VIL group, elapsed time for entire intubation was 42 +/- 18 seconds (mean +/- SD). It was significantly decreased in 4, 6 and 7th week compared in the first week. Residents showed different pattern of findings during their laryngoscopic procedure. CONCLUSIONS: The use of VIL improved success rate of tracheal intubation compared with OL. Retrospective analysis of video image revealed their progress and characteristics features in their laryngoscopic procedure. VIL was efficient in the education of the novice residents.

Adult↗