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PubMed2004

Low alfentanil target-concentrations improve hemodynamic and intubating conditions during induction with sevoflurane.

PURPOSE: To investigate the effects of different alfentanil target-concentrations on hemodynamics, respiration and conditions of tracheal intubation during an inhalation induction with 8% sevoflurane. METHODS: In this prospective randomized open-label study, 40 ASA I adult patients received alfentanil at the following target-concentrations: zero (Group 0), 25 (Group 25), 50 (Group 50) and 75 ng*mL(-1) (Group 75), starting five minutes before induction of anesthesia with 8% sevoflurane in 50% nitrous oxide. The ease of intubation was determined on fixed criteria and scored; arterial pressure, heart rate and bispectral index (BIS) were recorded at one-minute intervals. RESULTS: Times to allow tracheal intubation were shortened only in Group 75 (94 +/- 8 sec) as compared to Group 0 (140 +/- 11 sec, P < 0.05). BIS values, tracheal intubation scores and number of attempts were not different between groups. However, more patients suffered from apnea in Group 75. Heart rate and mean arterial pressure remained stable in Group 75 whereas they increased significantly in the three other groups. No patient suffered hypotension. CONCLUSION: Adding alfentanil at a 75 ng*mL(-1) target-concentration during an inhalation induction with 8% sevoflurane in 50% nitrous oxide allows intubation slightly earlier and provides stable hemodynamic conditions but the incidence of apnea during induction is higher. Lower concentrations are of little clinical interest.

Adult↗
PubMed2006

Intubation of SARS patients: infection and perspectives of healthcare workers.

PURPOSE: The outbreak of severe acute respiratory syndrome (SARS) in 2003 presented major challenges to the safety of anesthesiologists and other healthcare workers (HCWs). This study determined the incidence of SARS transmission to HCWs who intubated patients and analyzed the concerns of HCWs regarding personal and patient safety. METHODS: Healthcare workers who performed tracheal intubation in 10 Toronto hospitals were identified using the Ontario Public Health database. A questionnaire was used to collect information from the HCWs. To determine if the patterns of personal protection or concerns changed over time, data were analyzed according to whether the intubation occurred during SARS 1 (February 23 to April 21) or SARS 2 (April 22 to July 1). RESULTS: Thirty-three HCWs who performed 39 intubations on 35 SARS patients were interviewed. Three of 23 HCWs (13%) acquired SARS during SARS 1 whereas none (0/10) acquired SARS during SARS 2. Personal protection increased from SARS 1 to SARS 2 and HCWs' concerns changed over time. During SARS 1, concerns focused on the need for personal protective equipment whereas during SARS 2, concerns focused on the need for strict training and patient care protocols. HCWs perceived that their experiences were ineffectively integrated into risk management protocols. CONCLUSIONS: Protection guidelines failed to completely prevent the transmission of SARS to HCWs. Nine percent of the interviewed HCWs who intubated patients contracted SARS. A Risk Analysis Framework is presented to facilitate the rapid integration of HCWs' experiences into practice guidelines.

Adult↗
PubMed1994

[Difficult intubation due to facial malformations in a child. The laryngeal mask as an aid].

Variations in anatomy of the bony and soft-tissue structures of the neck and facial cranium due to trauma, disease, or dysmorphic syndromes may lead to severe intubation problems. These patients are admitted for mandibulofacial and otolaryngologic surgery. It is important to inspect the patient's outer and inner pharyngeal structures carefully during preoperative assessment, as suggested by Mallampati. The observer estimates the facility of intubation by inspection of the faucial pillars, soft palate, and uvula. Unfortunately, even careful examination does not predict every case of difficult intubation, so that unexpected problems may occur. There may also be difficulties in ventilating these patients with a face mask. Safe intubation is possible in these cases using the laryngeal mask airway (LMA), laryngoscopy with a rigid optical aid, and the fibreoptic bronchoscope. Case report. We report a 14-month-old girl with Goldenhar's syndrome (oculo-auricular dysplasia) who presented for soft-palate surgery. This syndrome belongs to the group of cranio-mandibular-facial malformations; the main symptoms are congenital unilateral malformations in the area of the 1st and 2nd branchial arches. The patient's jaw was hypoplastic with aplasia of the temporo-mandibular joint, which led to asymmetry of the lower face and an extremely short mandible. Additionally, we observed a large tongue in relation to the small jaw. Macrostomia is part of the syndrome, and may lead to underestimation of intubation problems.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, Inhalation↗
PubMed1998

Desflurane or isoflurane for paediatric ENT anaesthesia. A comparison of intubating conditions and recovery profile.

BACKGROUND: The inhaled anaesthetic desflurane is characterized by a rapid wash-in and wash-out and may be useful for short paediatric ENT procedures. Therefore, this study was designed to compare the effects of desflurane or isoflurane on intubating conditions and recovery characteristics in paediatric ENT patients. METHODS: In this prospective, randomised investigation, we studied 44 children scheduled for ENT surgery, aged 4-12 yr and classified ASA I-II. After thiopentone induction (5-8 mg/kg) the lungs were ventilated by face mask and the vaporizer was dialed to 1 MAC (age-adapted) of desflurane of isoflurane. A reduced dose of vecuronium (0.05 mg/kg) was administered, and intubating conditions were rated 3 min later. Following tracheal intubation, 50% nitrous oxide were added, and the concentration of desflurane or isoflurane was adjusted according to clinical needs. At the end of surgery all anaesthetics were discontinued simultaneously and recovery times were recorded. RESULTS: Intubating conditions were rated significantly better for desflurane (excellent or good 20 of 22) than for isoflurane (12 of 22). Recovery times were significantly shorter for desflurane than for isoflurane (mean +/- SE): spontaneous ventilation 4.0 +/- 0.5 min vs. 6.0 +/- 0.7 min, extubation 8.4 +/- 0.7 vs. 11.4 +/- 1.1 min and arrival at PACU 11.5 +/- 0.8 vs. 16.6 +/- 1.5 min. No airway complications (coughing, laryngospasm, or desaturation < 97%) were noted for either anaesthetic. CONCLUSIONS: Following an intravenous induction improved intubating conditions, shorter recovery times and the lack of airway complications make desflurane a suitable alternative to isoflurane for paediatric ENT anaesthesia.

Anesthesia Recovery Period↗
PubMed2006

[Bilateral hypoglossal nerve palsy following intubation].

Hypoglossal nerve palsy following intubation is a rare complication that can be reversible depending on the extent of nerve damage. A 63-year-old male with a sigma carcinoma was repeatedly intubated orotracheally due to postoperative complications. After the fourth intubation, bilateral, complete hypoglossal nerve palsy with severe dysarthria and swallowing disability was observed. A percutaneous endoscopic gastrostomy tube was inserted for nutrition and to prevent aspiration. Cerebral MRI showed no pathological findings, particularly in the brainstem. Electromyographic studies revealed pathological spontaneous activity of both glossal muscles without any motor unit potential consistent with an axonal lesion of both hypoglossal nerves. Nevertheless, complete clinical and electromyographical recovery occurred within 7 months. The bilateral hypoglossal nerve palsy in our patient was probably due to mechanical alteration during intubation, leading to axonotmesis. Hypoglossal nerve palsy following intubation might have a favourable prognosis as long as continuity of the nerve sheath is maintained.

Deglutition Disorders↗
PubMed2004

Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia.

OBJECTIVE: To identify routes and patterns of colonization with Pseudomonas aeruginosa in intubated patients to design strategies of prevention for respiratory infection. DESIGN AND SETTING: Prospective and observational study in the 16-bed intensive care unit of a teaching hospital. PATIENTS AND PARTICIPANTS: Ninety-eight intubated patients were investigated over a 3-year period. Those ventilated less than 72 h were excluded. MEASUREMENTS AND RESULTS: Samples from the tap water from each patient's room, stomach, oropharynx, subglottic secretions, trachea, and rectum were collected when the patient was intubated, and then three times per week. Pulsed-field gel electrophoresis was performed to type the strains. We identified 1,607 isolates pertaining to 35 different pulsotypes. Overall 54.2% of patients presented colonization, and tracheal colonization was present in 30.5%. Ten patients had colonization at intubation, and four of these developed ventilator-associated pneumonia (VAP) after a mean of 4+/-2 days. ICU-acquired colonization occurred in 31 patients, and 4 of these developed VAP after a median of 10+/-5 days. P. aeruginosa was isolated from the room's tap water in 62.4% of samples. More than 90% of tap water samples had pulsotypes 1 and 2, which were frequently isolated in the stomach (59%) but were only rarely associated with VAP. CONCLUSIONS: Although colonization/infection with P. aeruginosa in intubated patients tends to be endogenous, exogenous sources should not be ruled out. A combination of early identification (and eradication) of airways colonization by P. aeruginosa plus infection control measures targeted to reduce cross-contamination should be the basis to prevent pulmonary infection.

Aged↗
PubMed2000

Tracheal colonisation within 24 h of intubation in patients with head trauma: risk factor for developing early-onset ventilator-associated pneumonia.

OBJECTIVE: To investigate if tracheal colonisation within 24 h of intubation is a risk factor for developing early-onset ventilator-associated pneumonia (EP) in patients with head trauma. DESIGN: A prospective study in an intensive care unit of a university hospital. POPULATION: One hundred intubated patients were included with head trauma and Glasgow coma score at admission < or =12. METHODS: We took tracheal aspirate samples within 24 h of intubation and performed a protected bronchoalveolar mini-lavage when clinical diagnosis of pneumonia was made. MEASUREMENTS AND RESULTS: On admission time 68 patients (68%) were colonised in trachea, 22 patients were colonised by Staphylococcus aureus, 20 by Haemophilus influenzae, six by Streptococcus pneumoniae and 20 by gram-negative bacilli. The incidence of EP was 26%, and the microorganisms involved were Staph. aureus (44%), H. influenzae (31%), Strep. pneumoniae (12%), and gram-negative bacilli (13%). A multivariate logistic regression analysis showed that the tracheal colonization by Staph. aureus, H. influenzae or Strep. pneumoniae within 24 h of intubation was an independent risk factor for developing EP (odds ratio: 28.9; 95% confidence interval: 1.59-52.5). CONCLUSION: Colonisation of the trachea within 24 h of intubation by Staphylococcus aureus, Haemophilus influenzae or Streptococcus pneumoniae is a risk factor for developing EP in patients with head trauma.

Adult↗
PubMed2001

Changing patterns of airway accidents in intubated ICU patients.

OBJECTIVE: To document the changes in patterns of airway accidents in intubated patients. DESIGN: Prospective recording of all airway accidents over two periods: 1994-1997 and 1998-1999. PATIENTS: Ventilated patients (5,046) intubated for 9,289 days over 4 years (1994-1997) and 2,932 ventilated patients intubated for 6,339 days over 2 years (1998-1999). MEASUREMENTS: The incidence and pattern of airway accidents over a 2-year period were compared to an earlier similar analysis done in the previous 4 years. RESULTS: The total accident rate in the 1994-1997 period was 36 in 5,046 patients over 9,289 intubated-patient days. The total accident rate in the period 1998-1999 was 20 in 2,932 patients over 6,339 intubated-patient days. The frequency of blocked tracheal tube increased to equal that of unplanned extubation (UE) of endotracheal tube (ETT) as the commonest airway accident. There were nine episodes of blocked tracheal tube in the two current years compared to four in the previous 4 years and there were nine episodes of UE in the two current years compared to 15 in the previous 4 years. There were a total of 18 ETT accidents in 2,930 patients over 5,309 ETT days compared to a total of two tracheostomy accidents in 67 patients over 1,030 tracheostomy days. CONCLUSIONS: We noted a change of the pattern of airway accidents. We noted an increasing trend in the incidence of blocked tracheal tubes, associated with an increased duration of heat and moisture exchanger-filters use. We also noted that the incidence of tracheostomy tube accidents was similar to that of ETT accidents in the current study, unlike the earlier study where tracheostomy tube accidents were more frequent than ETT accidents. This was due to the elimination of tracheostomy tube displacements during the later study period. We associated this with the use of adjustable tracheostomy length tubes.

Accidents↗
PubMed2005

The course of epiphora after failure of silicone intubation for congenital nasolacrimal duct obstruction.

BACKGROUND: One of the indications for dacryocystorhinostomy (DCR) in children with congenital nasolacrimal duct obstruction (CNLDO) is failure of silicone intubation. We evaluated the course of epiphora after failure of silicone intubation for CNLDO when DCR was not performed. METHODS: In a comparative cohort study carried out at a tertiary referral center, ten eyes of seven consecutive children who had failure of silicone intubation manifested as persistent epiphora over 2 months and whose parents refused DCR were followed up for an average of 50.4 months (range 33-70 months). Three lacrimal drainage systems of three other children who had failure of silicone intubation underwent uneventful DCR. RESULTS: In eight (80%) of the ten consecutive eyes with congenital nasolacrimal duct obstruction (six of the seven children, 86%), there was spontaneous complete resolution of the epiphora and normal dye disappearance test (DDT) at the end of the follow-up period. One child with Down's syndrome, allergic rhinitis, asthma and multiple site obstructions had improvement of symptoms but abnormal DDT. The epiphora in all three children who underwent DCR had disappeared by 6 months after surgery when the silicone tube was removed. No complications were noted during the follow-up. CONCLUSIONS: Epiphora can spontaneously resolve after failure of silicone intubation in CNLDO, and DCR should no longer considered be compulsory in such cases unless complications evolve.

Child, Preschool↗
PubMed1996

Tracheobronchial lacerations after intubation and tracheostomy.

BACKGROUND: Although long-term complications of intubation and tracheostomy are well documented, little has been reported on acute complications of airway access techniques. METHODS: Fourteen patients (1 male and 13 female patients) aged 15 to 80 years presented with tracheobronchial lacerations after single-lumen intubation (n = 9), double-lumen intubation (n = 1), or tracheostomy (n = 4). RESULTS: A left bronchial laceration after double-lumen intubation was discovered and repaired intraoperatively. A tracheal laceration after single-lumen intubation was recognized during induction of anesthesia. The remaining 12 were diagnosed within 6 to 126 hours (median, 24 hours) after injury. All patients had mediastinal and subcutaneous emphysema. At endoscopy, 12 injuries were located in the thoracic trachea and 1 in the cervical trachea. Twelve underwent primary repair through a right thoracotomy (n = 11) or left cervicotomy (n = 1), and 1 was treated conservatively. Two patients with tracheostomy injury died postoperatively. All repairs healed well but one. The latter was performed 5 days after the injury; a dehiscence occurred, but healed spontaneously. CONCLUSIONS: We conclude that prognosis of tracheal lacerations depends both on the general health of the patient and on the rapidity of diagnosis and treatment.

Adolescent↗
PubMed1996

Surgical release for intubation purposes in postburn contractures of the neck.

Postburn contractures of the neck can cause difficult endotracheal intubation when cervical hyperextension and lifting of the mandible are impaired. alternative techniques to direct laryngoscopy may be hampered by the presence of rigid scar tissue which obscures the mandibular and laryngeal anatomy, or by the presence of microstomia following retraction of scar tissue in facial burns. This report describes our experience with a safe and quick surgical neck release to facilitate endotracheal intubation in such cases. Following release, intubation was established at the first attempt in all cases. Patients who have suffered flame burns to the thorax with an ascending involvement of the neck and mandibular region are particularly prone to develop extreme contractures. Problems with intubation should be anticipated in patients with healed burns of the neck, and equipment for aiding intubation should be on hand. Furthermore, the surgeon must be available during the induction of anaesthesia to perform an emergency neck release if necessary.

Adolescent↗
PubMed1984

Left mainstem bronchus intubation.

We report a case of a 78-year-old woman, previously in good health, who was endotracheally intubated and brought to the emergency department following sudden cardiac arrest. Physical examination revealed absent breath sounds over the right hemithorax, and a portable chest radiograph demonstrated left mainstem bronchus intubation. Although right mainstem bronchus intubation is a common complication of endotracheal intubation, left mainstem bronchus intubation is rare.

Aged↗
PubMed1992

Analysis of trauma intubations.

The timing of trauma patient intubation is dependent on clinical presentation and clinician judgment. We sought to correlate the timing of intubation with the presenting of physiologic parameters and clinical outcome to identify potential quality assurance audit filters. Patients (n = 82) were grouped by timing of intubation: PREHOSPITAL, paramedic intubation; IMMEDIATE, within 10 minutes of arrival; DELAYED, beyond 10 minutes but within 2 hours of arrival; and NONURGENT, beyond 2 hours or at the time of surgery. While mean revised trauma scores and Glasgow Coma Scale (GCS) scores differed for the groups, the mean length of hospital stay and the incidence of aspiration pneumonia were not significantly different. In the DELAYED group, 80% of those who developed aspiration pneumonia had a GCS < or = 13. Patients in the NONURGENT group were older and commonly presented with tachypnea. The survival rate for the NONURGENT group was lower than predicted by the TRISS method (P = .004). A GCS < or = 13 and age greater than 50 years with presenting respiratory rates of more than 25 breaths/min represent potential trauma intubation audit filters.

Adolescent↗
PubMedDate not supplied

Emergency intubation for paralysis of the uncooperative trauma patient.

The impact of paralysis followed by intubation was studied in patients who had been traumatized and subsequently admitted to Lehigh Valley Hospital Center. Trauma admission records between January 1987 and June 1988 were reviewed. Fifty-seven patients, intubated for control of agitation and combativeness, were divided into high injury severity (HIS) and low injury severity (LIS) subgroups using admission trauma (TS) and injury severity scores (ISS). Thirty-eight (70%) were classified as HIS and 19 (30%) as LIS. All HIS patients had significant injuries diagnosed following paralysis with intubation (PWI). Mortality in the HIS group was 9%. The LIS subgroup was compared to a randomly selected group of similarly injured blunt trauma patients who did not require PWI. There were significant differences (P less than 0.05) in age, hospital cost, hours per day of nursing care, and percent of patients with an ETOH level greater than 100 mg%. Emergency paralysis with intubation is an effective method for controlling the uncooperative, combative, seriously injured patient. However, patients with low injury severity who require restraint have higher costs and require more care if they are paralyzed and intubated than if they are not.

Adult↗
PubMed1988

Translaryngeal guided intubation solved a critical airway problem.

Airway obstruction during the induction of general anesthesia remains a persistent problem in modern anesthesia practice, particularly in obstetric patients. Generally, a careful preoperative airway evaluation uncovers most abnormalities that might make intubation difficult. The planning and preparation for additional intubation equipment facilitate an anticipated difficult intubation. However, situations may arise in which unanticipated airway obstruction occurs requiring prompt management. Although every anesthesia provider is trained to manage such acute airway problems, the provision of a patent airway is not always possible, particularly when repeated attempts at endoscopic or blind intubation have failed, leaving a bloody field that prevents optimal visualization, or when time does not allow to wake up the patient. In this article a difficult airway problem is reported in which translaryngeal guided intubation was lifesaving.

Abruptio Placentae↗
PubMed1989

Attenuation of the hemodynamic responses to endotracheal intubation with preinduction intravenous labetalol.

Endotracheal intubation following anesthesia induction frequently produces hypertension and tachycardia. This study evaluated the efficacy of preinduction IV labetalol for attenuating the hemodynamic responses to intubation following thiopental and succinylcholine induction of anesthesia. Two hours after diazepam (10 mg by mouth), 60 patients were randomized in a double-blind manner and received IV saline or labetalol at doses of 0.25, 0.5, 0.75, or 1 mg/kg in a parallel design study. Five minutes later, thiopental (4 mg/kg) and succinylcholine (1 mg/kg) were administered, and the trachea was intubated in 2 minutes. Nitrous oxide (70%) anesthesia was maintained for 10 minutes. Hemodynamic parameters were grouped and analyzed for significance (p less than 0.05) by two-way repeated measures analysis of variance and t-test with Bonferroni adjustments. Baseline group demographics and hemodynamics were comparable. All doses of labetalol significantly attenuated the rate-pressure product increase immediately postintubation versus placebo. There was a dose-dependent attenuation of the increases in heart rate and the systolic, diastolic, and mean blood pressures versus placebo following intubation. IV labetalol at doses up to 0.75 mg/kg offers an effective pharmacologic means of attenuating preoperative hemodynamic responses to endotracheal intubation.

Adult↗
PubMed1989

Effect of labetalol or lidocaine on the hemodynamic response to intubation: a controlled randomized double-blind study.

Labetalol, a combined alpha 1- and nonselective beta-adrenergic blocking drug, was compared to lidocaine or saline to minimize the hypertensive and tachycardic response to intubation in a controlled randomized double-blind study in patients undergoing surgical procedures under general anesthesia. Forty adult patients were divided into four groups of 10 each: placebo (saline), lidocaine 100 mg, labetalol 5 mg, or labetalol 10 mg. The double-blind preparation was administered as an IV bolus just prior to induction and 2 min before the stimulus of laryngoscopy and intubation. Heart rate and blood pressure were measured at 1-min intervals for 2 min prior to induction of anesthesia and through 6 min following induction of anesthesia. Labetalol 10 mg prevented a rise in heart rate after intubation compared to patients who received placebo, lidocaine 100 mg, or labetalol 5 mg. The hypertensive response to intubation was similar in all four groups. Labetalol 10 mg IV just prior to induction of anesthesia is a safe and cost-effective means of preventing tachycardia but not hypertension in response to laryngoscopy and intubation.

Adult↗
PubMedDate not supplied

Partial attenuation of the cardiovascular responses to tracheal intubation with oral nisoldipine.

STUDY OBJECTIVE: To evaluate the efficacy and safety of nisoldipine given orally in attenuating the cardiovascular responses to laryngoscopy and tracheal intubation. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Induction of anesthesia for elective surgery at a university hospital. PATIENTS: Thirty normotensive patients (ASA physical status I) undergoing elective surgery were assigned to one of three groups; placebo, nisoldipine 5 mg, or nisoldipine 10 mg. Each group consisted of ten patients. INTERVENTIONS: Either 5 mg of nisoldipine, 10 mg of nisoldipine, or a placebo was administered orally 2 hours before induction of anesthesia. Anesthesia was induced with thiopental sodium 5 mg/kg intravenously, and tracheal intubation was facilitated with vecuronium 0.2 mg/kg. During anesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Laryngoscopy lasting 30 seconds was attempted 2 minutes after administration of thiopental sodium and vecuronium. MEASUREMENTS AND MAIN RESULTS: Patients receiving the placebo showed a significant increase in mean arterial pressure associated with tracheal intubation. These increases following tracheal intubation were significantly reduced in patients receiving nisoldipine 10 mg compared with patients receiving the placebo (p less than 0.05). CONCLUSIONS: Oral administration of nisoldipine before induction of anesthesia is a simple, practical, and safe method for attenuating pressor response to laryngoscopy and tracheal intubation.

Administration, Oral↗