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PubMed1999

Hemodynamic response to tracheal intubation after vital capacity rapid inhalation induction (VCRII) with different concentrations of sevoflurane.

STUDY OBJECTIVE: To evaluate the blood pressure (BP) and heart rate (HR) response to tracheal intubation after vital capacity rapid inhalation induction (VCRII) with four concentrations of sevoflurane followed by nitrous oxide (N2O) 50% and sevoflurane in concentrations administered by clinical judgment. DESIGN: Prospective, randomized study. SETTING: University teaching hospital. PATIENTS: 60 unpremedicated, ASA physical status I and II adult patients undergoing surgery with general anesthesia. INTERVENTIONS: After fentanyl 3 micrograms/kg, VCRII was accomplished with four concentrations of sevoflurane in O2: Group 1 (n = 15): sevoflurane 3%; Group 2 (n = 15): sevoflurane 4%; Group 3 (n = 15): sevoflurane 5%; and Group 4 (n = 15): sevoflurane 6%. At loss of consciousness, rocuronium 0.6 mg/kg was given, and intubation was performed 90 seconds later. Thereafter, anesthesia continued with N2O 50% and sevoflurane. MEASUREMENTS AND MAIN RESULTS: BP and HR measurements were made at the ward (baseline), at loss of consciousness, and just prior to, and each minute after, tracheal intubation during a 5-minute period. The hemodynamic profile among groups was similar, with a slight hypertensive and tachycardic response to intubation. CONCLUSION: VCRII with sevoflurane 3% to 6% following fentanyl 3 micrograms/kg can be considered for blunting the hemodynamic response to tracheal intubation in healthy patients.

Adult↗
PubMed2003

Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy.

AIM: The aim of this study was to assess the success rate of bicanalicular intubation of lacrimal drainage apparatus in chronic dacryocystitis patients who were at high risk of failure of surgery of dacryocystorhinostomy. MATERIAL AND METHODS: A total of 24 patients with chronic dacryocystitis (25 eyes) including 11 males and 13 females (age range 3-80 years) having high risk factors of failure of dacryocystorhinostomy were enrolled. Factors such as previous attacks of acute dacryocystitis, trauma in lacrimal sac region, previously failed dacryocystorhinostomies, formation of false passages in the lacrimal drainage apparatus were considered. Conventional dacryocystorhinostomy followed by bicanalicular intubation of the lacrimal drainage apparatus with Jain metal silicone the lacrimal intubation tube (20-23 gauge) was performed in all these patients. The patients were followed up at weekly intervals for two months, at 6 months and at 1 year post surgery. RESULTS: A total of 25 eyes in 24 patients (including 11 males and 3 females) were operated upon using the technique of bicanalicular intubation of lacrimal drainage apparatus with conventional external dacryocystorhinostomy. The procedure was successfully performed in 22 out of the 25 eyes. Perioperative complications included punctual damage due to recurrent attempts at passing these probes in 2 patients and mild damage to nasal mucosa in 5 patients. The majority of patients did not experience any untoward symptoms from these silicone tubes. However, in three eyes there was felt a mild foreign body sensation and two patients had chronic conjunctival erythema. The tubes could not be retained in two of these three eyes. Additionally, in one eye there was spontaneous extrusion of tubes whilst sneezing 3 months after surgery. All these three eyes had a recurrence of symptoms due to non-retention of the tubes and needed re-operation. On average the tubes were retained for a period of six months before they were spontaneously extruded or removed. Fifteen patients retained the silicone tubes for more than 1 year. The procedure gave a success rate of 76% (19/25 eyes) and these were the eyes in which the tubes had been retained for more than 6 months. The success was not influenced by the age or sex of patient, laterality of eye, aetiology of chronic dacryocystitis, or evidence of bony deformity or abnormality of the sac. CONCLUSIONS: Bicanalicular intubation for lacrimal drainage system is a simple, inexpensive and straight forward adjunct to conventional external dacryocystorhinostomy. The procedure is strongly indicated for patients with chronic dacryocystitis who are at high risk of surgical failure. Carefully performed, it gives a 76% success rate and is not influenced by the different variables examined.

Adolescent↗
PubMedDate not supplied

A literature review of the prehospital use of neuromuscular blocking agents by air medical personnel to facilitate endotracheal intubation.

Air medical personnel in the United States have used neuromuscular blocking agents to facilitate endotracheal intubation in the field for more than a decade. This literature review examines 15 studies to investigate their experience and explores the following specific areas: the intubation success rate in patients who did or did not receive these agents, the intubation success rate of air medical personnel before and after they incorporated these agents into their practice, the neuromuscular blocking agents and adjunct medications used by air medical personnel, and the disposition of patients who could not be intubated after an agent was given. The data suggest that, overall, air medical personnel use these agents safely and effectively. Suggestions are offered for future studies, including examining ground time when agents are used to facilitate intubation, complications of their use in this setting, and the use of simulators to train personnel in the administration of these medications.

Air Ambulances↗
PubMedDate not supplied

The quick look airway classification. A useful tool in predicting the difficult out-of-hospital intubation: experience in an air medical transport program.

The unpredictable nature of the out-of-hospital care environment poses unique challenges for active airway management techniques. This descriptive study was conducted in the helicopter air medical transport (AMT) environment for a period of 32 months to determine whether initial direct airway visualization classification may provide a useful tool to predict the difficulty of intubation. Data extracted from documented oral intubation attempts included initial airway visualization grade, number of attempts, final airway management method, and procedural complications. Oral intubation was attempted on 429 patients. Initial airway visualization grades were found with the following frequency for grades I through IV: 65.6%, 21.5%, 8.6%, and 5.4%, respectively. Similarly, the average number of attempts was 1.34, 1.65, 1.97, and 2.39, respectively. The serious complication rate was 24%, 46%, 62%, and 65%, respectively. A statistically significant correlation (Spearman's rho) was found between increasing grade and both the number of intubation attempts (0.52) and the number of complications (0.45). Initial visualization classification may serve as a useful indicator in the out-of-hospital environment to help anticipate the difficulty of intubation and the need for early alternative airway management strategies. In this program, such classification is used to monitor airway management skills.

Air Ambulances↗
PubMedDate not supplied

The effect of a rapid sequence induction protocol on intubation success rate in an air medical program.

The purpose of this study was to examine the percentage of successful intubations before and after implementation of a rapid sequence induction (RSI) protocol in patients treated by our flight nurses and paramedics. The records of 100 intubation attempts before the RSI protocol was implemented and 98 after implementation were reviewed. Success rate of intubation was 79% in the preRSI patient group and 84.7% in the postRSI group. No significant difference existed in the number of patients successfully intubated preRSI compared with postRSI. The statistically significant patient characteristics associated with unsuccessful intubation were facial trauma, combativeness, vomiting, and nasal bleeding.

Air Ambulances↗
PubMed2003

Inhalational induction of anaesthesia with 8% sevoflurane in children: conditions for endotracheal intubation and side-effects.

BACKGROUND AND OBJECTIVE: This study was designed to assess the conditions for endotracheal intubation or insertion of a laryngeal mask airway following an inhalational induction using 8% sevoflurane and nitrous oxide without the use of muscle relaxants or opioids. METHODS: There were two groups: 30 children had endotracheal intubation and 30 children had a laryngeal mask airway inserted. Induction of anaesthesia was accomplished using an inspiratory concentration of sevoflurane 8% in a nitrous oxide and oxygen mixture. After an end-expiratory concentration of sevoflurane of at least 4% had been reached, when the pupils were miotic and centred, the trachea was intubated or a laryngeal mask inserted. The time to loss of consciousness and successful airway management was recorded. Jaw relaxation, movements, visibility, and position of the vocal cords and vital parameters were monitored. RESULTS: Jaw relaxation was complete in all children. The vocal cords were completely visible in all patients of the tracheal intubation group, whereas vocal cord relaxation was incomplete in five children. Nevertheless, all children had an atraumatic intubation or insertion of the laryngeal mask without the use of a muscle relaxant. Vital signs were stable in both groups. There were no cases of restlessness and/or postoperative shivering. Four patients in the endotracheal group (13.3%) were nauseous and three (10%) vomited, while two children (6.6%) in the laryngeal mask group experienced nausea and vomiting. CONCLUSIONS: Induction with sevoflurane in nitrous oxide and oxygen leads to fast loss of consciousness and provides ideal conditions for managing the airway without supplemental opioids or muscle relaxants. Furthermore, sevoflurane using this technique was very well tolerated, indicated by high haemodynamic stability and a reduced rate of postoperative restlessness, shivering, nausea and vomiting.

Anesthesia, Inhalation↗
PubMed2003

Target-controlled infusion of propofol for fibreoptic intubation.

BACKGROUND AND OBJECTIVE: In a retrospective study, we examined the suitability of a departmental clinical protocol for anaesthesia induction with target-controlled infusion of propofol developed for fibreoptic intubation in spontaneously breathing patients scheduled for outpatient oral surgery at the dental clinic of the Vienna University Hospital. METHODS: Propofol was administered using target-controlled infusion (Diprifusor) at increasing target plasma concentrations starting at 2.5 microg mL(-1). After 10 min, an intravenous dose of alfentanil (5-10 microg kg(-1)) was given for pain reduction. After a further 2 min, the patient was evaluated for response to auditory stimulation. If unresponsive, fibreoptic intubation was performed, otherwise the target concentration was increased by 0.2 microg mL(-1) every 2 min until non-responsiveness was attained. RESULTS: Tracheal intubation was successful in all patients without any haemodynamic instability. However, one patient required facemask ventilation for 2 min. No patient was aware of intubation. The plasma concentration required for non-responsiveness was 2.8 +/- 0.4 microg mL(-1) (mean +/- SD). CONCLUSIONS: When using a target-controlled infusion of propofol, fibreoptic intubation can be performed with complete amnesia of the procedure for the patient. However, assisted ventilation of the lungs may be necessary as spontaneous ventilation may cease.

Adult↗
PubMedDate not supplied

Factors influencing successful intubation in the prehospital setting.

OBJECTIVE: To explore the determinants influencing oral/nasal endotracheal intubation (OETI/NETI) and determine which cognitive, therapeutic, and technical interventions may assist prehospital airway management. DESIGN, SETTING, AND PARTICIPANTS: Prospective review of run reports and structured interviews of paramedics involved in OETI/NETI attempts were conducted in a high-volume, inner-city, advanced life support (ALS) system during an eight-month period (July 1991 to February 1992). Data were abstracted from run reports, and paramedics were asked in structured interviews to describe difficulties in OETI/NETI attempts. RESULTS: Of 236 patients studied, 88% (208) were intubated successfully. Success/failure rate was not related statistically to patients' ages (p = 0.78), medical or trauma complaint (89% vs 85%, p = 0.35), oral versus nasal route (88% vs 85%, p = 0.38), care time (scene+transport times: success, 18 minutes; failure, 20 minutes, p = 0.30), paramedic seniority (p = 0.13), or number of attempts per paramedic (p > 0.05). Increased level of consciousness (LOC) was associated with decreased success rate (p = 0.04). Paramedics reported difficulties in endotracheal intubation (ETI) attempts in 110 (46.6%) of patients. Factors reported to increase ETI difficulty were: 1) technical problems (35.6%); 2) mechanical problems (15.6%); and 3) combative patients (12.7%). CONCLUSIONS: Oral endotracheal intubation and NETI success rates identified in this study are similar to those described in the literature, although innovative strategies could be used to facilitate prehospital airway management. Many of the factors found to increase ETI difficulty could be ameliorated by the administration of paralytic agents, that is, for combative patients. Focused training in cadaver and animal labs coupled with recurrence training in the operating suites should be used on a regular basis to decrease difficulties in visualization. Interventions directed at alleviating mechanical difficulties that should be explored include new-to-the-field techniques, such as retrograde intubation, fiber-optic technology, and surgical tracheal access.

Adult↗
PubMed2006

Use of lidocaine and fentanyl premedication for neuroprotective rapid sequence intubation in the emergency department.

INTRODUCTION: Autoregulation is dysfunctional in the injured brain. Increases in intracranial and arterial pressure may therefore result in extension of the primary injury. Rapid sequence intubation (RSI) is a well-known cause of surges in both arterial pressure and intracranial pressure. Neuroprotective agents, namely lidocaine and fentanyl, have the potential to minimize the pressure surges implicated in secondary brain injury. The purpose of this study was to determine the frequency with which neuroprotective agents were used for neuroprotective RSI in the emergency department. METHODS: We conducted a retrospective chart review of all 139 patients intubated in the emergency department of Vancouver General Hospital between March and October 2003. Patients were eligible if there was an indication for neuroprotective agents defined as presumed intracranial pathology and a mean arterial pressure (MAP) > 85 mm Hg. Contraindications to fentanyl included MAP < 85 mm Hg or allergy to fentanyl. RESULTS: Seventy-seven patients were intubated for primary neurological indications. Indication for intubation included non-traumatic causes (n = 37) (including cerebrovascular accident or intracranial hemorrhage) and closed head injury (n = 40). The mean age (+/- standard deviation) was 52.3+/-20.4 years, and 31.4% were female. Fifty-seven (74.0%) patients had indications for neuroprotective agents, without contraindications. When neuroprotective agents were indicated, lidocaine was used in 84.2% (95% confidence interval [CI] 72.6%-91.5%) of patients while fentanyl was used in 33.3% (95%CI 22.4%-46.3%) of patients. Eleven percent of the intubations were performed with a fentanyl dose of delta 2 mcg/kg, which is the lower limit considered effective. CONCLUSIONS: Despite the potential benefit of using lidocaine and fentanyl in appropriate patients undergoing neuroprotective RSI in the emergency department, our study identified a significant underutilization of optimal premedication. The identification of barriers to use and the implementation of strategies to optimize use are necessary.

British Columbia↗
PubMed1999

The effect on intraocular pressure of endotracheal intubation or laryngeal mask use during TIVA without the use of muscle relaxants.

BACKGROUND: Depolarizing and non-depolarizing muscle relaxants possess many untoward side effects. In most patients endotracheal intubation may be performed with a propofol and alfentanil combination. The purpose of this study was to compare the effect on intraocular pressure (IOP) and haemodynamics of endotracheal (ET) intubation or laryngeal mask (LMA) insertion during total intravenous anaesthesia (TIVA) without the use of muscle relaxants. METHODS: In a randomised study, 20 patients scheduled for elective orthopaedic surgery were assigned to two groups of 10 patients. Anaesthesia was induced with i.v. alfentanil 40 micrograms/kg and propofol 2.5 mg/kg. LMA insertion or ET intubation was achieved by the same anaesthesiologist. Airway score, insertion score, patient response and haemodynamics were recorded. IOP measurements were recorded before and after induction, 1 and 2 min after ET intubation or LMA insertion, and 1 and 2 min after extubation. RESULTS: Mean arterial pressure and heart rate after insertion of the airway management devices was significantly higher than induction values in the ET group (P < 0.05), while during 2-3 min no significant changes were observed in LMA group. In all patients following propofol and alfentanil induction, IOP was significantly lower than preinduction values (P < 0.001). IOP following extubation was significantly higher than preinduction values in the ET group, but not in the LMA group (P < 0.001). CONCLUSION: During TIVA without the use of muscle relaxants neither LMA insertion nor ET intubation increased the IOP, but ET extubation did.

Adult↗
PubMed1999

An alternative method to intubate with laryngeal mask and see-through-bougie.

BACKGROUND: Different ways of managing the difficult airway is an important issue for the anaesthetist. We have investigated a technique with a see-through-bougie and laryngeal mask for intubation. METHODS: We report our experience with intubation of 30 patients using a see-through-bougie guided through a laryngeal mask with a fibreoptic bronchoscope. The bougie is then used as a guidance for a tracheal tube. RESULTS: In 29 of the 30 investigated patients, this method could be used. In one patient the method had to be abandoned because of a tortuous trachea. Seventeen patients were intubated within 2 min, 11 between 2 and 5 min and 1 required 10 min. The time was mainly dependent on the endoscopic experience of the anaesthetist. No patient sustained arterial desaturation. CONCLUSION: We conclude that intubation using a see-through-bougie and a laryngeal mask is a valuable method in the difficult intubation situation, when a temporary airway can be achieved with laryngeal mask, since it permits continuous ventilation and visual control throughout the procedure.

Adult↗
PubMed2001

A survey of tracheal intubation difficulty in the operating room: a prospective observational study.

BACKGROUND: The purpose of this study is to describe all degrees of endotracheal intubation difficulty among patients attended by eight anesthesiologists during routine surgery over a six-month period. Airway characteristics were routinely assessed preoperatively, according to the anesthesiologists' usual practice. METHODS: Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS), a quantitative score based on seven variables. An IDS value of 0 is consistent with a procedure without difficulty, and an IDS > 5 with a procedure involving moderate to major difficulty. RESULTS: For 1171 patients undergoing tracheal intubation, IDS was 0 in 55%, and greater than 5 in 8% of cases. External laryngeal pressure, repositioning the patient and added use of a stylet were the most frequent methods chosen to facilitate tracheal intubation. CONCLUSION: There was a high incidence (37%) of minor difficulties encountered during routine surgery.

Adolescent↗
PubMed2001

One way to ventilate patients during fibreoptic intubation.

Occasionally anaesthesiologists find themselves in situations where ventilation during intubation with a fibreoptic bronchoscope (FOB) is desirable. In order to ventilate the patient during the FOB intubation, we used a 90 degree angle swivel connector, normally used for fibreoptic bronchoscopia in an intubated patient. After a nasotracheal tube is placed with the tip in the oropharynx, ventilation of the patient is possible via this tube by closing the mouth and other nostril. The fibrescopic procedure is done through the right-angle connector with suction port and the tube is used to guide the tip of the FOB to the aditus laryngis. The method has been used in 7 patients who were impossible to intubate with a conventional procedure. In all patients ventilation was possible and intubation was performed in 5 min (range 1-15).

Arthritis, Rheumatoid↗
PubMed1993

The role of nasolacrimal intubation in the management of childhood epiphora.

Nasolacrimal intubation has been advocated to obviate the need for dacryocystorhinostomy (DCR) for childhood epiphora which fails to resolve despite apparently successful probings. Twenty-eight intubations were attempted on children falling into this category. Of these, 25 were anatomically successful intubations (3 having had to be abandoned because of difficulties in retrieving the silicone tubes from the nose). Twenty patients (80%) had complete resolution of symptoms, 2 (8%) had improvement of symptoms such that no further intervention was necessary and 3 (12%) proceeded to DCR. A greater likelihood of a good outcome was seen if the tubes were left in situ for 6 months or more. We suggest that primary nasolacrimal intubation (that is nasolacrimal intubation without DCR) should be the next step in the management of childhood epiphora which fails to resolve after two probings. This approach may avoid a DCR in over 80% of children.

Child↗
PubMed1999

The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns.

OBJECTIVE: To determine the practical value of the new pediatric disposable ETCO2 detector Pedi-CAP in verifying endotracheal tube placement in neonatal resuscitation. METHODS: Infants who required endotracheal intubation in the delivery room or the neonatal intensive care unit (NICU) were included in a prospective study in which the endotracheal tube placement was determined clinically and simultaneously by the Pedi-CAP and confirmed by chest radiograph. The Pedi-CAP and clinical evaluation determination times of the endotracheal tube placement were measured and compared. The accuracy and ease of the Pedi-CAP use were tested. RESULTS: Forty-five newborns (450 to 4620 gm) who needed endotracheal intubation were included in the study. Twenty-four (53.3%) were intubated in the delivery room and 21 (46.7%) in the NICU. The Pedi-CAP color indicator correlated with the clinical evaluation and radiograph findings of proper intubation in 30 of 33 patients (sensitivity 91%, specificity 100%, positive predictive value 100%, and negative predictive value 80%). There were three false-negative results in patients with severe cardiorespiratory depression. The Pedi-CAP color indicator correlated with the clinical evaluation for the ET-tube being in the esophagus in 12 of 12 patients (sensitivity, specificity, and positive and negative predictive value were all 100%). The time required to determine the tube position by clinical evaluation was 0 to 90 seconds (mean = 39.7 seconds; SD +/- 15.3 seconds). The time required with the disposable ETCO2 detector was 4 to 12 seconds (mean = 8.1 seconds; SD +/- 2.9 seconds; p < 0.001). CONCLUSION: The use of a disposable pediatric endotracheal CO2 detector significantly reduces the time spent in verifying the endotracheal tube position (trachea versus esophagus) in newborns, including premature babies with body weight < 1000 gm. This is of particular benefit to babies who are erroneously intubated in the esophagus, because using the device allows much faster detection of this problem and much earlier reintubation.

Carbon Dioxide↗
PubMed1998

Pressure changes over the anterior neck during tracheal and oesophageal intubation.

Pressure changes were measured on the skin over the cricoid and thyroid cartilages during intubation of the oesophagus or trachea in 21 consenting patients. A 100-ml bag of saline was firmly fixed to the anterior neck and the pressure changes in the bag recorded. Typical and distinctively different pressure patterns for tracheal and oesophageal intubation were recorded. Oesophageal intubation was accompanied by a statistically significantly higher and longer pressure rise and, most characteristically, by an obvious and sustained rise in baseline pressure. This method is, however, neither practical nor recommended for clinical use in detecting accidental oesophageal intubation. Capnography should always be used during tracheal intubation as an ongoing capnographic waveform provides the only guarantee of correct tracheal placement.

Adult↗
PubMed1999

Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia.

We determined the effective time to satisfactory intubation conditions after the administration of rocuronium 0.6 mg.kg-1 to 120 unpremedicated adult patients anaesthetised with propofol 2.5 mg.kg-1 or thiopentone 5 mg.kg-1. Intubation conditions were assessed in 10 subgroups of 12 patients at 30, 40, 50, 60 and 70 s. The effective times to satisfactory intubation conditions in 50 and 90% of patients were obtained by the method of maximum likelihood after log time-probit response transformations. Intubation conditions after induction of anaesthesia with propofol were satisfactory in 5/12 patients at 30 s, 7/12 at 40 s, 10/12 at 50 s, 11/12 at 60 s and 11/12 at 70 s compared with 1/12 patients at 30 s, 2/12 at 40 s, 5/12 at 50 s, 7/12 at 60 s and 8/12 at 70 s after induction with thiopentone. The effective times to satisfactory intubation conditions in 50% and 90% (95% confidence intervals) of patients after rocuronium 0.6 mg.kg-1 were 34 (26-40) s and 61 (50-81) s in patients given propofol compared with 57 (48-69) s and 101 (79-167) s in patients given thiopentone. We conclude that rocuronium 0.6 mg.kg-1 may be a suitable alternative to suxamethonium during rapid sequence induction of anaesthesia with propofol in situations where suxamethonium is contraindicated.

Adolescent↗
PubMed2000

Intra-ocular pressure and haemodynamic changes after tracheal intubation and extubation: a comparative study in glaucomatous and nonglaucomatous children.

This prospective, controlled study was conducted to compare the effects of tracheal intubation and extubation on intra-ocular pressure changes and haemodynamic parameters in paediatric patients with and without glaucoma. The children were scheduled for intra-ocular surgery. Twenty children with normal intra-ocular pressure and 15 with glaucoma were studied. A standardised general anaesthetic was administered to both groups. After 5 min of anaesthesia, intra-ocular pressure, heart rate and noninvasive blood pressure were measured. These measurements were repeated 30 s and 2 min after tracheal intubation. Further measurements were taken before, and 30 s and 2 min after extubation. The increase in intra-ocular pressure after intubation was greater in the glaucomatous group than in the normal group. The increase in intra-ocular pressure was greater after extubation than intubation in both groups, but was similar in the two groups. However, because of the already increased intra-ocular pressure in glaucomatous children, they may be at an increased risk of visual damage after intubation and extubation.

Anesthesia, General↗