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PubMed2000

Tracheal intubating conditions after induction with sevoflurane 8% in children. A comparison with two intravenous techniques.

We studied tracheal intubating conditions in 120 healthy children, aged 3-12 years, in a blinded, randomised clinical trial. Children were randomly allocated to one of three groups: group PS, propofol 3 mg.kg-1 and succinylcholine 1 mg.kg-1 (n = 40); group PA, propofol 3 mg.kg-1 and alfentanil 10 microg.kg-1 (n = 40); group SF, sevoflurane 8% in 60% nitrous oxide in oxygen for 3 min (n = 40). Tracheal intubating conditions were graded according to ease of laryngoscopy, position of vocal cords, coughing, jaw relaxation and movement of limbs. Overall intubating conditions were acceptable in 39 of 40 children in the propofol/succinylcholine group, 21 of 40 children in the propofol/alfentanil group and 35 of 40 children in the sevoflurane group. Children receiving propofol and succinylcholine or sevoflurane had better intubating conditions overall than those given propofol and alfentanil (p < 0.01). In conclusion, anaesthetic induction and tracheal intubation using sevoflurane 8% for 3 min is a satisfactory alternative to propofol with succinylcholine in children.

Alfentanil↗
PubMed2000

Learning fibreoptic endoscopy. Nasotracheal or orotracheal intubations first?

We have studied the extent to which learning fibreoptic nasotracheal endoscopy first helped anaesthetists to learn fibreoptic orotracheal endoscopy later, and vice versa. After preliminary training on a bronchial tree model, 30 anaesthetic trainees were randomly allocated to the nasal first/oral second group, who performed 10 nasal intubations followed by 10 oral intubations, or the oral first/nasal second group, who performed 10 oral intubations followed by 10 nasal intubations, in anaesthetised, ASA group I or II patients undergoing elective oral or general surgery. Each type of endoscopy was taught in a standard manner, with the aid of an endoscopic video-camera system, under the supervision of experienced instructors. Performing nasal endoscopy second (average 70.8 s) took significantly less time than performing it first (average 84.4 s) and performing oral endoscopy second (average 35.2 s) took significantly less time than performing it first (average 48.5 s). The mean (SD) total endoscopy time for all the endoscopies (both nasal and oral) in the nasal first/oral second group [1196 (162) s] was not significantly different from that for all the endoscopies in the oral first/nasal second group [1193 (188) s]. Because there is no advantage or disadvantage to be gained in starting to learn either type of endoscopy first, graduated training programmes can be planned according to the availability of suitable patients for fibreoptic intubation, without instructors needing to consider whether trainees make better progress if they learn one technique before the other.

Adult↗
PubMed2003

Use of the bougie in simulated difficult intubation. 2. Comparison of single-use bougie with multiple-use bougie.

We studied the success rates for tracheal intubation in 32 healthy, anaesthetised patients during simulated grade IIIa laryngoscopy, randomised to either the multiple-use or the single-use bougie. Success rates (primary end-point) and times taken (secondary end-point) to achieve tracheal intubation were recorded. The multiple-use bougie was more successful than the single-use one (15/16 successful intubations vs. 9/16; p = 0.03). With either device, median [range] total tracheal intubation times for successful attempts were < 54 [24-84] s and there were no clinically important differences between these times. We conclude that the multiple-use bougie is a more reliable aid to tracheal intubation than the single-use introducer in grade IIIa laryngoscopy.

Adolescent↗
PubMed1999

The onset of neuromuscular block at the masseter muscle as a predictor of optimal intubating conditions with rocuronium.

After an intubating dose of rocuronium satisfactory intubating conditions are achieved before the onset time at the adductor pollicis. We examined the possibility that measurement of the relaxation of the masseter muscle is a more appropriate guide when determining the intubating time. Simultaneous accelerometry with a 0.1-Hz single twitch stimulation of the chin and thumb was performed in 20 patients after 0.6 mg kg-1 rocuronium. We observed a significantly more brief mean lag time and onset time at the masseter muscle (22.5 and 61 vs. 32.5 and 160 s). The corresponding mean relaxation at the onset time was also significantly more pronounced at the masseter muscle (99.6 vs. 97.6%). A mean onset time at the masseter muscle of 61 s as produced by rocuronium corresponds clinically with excellent or good intubating conditions. From these results, we suggest that measurement of the onset time of muscle relaxation at the masseter muscle appears to be a better predictor of good intubating conditions than measurements made using the adductor pollicis muscle after administration of rocuronium.

Adolescent↗
PubMed2000

Accuracy of end-tidal carbon dioxide monitoring using the NBP-75 microstream capnometer. A study in intubated ventilated and spontaneously breathing nonintubated patients.

Arterial carbon dioxide partial pressure measurements using the NBP-75 microstream capnometer were compared with direct PaCO2 values in patients who were (a) not intubated and spontaneously breathing, and (b) patients receiving intermittent positive pressure ventilation of the lungs and endotracheal anaesthesia. Twenty ASA physical status I-III patients, undergoing general anaesthesia for orthopaedic or vascular surgery were included in a prospective crossover study. After a 20-min equilibration period following the induction of general anaesthesia, arterial blood was drawn from an indwelling radial catheter, while the end-tidal carbon dioxide partial pressure was measured at the angle between the tracheal tube and the ventilation circuit using a microstream capnometer (NBP-75, Nellcor Puritan Bennett, Plesanton, CA, USA) with an aspiration flow rate of 30 mL min(-1). Patients were extubated at the end of surgery and transferred to the postanaesthesia care unit, where end-tidal carbon dioxide was sampled through a nasal cannula (Nasal FilterLine, Nellcor, Plesanton, CA, USA) and measured using the same microstream capnometer. In each patient six measurements were performed, three during mechanical ventilation and three during spontaneous breathing. A good correlation between arterial and end-tidal carbon dioxide partial pressure was observed both during mechanical ventilation (r = 0.59; P = 0.0005) and spontaneous breathing (r = 0.41; P = 0.001); while no differences in the arterial to end-tidal carbon dioxide tension difference were observed when patients were intubated and mechanically ventilated (7. 3 +/- 4 mmHg; CI95: 6.3-8.4) compared to values measured during spontaneous breathing in the postanesthesia care unit, after patients had been awakened and extubated (6.5 +/- 4.8 mmHg; CI95: 5. 2-7.8) (P = 0.311). The mean difference between the arterial to end-tidal carbon dioxide tension gradient measured in intubated and non-intubated spontaneously breathing patients was 1 +/- 6 mmHg (CI95: -11-+13). We conclude that measuring the end-tidal carbon dioxide partial pressure through a nasal cannula using the NBP-75 microstream capnometer provides an estimation of arterial carbon dioxide partial pressure similar to that provided when the same patients are intubated and mechanically ventilated.

Aged↗
PubMed1998

Tracheal intubation without neuromuscular blockade in children: a comparison of propofol combined either with alfentanil or remifentanil.

Forty healthy children, aged between two and 12 years of age undergoing elective surgery where the anaesthetic technique involved tracheal intubation followed by spontaneous ventilation were studied. Induction of anaesthesia was with either alfentanil 15 micrograms.kg-1 or remifentanil 1 microgram.kg-1 followed by propofol 4 mg.kg-1 to which lignocaine 0.2 mg.kg-1 had been added. Intubating conditions were graded on a four point scale for ease of laryngoscopy, vocal cord position, degree of coughing, jaw relaxation and limb movement. All children were successfully intubated at the first attempt. There were no significant differences in the assessments of intubating conditions between the two groups. Arterial blood pressure and heart changes were similar in the two groups with both alfentanil and remifentanil attenuating the haemodynamic response to tracheal intubation. The time taken to resumption of spontaneous ventilation was similar in both groups.

Alfentanil↗
PubMed1998

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.

Air Ambulances↗
PubMed2000

Pseudopolyp of the right laryngeal ventricle following atraumatic intubation: a diagnostic dilemma.

The traumatic effects of tracheal intubation are well recognized. Whilst these usually follow prolonged intubation, acute lesions have been described, usually following a traumatic intubation technique. We present a case of acute, localized swelling of the right laryngeal ventricle which followed an entirely atraumatic intubation by an experienced paediatric anaesthetist. The lesion was not present at the time of intubation, but developed subsequently during the surgical procedure. Although previously observed at our institution, such lesions have not been described in the literature. The potential for a diagnostic pitfall, by mistaking the lesion for a laryngeal cyst or nodule, is discussed.

Humans↗
PubMed2002

Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children.

BACKGROUND: The purpose of our study was to determine whether a smaller dose of rocuronium than previously reported could provide similar intubating conditions to suxamethonium during rapid-sequence induction of anaesthesia in children. METHODS: One hundred and twenty ASA I, unpremedicated children, aged 1-10 years, who were undergoing elective surgery, were randomized into three groups to receive rocuronium 0.6 mg.kg-1, rocuronium 0.9 mg.kg-1 or suxamethonium 1.5 mg.kg-1. The study was double-blinded, anaesthesia and timing of injection was standardized to alfentanil 10 microg.kg-1, thiopentone 5 mg.kg-1 and the study drug. Intubation was attempted at 30 s after injection of neuromuscular relaxant and intubating conditions graded as excellent, good, poor or impossible. RESULTS: All 120 children were successfully intubated within 60 s without need for a second attempt after administration of neuromuscular relaxant. Differences between suxamethonium and rocuronium 0.6 mg.kg-1 and between the two doses of rocuronium were statistically significant (P=0.016 and 0.007, respectively). CONCLUSIONS: Rocuronium 0.9 mg.kg-1 provides similar intubating conditions to suxamethonium 1.5 mg.kg-1 during modified rapid-sequence induction using alfentanil and thiopentone in children (P=0.671). Rocuronium 0.6 mg.kg-1 was inadequate.

Alfentanil↗
PubMed2003

Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation.

Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with >250,000 patient visits per year. Four protocols were established for 1) children <10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P <.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.

Adolescent↗
PubMed2004

Difficult intubation in pediatric cardiac anesthesia.

OBJECTIVE: The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. DESIGN: Retrospective analysis. SETTING: Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital. PARTICIPANTS: All children undergoing congenital heart surgery. INTERVENTIONS: Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. MEASUREMENTS AND MAIN RESULTS: A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). CONCLUSION: The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.

Analgesics, Opioid↗
PubMed2003

QT dispersion increases during intubation in patients with coronary artery disease.

Anesthetic drugs have been shown to increase QT interval, however data regarding their effects on QT dispersion (QTd) are scarce, especially in patients with coronary artery disease (CAD). We tested whether induction of Anesthesia with thiopental and etomidate would increase QTd in patients with CAD. Thirty American Society of Anesthesiologists (ASA) physical status I-II patients without CAD were randomly allocated to groups I (n = 15) and II (n = 15) and 30 ASA physical status III patients with CAD were randomly allocated to groups III (n = 15) and IV (n=15). Anesthesia was induced with thiopental 5-7 mg/kg IV in groups I and III and with etomidate 0.2-0.3 mg/kg IV in groups II and IV. Endotracheal intubation was facilitated with vecuronium bromide 0.1 mg/kg IV. Twelve-lead electrocardiogram (ECG) was recorded in all patients at baseline (ECG(1)), 1 min after the induction agent (ECG(2)), 1 min (ECG(3)) and 5 min (ECG(4)) after intubation. Anesthesia was maintained with isoflurane and nitrous oxide in 34 % oxygen after ECG(2) recording. QTd and corrected QT dispersion (QTcd) were calculated. In patients with CAD induced with thiopental, QT dispersion increased significantly during the intubation period compared with baseline (from 43.0 +/- 25.6 ms to 69.2 +/- 25.3 ms; P <.01). Likewise, QT dispersion also increased during intubation in patients with CAD induced with etomidate (from 41.5 +/- 17.2 ms to 80.0 +/- 33.6 ms; P <.001). There was no increase in QT dispersion in patients without known CAD. QT dispersion seems to be increased during the intubation period in patients with CAD regardless of the induction agents used.

Aged↗
PubMed2003

[Rupture of the trachea after emergency endotracheal intubation].

The rupture of the trachea is a rare but serious complication after endotracheal intubation. We report the case of a 77-year-old severely diseased woman with emergency intubation after development of acute respiratory distress. Four days after the emergency intubation a laceration of the membraneous part of the trachea was diagnosed. The patients general condition and the infaust prognosis resulted in the lack of therapeutic options and the death of the patient. According to the forensic autopsy the secondary perforation is probably a consequence of intubation or a pressure lesion of the tube in combination with a weakness of the membraneous part of the trachea due to impaired microperfusion. Every physician performing an intubation has to be aware of the risk and the consequences of a tracheal rupture.

Aged↗
PubMed2005

[Topographic electroencephalography: endotracheal intubation during anaesthesia with propofol/fentanyl].

OBJECTIVE: We used quantitative analysis of the electroencephalogram (EEG) during routine clinical practice to assess the effect of tracheal intubation following induction of anesthesia with propofol and fentanyl. METHODS: The topographic EEG was recorded from eight bipolar electrode derivations in 25 patients. Z-scores relative to age expected normative data were computed for relative power in the delta, theta, alpha and beta frequency bands. Multivariate statistics (Hotellings' t-sqare) were used to evaluate changes in regional brain electrical activity. RESULTS: Tracheal intubation induced an increase in alpha and beta frequencies, while delta power was reduced (F-values: Delta: 7.68, p = 0.011; Alpha 31.93; p < 0.001; Beta 12.85, p = 0.001). The most pronounced regional effect was seen for the alpha frequency band with the largest increase in both fronto-temporal regions (F-value 33.89, p < 0.001). During clinical practice the patients received propofol 2.7 (+/- 1.2; minimum: 0.5, maximum 6.9) mg kg (- 1) and fentanyl 2 (+/- 1; minimum 1, maximum 4) microg kg (- 1). Vital parameters did not change during intubation. CONCLUSION: Individual titration of the dose of propofol and fentanyl as done during routine clinical practice is not sufficient to block the strong noxious stimulation of intubation. Tracheal intubation resulted in "classical" cortical arousal. It remains open whether this cortical wake-up phenomenon has a clinical impact.

Adult↗
PubMed1996

[Intubation requirements after rocuronium and succinylcholine].

OBJECTIVE: Rocuronium is a new non-depolarising steroidal muscle relaxant with a short onset time. The present study was undertaken to compare intubating conditions as well as onset and clinical duration of a single dose of 0.6 mg/kg (2 x ED95) with a single dose of 1 mg/kg suxamethonium (3 x ED95). METHODS: After obtaining informed consent and approval of the Ethics Committee, 40 adult patients (ASA I-III) participated in this study. After premedication with oxazepam, anaesthesia was induced with fentanyl and propofol and maintained with propofol, N2O and supplements of fentanyl as needed. Muscular relaxation was assessed by EMG recording of adductor pollicis muscle after supramaximal single twitch stimulation of the ulnar nerve every 10 s. Patients were allocated randomly to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg. The following parameters were measured: intubating conditions 60 s after injection, onset time and clinical duration of neuromuscular block, % block at intubation, heart rate, blood pressure and arterial oxygen saturation. RESULTS: (mean +/- SD). Intubating conditions after rocuronium and suxamethonium were found to be clinically acceptable (excellent or good) in 90% of patients, though there was only a partial blockade of the adductor pollicis muscle with rocuronium (71 +/- 23%) compared to suxamethonium (95 +/- 14%) (p < 0.05). The onset time and clinical duration of relaxation was shorter after suxamethonium (p < 0.05) and occurred at 0.8 +/- 0.2, 7 +/- 2.1 and 3.2 +/- 1.3, 29 +/- 11 min after suxamethonium and rocuronium respectively. CONCLUSION: At a dosage of 0.6 mg/kg, rocuronium has an onset time of about 3 min and a clinical duration of relaxation of nearly half an hour. These data are supported by various studies, while others show shorter times, probably due to different monitoring techniques. In spite of the pharmacodynamic differences between suxamethonium and rocuronium, the intubating conditions after administration of both compounds are comparable and develop at the same rate.

Adolescent↗
PubMed1998

[Ritleng-lacrimal intubation system for injured canaliculi].

BACKGROUND: Intubation of the lacrimal pathway is used to restore the canaliculi. This procedure is often complicated by the so called accordion-phenomenon. PATIENTS AND METHODS: During the last 4 years we used a new system for lacrimal intubation: the Silicon intubationset designed by Ritleng. It consists of a silicon tube which is connected to a polypropylene tube and a stainless probe for lacrimal insertion. We used this set in 24 lacrimal lacerations of the lacrimal pathway. RESULTS: With this lacrimal intubation set lacerated canalicula in 24 patients could be quickly reapproximated in 20 minutes under general anesthesia without complications. CONCLUSION: The silicon intubation set allows quick and safe silicon tubing of injured canalicula. The new intubation set is a great advantage in operating of lacerated canalicula and suitable even for surgeons in training.

Adolescent↗
PubMed1993

[Fiberoptic intubation of neurosurgical patients].

Patients with cervical spine injury presenting with respiratory distress require airway management that does not compromise integrity of the atlanto-occipital joint. Endotracheal intubation by means of direct laryngoscopy is not suitable. The method of choice is nasotracheal intubation of the awake patient, using a flexible fibre bronchoscope. If anatomy or surgical access render the nasal approach impossible, fibre optic intubation can be performed orotracheally, utilising specific technical aids. Flexible fibrescopes are available in different sizes (length and diameter): selection is base on the patient's anatomical requirements. Aids to orotracheal intubation are constructed with a bore wide enough to accommodate an endotracheal tube, and a face mask equipped with an extra intubation port allowing introduction of an endotracheal tube, slipped over a fibrescope. Premedication of the patients consists of an orally administered benzodiazepine. Topical anaesthesia and vasoconstriction of the nasal passages are achieved by cocaine (5-10%), or a local anaesthetic, combined with a vasoconstrictor. The selected nostril is prepared by means of introducing a nasopharyngeal airway, which--lubricated with xylocaine gel and left in place for few minutes--widens the nostril and facilitates passage of the endotracheal tube. Through the other nostril, oxygen is administered. Systemic analgo-sedation is strictly limited to fentanyl, 0.1 mg i.v. Topical anaesthesia of the larynx and cranial trachea is achieved by xylocaine, 2%, administered under direct vision through the instrumentation channel of the fibrescope.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2002

Laryngeal mask airway--a novel method of airway protection during ERCP: comparison with endotracheal intubation.

BACKGROUND: ERCP sometimes requires deep sedation and rarely general anesthesia with airway protection. The laryngeal mask airway device is placed perorally to create a seal over the larynx. Unlike endotracheal intubation, no tube traverses the vocal cords, thus reducing airway stimulation and obviating the need to administer muscle relaxants. The feasibility of using the laryngeal mask airway during ERCP was evaluated and recovery times compared for patients undergoing ERCP with the laryngeal mask airway versus endotracheal intubation. METHODS: In this retrospective cohort study, anesthesia records were reviewed for anesthesiologist-assisted ERCP procedures performed during a 30-month period. Demographics, procedure duration, and time from endoscope removal to extubation were abstracted. Either propofol or inhalation agents were used for anesthesia in all patients. OBSERVATIONS: Anesthesiologists administered sedation for 41 ERCPs. The airway was managed in 12 patients with endotracheal intubation and the laryngeal mask airway in 20 patients. Six patients underwent laryngeal mask airway insertion and removal while prone. A therapeutic duodenoscope was passed beyond the laryngeal mask airway with little or no resistance in all cases. Repositioning the laryngeal mask airway during the procedure was required in 1 case. Laryngeal mask airway use was associated with shorter extubation time compared with endotracheal intubation (7.2 vs. 12 min.; p = 0.004). There were no airway complications. CONCLUSION: ERCP can be performed while using the laryngeal mask airway for airway protection. The laryngeal mask airway can be placed with the patient prone, obviating the need to change position. Laryngeal mask airway shortens extubation time compared with endotracheal intubation.

Cholangiopancreatography, Endoscopic Retrograde↗