The air-Q as a conduit for fiberoptic aided tracheal intubation in adult patients undergoing cervical spine fixation: A prospective randomized study

The air-Q? intubating laryngeal airway is a supraglottic airway device which was designed to allow adequate patient ventilation and reliable blind endotracheal tube intubation.ObjectivesTo investigate the efficacy of air-Q as a conduit for fiberoptic endotracheal intubation in adult patients with limited cervical spine mobility compared with fiberoptic-guided intubation alone.DesignProspective randomized study.PatientsSixty adult (12 female) patients, ASA physical status I and II scheduled for cervical spine fixation under general anesthesia. Patients were randomized into two parallel groups. Exclusion criteria includes, history of difficult airway, mouth opening <3 cm, Mallampati class ?III and, increased risk of aspiration of gastric contents.InterventionIn the first group, endotracheal intubation was aided with the fiberoptic scope while patients in the second group were intubated with the fiberoptic scope guided with the air-Q as a conduit. The number of attempts and time to successful insertion of air-Q and endotracheal tube were recorded. The fiberoptic quality of the vocal cords view as seen through the air-Q and ease of endotracheal tube insertion were also assessed.ResultsThe air-Q was easily inserted in all patients of the second group with mean insertion time (22.6 ± 4.3 s). The air-Q provided a good fiberoptic view of the vocal cords and successful tracheal intubation in 29 (96.7%) patients of the second group on the first attempt. Time to tracheal intubation in the second group was significantly shorter than the first group (21.6 ± 5.7 and 29.8 ± 6.2 s respectively). The air-Q was easily removed without any complications.ConclusionsThe air-Q as a conduit for fiberoptic scope provided a better view of the vocal cords and, less insertion time of the endotracheal compared to fiberoptic-aided endotracheal intubation in adult patients with limited cervical spine mobility scheduled for cervical spine fixation.     

Cervical spine fractures in patients with ankylosing spondylitis: Importance of early management

IntroductionAnkylosing spondylitis (AS) affects 0.5% of the population. Alteration of the biomechanical properties of the spine related to AS explains the high prevalence of traumatic vertebral fractures and risk of instability. At admission, 65% of patients present neurological signs. There are no reported studies regarding secondary neurological deterioration. The aim of this study was to evaluate the rate of secondary neurological deterioration before surgical treatment of spine fracture in a context of AS.MethodsThis retrospective cases series consisted of patients admitted for traumatic cervical spine fractures or luxation in a context of AS between June 2007 and December 2012. Clinical status was evaluated using Frankel classification at time of trauma, at admission to the neurosurgery ward, as well as before and after surgery. Delay between trauma and admission, and between admission and surgery was recorded. Causes of morbidity, mortality and surgical management were discussed.ResultsDuring the study period, seven patients were admitted for traumatic cervical spine fracture or luxation. All patients were autonomous before trauma. Between trauma and transfer to neurosurgery ward, the status of four patients worsened. Mean delay between trauma and admission was 12.9 days (range 1 to 60 days). Between admission to neurosurgery ward and surgical treatment, two more patients worsened and only two patients remained autonomous. Mean delay between admission and surgery was 15.7 h (range 2 to 24 h). Neurological deterioration was due to both deterioration during transfer despite immobilization with a rigid cervical collar and failure of X-ray to reveal any fractures, in two and three cases respectively. After surgery, clinical status remained unchanged in two patients, four patients improved, and one patient worsened. Two patients died from respiratory failure a few days after surgery due to neurological deterioration. Five patients had a delayed diagnosis (> 24 h).ConclusionCervical spine fracture in AS is a serious condition with high instability. Our series emphasizes the necessity of early surgical treatment because of risk of secondary neurological deterioration in cases of delayed treatment. CT scan must be the gold standard for exploration of these patients.     

Awake tracheal intubation in anticipated difficult airways: LMA Fastrach vs flexible bronchoscope: A pilot study

Study objectiveTo compare the use of LMA Fastrach intubating laryngeal mask airway (ILMA) to flexible bronchoscopy (FB) for awake intubation in patients with difficult airways.DesignRandomized prospective study.SettingLarge academic medical center.PatientsForty adult patients, American Society of Anesthesiologists I-IV, meeting the criteria for awake intubation based on history and physical examination.InterventionsAfter sedation and airway topicalization, patients were randomized to either FB group, n = 19, or ILMA group, n = 21. All intubations were performed by or under the supervision of an attending anesthesiologists, with variable participation of residents or certified registered nurse anesthetists. A maximum of three attempts were permitted with the assigned technique, to be followed by the alternative method in case of failure.MeasurementsTimes to carbon dioxide (end-tidal carbon dioxide) detection, endotracheal tube placement, number of attempts, training level of operator, and adverse events were recorded. Blood pressure, oxygen saturation, and heart rate were measured. Patients were interviewed the following day regarding their experience and satisfaction.Main resultsOverall intubation success rate within three attempts was 95% for both groups. However, successful intubation on the first attempt occurred at a significantly higher rate with ILMA vs FB (95% vs 58%; P = .0028). Total mean time to endotracheal tube placement was also significantly shorter in the ILMA group vs FB (92 vs 246 seconds; P = .0001). There were no adverse events in either group, and patient satisfaction was not significantly different.ConclusionAwake intubation can be performed successfully and expeditiously with the use of LMA Fastrach in patients with a difficult airway and no contraindication to a blind technique. It compared favorably to the use of the fiberoptic bronchoscope in the patient cohort presented in this study.     

Hemodynamic changes occurring with tracheal intubation by direct laryngoscopy compared with intubating laryngeal mask airway in adults: A randomized comparison trial

BackgroundHemodynamic changes are major problems due to general anesthesia. We designed a prospective randomized study to compare the hemodynamic responses due to direct laryngoscopy (DL) and intubating laryngeal mask airway (ILMA).MethodsSeventy adult ASA-I and ASA-II patients referred to anesthesia department were randomly divided into two groups: direct laryngoscopy (Macintosh laryngoscope) and ILMA. Systolic, diastolic and mean arterial blood pressure and heart rate were recorded at baseline, preintubation, 1, 3 and 5 min after intubation following intubation. Also some complications including sore throat, laryngospasm, hoarseness and cough were evaluated.ResultsMean age of studied patients in DL group (including 11 (31.4%) male) was 35.5 ± 12.2 and 35.5 ± 9 years old in ILMA group (including 16 (45.7%) male). There was no significant difference between two studied groups about measured hemodynamic indices (P < 0.05, CI = 95%). The results showed that the just difference between increment of diastolic blood pressure and mean arterial pressure after 5 min interval of two studied groups was significant (P = 0.04; P = 0.034). There was no significant difference between the number of patients with positive complications and those without them (P < 0.05).ConclusionLaryngoscoy through the intubating laryngeal mask airway was associated with lesser mean arterial pressure and diastolic blood pressure when compared to intubation by direct laryngoscope. Thus this technique seems to reduce hemodynamic response to tracheal intubation.     

Comparative study between Air-Q and Intubating Laryngeal Mask Airway when used as conduit for fiber-optic

This study compared Air-Q and Intubating LMA when used as a conduit for endotracheal intubation.MethodsOne hundred patients scheduled for surgical operations under general anesthesia were randomly allocated into two equal groups (n = 50). Group I: Air-Q and group II: Intubating Laryngeal Mask Airway (ILMA) in both groups intubation was done by Fiberoptic bronchoscope (FOB) through study device. After induction of anesthesia, patients were ventilated with Air-Q or ILMA. Then, endotracheal tube (ETT) was inserted through study device. Recorded measurements were as follows: number of attempts and duration of insertion of device, peak airway pressure and fiberoptic grading of laryngeal view. Also, we recorded number of attempts and duration of insertion of ETT and the incidence of blood stain on device and sore throat grading.ResultsDuration of insertion of Air-Q was 13.300 ± 3.471 s, whilst that of ILMA was 19.640 ± 4.737 s (p < 0.001). In group I, peak airway pressure was 26.400 ± 2.176 cmH₂O, whilst, in group II, it was 25.260 ± 1.468 cmH₂O (p < 0.01). Full view of vocal cords amounted to 78% and 26% of Groups I and II patients, respectively (p < 0.001). Time of insertion of ETT was 33.5 ± 6.795 s in group I, whilst in group II, it was 39.5 ± 6.566 s (p < 0.001). Blood stain was found on supraglottic device in 46% and 22% of cases in Groups I and II, respectively (p < 0.01).ConclusionAir-Q proved to be an excellent conduit for endotracheal intubation compared to the ILMA.     

Comparação de videolaringoscópio com canal e máscara laríngea na intubação traqueal de pacientes obesos: estudo clínico randomizado

BackgroundObesity causes various difficulties in intubation and ventilation, which are confronted due to increased fat tissue in the upper airway and diminished compliance in the chest wall. Videolaryngoscopes and Intubating Laryngeal Mask Airway (ILMA) are good options as recommended by the American Society of Anesthesologists (ASA) difficult airway guidelines. We aimed to compare ILMA and Airtraq (a channeled videolaryngoscope) in obese patients.MethodsEighty patients with ASA physical status I‐III, aged between 18 and 65 years and with a body mass index greater than 35 kg.m^‐2, who were undergoing elective surgery requiring orotracheal intubation, were included in the study. Patients were intubated with one of the devices cited.ResultsThere was no difference between the number of intubation attempts, insertion times and need for optimisation manoeuvres of Airtraq and ILMA. The intubation with Airtraq was accomplished in a shorter period of time than in that in the ILMA group (29.9 ± 22.1 s vs. 50.7 ± 21.2 s; p < 0.001). A significant difference was found when the times of total intubation were compared (29.9 ± 22.1 s vs. 97.4 ± 42.7 s; p < 0.001). The mean arterial pressure statistically increased after device insertion in the ILMA group (p < 0.05).ConclusionsAirtraq appears to be superior to ILMA in obese patients, with a total of time intubation of less than 60 seconds and with low mean arterial pressure changes. However, ILMA is still a useful tool that provides both ventilation and intubation throughout the whole intubation process.     

Os efeitos do remifentanil sobre os marcadores do estresse oxidativo durante a cesariana,em correlação com a hemodinâmica materna e o desfecho neonatal: um estudo randômico controlado

Background and objectiveRemifentanil is used to attenuate maternal hemodynamic response to intubation and surgical stress during Induction–Delivery period of cesarean section. The goal was to compare the effects of two remifentanil dosing regimens on oxidative stress level, in correlation with its hemodynamic and neonatal effects.MethodsFifty‐one patients, 17 per group, enrolled for elective cesarean section were randomly divided by computer‐generated codes into three parallel groups: (A) patients received a 1 μg.kg⁻¹ remifentanil bolus immediately before induction, followed by 0.15 μg.kg⁻¹.min⁻¹ infusion, that was stopped after skin incision; (B) patients received a 1 μg.kg⁻¹ remifentanil bolus immediately before induction; (C) (control), patients did not receive remifentanil until delivery. Maternal venous blood samples were taken at basal time, at extraction and 30 minutes after the end of operation for spectrophotometrical determination of malondialdehyde and advanced oxidation protein products concentration. The same was conducted for umbilical venous sample.ResultsSystolic blood pressure and heart rate remained significantly lower in group A compared to B and C during entire Induction–Delivery period (p < 0.001, p = 0.02 after intubation; p = 0.006, p = 0.03 after skin incision; p = 0.029, p = 0.04 after extraction; respectively). Malondialdehyde concentration was lower at time of extraction in maternal blood in group A compared to B and C (p = 0.026). All neonatal Apgar scores were ≥ 8 and umbilical acid–base values within normal range.ConclusionsThe remifentanil dosing regimen applied in group A significantly attenuated lipid peroxidation and maternal hemodynamic response during entire I–D period, without compromising neonatal outcome.     

Comparative study between fibro-optic bronchoscope and rigid laryngoscope in direct laryngoscopy with microlaryngosurgery

ObjectiveAnesthesia of patient for direct laryngoscopy (DL) and microlaryngosurgery (MLS) was technically challenging. The anesthetist had usually concern about the loss of spontaneous ventilation and occurrence of obstruction after induction with IV drugs. The aim of this study was to compare between flexible fibro-optic bronchoscope and direct rigid laryngoscope during awake intubation in patients with laryngeal mass scheduled for direct laryngoscopic surgery (DL) and microlaryngosurgery (MLS). It was a study to assess the best way for intubation with the least side effects, discomfort to the patients and high success rate of intubation.MethodsFourty adult patients Malampati 1,2 and ASA I,II,III with small laryngeal mass or polyp scheduled for direct laryngoscope (DL) and microlaryngoscopic surgery. They were randomly computerized divided into two groups 20 patients in each group; Group FO; intubation with flexible fibro-optic bronchoscope. Group RL; intubation with rigid laryngoscope.ResultsThe time of intubation was statistically significantly higher in fibro-optic group (group FO) (92 ± 34 s) than rigid laryngoscope group (group RL) (35 ± 5 s). There were two patients in group RL needed 2nd intubation attempt for better visualization of the view but there were six patients in group FO needed 2nd intubation attempt for suction of secretion and blood. According to modified six point scale the patients ranged between 1 and 3 in group FO while they range between 2 and 4 in group RL.ConclusionThe study suggested that the flexible fibro-optic bronchoscope was very comfortable to the patients and less traumatic with less cardiovascular stress but it took longer time and had a higher incidence of 2nd attempt and failure rate. Accordingly, it recommend the use of flexible fibro-optic bronchoscope in expected small size and non-bloody mass with prepared rigid laryngoscope and tube with stylet to be ready to use if needed.     

Remifentanil versus placebo for analgesia during external cephalic version: a randomised clinical trial

BackgroundBreech presentation occurs in up to 3% of pregnancies at term and may be an indication for caesarean delivery. External cephalic version can be effective in repositioning the fetus in a cephalic presentation, but may be painful for the mother. Our aim was to assess the efficacy of remifentanil versus placebo for pain relief during external cephalic version.MethodsA randomized, double-blind, controlled trial that included women at 36–41 weeks of gestation with non-cephalic presentations was performed. Women were randomized to receive either a remifentanil infusion at 0.1 μg/kg/min and demand boluses of 0.1 μg/kg, or saline placebo. The primary outcome was the numerical rating pain score (0–10) after external cephalic version.ResultsSixty women were recruited, 29 in the control group and 31 in the remifentanil group. There were significant differences in pain scores at the end of the procedure (control 6.5 ± 2.4 vs. remifentanil 4.7 ± 2.5, P = 0.005) but not 10 min later (P = 0.054). The overall success rate for external cephalic version was 49% with no significant differences between groups (remifentanil group 54.8% vs. control group 41.3%, P = 0.358). In the remifentanil group, there was one case of nausea and vomiting, one of drowsiness and three cases of fetal bradycardia. In the control group, there were three cases of nausea and vomiting, one of dizziness and nine cases of fetal bradycardia.ConclusionIntravenous remifentanil with bolus doses on demand during external cephalic version achieved a reduction in pain and increased maternal satisfaction. There were no additional adverse effects, and no difference in the success rate of external cephalic version or the incidence of fetal bradycardia.     

Impact of pillow height on double-lumen endotracheal tube intubation with McGRATH MAC: a prospective randomized clinical trial

Study objectiveThis study aimed to compare the impact of pillow height on double-lumen tracheal tube (DLT) intubation with McGRATH MAC (McG) in patients undergoing elective surgery.DesignRandomized clinical trial.SettingOperating room.PatientsFifty adult patients scheduled for elective surgery under 1-lung ventilation with an American Society of Anesthesiologists physical status of 1 to 3.InterventionsDLT intubation with McG was performed with a high pillow (HP group; 25 patients) or low pillow (LP group; 25 patients) by anesthesiologists.MeasurementsIntubation time, number of laryngoscopy, number of tracheal intubation attempts to successful intubation, percentage of glottic opening score, and subjective difficulty of laryngoscopy and tube passage through the glottis were assessed.Main ResultsIntubation time was significantly shorter in the HP group compared with the LP group (HP: 32.1 ± 14.9 seconds vs LP: 49.4 ± 11.2 seconds, P < .001). The number of laryngoscopy were 1 (HP group, 22 patients; LP group, 17 patients), 2 (HP group, 3 patient; LP group, 7 patients), and 3 (HP group, 0 patient; LP group, 1 patient), with no significant difference between the 2 groups (P = .197). Although the percentage of glottic opening score did not significantly differ between HP and LP groups (HP: 95.6% ± 6.7% vs LP: 96.0% ± 12.3%, P = .08), the number of tracheal intubation attempts was significantly lower in the HP group compared with the LP group (P = .009). The visual analog scale score for laryngoscopy did not significantly differ between the 2 groups (P = .54). However, the visual analog scale for tube passage through the glottis was significantly higher in the LP group than in the HP group (P < .001).ConclusionsIntubation with an HP was associated with a better DLT intubation profile than with an LP with McG, possibly due to smoother tracheal tube progression through the glottis.     

Comparison of virtual bronchoscopy to fiber-optic bronchoscopy for assessment of inhalation injury severity

PurposeCompare virtual bronchoscopy (VB) to fiberoptic bronchoscopy (FOB) for scoring smoke inhalation injury (SII).MethodsSwine underwent computerized tomography (CT) with VB and FOB before (0) and 24 and 48 h after SII. VB and FOB images were scored by 5 providers off line.ResultsFOB and VB scores increased over time (p < 0.001) with FOB scoring higher than VB at 0 (0.30 ± 0.79 vs. 0.03 ± 0.17), 24 h (4.21 ± 1.68 vs. 2.47 ± 1.50), and 48 h (4.55 ± 1.83 vs. 1.94 ± 1.29). FOB and VB showed association with PaO₂-to-FiO₂ ratios (PFR) with areas under receiver operating characteristic curves (ROC): for PFR ≤ 300, VB 0.830, FOB 0.863; for PFR ≤ 200, VB 0.794, FOB 0.825; for PFR ≤ 100, VB 0.747, FOB 0.777 (all p < 0.001). FOB showed 80.3% specificity, 77% sensitivity, 88.8% negative-predictive value (NPV), and 62.3% positive-predictive value (PPV) for PFR ≤ 300 and VB showed 67.2% specificity, 85.5% sensitivity, 91.3% NPV, and 53.4% PPV.ConclusionsVB provided similar injury severity scores to FOB, correlated with PFR, and reliably detected airway narrowing. VB performed during admission CT may be a useful screening tool specifically to demonstrate airway narrowing induced by SII.     

The concentration of desflurane preventing spectral entropy change during surgical stimulation: A prospective randomized trial

Study objectiveTo determine the concentration of desflurane necessary to blunt changes in spectral entropy during surgical incision when two different target-controlled effect-site concentrations of remifentanil (1 and 3 ng/ml) were infused.DesignProspective, randomized controlled study.SettingOperating room of a university hospital.InterventionsForty-two patients undergoing general anesthesia for elective surgery were enrolled and randomly allocated to the R1 (1 ng/ml of remifentanil, n = 21) or R3 (3 ng/ml of remifentanil, n = 21) group. After at least a 10-min administration of target-controlled remifentanil concentration and predetermined end-tidal desflurane following endotracheal intubation, changes in spectral entropy in response to surgical incision were evaluated.MeasurementsConcentration of desflurane necessary to blunt changes in spectral entropy during surgical incision for each group was determined using Dixon's up-and-down method. Hemodynamic variables including mean arterial pressure (MAP) and heart rate (HR) were measured.Main resultsConcentration of desflurane necessary to blunt changes in spectral entropy during surgical incision in 50% of patients (EC₅₀) was 4.1% (95% CI: 3.5–4.7%) for the R1 group and 3.4% (95% CI: 3.0–3.8%) for the R3 group (P = 0.033). Additionally, the calculated EC₉₅ values using the logistic regression analysis for the R1 and R3 groups were 5.8% (95% CI: 5.0–10.8%) and 5.1% (95% CI: 4.3–10.6%), respectively. MAPs and HRs were significantly higher in the R1 than in the R3 group after surgical incision.ConclusionsDesflurane 4.1% with remifentanil 1 ng/ml and desflurane 3.4% with remifentanil 3 ng/ml significantly blunt the change in spectral entropy after surgical incision in 50% of patients.     

Efficacy of different doses of atracurium on intubating conditions of burned patients

BackgroundBurned patients exhibit resistant response to nondepolarizing muscle relaxants. This study was designed to investigate the efficacy of high dose atracurium (3 and 4 times ED95) with and without application of the priming principle on the intubating conditions and the onset times in burned patients.MethodsASA physical status I and II patients undergoing burn related surgery, were randomly allocated into one of four groups of 20 patients each. Group I received 1 ml placebo followed 3 min later by atracurium 0.75 mg/kg, group II received atracurium 0.04 mg/kg as the priming dose followed 3 min later by atracurium 0.71 mg/kg, group III received 1 ml placebo followed 3 min later by atracurium 1 mg/kg and group IV received atracurium 0.04 mg/kg as the priming dose followed 3 min later by atracurium 0.96 mg/kg. Datex relaxograph was used at the adductor pollicis to monitor and record the twitch response to the train of four (TOF) stimulation.ResultsThe conditions for intubation improved significantly with increasing the dose of atracurium, as we seen, when comparing patients in group IV and group I. Onset times were significantly delayed in groups I and II compared with groups III and IV.ConclusionCombinations of 4 times ED95 of atracurium together with the application of the priming principle are required to overcome the resistance and produce satisfactory intubating conditions in burned patients.     

A dose–response study of remifentanil for attenuation of the hypertensive response to laryngoscopy and tracheal intubation in severely preeclamptic women undergoing caesarean delivery under general anaesthesia

BackgroundRemifentanil is known to attenuate the cardiovascular responses to tracheal intubation. We determined effective doses (ED₅₀/ED₉₅) of remifentanil to prevent the pressor response to tracheal intubation in patients with severe preeclampsia.MethodsSeventy-five women with severe preeclampsia were randomly allocated to one of five remifentanil dose groups (0.25, 0.50, 0.75, 1.0, or 1.25 μg/kg) given before induction of anaesthesia using thiopental 5 mg/kg and suxamethonium 1.5 mg/kg. Systolic arterial pressure, heart rate and plasma catecholamine concentrations were measured. Neonatal effects were assessed by Apgar scores and umbilical cord blood gas analysis. A dose was considered effective when systolic arterial pressure did not exceed 160 mmHg for more than 1 min following tracheal intubation.ResultsBaseline systolic blood pressure and heart rate did not differ among the groups. The intubation-induced increases of heart rate and blood pressure were attenuated in a dose-dependent manner by remifentanil. ED₅₀ and ED₉₅ were 0.59 (95% CI 0.47–0.70) μg/kg and 1.34 (1.04–2.19) μg/kg, respectively. Norepinephrine concentrations remained unaltered following intubation but increased significantly at delivery, with no differences between the groups. Apgar scores and umbilical arterial and venous pH and blood gas values were comparable among the groups. Two women each in the 1.0 and 1.25 μg/kg groups received ephedrine for hypotension defined as systolic arterial pressure <90 mmHg.ConclusionsThe ED₉₅ of remifentanil for attenuating the hypertensive response to tracheal intubation during induction of anaesthesia in severely preeclamptic patients undergoing caesarean delivery under general anaesthesia was 1.34 μg/kg.     

Macintosh laryngoscope versus Bonfils Intubation Endoscopes in endotracheal intubation: Hemodynamic,intra-ocular pressure and serum catecholamine responses

ObjectiveOne of the alternative methods in managing patients for endo-tracheal intubation is the Bonfils fiberscope. We studied the efficacy of Bonfils fiberscope in comparison to the classical laryngoscope with Macintosh blade inhemodynamic, serum catecholamine and intra-ocular pressure responses.MethodsIn a prospective, randomized trial 40 patients ASA I or II aged ?18 years scheduled for gynecological, urinary and lower abdominal procedures in supine position were randomly allocated to one of two groups; 20 patients each; according to intubating device by using either Macintosh laryngoscope (L) group or Bonfils Intubation Endoscopes (B) group. Pre-induction (baseline) and pre-insertion values of HR, MAP, IOP and blood samples for catecholamine level were recorded and repeated at 1, 3, and 5 min after intubation.ResultsThere was significant increase in HR, MAP, IOP and catecholamine level in L group at 1, 3, and 5 min after intubation.ConclusionBonfils laryngoscope had superiority over Macintosh as a method of intubation in situations where minimal changes in hemodynamic, catecholamine level and intraocular pressure are desirable.     

Low-dose butorphanol alleviates remifetanil-induced hyperalgesia in patients undergoing laparoscopic cholecystectomy

ObjectiveTo evaluate the effects of low-dose butorphanol on hyperalgesia induced by high-dose remifetanil in patients undergoing laparoscopic cholecystectomy.DesignRandomized double-blind clinical trial.SettingIntraoperative.PatientsSeventy-five patients scheduled for laparoscopic cholecystectomy were enrolled.InterventionsRandomly allocated into 3 groups, low dose of remifentanil (LR) group and high dose of remifentanil (HR) group received low (0.1 μg kg^− 1 min^− 1) or high (0.3 μg kg^− 1 min^− 1) doses of remifentanil, respectively, and butorphanol combined with remifentanil (BR) group received remifentanil (0.3 μg kg^− 1 min^− 1) and butorphanol (0.2 μg/kg).MeasurementsThe visual analog scale scores and cumulative consumption of fentanyl were recorded.Main resultsVisual analog scale scores were significantly higher in the HR group than in the LR and BR groups (P < .001). The dose of intravenously given fentanyl was significantly higher in the HR group than in the LR and BR groups (P < .001). In addition, the HR group showed a significantly higher cumulative consumption of fentanyl during 5 to 8 hours after the operation (P < .001).ConclusionsA high dose of remifentanil induces postoperative hyperalgesia, which could be prevented by a continuous intravenous administration of a low dose of butorphanol.     

Efficacy and side effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for labour: an observational study

BackgroundRemifentanil has a suitable pharmacological profile for labour analgesia. In this prospective, observational study, intravenous patient-controlled analgesia with remifentanil, using stepwise bolus doses without background infusion, was examined during the first and second stages of labour. Outcomes were pain reduction, maternal satisfaction, maternal and neonatal side effects and remifentanil metabolism in the neonate.MethodsParturients with normal term singleton pregnancies were recruited. The initial remifentanil bolus dose was 0.15 μg/kg, increasing in steps of 0.15 μg/kg, with a 2-min lock-out. Pain scores using a 100 mm visual analogue scale, systolic and diastolic blood pressures, respiratory rate and maternal sedation were recorded every 15 min. Maternal oxygen saturation and heart rate were monitored continuously. Neonatal data included Apgar scores, clinical examination, naloxone use, resuscitation, umbilical cord blood gases and remifentanil concentrations.ResultsForty-one parturients were enrolled. Pain scores were significantly reduced in the first 3 h of patient-controlled analgesia use compared to baseline, and at the end of the first and second stages of labour (P < 0.05). Maximal pain reduction was 60% (P < 0.01). One patient had inadequate pain relief and converted to epidural analgesia. The mean highest dose of remifentanil was 0.7 μg/kg [range 0.3–1.05]. Ninety-three percent of patients were satisfied with their analgesia. The lowest oxygen saturation was 91% and the lowest respiratory rate was 9 breaths/min. Eleven parturients (27%) received supplemental oxygen due to oxygen saturations <92%. Maternal sedation was moderate, and neonatal data reassuring.ConclusionsRemifentanil intravenous patient-controlled analgesia provides adequate pain relief and high maternal satisfaction during the first and second stages of labour. Maternal sedation and respiratory depression may occur, but no serious neonatal side effects were recorded. Careful monitoring is mandatory.     

Differences in maternal temperature during labour with remifentanil patient-controlled analgesia or epidural analgesia: a randomised controlled trial

BackgroundEpidural analgesia and remifentanil patient-controlled analgesia are two popular techniques for the treatment of labour pain, each with its own efficacy and toxicity.MethodsParturients requesting analgesia were randomly assigned to either patient-controlled intravenous remifentanil or epidural analgesia. Control patients consisted of parturients not requesting pain medication. The primary objective was to compare the incidence of maternal fever (temperature ⩾38°C); secondary outcomes included the incidence of low oxygen saturation, pain scores, nausea and vomiting, sedation scores, pruritus and neonatal outcome.ResultsData from 140 parturients were analysed: 49 received remifentanil analgesia, 49 epidural analgesia and 42 no analgesia (controls). Fever (temperature ⩾38°C) developed in 10% of remifentanil patients compared to 37% of epidural patients and 7% of control patients (P <0.001). One or more hypoxaemic events (oxygen saturation <90% for at least 1 min) occurred in 48% of patients on remifentanil versus 15% of patients on epidural analgesia and 20% of control patients (P=0.003). Although pain intensity scores differed significantly between the two groups in favour of the epidural, mean satisfaction scores were similar in both analgesia groups (remifentanil 8.1 ± 1.2 vs. epidural 8.4 ± 1.2). Remifentanil analgesia was associated with a higher incidence of nausea and deeper levels of sedation. The differences in haemodynamic parameters between groups were small and clinically insignificant.ConclusionsDuring treatment of labour pain, epidural analgesia is associated with a higher incidence of maternal fever, while remifentanil analgesia results in more frequent and deeper hypoxaemic events.     

Intraocular pressure changes: the McGrath video laryngoscope vs the Macintosh laryngoscope; a randomized trial

Study ObjectiveTo determine the effects of the McGrath Series 5 video laryngoscope on intraocular pressure (IOP) during laryngoscopy.DesignProspective, randomized, double blind.SettingOperating room.PatientsEighty adult patients of American Society of Anesthesiologist physical status 1 scheduled for nonophthalmic elective surgery under general anesthesia.InterventionsThe endotracheal intubation was provided using McGrath series 5 video laryngoscope in MG group (n = 40) or Macintosh laryngoscope in M group (n = 40).MeasurementsThe IOP of the right and left eyes was measured before and after the laryngoscopic process.Main ResultsThe mean arterial blood pressure values just before laryngoscopy and intubation and after intubation were 77.38 ± 6.18 and 97.38 ± 12.77 in the McGrath video laryngoscope group and 75.85 ± 7.88 and 99.12 ± 14.30 in the Macintosh laryngoscope group, respectively. The IOP values of the left eye after intubation and at the 5th and the 10th minutes in the Macintosh laryngoscope group were found to be significantly higher than those in the McGrath video laryngoscope group (P = .019, P = .019, and P = .007, respectively). In addition, the IOP values of the right eye were found to be higher after intubation and at the 5th and the 10th minutes in the Macintosh laryngoscope group, compared to the McGrath video laryngoscope group (P = .009, P = .021, and P = .011, respectively). The mean IOP values for the left eye just before laryngoscopy and intubation and after intubation were 10.65 ± 2.52 and 15.57 ± 3.62 in the McGrath video laryngoscope group, and for the right eye, they were 10.60 ± 1.64 and 17.17 ± 2.38 in the Macintosh laryngoscope group, respectively.ConclusionThe McGrath Series 5 video laryngoscope may provide a lower IOP level compared to the Macintosh laryngoscope in an otherwise healthy, young patient population.