Effect of fiberoptic intubation on myocardial ischemia and hormonal stress response in diabetics with ischemic heart disease

BackgroundDiabetic patients with ischemic heart disease can greatly benefit from decreasing the stress response to intubation with its metabolic sequelae. The use of fiberoptic bronchoscopy will eliminate the response to direct laryngoscopy while lubrication of ETT with lidocaine gel 2% will decrease the response to endotracheal intubation. This study was conducted to compare the stress response hormones (glucose, cortisol and c-peptide) and the hemodynamic responses to intubation between direct laryngoscopy and fiberoptic bronchoscopy in diabetic ischemic patients.Patients and methodsForty-four adult diabetic patients with ischemic heart disease, ASA II, with a blood glucose level between 120 and 180 mg/dL, requiring orotracheal intubation under general anesthesia were divided into 2 equal groups. The laryngoscopic group (n = 22) and the fiberoptic group (n = 22). Ovassapian airway was used to facilitate fiberoptic intubation with avoidance of jaw thrust maneuver. Blood glucose, cortisol and c-peptide were recorded before induction and 10 min after intubation and compared between both groups. The hemodynamic parameters were recorded and compared between both groups. Automated ST segment monitoring was used to detect ischemia.ResultsThere was statistically significant increase in HR, SBP and DBP in laryngoscopic group than in fiberoptic group. However, the incidence of ECG ST-segment changes was comparable with no statistically significant difference between groups. There were no statistically significant differences regarding glucose, cortisol and c-peptide levels between the study groups pre and post-induction. The intubation time in the fiberoptic group showed a statistically significant increase in comparison with the laryngoscope group (39 ± 12.04 vs. 29.3 ± 8.54 s; P < 0.05).ConclusionThe optimum use of fiberoptic bronchoscope with avoidance of jaw thrust maneuver attenuates the hemodynamic response to intubation which is beneficial in diabetic patients with ischemic heart disease. Stress response hormones showed no statistically significant difference between groups.     

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.     

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.     

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.     

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.     

Air-Q the Intubating Laryngeal Airway: Comparative study of hemodynamic stress responses to tracheal intubation via Air-Q and direct laryngoscopy

Background: Tracheal intubation is the gold standard for securing airway. Tracheal intubation through DLS produces marked hemodynamic stress responses. The Air-Q is a new supraglottic airway device. The purpose of this study was to determine whether endotracheal intubation through Air-Q is associated with lesser hemodynamic stress responses.Methods: 60 patients scheduled for elective surgery under general anesthesia requiring endotracheal intubation were randomly assigned into two groups. Direct laryngoscopy group and Air-Q group. Blood pressure and heart rate were recorded before, after induction, immediately after intubation and every minute for 4 min after intubation. The intubation time was recorded. Upon removal of the Air-Q, trauma to the upper airway was reported.Results: The intubation time was shorter in the DLS group compared with the Air-Q group (P value < 0.05). A significant reduction in BP was evident after the induction of anesthesia in both groups. Immediately after intubation, there was a significant increase in BP compared with the preintubation values. A decline was inspected between 1 and 4 min postintubation in both groups with significant difference immediately, at 1 and 2 min postintubation between the two groups. There were significant increase in HR immediately, at 1 and 2 min postintubation compared with the preintubation values, but there was no significant difference at each time point between two groups. Sore throat was more in the Air-Q group (P value <0.05).Conclusion: The hemodynamic stress response to intubation by Air-Q is less than that of DLS despite the longer duration of the former.     

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.     

Comparative study of awake endotracheal intubation with Glidescope video laryngoscope versus flexible fiber optic bronchoscope in patients with traumatic cervical spine injury

BackgroundThe Gldiescope video laryngoscope (GVL) as a recent intubating device has gained much popularity in difficult intubation over the last decade. It can be used as a substitute to flexible fiber optic bronchoscope (FOB) in intubating challenges. The object of this study is to compare the utility of GVL and FOB for intubating time, attempts, effects on hemodynamics, adverse effects, patient satisfaction and post intubation neurological outcome during awake intubation in traumatic cervical spine injury.MethodsFifty patients undergoing post traumatic cervical spine fixation under general anesthesia were randomly allocated to two groups in a prospective, controlled non-blinded study. All patients were premedicated with glycopyrrolate 0.2 mg iv and midazolam 1 mg iv that be repeated up to 0.05 mg/kg followed with a bolus dose of remifentanil 1.5 μg/kg then a continuous remifentanil infusion of 0.15 μg/kg/min for 3 min before procedure. Each patient underwent a wake endotracheal intubation with either GVL (G group) or FOB (F group) with manual in line stabilization (MILS). Intubating time, intubating attempts, hear rate (HR), mean arterial pressure (MAP), oxygen desaturation (SO₂ < 90%), sore throat, patient satisfaction and postintubation neurological outcome were recorded.ResultsIntubating time was significantly lower in G group compared with F group (26 ± 5 versus 72 ± 11 respectively), while the percentage of the first successful intubating attempt was insignificantly higher in G group (88%) than in F group (72%). Both HR and MAP were significantly increased only in F group during intubation in comparison with the basal line values. Both devices were safe for post neurological outcome. No significant differences of adverse effects or patient satisfaction were recorded between groups.ConclusionThe GVL is a safe surrogate for FOB during awake intubation for post traumatic cervical spine fixation.     

Comparação de traqueotomia percutânea precoce e tardia em unidade de terapia intensiva para adultos

Background and objectivesPercutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit.MethodsPercutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0–7th days of endotracheal intubation were grouped as early and after the 7 th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18 years old, patients with positive end‐expiratory pressure above 10 cmH₂O and those with bleeding diathesis or platelet count under 50,000 dL^‐1 were not included in the study. Durations of mechanical ventilation and intensive care stay were noted.ResultsThere was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p < 0.05).ConclusionEarly tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.     

Análisis de los factores de intubación difícil en cirugía bariátrica. Influencia en la elección del bloqueante neuromuscular de la disponibilidad de sugammadex

ObjectiveTo determine the incidence of difficult tracheal intubation (DTI), as well as predictive factors for DTI and what influences the choice of the neuromuscular blocking agent (succinylcholine or rocuronium).MethodsThis is an observational, prospective study on consecutive bariatric surgery patients. Tracheal intubation was performed by direct laryngoscopy with a preformed tracheal tube. DTI was considered when there was a Cormack-Lehane classification of iii-iv or when it was necessary to apply the DTI algorithm, which consisted in the use of Frova guide, and Airtraq video-laryngoscope as second choice, and finally awaking the patient and sugammadex reversal if rocuronium was the selected neuromuscular blocking agent. Thereafter, tracheal intubation was performed using an awake fibroscopic techniqueResultsOne hundred and sixty six patients were included. In one case, conscious fiberscope tracheal intubation was performed. Succinylcholine was selected for 14 patients, and rocuronium for 151 patients. Fifteen patients had a DTI (9%): in 4 Airtraq was deemed necessary. One patient received sugammadex to reverse neuromuscular blockade. Conscious tracheal intubation represented 1.2% (95% CI; 0.3-4%). DTI was associated with Mallampati score of 3-4 (odds ratio, 3 [95% CI; 1.37-6.8], sensitivity of 33%, specificity of 91%) and with thyromental distance < 6 cm (odds ratio, 4.8 [95% CI; 1.45-16]; sensitivity of 53%; specificity of 79%).ConclusionRescue airway protocol with Frova and Airtraq avoided the use of sugammadex, except in one patient.     

Goal directed preemptive ephedrine attenuates the reperfusion syndrome during adult living donor liver transplantation

BackgroundEnd-stage liver disease is associated with marked hemodynamic disturbances that are further deteriorated during liver transplantation and is aggressively represented in the form of postreperfusion syndrome (PRS).AimThe aim was to test the hypothesis that preemptive ephedrine administration pre-reperfusion targeting a rational level of mean arterial blood pressure (MAP) of 85–100 mmHg, may reduce the incidence of PRS.Patient and methodsOne hundred recipients for adult living donor liver transplantation (ALDLT) were prospectively randomized into 2 groups; group C, control group and group E, who received ephedrine 2.5–5 mg/min starting 5 min before reperfusion till mean arterial blood pressure (MAP) reached 85–100 mmHg. Hemodynamic parameters including MAP, heart rate (HR), Transesophageal Doppler (TED) parameters including corrected flow time (FTc), systemic vascular resistance (SVR), and cardiac output (COP) were measured; just predrug administration, just before reperfusion, just after reperfusion, 5 min after reperfusion and at the end of surgery. Cold and warm ischemia times (C/WIT), duration of anhepatic phase and total duration of surgery were recorded. The incidence of PRS, the need of rescue vasoconstrictor for hemodynamic instability at time of reperfusion, need for postreperfusion vasoconstrictor infusions, over shooting of hemodynamics, postreperfusion fibrinolysis indicated by fibrinogen level and maximum lysis parameter of rotational thromboelastometry (ROTEM) were compared between both groups.ResultsThe mean dose of ephedrine required was (12.5 ± 7.5 mg). Group E had statistically significant increase in MAP, SVR, and COP; just before reperfusion, just after reperfusion and 5 min after reperfusion readings. There were no statistical significant differences between the 2 groups at the end of surgery. The incidence of PRS and the need of rescue adrenaline at the time of reperfusion, and the postreperfusion need for vasoconstrictor infusion decreased significantly in group E when compared to group C. Also postoperative mechanical ventilation decreased significantly in group E.ConclusionThe preemptive goal directed titration of ephedrine against a target MAP pre-reperfusion could decrease the incidence of PRS by 40%, attenuated the hypotensive response to reperfusion and decreased the need for postreperfusion vasoconstrictor support without over shooting of any of the monitored hemodynamic indices.     

The use of the GlideScope® for tracheal intubation in patients with halo vest

ObjectiveGlideScope^® provides better laryngoscopic view and is advantageous in tracheal intubation in ankylosing spondylitis patients with difficult airway.MethodsThis study was performed to investigate the use of the GlideScope^® for tracheal intubation in 15 patients wearing halo vests scheduled for elective surgery under general anesthesia. Preoperative airway assessments were evaluated to predict the difficulty of tracheal intubation. Before intubation, all patients were given a modified Cormack and Lehane (MCLS) grade and percentage of glottic opening (POGO) score by the intubating anesthesiologist having resorted to direct laryngoscopy (DL) with a Macintosh Size 3 blade depiction. Then intubation with the GlideScope^® was performed, during which the larynx was inspected and given another MCLS grade and POGO score.ResultsFourteen of the 15 patients had MCLS Grade III or IV by direct Macintosh laryngoscopy and were considered to have a difficult laryngoscopy. Nasal tracheal intubation by the GlideScope^® was successful on all occasions. The GlideScope^® improved the MCLS grade and POGO score in all patients who had put on a halo vest as compared with those on DL (p < 0.01). The GlideScope^® also provided a better laryngoscopic view than that by a DL. All of the patients who wore halo vests and presented with suspected difficult airways could be intubated successfully with the GlideScope^®.ConclusionThe use of the GlideScope^® for tracheal intubation could be an alternative option in patients with a difficult airway, whose surgery was circumscribed under general anesthesia with tracheal intubation.     

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.     

Efficacy of laser acupuncture in attenuating hemodynamic response to orotracheal intubation and postoperative nausea and vomiting in children undergoing strabismus surgery

BackgroundLaser acupuncture may be offered to patients with needle phobia and children. This study aimed to investigate efficacy of the acupuncture point stimulation (Liv3 and P6) in preventing PONV and hemodynamic response to intubation in children.MethodsSixty children, ASA I or II aged 3–12 years, undergoing strabismus surgery were divided into 3 equal groups; 20 child each Group I (laser acupuncture group), Group II (ondansetron group) 0.15 mg/kg IV group and Group III (control group). Laser stimulation was performed bilaterally over 30 s, 15 min before induction of anesthesia and 15 min after arriving in the recovery room. Systolic, mean and diastolic BP and HR were measured in groups I and III before induction (times 1, 2), before intubation (time 3) and every minute after intubation for 5 min (times 4–8). 0–3 PONV scale was reported in all 3 groups I, II and III at 0–1 h, 1–6 h and 0–12 h postoperatively.ResultsMABP and HR were significantly less in the acupuncture group at T4, T5 (P values are < 0.05) as compared with the control group. Nausea, retching and vomiting in the control group were statistically significantly higher than both acupuncture and ondansetron groups at all intervals.ConclusionLaser stimulation of acupuncture points P6 and Liv3 decreases but does not prevent hemodynamic stress-response to endo-tracheal intubation in children, and effectively decreases postoperative nausea, retching, and vomiting in children undergoing strabismus surgery.     

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.     

Efeito de diferentes doses de esmolol sobre a resposta hemodinâmica,BIS e resposta de movimento durante a intubação orotraqueal: estudo prospectivo,randômico e duplo‐cego

ObjectiveA prospective, randomized and double‐blind study was planned to identify the optimum dose of esmolol infusion to suppress the increase in bispectral index values and the movement and hemodynamic responses to tracheal intubation.Materials and methods120 patients were randomly allocated to one of three groups in a double‐blind fashion. 2.5 mg kg⁻¹ propofol was administered for anesthesia induction. After loss of consciousness, and before administration of 0.6 mg kg⁻¹ rocuronium, a tourniquet was applied to one arm and inflated to 50 mm Hg greater than systolic pressure. The patients were divided into 3 groups; 1 mg kg⁻¹ h⁻¹ esmolol was given as the loading dose and in Group Es50 50 μg kg⁻¹ min⁻¹, in Group Es150 150 μg kg⁻¹ min⁻¹, and in Group Es250 250 μg kg⁻¹ min⁻¹ esmolol infusion was started. Five minutes after the esmolol has been begun, the trachea was intubated; gross movement within the first minute after orotracheal intubation was recorded.ResultsIncidence of movement response and the ΔBIS max values were comparable in Group Es250 and Group Es150, but these values were significantly higher in Group Es50 than in the other two groups. In all three groups in the 1 st minute after tracheal intubation heart rate and mean arterial pressure were significantly higher compared to values from before intubation (p < 0.05). In the study period there was no significant difference between the groups in terms of heart rate and mean arterial pressure.ConclusionIn clinical practise we believe that after 1 mg kg⁻¹ loading dose, 150 μg kg⁻¹ min⁻¹ iv esmolol dose is sufficient to suppress responses to tracheal intubation without increasing side effects.     

Complicaciones durante la intubación traqueal repetida en la unidad de cuidados intensivos. Estudio prospectivo,observacional comparando primera intubación y reintubación

Background of the studyThe goal of the study was to compare the incidence of complications, technical difficulty of intubation and physiologic pre-intubation status between the first intubation and reintubation performed on the same patient in an ICU.Materials and methodsThe study was approved by the ethics committee of Galicia (Santiago-Lugo, code No. 2015-012). Due to the observational, noninterventional, and noninvasive design of this study, the need for written consent was waived by the ethics committee of Galicia. Patients requiring tracheal intubation and reintubation in the ICU were included in this prospective observational study. Main endpoint was to compare the incidence of complications, physiologic pre-intubation status, and the rate of technical difficulty of intubation between the first intubation and reintubation performed on the same patient in an ICU.Results and discussion504 patients were intubated in our ICU during the study period, and 82 (16%) required reintubation. There was no difference between the first intubation and reintubation regarding number of total complication (35% vs 33%; P = .86), hypotension (24% vs 24%; P = 1), hypoxia (26% vs 26%; P = 1), esophageal intubation (1% vs 1%; P = 1), and bronchoaspiration (2% vs 1%; P = .86). Physiologic pre-intubation status and technical difficulty of intubation did not differ between the first intubation and reintubation.ConclusionsIn our ICU patients requiring tracheal reintubation, incidence of complications, physiologic pre-intubation status, and technical difficulty of intubation did not differ between the first intubation and reintubation.     

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.     

Dexmedetomidine versus propofol for sedation during gastrointestinal endoscopy in pediatric patients

ObjectiveTo compare the sedative, hemodynamic, respiratory and adverse effects of dexmedetomidine versus propofol during gastrointestinal endoscopy (GIE) in pediatrics.MethodsAfter obtaining approval of the research and ethics committee and informed consent of the parents of the patients, eighty pediatric patients ASA I/II aged 1–14 years, scheduled for gastrointestinal endoscopy were randomized into dexmedetomidine group or propofol group. Sedation was achieved with propofol 2 mg/kg bolus then infused at 100 μg/kg/min or dexmedetomidine 2.5 μg/kg over 10 min then infused at 2 μg/kg/h to achieve a Ramsay sedation scale (RSS) ⩾5. HR, MAP, RR and SPO2 were continuously monitored and analyzed at (T0) baseline, (T1) after induction, (T2) after insertion of endoscope, (T3) during procedure, (T4) recovery period. Times of induction, procedure, and recovery were reported together with any adverse effects.ResultsThere were no significant differences in demographic data between the two groups. HR values were significantly lower in dexmedetomidine group at T1, T2 and T3 (83.95 ± 13.79 versus 92.95 ± 12.38, 103.35 ± 15.34 versus 112.75 ± 12.79 and 90.80 ± 13.99 versus 104.05 ± 10.73) beats/min respectively, (p-value < 0.05). No significant differences were found in MAP, RR and SPO2 values between groups at all time points. Induction and recovery times were significantly longer in dexmedetomidine group 10.51 ± 1.75 versus 3.17 ± 0.72 min and 28.55 ± 7.95 versus 13.68 ± 3.35 min (p-value < 0.001). Seven patients in dexmedetomidine group (17.5%) versus one patient in propofol group (2.5%) showed unwanted movement (p-value 0.057), and no cases in dexmedetomidine group demonstrated oxygen desaturation versus 6 patients (15%) within propofol group (p-value 0.026).ConclusionDexmedetomidine sedation during GIE provides more respiratory safety and HR stability presenting itself as a suitable alternative agent especially for the relatively longer procedures.     

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.