A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway – a randomized clinical trial

Introduction:  Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15°. The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80°. We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway.
Methods:  In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack–Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded.
Results:  TTBV in DL was 5.5 (4–8) s and 7 (4.2–9) s in VL. TTI in DL was 21 (17–29) s and in VL 27 (22–37) s ( P  = 0.006). The view as assessed by POGO score was 97.5% (60–100%) in DL and 100% (100–100%) in the VL ( P  = 0.003). Data are presented as median and interquartile range and analyzed using t -test.
Discussion:  This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.     

不同可视喉镜单颅缝早闭患儿经鼻气管插管中的应用比较

目的 观察不同可视喉镜1~6个月单颅缝早闭患儿经鼻气管插管中的临床应用效果。
方法 选择择期全麻下行单颅缝早闭手术患儿80例,男39例,女41例,月龄1～6个月,体重4～8 kg,ASA Ⅰ或Ⅱ级。随机分为两组：大角度可视喉镜组（L组）和小角度可视喉镜组（S组）,每组40例。麻醉诱导后,L组使用国产大角度可视喉镜,S组使用国产小角度可视喉镜,采用加强型导管行经鼻插管,导管均经柔软管芯塑形成特殊形状。记录声门暴露Cormack-Lehane（C-L）分级、插管次数,计算首次插管成功率。记录插管时间、拔管时间,插管前即刻和插管后1 min的HR、MAP、SpO₂。记录鼻腔出血、进入食管、咽部软组织损伤等插管时并发症和拔管后声音嘶哑情况。
结果 L组C-L分级Ⅰ级比例明显高于S组（P＜0.05）,插管时间明显短于S组（P＜0.05）。两组C-L分级暴露良好（Ⅰ级和Ⅱ级）比例、首次插管成功率和拔管时间差异无统计学意义。插管后1 min S组HR明显快于L组、MAP明显高于L组（P＜0.05）。S组有1例首次插管时导管误入食管,重新塑形再次插管成功。两组插管时鼻腔出血、咽部软组织损伤和拔管后声音嘶哑发生率差异无统计学意义。
结论 两种国产可视喉镜均可以用于1~6个月单颅缝早闭患儿的经鼻气管插管,大角度可视喉镜配套使用的镜片弯曲度大且体积相对较小,临床效果相对较好。     

How do pediatric anesthesiologists define intraoperative hypotension?

Introduction: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from ‘normal’, there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire‐based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Methods: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e‐mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. Results: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20–30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5–7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). Conclusions: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.     

Validation of the glidescope video laryngoscope in pediatric patients

Background:  GlideScope laryngoscopy provides a glottic view equal or superior compared to Macintosh laryngoscopy for endotracheal intubation in adult patients. Data evaluating GlideScope laryngoscopy in pediatric patients are lacking. This study compared intubation times of GlideScope laryngoscopy vs Macintosh laryngoscopy in pediatric patients.
Methods:  Sixty ASA I–III patients, aged 10 years or less, were included in this study. Prior to intubation, airway characteristics were measured, and all patients were given an airway class by a separate anesthesiologist using a Macintosh laryngoscope. Patients were then randomly assigned for endotracheal intubation using a Macintosh laryngoscope or the GlideScope, and intubation time was measured. All blades were investigated for blood traces as a surrogate of laryngeal injury.
Results:  Demographic data and airway characteristics were not statistically significant different between groups. GlideScope intubation time (14 ± 5 s) was not different from Macintosh intubation time (13 ± 5 s). Blood traces were not observed on Macintosh or GlideScope blades.
Conclusion:  The GlideScope video laryngoscope is equally suitable to facilitate orotracheal intubation in pediatric patients compared to the Macintosh laryngoscope with respect to intubation time and laryngeal trauma.     

Tosight视频喉镜在Klippel-Feil综合征患儿气管插管中的应用

目的探讨Tosight视频喉镜在Klippel-Feil综合征(KFS)患儿气管插管中的应用效果。方法 20例KFS患儿,年龄4~12岁,ASAⅡ或Ⅲ级,随机均分为两组:Tosight可视喉镜组(T组)和Macintosh喉镜组(M组)。记录喉镜下喉部显露分级(Cormack-Lehane分级)、气管插管时间、气管插管次数、插管成功率和并发症发生情况。结果 T组全部完成气管插管,M组完成6例气管插管。T组气管插管时间明显短于、插管次数明显少于M组(P0.05)。两组患儿均无严重并发症发生。结论 Tosight视频喉镜用于KFS患儿气管插管操作简单,声门暴露清晰,插管成功率高,插管时间短,优于Macintosh喉镜。     

HC可视喉镜在新生儿唇裂手术的应用

目的探讨HC可视喉镜在新生儿唇裂手术气管插管时的临床效果和安全性。方法择期行全麻下唇裂修补手术患儿52例,男32例,女20例,出生1~28d,体重2.6~4.8kg,ASAⅠ或Ⅱ级,随机均分为普通喉镜组(A组)和HC可视喉镜组(B组)。静注咪达唑仑0.1mg/kg、芬太尼2~4μg/kg、罗库溴铵快速麻醉诱导,吸入1%~3%七氟醚维持麻醉。术中连续监测BP、HR、SpO2和PETCO2。记录患儿声门暴露情况、一次插管成功率和插管时间,以及并发症情况。结果与A组比较,B组声门暴露率、一次插管成功率差异无统计学意义,但气管插管时间明显缩短(P0.05)。插管时及拔管后两组均未见明显并发症。结论 HC可视喉镜可以安全地应用于新生儿唇裂手术的气管插管,缩短气管插管时间。     

可视喉镜联合纤维支气管镜在声门显露困难患者双腔支气管插管中的应用

目的探讨GlideScope可视喉镜联合纤维支气管镜引导在声门显露困难患者双腔支气管插管中的应用。方法选择择期行胸科手术患者40例,男24例,女16例,年龄24~78岁,ASAⅠ或Ⅱ级,MallampatiⅢ或Ⅳ级,随机分为GlideScope可视喉镜组(GF组)和Macintosh喉镜组(M组),每组20例。GF组运用可视喉镜联合纤维支气管镜引导进行支气管插管及对位;M组运用传统方法(先用Macintosh喉镜插管,再使用纤维支气管镜对位)。记录患者喉镜下声门显露程度Cormack-Lehane分级、插管时间、插管一次成功率、需喉部按压的患者例数以及术后48h内的声音嘶哑及咽痛情况。结果GF组Cormack-Lehane分级明显低于M组(P0.01)。GF组插管时间明显短于M组[(104.3±11.1)s vs.(138.6±33.0)s](P0.01),一次插管成功率明显高于M组(90%vs.55%)(P0.05),需要喉部按压患者比例明显低于M组(20%vs.90%)(P0.01),术后声音嘶哑和咽痛的发生率明显低于M组(5%vs.35%,25%vs.75%)(P0.05)。结论与传统方法比较,可视喉镜联合纤维支气管镜引导用于声门显露困难患者可以提高插管的成功率,减少插管时的应激反应,降低声嘶和咽痛的发生率。     

Randomized controlled trial of sevoflurane for intubation in neonates

BACKGROUND: Our aim was to determine whether sevoflurane can be used with safety and efficacy for anesthesia during intubation in term and preterm neonates in a prospective randomized-controlled nonblinded study in a tertiary neonatal intensive care unit. METHODS: Thirty-three neonates were randomly allocated to receive sevoflurane (inspired concentrations varying from 2% to 5%) or no medication (preoxygenation with 100% oxygen alone) before intubation. Minute by minute heart rate (HR), mean arterial blood pressure, SpO(2) and number of episodes of bradycardia (HR < 100 b.min(-1)) and desaturation (SpO(2) < 85% for >30 s) were noted from 5 min before to 10 min after intubation. Operator experience, ease and number of attempts were noted. RESULTS: No major adverse events were noted in the study group compared with the control group [hypotension (37.5% vs 37.5%, NS), number of desaturations [37.5% vs 44.5%, NS)]. Hypertension (25%, vs 56.3%P = 0.04) and incidence of bradycardias (8.3% vs 44.4%, P < 0.01) were greater in the control group. Intubation was easier in the study group: no movements: 95.5% vs 28% (P < 0.005); good glottis visualization: 73% vs 33% (P = 0.013). The failure rate was lower in the study group (25% vs 39%), but this difference was not statistically significant. CONCLUSION: Anesthesia for intubation with sevoflurane in neonates is well tolerated, even in the less mature. It facilitates the conditions for intubation and leads to fewer adverse events. Other studies are necessary to confirm these preliminary results.     

Anesthetic experience of 100 pediatric tracheostomies

Background:  Tracheostomy is more hazardous in the pediatric population than in adults (Paediatr Nurs, 17, 2005, 38; Int J Pediatr Otorhinolaryngol, 67, 2003, 7; J R Soc Med, 89, 1996, 188). Airway management in these children and infants is potentially challenging. Previous case series of pediatric tracheostomy published in the surgical journals make little mention of anesthetic techniques used and do not describe airway management. The aim of this study was to review the anesthetic, and in particular the airway management of children undergoing tracheostomy at Great Ormond Street Hospital (GOSH).
Methods:  Between September 2004 and December 2007, the ENT surgical database showed that 109 children had a surgical tracheostomy performed at GOSH. We were only able to locate the notes of 100 of these cases. The anesthetic records of these 100 patients undergoing tracheostomy were analyzed retrospectively.
Results:  Ninety-four percent (94/100) of tracheostomies were elective, and 6% (6/100) were emergency. In this study, 26% (26/100) of children were recorded as difficult to intubate. These difficult airways were managed as follows: 10/26 used a laryngeal mask airway (LMA), 5/26 were managed with facemask alone, 3/26 had fiber-optic intubation, 5/26 had surgical intubation and 2/26 were intubated with the aid of a bougie and cricoid pressure.
Conclusions:  This case series demonstrates that intubation is difficult in up to 26% of children presenting for tracheostomy. While intubation of the trachea remains the preferred option when anesthetizing children for tracheostomy, the LMA or facemask can provide a successful airway where intubation is not possible. The use of the LMA or facemask may therefore be life saving in the unintubatable child.     

Frequency of anesthetic cardiac arrests in infants: Effect of pediatric anesthesiologists

Study Objective: To determine whether the presence of pediatric anesthesiologists decreases the frequency of anesthetic-related cardiac arrests in infants (children who are 1 year of age or younger).

Design: A comparative retrospective study of anesthetics and cardiac arrests during a 7-year period.

Setting: The main operating room (OR) suite of a large university hospital.

Patients: All patients age 1 year or less undergoing surgical anesthesia from July 1983 through March 1990.

Interventions: Computerized anesthetic and operative patient records were queried for patient age, ASA physical status, body weight, surgical procedure, intraoperative complications, and the identity of the attending anesthesiologist. In each case, it was determined whether a pediatric anesthesiologist was in attendance and whether a cardiac arrest due to anesthesia occurred. Pediatric anesthesiologists were identified as those with pediatric fellowship training or the equivalent. The study population was divided into two groups: (1) the pediatric anesthesiologist group, with 2,310 patients whose anesthetics were supervised by pediatric anesthesiologists; (2) the nonpediatric anesthesiologist group, with 2,033 patients.

Measurements and Main Results: Mean age and weight were comparable in the two groups, and the distribution of physical status did not differ. No anesthesia-related cardiac arrests occurred in the pediatric anesthesiologist group; four anesthetic cardiac arrests occurred in the nonpediatric anesthesiologist group, for a frequency of 19.7 per 10,000 anesthetics. This difference between provider groups is significant (Fisher's exact probability test, p = 0.048).

Conclusions: The results suggest that the use of pediatric anesthesiologists for all infants 1 year of age or younger might decrease anesthetic morbidity in this age-group.     

可视喉镜在新生儿手术气管插管中的应用

目的探讨可视喉镜在新生儿手术气管插管中的应用。方法选择2013-07—2013-12间行新生儿手术50例为研究对象,随机分为可视喉镜组(A组)25例和直接喉镜组(B组)25例,比较两组新生儿气管插管时声门暴露时间,完成气管插管的时间,插管一次成功率和新生儿插管前3 min、插管时及插管后3 min的平均动脉压(MAP)、心率(HR)的变化及插管相关不良反应。结果 A组与B组相比,A组声门暴露时间,完成气管插管的时间均明显缩短,A组插管一次成功率96%,B组插管一次成功率80%,差异有统计学意义。两组新生儿插管前和插管后3 min的MAP和HR比较,差异无统计学意义。但与B组相比,插管时A组新生儿MAP和HR明显降低,差异有统计学意义。A组新生儿插管时不良反应明显低于B组,差异有统计学意义。结论可视喉镜可提高新生儿手术气管插管时成功率,缩短声门暴露时间,气管插管的时间,降低插管不良反应,提高新生儿手术麻醉安全性。     

Iatrogenic damage to the pediatric airway Mechanisms and scar development

Iatrogenic damage to the pediatric airway occurs rather often. Most injuries will heal without any sequelae because larynx and trachea of children tolerate considerable trauma. However, sometimes the injury is penetrating the mucosa and scar formation can lead to an obstruction of the airway which is followed by a tracheostomy and long term surgery. A great problem is the early detection of trauma since noisy breathing develops often late when scar formation has occluded more than 50% of the airway. A selection of photo documents of airway endoscopy out of more than 5000 photos from the years 1987–2007 were used to explain the development of injuries from minor lesions to large areas of necrosis of the mucosa of larynx and trachea of infants and children. The visualization of airway lesions might help to prevent iatrogenic damage.     

鼾症患者使用三种不同可视喉镜行经口气管插管的比较

目的探讨Clarus可视喉镜、HPHJ-A视频喉镜和Airtraq可视喉镜在鼾症患者经口气管插管中的应用价值。方法选择拟行择期手术的鼾症患者90例,男39例,女51例,年龄22~55岁,BMI 25~29 kg/m2,ASAⅠ~Ⅲ级,随机分为三组:Clarus可视喉镜组(C组)、HPHJ-A视频喉镜组(H组)和Airtraq可视喉镜组(A组),每组30例。记录插管时间、首次插管成功率。记录麻醉诱导前(T0)、插管前(T1)、插管后即刻(T2)、插管后1 min(T3)、3 min(T4)时的HR、MAP、心率-收缩压乘积(RPP),记录咽喉损伤和出血情况。结果 C组均成功插管,H组插管失败有2例,A组插管失败有1例,后经Clarus可视喉镜均插管成功。C组插管完成时间明显长于H组和A组(P0.05),三组插管尝试次数差异无统计学意义。与T0时比较,T1时三组HR明显减慢,MAP、RPP明显降低(P0.05)。与T1时比较,T2时三组HR明显增快、MAP、RPP明显升高(P0.05),T3时H组和A组HR明显增快,三组MAP和RPP明显升高(P0.05)。T2时C组HR明显慢于H组和A组,RPP明显低于H组和A组(P0.05)。三组咽喉损伤和出血情况等不良反应差异无统计学意义。结论对于鼾症患者行经口气管插管时,与HPHJ-A视频喉镜和Airtraq可视喉镜比较,Clarus可视喉镜所需张口度要求低,血流动力学影响小,但插管所需时间较长,在预防咽喉损伤上并无明显优势。     

A new video laryngoscope-an aid to intubation and teaching

In recent decades, video techniques have been employed in the majority of endoscopic procedures because of several distinct advantages provided. These include the following: The displayed anatomy is magnified. Recognition of the anatomical structures and anomalies is easier, and manipulation of airway devices is facilitated. When assistance is required, the operator and assistant can coordinate their movements because each sees exactly the same image on the video monitor. As a result, video techniques have become the method of choice in teaching.

The Video Macintosh Intubating Laryngoscope System (VMS) was designed employing a standard Macintosh blade and laryngoscope handle. A camera was incorporated into the handle with a short image and light bundle. The magnified anatomy is displayed on an 8-inch monitor, which is attached to a swivel arm on a small cart. Observation and manipulation can be performed in one axis.

A total of 235 patients were studied and were divided into two groups: Group A (n = 217), in whom intubation was thought unlikely to be difficult, and Group B (n = 18), in whom difficulty with intubation was anticipated.

External laryngeal manipulation (ELM) was required in 22 of the 217 Group A patients (10%). All intubations but one in this group were successful. In the second group (B) of 18 patients who had anatomical conditions that suggested that direct laryngoscopy might be challenging, all 18 cases required ELM but all were successfully intubated using the VMS.

The improved coordination afforded by an image on a video monitor seen by both the assistant providing laryngeal manipulation and the anesthesiologist handling the laryngoscope results in a significant advantage over the conventional laryngoscope technique. As a consequence, the learning curve is short. In our view, video laryngoscopy will become the method of choice in teaching.     

雷米芬太尼在小儿麻醉中的临床应用近况

雷米芬太尼（remifentanil）是目前最新的短效斗一阿片样受体激动剂，其药代动力学参数小儿与成人相似。可用在小儿静吸复合麻醉及全凭静脉麻醉的诱导及维持中，包括心脏及非心脏手术，控制性降压、门诊手术麻醉。但不适合小儿清醒镇静中使用。雷米芬太尼的镇痛和呼吸抑制作用呈剂量依赖型，且镇痛作用有最大效应限制。临床应用须结合小儿的生理特点，个体化用药。     

Distraction with a hand-held video game reduces pediatric preoperative anxiety

BACKGROUND: Video games have received widespread application in health care for distraction and behavior modification therapy. Studies on the effect of cognitive distraction during the preoperative period are lacking. We evaluated the efficacy of an interactive distraction, a hand-held video game (VG) in reducing preoperative anxiety in children. METHODS: In a randomized, prospective study of 112 children aged 4-12 years undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia, using the modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative behavior changes were assessed with the Posthospital Behavior Questionnaire (PHBQ). Patients were randomly assigned to three groups: parent presence (PP), PP+a hand-held VG, and PP+0.5 mg.kg-1 oral midazolam (M) given>20 min prior to entering the operating room. RESULTS: There was a statistically significant increase in anxiety (P<0.01) in groups M and PP at induction of anesthesia compared with baseline, but not in VG group. VG patients demonstrated a decrease in anxiety from baseline (median change in mYPAS -3), the difference compared with PP (+11.8) was significant (P=0.04). The change in anxiety in the M group (+7.3) was not statistically different from other groups. Sixty-three percent of patients in VG group had no change or decrease in anxiety after treatment, compared with 26% in M group and 28% in PP group (P=0.01). There was no difference in anxiety changes between female and male patients. CONCLUSIONS: A hand-held VG can be offered to most children as a low cost, easy to implement, portable, and effective method to reduce anxiety in the preoperative area and during induction of anesthesia. Distraction in a pleasurable and familiar activity provides anxiety relief, probably through cognitive and motor absorption.