Comparison of the Bullard and Macintosh Laryngoscopes for Endotracheal Intubation of Patients with a Potential Cervical Spine Injury

Background: In the emergency trauma situation, in-line stabilization (ILS) of the cervical spine is used to reduce head and neck extension during laryngoscopy. The Bullard laryngoscope may result in less cervical spine movement than the Macintosh laryngoscope. The aim of this study was to compare cervical spine extension (measured radiographically) and time to intubation with the Bullard and Macintosh laryngoscopes during a simulated emergency with cervical spine precautions taken.

Methods: Twenty-nine patients requiring general anesthesia and endotracheal intubation were studied. Patients were placed on a rigid board and anesthesia was induced. Laryngoscopy was performed on four occasions: with the Bullard and Macintosh laryngoscope both with and without manual ILS. Cricoid pressure was applied with ILS. To determine cervical spine extension, radiographs were exposed before and during laryngoscopy. Times to intubation and grade view of the larynx were also compared.

Results: Cervical spine extension (occiput-C5) was greatest with the Macintosh laryngoscope (25.9 [degree sign] +/- 2.8 [degree sign]). Extension was reduced when using the Macintosh laryngoscope with ILS (12.9 +/- 2.1 [degree sign]) and the Bullard laryngoscope without stabilization (12.6 +/- 1.8 [degree sign]; P < 0.05). Times to intubation were similar for the Macintosh laryngoscope with ILS (20.3 +/- 12.8 s) and for the Bullard without ILS (25.6 +/- 10.4 s). Manual ILS with the Bullard laryngoscope results in further reduction in cervical spine extension (5.6 +/- 1.5 [degree sign]) but prolongs time to intubation (40.3 +/- 19.5 s; P < 0.05).     

Patient-controlled epidural analgesia for labor and delivery: a novelty or a practical method?

Patient-controlled analgesia, familiar worldwide as “PCA” and derived from a conceptual framework designed to improve standards of pain relief, developed rapidly from an experimental paradigm to the gold standard of modern acute pain management. While PCA has been universally adopted for postoperative parenteral drug administration, as an approach to epidural drug delivery during childbirth, its acceptance has been slow and characterized by isolated flourishes of energy and pockets of clinical activity. Once largely confined to academic or tertiary maternity units, patient-controlled epidural analgesia (PCEA) now seems to be more widely used, although new survey data are awaited before this impression can be affirmed or refuted. World wide, the clinical use of PCEA during labor and delivery varies widely. In parts of North America and Western Europe, PCEA has firmly established a place in the provision of epidural analgesia for parturition, partly accounted for by regional practice patterns, by requirements with respect to epidural management by medical and nursing staff, and by remuneration issues. In other countries and institutions, a variety of factors, not least of which is cost-containment, finds PCEA rarely considered as an alternative to continuous infusion epidural analgesia (CIEA) or intermittent bolus epidural analgesia (IBEA). Consumer-focused epidural services placing emphasis on choice or satisfaction frequently offer PCEA as an option or have adopted PCEA as the routine approach. Nevertheless, while there is strengthening evidence for several advantages of PCEA compared with the alternatives methods of drug delivery, assessing and documenting maternal satisfaction is difficult and any general benefit of PCEA in this respect is largely theoretical. This chapter reviews the literature pertaining to the efficacy and safety of PCEA during labor and delivery, especially in comparison with CIEA and IBEA.     

Influence of Lidocaine on Endotoxin-induced Leukocyte-Endothelial Cell Adhesion and Macromolecular Leakage in Vivo

Background: Endotoxin activates leukocyte-endothelial cell adhesion, vascular leakage, and changes in vascular microhemodynamics. The aim of this study was to determine whether lidocaine, which inhibits the activation of leukocytes, could attenuate microcirculatory disturbances during endotoxemia.

Methods: Thirty anesthetized male rats were randomly assigned to receive one of three treatments (n = 10 for each group): infusion of saline (control group), infusion of Escherichia coli endotoxin (LPS group: 2 mg [center dot] kg sup -1 [center dot] h sup -1 lipopolysaccharides) without lidocaine treatment, or infusion of endotoxin with lidocaine pretreatment 30 min before baseline measurements (lidocaine group: intravenous bolus of 2 mg/kg and continuous infusion of 2 mg [center dot] kg sup -1 [center dot] h sup -1). Leukocyte adherence, erythrocyte velocity (VRBC), and vessel diameters (Dv) were determined at baseline and at 60 and 120 min in mesenteric post-capillary venules using in vivo videomicroscopy. Macromolecular leakage was determined by measuring the extravasation of fluorescence-labeled albumin. Venular wall shear rate (tau) was calculated according to the equation tau = 8 [center dot] VRBC [center dot] Dv sup -1.

Results: Lidocaine significantly attenuated the increase of leukocyte adherence during endotoxemia. There were no significant differences of tau within or between the groups. Macro-molecular leakage exhibited the greatest increase in the LPS group. In the lidocaine group, it was significantly decreased but still increased compared with the control group.     

Are nasal spectacles adequate for supplementary oxygen in patients after anaesthesia?

Two methods of oxygen delivery were compared when used postoperatively after a general anaesthetic had been administered. There were 255 patients randomly allocated to receive oxygen via nasal spectacles or a Hudson face mask in the initial postoperative period. Oxygen saturation was monitored using pulse oximetry. Seven percent of patients who received the Hudson mask and 14% of patients who received nasal spectacles desaturated below 94% (P = 0.10). Age, weight or American Society of Anesthesiologists (ASA) status did not predict oxygen desaturation; however, desaturation occurred more frequently in male patients with nasal spectacles undergoing abdominal surgery. If male patients who had abdominal surgery with muscle relaxants are excluded from the nasal spectacle group, the desaturation incidences for spectacles and masks are similar (10% versus 7%, P = 0.38). Using nasal spectacles for all postoperative oxygen therapy in selected patients is therefore feasible and could provide substantial cost-saving.