Intubation Conditions Research Articles

Safety of Propofol as an Induction Agent for Urgent Endotracheal Intubation in the Medical Intensive Care Unit

Propofol is known to provide excellent intubation conditions without the use of neuromuscular blocking agents. However, propofol has adverse effects that may limit its use in the critically ill patients, particularly in the hemodynamically unstable patient. We report on the safety and efficacy of propofol for use as an agent for urgent endotracheal intubation (UEI) in the critically ill patients. We reviewed the outcomes of 472 consecutive UEIs performed by a medical intensive care unit (ICU) team at a tertiary care hospital from November 2008 through November 2012. Outcome data were collected prospectively as part of an ongoing quality improvement project. Propofol was used as the sole sedative agent in 409 (87%) of the 472 patients. In 18 (4%) of the 472 patients, other agents (midazolam, lorazepam, or etomidate) were used in addition to propofol. Of the 472, 10 (2%) intubations were performed with a sedative agent other than propofol, and 35 (7%) of the 472 intubations were performed without any sedating agent. Endotracheal tube insertion was successful in all 472 patients. Complications of UEI in those patients who received propofol were as follows: desaturation (Sao 2 < 80%) 30 (7%) of the 427, hypotension (systolic blood pressure < 70 mm Hg) 19 (4%) of the 427, difficult intubation (>2 attempts) 44 (10%) of the 427, esophageal intubation 24 (6%) of the 427, aspiration 6 (1%) of the 427, and oropharyngeal injury 4 (1%) of the 427. There were no deaths. Average dose of propofol was 99 mg (standard deviation 7.39) per person. Our results compare favorably with the complication rate of UEI reported in the critical care and anesthesiology literature and indicate that propofol is a useful agent for airway management in the ICU.

Pharmacodynamics of cisatracurium in the intensive care unit: an observational study

BackgroundData from previous studies indicate that optimal conditions for intubation are met 120 seconds after administration of 0.15 mg.kg-1 cisatracurium (ED95 × 3) following the induction of anesthesia. The aim of this study was to compare the doses required for complete paralysis after induction of anesthesia in ICU patients with the dose used in patients undergoing elective surgery.MethodsSeventeen ICU patients undergoing percutaneous tracheostomy and 17 patients undergoing an elective surgical procedure under muscle relaxation were included. In both groups, an initial intravenous bolus of cisatracurium besylate was given at a dose of 0.15 mg.kg-1 followed by repeated boluses of 0.03 mg.kg-1 every four minutes. The objective was to obtain no response to the train-of-four (TOF). The contractile response of the corrugator supercilii muscle was monitored every minute by observing the TOF in response to a peripheral nerve stimulator with a constant current set to 60 mA.ResultsAfter the initial dose of cisatracurium, none of ICU patients (0/17) versus 15/17 of the elective surgery patients were completely paralyzed (P < 0.0001). There was a delay in the onset of neuromuscular blockade among the ICU patients. The cumulative doses of cisatracurium were significantly higher in the ICU group with 38 ± 14 mg (that is, 10 ± 4.7 ED95) versus 11 ± 2 mg (that is, 3 ± 0.3 ED95) in the elective surgery group (P < 0.0001).ConclusionThe dosing of cisatracrurium for ICU patients, which is based on the dose recommended for elective anesthesia, is unsuitable because the onset is too slow. This phenomenon is probably caused by changes in the pharmacodynamics and pharmacokinetics. These data suggest that neuromuscular monitoring should be used in the ICU.

Dose requirements of remifentanil for intubation in nonparalyzed Chinese children

The objective of this study was to determine ED50 and ED95 of remifentanil for intubation combined with propofol in nonparalyzed Chinese children. Forty-seven American Society of Anesthesiologists Class I children aged 4-11 years weighing 14-33.5 kg underwent general anesthesia with 2.5 mg·kg(-1) of intravenous propofol followed by remifentanil in Wenzhou, China. The initial dose of remifentanil was 2.5 μg·kg(-1) injected over 60 s. Intubation was attempted 30 s after the completion of remifentanil injection. Level of difficulty to intubate was graded on a scoring system. If the initial intubation condition was deemed satisfactory, subsequent remifentanil doses were decreased by 0.25 μg·kg(-1). If the intubating condition was deemed unsatisfactory, subsequent remifentanil doses were increased by 0.25 μg·kg(-1). Mean arterial pressure, heart rate, and pulse oximetry were documented before and after induction, immediately after intubation, and 1 min after intubation. The ED50 of remifentanil used to render a satisfactory intubating condition used in combination with 2.5 mg·kg(-1) of propofol in nonparalyzed Chinese children was 2.30 μg·kg(-1) (95% confidence interval: 2.28-2.31 μg·kg(-1)), and the ED95 is 2.75 μg·kg(-1) (95% confidence interval: 2.59-3.35 μg·kg(-1)). These doses were lower than previously reported. When used in combination with 2.5 mg·kg(-1) of intravenous propofol, ED50 and ED95 of remifentanil for adequate intubation in nonparalyzed children were lower than previously reported, at 2.30 and 2.75 μg·kg(-1), respectively.

Paramedic rapid sequence intubation in patients with non-traumatic coma

IntroductionPre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation...

Propofol for pediatric tracheal intubation with deep anesthesia during sevoflurane induction: dosing according to elapsed time for two age groups

Study ObjectiveTo determine, for two different age groups, the effect of duration of sevoflurane administration on the amount of propofol needed when performing tracheal intubation. DesignClassic Dixon’s Up-and-Down sequential method. SettingUniversity based operating rooms. Patients106 ASA physical status 1 and 2 patients aged one to 11 years. InterventionsPatients were allocated to the 1–6 year (≥ 12 and < 72 mos) and 6–11 year (≥ 72 and < 132 mos) age groups. Midazolam 0.5 mg/kg was given orally to the 1–6 year group, and all patients were induced with 8% dialed sevoflurane and 67% nitrous oxide (N2O), with N2O discontinued and sevoflurane dialed to 5% after one minute and 1.5 minutes for the younger and older age groups, respectively. Intravenous access was obtained and propofol was promptly administered. Propofol dose was determined according to age group and whether propofol was given 2–4, 4–6, or 6–8 minutes after the start of sevoflurane induction, with Dixon’s Up and Down Method used separately for each specific age/time group. Tracheal intubation conditions one minute after propofol were evaluated. MeasurementsIsotonic regression determined propofol ED50 estimates for excellent tracheal intubation conditions, and linear regression determined the effect of propofol dose on change in systolic blood pressure (SBP). Main ResultsEstimated propofol ED50 doses for 1–6 year olds, with 95% confidence intervals (CIs), were 1.48 mg/kg (0.80, 2.03), 0.00 mg/kg (0.00, 0.38), and 0.07 mg/kg (0.00, 0.68) in the 2–4, 4–6, and 6–8 minute groups, respectively, with estimated differences between the 2–4 minute group versus the 4–6 and 6–8 minute groups being 1.47 mg/kg (95% CI = 1.04, 2.06) and 1.41 mg/kg (95% CI = 0.74, 2.04), respectively. Estimated propofol ED50 doses for 6–11 year olds, with 95% CIs, were 2.35 mg/kg (1.97, 2.45) and 2.33 mg/kg (1.59, 2.45) in the 2–4 and 4–6 minute groups, respectively. Diminutions in SBP at one minute and two minutes after propofol administration were dose dependent for children 1–6 years of age, decreasing 5.3% and 8.1% for each 1 mg/kg of propofol, respectively. ConclusionThe amount of propofol needed to supplement sevoflurane in children 1–6 years of age can be expected to decrease after 4 minutes of sevoflurane.

Intubation without muscle relaxation for suspension laryngoscopy: a randomized, controlled study.

The objective of the following study is to examine the effectiveness and safety of suspension laryngoscopy under intubation with propofol and remifentanil alone for vocal fold nodule (VFN) excision. A total of 40 patients were equally and randomly assigned to elective VFN excision using suspension laryngoscopy under intubation with propofol and remifentanil alone (Group A) or with supplementary cisatracurium (Group B). Intubation time was significantly longer in Group A than in Group B (300.0 ± 30.0 s vs. 265.2 ± 38.7 s, P = 0.003). The two groups showed similar Cormack-Lehane classifications, intubation conditions and ease of suspension laryngoscopy. Both groups showed favorable cardiopulmonary safety profiles. Post-anesthesia recovery was significantly more rapid in Group A than in Group B, in terms of times to spontaneous breathing return (7.2 ± 1.4 min vs. 10.9 ± 1.6 min, P < 0.001), consciousness return (7.4 ± 1.5 min vs. 12.3 ± 1.8 min, P < 0.001), removal of tracheal intubation (8.1 ± 1.5 min vs. 13.2 ± 1.7 min, P < 0.001) and operating room discharge (12.7 ± 1.4 min vs. 22.1 ± 1.3 min, P < 0.001). Use of propofol and remifentanil alone provides favorable intubation and anesthesia conditions for suspension laryngoscopic VFN excision and accelerates post-anesthesia recovery.

Comparison of intubating conditions and haemodynamic responses during rapid tracheal intubation using either suxamethonium or rocuronium with ephedrine pretreatment

Background: Suxamethonium is considered as the “gold standard” for tracheal intubation. Because of innumerable contraindications for the use of this drug, there is a continuous search for other alternatives. Methods: In a prospective, randomized and double-blind study, we compared the intubating conditions and haemodynamic responses during rapid tracheal intubation using either suxamethonium or rocuronium with ephedrine pretreatment. We recruited 50 patients and allocated them into 2 groups (n= 25 each); Group S: received suxamethonium 1.5 mg/kg and Group R: received rocuronium 0.6 mg/ kg with ephedrine 100 μg/kg pretreatment. All patients were induced with 2 mg/kg propofol and intubation was attempted at 60 seconds. Haemodynamic responses and quality of intubating conditions were assessed. Results: Both groups were comparable in respect to age, sex, weight, Mallampati grade, Cormack Lehane grade and duration of laryngoscopy. Although both groups had clinically acceptable intubating conditions (good and excellent), there were more number of patients with better intubation score in Group S compared to Group R (p = 0.014). Conclusion: Suxamethonium still continues to be the “gold standard” for providing ideal tracheal intubation conditions. However, in conditions where suxamethonium is contraindicated, rocuronium-ephedrine combination can be used as an alternative to intubate the trachea at 60 seconds.

Comparing the effects of three different additional doses of propofol infusion on intubation condition and hemodynamic changes during general anesthesia under elective surgery: A randomized, placebo-controlled, double blind clinical trial.

Background:Laryngoscopy and endotracheal intubation can induce unfavorable hemodynamic changes as propofol itself can induce hypotension. The aim of this study was to compare the effects of three different additional doses of propofol infusion on intubation conditions and hemodynamic changes occurred after intubation.Materials and Methods:This double-blinded prospective study was performed on 140 patients aged 18-60 who received different additional doses of propofol and were randomly allocated into 4 groups as follows: A: Received additional dose of propofol 0.5 mg/kg infused after an initial dose 1.5 mg/kg. B: Received additional dose of propofol 1 mg/kg infused after an initial dose 1 mg/kg. C: Received additional dose of propofol 1.5 mg/kg after an initial dose 1 mg/kg. D: Received propofol 2 mg/kg as a bolus with no additional dose.Results:Intubation conditions were acceptable in 91.4% of Group A patients, 94.2% of Group B patients, 97.1% of Group C patients and 68.5% of Group D patients. There were no significant differences in the mean of heart rate between four groups at any time before and after laryngoscopy. Mean arterial pressure (MAP) 3 min after laryngoscopy was significantly lower in Group D versus Group A (P = 0.015) while MAP was not different at any time between other groups.Conclusion:Infusion of propofol 1.5 mg/kg added to initial bolus dose of propofol 1 mg/kg improves intubation conditions significantly without inducing hemodynamic changes.

A comparison of dexmedetomidine plus ketamine combination with dexmedetomidine alone for awake fiberoptic nasotracheal intubation: A randomized controlled study.

Background and Aims:We designed a study to compare the effectiveness of dexmedetomidine plus ketamine combination with dexmedetomidine alone in search of an ideal sedation regime, which would achieve better intubating conditions, hemodynamic stability, and sedation for awake fiberoptic nasotracheal intubation.Materials and Methods:A total of 60 adult patients of age group 18-60 years with American Society of Anesthesiologists I and II posted for elective surgery under general anesthesia were randomly divided into two groups of 30 each in this prospective randomized controlled double-blinded study. Groups I and II patients received a bolus dose of dexmedetomidine at 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. Upon completion of the dexmedetomidine bolus, Group I patients received 15 mg of ketamine and an infusion of ketamine at 20 mg/h followed by awake fiberoptic nasotracheal intubation, while Group II patients upon completion of dexmedetomidine bolus received plain normal saline instead of ketamine. Hemodynamic variables like heart rate (HR) and mean arterial pressure (MAP), oxygen saturation, electrocardiogram changes, sedation score (modified Observer assessment of alertness/sedation score), intubation score (vocal cord movement and coughing), grimace score, time taken for intubation, amount of lignocaine used were noted during the course of study. Patient satisfaction score and level of recall were assessed during the postoperative visit the next day.Results:Group I patients maintained a stable HR and MAP (<10% fall when compared with the baseline value). Sedation score (3.47 vs. 3.93) and patient satisfaction score were better in Group I patients. There was no significant difference in intubation scores, grimace scores, oxygen saturation and level of recall when compared between the two groups (P > 0.05).Conclusion:The use of dexmedetomidine plus ketamine combination in awake fiberoptic nasotracheal intubation provided better hemodynamic stability and sedation than dexmedetomidine alone.

Effects of pretreatment with different neuromuscular blocking agents on facilitation of intubation with rocuronium: A prospective randomized comparative study.

Background and Aims:Priming principle refers to administration of a small dose of non-depolarising blocker, which when followed by a large intubating dose produces a relatively rapid and profound blockade to ensure suitable conditions for endotracheal intubation. We aimed to compare the effects of rocuronium, vecuronium, and atracurium as “pretreatment” drugs on intubating conditions with rocuronium facilitated endotracheal intubation.Methods:This double-blinded, randomised controlled prospective study was carried out at a tertiary health care hospital on patients undergoing surgical procedures under general anaesthesia. They were randomly allocated into three groups (n = 35) by computer generated randomisation chart to receive either rocuronium (0.06 mg/kg body weight) (Group A); vecuronium (0.01 mg/kg body weight) (Group B) or, atracurium (0.05 mg/kg body weight) (Group C), followed by intubating dose (0.6 mg/kg body weight) of rocuronium. The haemodynamic parameters and intubating conditions were studied and statistically analysed by ANOVA test and Student's t-test as applicable using statistical package for the social sciences 16.0 for windows (SPSS Inc., Chicago, IL, USA).Results:Excellent intubating conditions were noted in maximum number of patients in Group C (97.41%). No significant differences were observed in the systolic blood pressure in all the three groups at all-time intervals. The mean arterial pressure rose significantly from baseline value to maximum, at ‘0’ min in all the groups; however, no significant difference was observed amongst the groups (P > 0.05).Conclusion:Pretreatment with rocuronium bromide can facilitate endotracheal intubation in 60 s irrespective of non-depolarising muscle relaxants used for priming; however, it cannot attenuate haemodynamic changes associated with laryngoscopy and intubation.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

OBJECTIVE:Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation.METHODS:In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis.RESULTS:A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation.CONCLUSION:All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients.

Do we need a protocol for weaning patients from noninvasive ventilation?

Do we need a protocol for weaning patients from noninvasive ventilation?

Techniques of rapid sequence induction and intubation at a university teaching hospital.

Rapid sequence induction and intubation (RSII) is a medical procedure involving a prompt induction of general anesthesia by using cricoid pressure that prevents regurgitation of gastric contents. The factors affecting RSII are prophylaxis for aspiration, preoxygenation, drug and equipment preparation for RSII, ventilation after induction till intubation and patient condition. We sometimes saw difficulties with the practice of this technique in our hospital operation theatres. The aim of this study was to assess the techniques of rapid sequence induction and intubation. Hospital based observational study was conducted with a standardized checklist. All patients who were operated upon under general anesthesia during the study period were included. The techniques of RSII were observed during the induction of anesthesia by trained anesthetists. Altogether 140 patients were included in this study with a response rate of 95.2%. Prophylaxis was not given to 130 patients (92.2%), and appropriate drugs were not used for RSII in 73 patients (52.1%), equipments for difficult intubation in 21 (15%), suction machines with catheter not connected and turned on in 122 (87.1%), ventilation for patients after induction and before intubation in 41 (29.3%), cricoid pressure released before cuff inflation in 12 (12.1%), and difficult intubation in 8 (5.7%), respectively. RSII with cricoid pressure was applied appropriately in 94 (67.1%) patients, but cricoid pressure was not used in 46 (32.9%) patients. The techniques of rapid sequence induction and intubation was low. Training should be given for anesthetists about the techniques of RSII.

Prophylactic effect of ephedrine to reduce hemodynamic changes associated with anesthesia induction with propofol and remifentanil.

Background:One of the complications of anesthesia induction with propofol is a substantial decrease in arterial blood pressure and heart rate (HR), which can be intensified by adding remifentanil. This study aimed to assess the prophylactic effects of two doses of ephedrine to control the hypotension and bradycardia caused by anesthesia induced with propofol and remifentanil.Materials and Methods:A total of 150 patients candidate for short-term minor elective orthopedic and ophthalmic surgery under general anesthesia were randomized to three groups receiving normal saline, low dose ephedrine (0.07 mg/kg) or high dose ephedrine (0.15 mg/kg). Anesthesia was induced in all groups with propofol 2.5 mg/kg and remifentanil 3 μg/kg. No neuromuscular blocking agent was used. Patients’ hemodynamic status was assessed in the following four steps: Immediately before, 2 min after induction of anesthesia, as well as 1 and 5 min after intubation.Results:A total of 143 patients consisting of 46 patients in the low dose ephedrine (0.07 mg/kg) group, 49 patients in the high dose ephedrine (0.15 mg/kg) group and 48 controls completed the trial. In all three groups, after induction of anesthesia, significant decreases occurred in the mean systolic, diastolic and mean arterial pressures, as well as in the mean HR. This decline was highest in the control group and lowest in the high dose ephedrine (0.15 mg/kg) group.Conclusion:Our findings suggest that the administration of high dose ephedrine (0.15 mg/kg) may have a significant effect in preventing hypotension and bradycardia after anesthesia induction with propofol and remifentanil.

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Introduction: Mucus plugging of the upper airway leading to atelectasis is a common problem in the critical care setting due to ineffective cough, excessive secretions, endotracheal intubation, and other such conditions faced by critically-ill patients. Since the advent of fiberoptic technology, fle

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Introduction: A variety of medications are used to facilitate tracheal intubation (TI) in critically ill children in pediatric ICUs (PICUs), with the goal of achieving a level of sedation that will generate favorable intubation conditions. Options for sedation include narcotics, benzodiazepines, ketamine, propofol, and etomidate; additionally, neuromuscular blockade may be employed. Often specific medications are selected for at risk patients to minimize adverse TI Associated Events (TIAE's). Traditionally, vagolytics (atropine/glycopyrrolate) are used as adjunctive TI medications to prevent bradycardia during TI induction. In addition, ketamine is often chosen to prevent medication-induced hypotension during TI induction in critically ill children. However, the data to support these practices are limited. We hypothesize: 1. In patients at risk for bradycardia, the use of a vagolytic agent as part of the TI induction regimen will be associated with a lower incidence of bradycardia, when compared to regimens without vagolytics; 2. In patients at risk for hypotension, the administration of ketamine as part of the TI induction regimen will be associated with a lower incidence of hypotension during TI, when compared to regimens without ketamine. Methods: With IRB approval, consecutive TI quality improvement data from 19 PICUs were prospectively collected from 7/2010 to 12/2012 into the National Emergency Airway Registry for Children (NEAR4KIDS) with > 95% compliance at each site. Adverse TIAEs were a priori defined with consensus-based operational definitions. These include physiological responses such as bradycardia, hypotension or cardiac arrest with/without return of spontaneous circulation. Fisher's exact test was used as univariate analysis with p<0.05 considered significant. Multivariate logistic regression was used to adjust for patient-level confounders. Results: There were 3382 primary TIs reported across the 19 centers. The median patient age was 1 year [IQR:0-7]. Fentanyl and midazolam were the most commonly used TI induction medications. Overall, fentanyl was used in 63% of TIs (22-90% at each site), and midazolam was used in 58% of TIs (7-82% at each site). Neuromuscular blockers were used in 3111 (92%, 75-95% at each site). Rocuronium was the most commonly used paralytic (69% of all neuromuscular blockers). Propofol was used in 15% of TI's (range 2-84%). Both Etomidate (1.7 %) and succinylcholine (0.74%) were used very infrequently. Vagolytics were used in 37% of TIs, more commonly for infants <1yr (51%) vs. children > 1yr (28%, p<0.001). Contrary to our hypothesis, vagolytic use was associated with a higher incidence of bradycardia (2.4% vs.0.9%, p=0.002), even after adjusting for diagnostic category (cardiac condition) and age (OR 2.6, 95% CI 1.46-4.71, p<0.001). Ketamine was used in 27% of TIs, more often for patients whose indication for TI was unstable hemodynamics (39% vs. 25%, p<0.001). Ketamine use was not associated with significantly lower incidence of hypotension when compared with other regimens without ketamine (incidence of new hypotension: 8% vs. 14%, p=0.1). Conclusions: A variety of TI induction medications are used in critically ill children. For children intubated in the PICU, 1) Vagolytic use was common but NOT associated with lower incidence of bradycardia even when controlling for diagnosis and age. 2) Ketamine was used more commonly than other sedatives for patients with hemodynamic instability, but was NOT associated with reduced incidence of new hypotension.

Comparison of the effects of remifentanil and remifentanil plus lidocaine on intubation conditions in intellectually disabled patients

Background and objectivesThis is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. MethodsFifty intellectually disabled, American Society of Anesthesiologists I–II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2μgkg−1 remifentanil (Group 1, n=25) or a combination of 2μgkg−1 remifentanil and 1mgkg−1 lidocaine (Group 2, n=25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5min after intubation. ResultsAcceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p=0.000) ConclusionBy the addition of 2μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1mg/kg lidocaine to 2μg/kg remifentanil does not provide any additional improvement in the intubation parameters.

Comparison of sedation scores and propofol induction doses in dogs after intramuscular premedication with butorphanol and either dexmedetomidine or medetomidine

ObjectiveTo compare sedation scores and propofol induction doses in dogs receiving either dexmedetomidine or medetomidine, both with butorphanol intramuscularly (IM) prior to general anaesthesia. Study designProspective, ‘blinded’, randomized, clinical study. AnimalsFifty client‐owned dogs scheduled for elective diagnostic imaging procedures. MethodsDogs were allocated to receive butorphanol 0.1 mg kg−1 with either medetomidine (group M) 0.01 mg kg−1 or dexmedetomidine (group D) 0.005 mg kg−1 IM. Sedation was scored before and 20 minutes after pre‐anaesthetic medication using a composite simple descriptive sedation score giving a score of 0 to 15 (0 = no sedation; 15 = profound sedation). Forty‐five minutes after pre‐anaesthetic medication, propofol was administered in increments of 0.5 mg kg−1 over 15 seconds until tracheal intubation was possible. The time required to check intubation conditions between each propofol aliquot was 15 seconds. Total propofol dose required to perform tracheal intubation and the number of dogs achieving a clinically desired sedation score of ≥9/15 was recorded in each group. Sedation score and propofol dose were compared using the Mann‐Whitney U‐test. Results are reported as median (range). Statistical significance was set at p < 0.05. ResultsThe sedation score 20 minutes after pre‐anaesthetic medication was significantly higher in group M [11 (2–14)] than in group D [7 (0–14)]. There was no significant difference between propofol dose requirements in group M [1.5 (1–2.5) mg kg−1] or D at [1.5 (1–3) mg kg−1]. Significantly more dogs in group M achieved a sedation score of ≥9/15 than in group D. Conclusions and clinical relevanceCombined IM with butorphanol, medetomidine 0.01 mg kg−1 produced effective sedation more frequently than dexmedetomidine 0.005 mg kg−1 in dogs undergoing sedation prior to anaesthesia for elective procedures but this did not affect the propofol dose required for induction of anaesthesia significantly.

Comparison of dexmedetomidine and sufentanil for conscious sedation in patients undergoing awake fibreoptic nasotracheal intubation: a prospective, randomised and controlled clinical trial

Fibreoptic intubation is a valuable technique for difficult airway management in which conscious sedation is paramount. To investigate the efficacy and safety of dexmedetomidine (DEX) and sufentanil (SUF) for conscious sedation during awake nasotracheal intubation under vision by a fibreoptic bronchoscope. Forty patients with anticipated difficult airways of American Society of Anesthesiologists I-II scheduled for awake fibreoptic nasotracheal intubation were randomised into two groups each containing 20 subjects. DEX group received DEX at a dose of 1.0 μg/kg over 10 min followed by a continuous infusion of 0.5 μg/kg per hour, while SUF group received SUF target controlled infusion in which the target plasma concentration was 0.3 ng/mL. The nasotracheal intubation conditions and the tolerance to nasotracheal intubation were observed; the occurrence of adverse events including hypertension, bradycardia and respiratory depression during nasotracheal intubation and post-surgical throat pain and hoarseness, and post-surgical memory score were recorded. Better nasotracheal intubation conditions and higher tolerance to intubation were observed in DEX group than those in SUF group (P < 0.05). The incidence rates of hypertension, respiratory depression during intubation and throat pain after surgery were lower in DEX group than those in SUF group; however, the incidence of bradycardia was higher in DEX group than that in SUF group. DEX provides better nasotracheal intubation conditions, improves patients' tolerance to intubation and leads to lower occurrence of hypertension, respiratory depression and throat pain and post-surgical memory score for sedation during awake fibreoptic nasotracheal intubation.

Tracheal intubation in intellectually disabled patients: Clinical usefulness of remifentanil and sevoflurane without a muscle relaxant

To compare two remifentanil doses (1 µg/kg and 2 µg/kg) in order to determine the preferred dose in intellectually disabled patients undergoing day care dental surgery under sevoflurane-induced general anaesthesia. Patients were randomly assigned to receive either 1 µg/kg (group 1) or 2 µg/kg (group 2) remifentanil; both groups received 8% sevoflurane anaesthesia induction. All other conditions were identical in both groups. Heart rate (HR), mean arterial pressure (MAP) and intubation conditions were assessed. A total of 27/30 (90.0%) patients in group 1 and 29/30 patients (96.7%) in group 2 had acceptable intubation conditions. Remifentanil administration resulted in significant reductions in HR compared with baseline levels, in both groups. There were no significant between-group differences in HR at any timepoint. MAP decreased significantly compared with baseline in group 2 only. Successful tracheal intubation in intellectually disabled patients can be accomplished with a combination of 1 µg/kg or 2 µg/kg remifentanil and 8% sevoflurane anaesthesia induction, without the requirement for neuromuscular blocking drugs.