Intubation Conditions Research Articles

Traçabilité de la gestion de l’utilisation des curares dans le dossier d’anesthésie en chirurgie viscérale : une étude observationnelle et multicentrique

Objectives To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes. Type of study Prospective, observational and multicenter. Patients and methods A single operator analysed 1453 files proposed by nine anaesthetists’ teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied. Results Items related to laryngoscopy and intubation conditions were observed in 43% (0–95) [general average (intercentres min–max)] and in 11% (0–97) of the files, respectively. At least one level of paralysis was reported in 23% (0–96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4–96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12–89) of the notes. Adductor pollicis was concerned for 30% (1–89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3–19) of the documents. Pharmacological reversal was noted for 25% (4–67) of the patients; the assessment of the effects so produced was reported in 8% (0–58). Conclusion In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline – defining the criteria for producing a good documentation of the muscle relaxant use – becomes necessary to secure these practices for all physicians using muscle relaxants.

Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS

Objectives For experienced personnel endotracheal intubation (ETI) is the gold standard to secure the airway in prehospital emergency medicine. Nevertheless, substantial procedural difficulties have been reported with a significant potential to compromise patients’ outcomes. Systematic evaluation of ETI in paramedic operated emergency medical systems (EMS) and in a mixed physician/anaesthetic nurse EMS showed divergent results. In our study we systematically assessed factors associated with difficult ETI in an EMS exclusively operating with physicians. Methods Over a 1-year period we prospectively collected data on the specific conditions of all ETIs of two physician staffed EMS vehicles. Difficult ETI was defined by more than 3 attempts or a difficult visualisation of the larynx (Cormack and Lehane grade 3, or worse). For each patient ETI conditions, biophysical characteristics and factors of the surrounding scene were assessed. Additionally, physicians were asked whether they had expected difficult ETI in advance. Results Out of 3979 treated patients 305 (7.7%) received ETI. For 276 patients complete data sets were available. The incidence of difficult ETI was 13.0%. In 4 cases (1.4%) ETI was impossible, but no patient was unable to be ventilated sufficiently. Predicting conditions for difficult intubation were limited surrounding space on scene ( p < 0.01), short neck ( p < 0.01), obesity ( p < 0.01), face and neck injuries ( p < 0.01), mouth opening < 3 cm ( p < 0.01) and known ankylosing spondylitis ( p < 0.01). ETI on the floor or with C-spine immobilisation in situ were of no significant influence. The incidence of unexpected difficult ETI was 5.0%. Conclusions In a physician staffed EMS difficult prehospital ETI occurred in 13% of cases. Predisposing factors were limited surrounding space on scene and certain biophysical conditions of the patient (short neck, obesity, face and neck injuries, and anatomical restrictions). Unexpected difficult ETI occurred in 5% of the cases.

Effectiveness of sevoflurane or propofol combined with remifentanil for intubation without muscle relaxants

Objectives: We aimed to investigate the reliability of the hypothesis that whether sevoflurane-remifentanil could offer equivalent intubation conditions with propofol-remifentanil in the absence of muscle relaxants. Materials and methods: Total of 80 patients of ASA grades I and II scheduled for elective surgery were randomly allocated into two groups. Patients in group I received an infusion of remifentanil 1 mcg/kg/min and inhalation of sevoflurane 8% until the Bispectral index (BIS) being less than 60. Patients in group II received a co-infusion of remifentanil and propofol 1 mg/kg/h until BIS is <60. Intubation was attempted when BIS is <60. Intubation conditions were assessed as optimal, good, marginal, and poor using vocal cord opening, jaw relaxation and patient's movements. The heart rate and mean arterial blood pressure (ABP) were recorded before and during the induction, and thereafter, 1, 2 and 5 minutes following intubation. The time for BIS to be <60 was recorded. Results: Optimal intubation conditions were achieved more often in group II than in group I (90% versus 45%, p=0.002). The ratio of patients showing optimal or good intubating conditions was 80% in group I and 100% in group II (p=0.035). Time required for BIS was shorter in group II than in group I (47.1±27.2 sec vs. 111.9±60.6 sec, p<0.001). In both groups, there was a decrease in heart rate and mean ABP compared to baseline. Conclusion: Under BIS monitorization, propofol-remifentanil combination offered better intubation conditions and shorter anesthesia induction period compared with sevoflurane-remifentanil.

Intravenous lidocaine has no impact on rocuronium-induced neuromuscular block but improves intubation conditions: Randomised study

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Local and Regional Anaesthesia

Factors affecting the intubation conditions provided by suxamethonium: A meta-regression analysis

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Local and Regional Anaesthesia

Comparison of pharmacodynamics and circulatory function of domestic and imported rocuronium

Objective To compare the phaimacodynamics and circulatory function of domestic and imported rocuronium. Methods This is a five center study of rocuronium. Two hundred and ten ASA Ⅰ or Ⅱ patients aged 18-65 yr undergoing elective surgery under general anesthesia were randomly divided into 2 groups (n = 105 each): domestic rocuronium group (group Ⅰ ) and imported rocuronium group (group Ⅱ ) . Anesthesia was induced and maintained with TCI of propofol (target plasma concentration = 3 mg/L) and remifentanil (target effect-site concentration = 2-4 μg/L) . Tracheal intubation was facilitated with intravenous rocuronium 0.6 mg/kg. The N-M function was assessed by accelerography (TOF-Watch(R) SX, Organon, Netherlands) using TOF stimulation of ulnar nerve. Onset time, clinical duration, 75% recovery time,recovery indexes, the extent of maximal NM blockade and intubation conditions (ease of laryngoscopy, position of vocal cords and airway reaction) were monitored and recorded. BP and HR were also recorded. Results There were no significant differences in the onset time, clinical duration, recovery indexes, the extent of maximal N-M blockade, the intubation conditions, BP, HR and adverse reactions between groups Ⅰ and Ⅱ ( P ＞ 0.05) . The 75% recovery time was significantly longer in group Ⅱ than in group Ⅰ (P ＜ 0.05＝. Conclusion The pharmacodynamics of domestic and imported rocuronium is comparable. The two drugs have no adverse effect on the circulatory function. Key words: Androstanols; Neuromuscular blockade; Dose-response relationship, drug; Blood circulation

Impact of the use of an automated chest-compression device on airway management during out-of-hospital cardiopulmonary resuscitation: The PLAINT study

Introduction Automated chest-compression devices (ACCDs) have recently been proposed in the management of out-of-hospital cardiac arrest (cardiopulmonary resuscitation, CPR). During CPR, it is still unknown whether the ACCD or intubation is to be first implemented. Knowing the impact of an ACCD on intubation conditions could strongly contribute to determine the best sequence. Therefore, we undertook an experimental study on intubation conditions on a mannequin with or without the use of an ACCD. Methods Emergency physicians and nurses experienced in the field of cardiac-arrest management (including orotracheal intubation) were randomly assigned to three scenarios to intubate a mannequin: patient lying on the floor without an ACCD (group 1), patient lying on the floor with the ACCD switched off (group 2) or switched on (group 3). The primary end point was intubation time. Estimated intubation difficulty evaluated on a visual analogue scale (VAS), ranging from 0 (easy) to 100 (impossible), number of attempts, Cormack grade and dental traumatisms associated with the intubation procedure were secondary end points. Results A total of 44 operators performed the intubation. Times to intubation were 14 (11–22), 15 (10–21) and 18 (15–27) s for groups 1, 2 and 3, respectively. The VAS difficulties were 12 (5–25), 15 (10–25) and 15 (5–21), respectively. Intubation conditions did not differ between the ‘without an ACCD group’ and the ‘switched-off ACCD group’. In the ‘switched-on ACCD group’, time to intubation was significantly increased in comparison with groups 1 and 2 with a median difference of 4 (1–10) and 3 (0–7) s, respectively. The VAS difficulty was also significantly increased in the ‘switched-on ACCD group’. Other secondary end-point criteria did not differ between the three groups. Conclusion Due to the major role of compression during CPR, we suggest that the ACCD should not be systematically switched off for routine intubation.

Effects of vecuronium priming and ephedrine pretreatment on the onset time of neuromuscular blockade of vecuronium during induction period

Objective To evaluate the effect of vecuronium priming, ephedrine pretreatment, and vecuronium priming combined with ephedrine pretreatment on the onset time of neuromuscular blockade of vecuronium, intubation conditions and their hemodynamic effects during induction period. Methods Forty-eight adult patients with ASA grade Ⅰ or Ⅱ , scheduled for elective surgery were randomly allocated to four groups with 12 cases in each. Just 3 min before induction, the patients were injected with ephedrine 70 μg/kg and vecuronium priming 0.01 mg/kg in group Ⅰ , vecuronium 0.01 mg/kg in group Ⅱ , ephedrine 70 μg/kg in groupⅢ, and normal saline 0.5 ml in group Ⅳ. Followed by a four min priming or/and pretreatment interval, the intubation dose of vecuronium was injected (vecuronium 0.09 mg/kg in group Ⅰ and group Ⅱ , vecuronium 0.1 mg/kg in group Ⅲ and Ⅳ ). The neuromuscular block was monitor by acceleromyography (TOF Watch SX, Organon) using train of four stimulation (TOF) every 15 s.Endotracheal intubation was performed by a blinded investigator in 2 min. Time to maximal twitch depression was recorded, Intubation conditions were assessed, heart rate and mean blood pressure were observed and recorded as well right before the induction, 1 min after the induction and every minute after endotracheal intubation for 5 min. Results The onset times in group Ⅰ , Ⅱ , Ⅲ and Ⅳwere (99±13), (131±24), (143±20) and (185±26) s, respectively. The onset time of vecuronium in group Ⅰ , Ⅱ and Ⅲ was significantly shorter than that in group Ⅳ (P＜0.001). The onset time of vecuronium in group Ⅰ was faster than that in group Ⅱ and group Ⅲ (P＜0.005). The intubation conditions were better in group Ⅰ , Ⅱ and Ⅲ than those in groupⅣ.There were no significant change in mean blood pressure during the induction in all patients, but heart rates in group Ⅰ , Ⅲ (both with ephedrine pretreatment) were much higher( P＜0.05 ). Conclusion Either vecuronium priming or ephedrine pretreatment can shorten the onset time of vecuronium. The combination of vecuronium priming with ephedrine pretreatment accelerates the onset of vecuronium; In combination with ephedrine, it has no effect on hypotension induced by propofol injection. Key words: Vecuronium; Ephedrine; The onset time; Hemodynamics; The intubating conditions

Remifentanil as single agent to facilitate awake fibreoptic intubation in the absence of premedication*

Remifentanil is increasingly being used as the primary agent to provide sedation during awake fibreoptic nasal intubation. In this observational study, we aimed to determine the optimal effect site concentration of remifentanil, using a target controlled infusion based on the Minto pharmacological model, to provide optimal safe intubation conditions without the use of other sedatives/premedication and/or spray-as-you-go local anaesthesia. Twenty patients with anticipated difficult airway participated in the study. Good intubating conditions were achieved in all patients with mean (SD) effect site concentration of 6.3 (3.87) ng.ml(-1) of remifentanil recorded at nasal endoscopy and 8.06 (3.52) ng.ml(-1) during tracheal intubation. No serious adverse event occurred during any of these procedures. These preliminary findings suggest that this is a feasible and safe technique for awake fibreoptic nasal intubation.

Optimum Bolus Dose of Propofol for Tracheal Intubation during Sevoflurane Induction without Neuromuscular Blockade in Children

The purpose of this study was to determine the optimum bolus dose of propofol required to provide excellent conditions for tracheal intubation following inhalational induction of anaesthesia using 5% sevoflurane without neuromuscular blockade. Twenty-eight children, aged three to seven years, requiring anaesthesia for short duration surgery were recruited. Two minutes after beginning the inhalational induction with 5% sevoflurane and 60% nitrous oxide, a predetermined dose of propofol was injected over 10 seconds. Propofol dose was determined using the Dixon's up-and-down method, starting from 3 mg/kg (0.5 mg/kg as a step size). Laryngoscopy was performed 50 seconds after propofol injection. The optimum dose of propofol required for excellent intubating conditions was 1.39±0.37 mg/kg in 50% of children during inhalation induction using 5% sevoflurane and 60% nitrous oxide in the absence of neuromuscular blocking agents. From probit analysis, the 95% effective dose of propofol was 2.33 mg/kg (95% confidence interval 1.78 to 6.21 mg/kg).

CobraPLUS and Cookgas air-Q versus Fastrach for blind endotracheal intubation: a randomised controlled trial

CobraPLUS and Cookgas air-Q are supraglottic airways expected to allow safe ventilation as well as reliable blind intubation. In a prospective, controlled trial, we hypothesised that quality of ventilation and success rate of blind endotracheal intubation of these new devices would be superior to the Fastrach intubating laryngeal mask airway (ILMA). When blind intubation failed the quality of fibrescope-guided intubation was investigated. To allow identification of those patients in whom blind intubation would be difficult, we investigated the predictive value of currently used predictors for ease of endotracheal intubation. One hundred and eighty adult patients with documented BMI, Mallampati score, Cormack-Lehane classification, interincisor gap and thyromental distance were randomised into three groups according to the device used. Ventilation conditions were rated as excellent, good or difficult. When blind intubation failed, fibrescope-guided intubation conditions were rated as well. Statistical analysis was performed by a χ-test. The quality of ventilation was excellent for all devices. Three patients in the CobraPLUS group and two patients in the ILMA and the Cookgas groups needed a slight reposition. Blind intubation through the CPLA was successful in 47%, through the Cookgas in 57%, whereas the Fastrach group had a success rate of 95%. Fibreoptic intubation was possible in all but one patient. None of the registered scores and measures allowed prediction of difficult blind intubation. All devices appeared to be safe airways. The Fastrach ILMA proved to be a reliable facilitator for blind intubation. CobraPLUS and Cookgas air-Q allowed an easy fibrescopic intubation. Failed blind intubations could not be predicted by the used parameters.

The effect of ketamine on tracheal intubating conditions without neuromuscular blockade during sevoflurane induction in children

The purpose of this study was to investigate the effect of ketamine on intubating conditions for tracheal intubation during anesthesia induction with sevoflurane and alfentanil in pediatric patients. After obtaining parental consents, 50 children, aged 3-10years, were randomly allocated into two groups to receive either i.v. ketamine 0.5mg/kg (ketamine group, n=25) or i.v. saline 5ml (control saline group, n = 25). One minute after injection of the study drug (ketamine or saline), anesthesia was induced with 5% sevoflurane, followed by injection of alfentanil 10μg/kg 1min later. The trachea was intubated 4min after inhalational induction of anesthesia. Acceptable intubation was defined as excellent or good intubating conditions. Mean arterial pressure (MAP) and heart rate (HR) were recorded during the induction period. The percentage of patients with acceptable intubating conditions was higher in the ketamine group (87%) than in the control group (52%) (P=0.0129). MAP before intubation was significantly lower in the control group than in the ketamine group (P=0.001). This study demonstrated that administration of ketamine 0.5mg/kg could improve intubating conditions for tracheal intubation without neuromuscular blockade and preserve hemodynamic stability during sevoflurane inhalation induction with alfentanil in children.

Propofol versus midazolam for intubating preterm neonates: a randomized controlled trial

The ideal combination of premedication for neonatal tracheal intubation has not been established. The aim of this preliminary study was to compare the intubation conditions between propofol and midazolam as premedication for tracheal intubation in neonates. A double-blinded, randomized, controlled trial was performed, and 20 preterm neonates (28 to 34 week) underwent tracheal intubation following the use of remifentanil associated to either propofol (n = 10) or midazolam (n = 10). Intubation conditions were scored according to a four-point scale. According to the main outcome measured (identification of a 50% difference in the intubation conditions), there were no differences regarding the number of attempts and the overall intubation conditions among the groups (P = 1.00). Both combinations of premedications have no differences regarding the quality of intubation, which could be of clinical interest. Besides midazolam, propofol could be a valid alternative as hypnotic for premedication for endotracheal intubation in neonates.

Efficacy of different doses of dexmedetomidine for conscious blind nasotracheal intubation

Objective To investigate the effect of different doses of dexmedetomidine for conscious blind nasotracheal intubation. Methods Fifty-one ASA?～? patients undergoing general anesthesia for elective surgery were randomly divided into 3 groups.The type of anesthesia for tracheal intubation (n = 17 each ): group ? received surface anesthesia only; group ? and ? received dexmedetomidine 0.5 or 1.0 礸/kg on top of surface anesthesia. All patients received surface anesthesia of nasal cavity, pharynx and larynx, trachea with 1% tetracaine. In group ? and group ? Dexmedetomidine 燞 ydrohloride 營 njection (batch number 10061434, approved number H20090248, produced by Jiangsu HengRui pharmaceutical Co., LTD) was diluted reach to 4 μ g/ml with the 0.9% sodium chloride solution. Then Dexmedetomidine 0.5 or 1.0 礸/kg Ⅳ 15 min. 1 min later conscious blind nasotracheal intubation was operated. MAP, HR and SpO2 were continuously monitored and recorded before anesthesia (T0), before trachea cannula (T1), when tracheal tube was inserted into nasal (T2) and advanced through vocal cords into trachea (T3). Responses like nausea,coughing and restlessness were also recorded. The patient 抯 awareness of the intubation was noted after operation. Results MAP and HR were significantly increased at T2 and T3, compared with them at T0 in group ?(P＜ 0.05). MAP was significantly decreased at T1, compared with it at T0 (P＜ 0.05); while MAP and HR were significantly increased at T3, compared with then at T0 in group Ⅱ (P＜ 0.05).MAP was significantly decreased at T1 、 T2and T3, compared with it at T0 (P＜ 0.05);and HR was significantly decreased at T1,compared with it at T0 (P＜ 0.05) in group ?. MAP and HR were significantly increased at T1、 T2 and T3 in group ?, compared with them in group ? and ? (P＜ 0.01). SpO2 was significantly decreased at T3in group ?,compared with it in group ? and ? (P＜ 0.01). MAP was significantly decreased at T1 、T2and T3 in group ?,compared with it in group ? (P＜ 0.05). HR was significantly decreased at T2and T3 in group ? ,compared with it in group ? (P＜ 0.05). The incidence of coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.05). The incidence of nausea coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.01). The incidence of nausea, coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.05). Conclusion Dexmedetomidine 1.0 礸/kg given via Ⅳ slowly on top of surface anesthesia with 1% tetracaine can provide a good intubation condition with less intubation response for conscious blind nasotracheal intubation. It抯 safe and effective. Key words: Dexmedetomidine; Conscious blind nasotracheal intubation; Conscious sedation

Tracheal intubation for cesarean section without muscle relaxant: An alternative for rapid tracheal intubation with no adverse neonatal effect

BackgroundDifficult tracheal intubation following induction of general anaesthesia for caesarean section is a cause of morbidity and mortality. Till today, succinyl choline is the relaxant of first choice for endo-tracheal intubation However, its use is associated with marked muscle fasciculations and intense muscle pains on the day after the operation especially in young patients. Tracheal intubation may be accomplished without a muscle relaxant. In this study, we evaluated in double-blinded, prospective, randomized intubation conditions for cesarean section with fentanyl without muscle relaxant administration to obtain clinically acceptable intubation conditions and cardiovascular responses.MethodsAfter the gaining of ethical approval, 100 parturients scheduled for elective cesarean delivery were randomly allocated to receive both fentanyl 2 μg/kg and propofol 2 mg/kg in group F, propofol 2 mg/kg and succinyl choline 1 mg/kg in group S. Tracheal intubation was graded by the anesthesiologist performing the intubation who was blinded to induction agents.ResultsOverall intubating conditions were regarded as acceptable in 90%, and 94% of patients in groups F and S, respectively. Apgar score and blood gases of babies were not different between two groups.ConclusionThe results suggested that healthy pre-medicated women with favorable airway anatomy who are scheduled for cesarean section can be reliably trachealy intubated 90 s after co-administration of fentanyl 2 μg/kg and propofol 2 mg/kg with satisfactory fetal outcome.

Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: a prospective, randomized controlled trial

IntroductionSuccinylcholine and rocuronium are widely used to facilitate rapid sequence induction (RSI) intubation in intensive care. Concerns relate to the side effects of succinylcholine and to slower onset and inferior intubation conditions associated with rocuronium. So far, succinylcholine and rocuronium have not been compared in an adequately powered randomized trial in intensive care. Accordingly, the aim of the present study was to compare the incidence of hypoxemia after rocuronium or succinylcholine in critically ill patients requiring an emergent RSI.MethodsThis was a prospective randomized controlled single-blind trial conducted from 2006 to 2010 at the University Hospital of Basel. Participants were 401 critically ill patients requiring emergent RSI. Patients were randomized to receive 1 mg/kg succinylcholine or 0.6 mg/kg rocuronium for neuromuscular blockade. The primary outcome was the incidence of oxygen desaturations defined as a decrease in oxygen saturation ≥ 5%, assessed by continuous pulse oxymetry, at any time between the start of the induction sequence and two minutes after the completion of the intubation. A severe oxygen desaturation was defined as a decrease in oxygen saturation ≥ 5% leading to a saturation value of ≤ 80%.ResultsThere was no difference between succinylcholine and rocuronium regarding oxygen desaturations (succinylcholine 73/196; rocuronium 66/195; P = 0.67); severe oxygen desaturations (succinylcholine 20/196; rocuronium 20/195; P = 1.0); and extent of oxygen desaturations (succinylcholine -14 ± 12%; rocuronium -16 ± 13%; P = 0.77). The duration of the intubation sequence was shorter after succinycholine than after rocuronium (81 ± 38 sec versus 95 ± 48 sec; P = 0.002). Intubation conditions (succinylcholine 8.3 ± 0.8; rocuronium 8.2 ± 0.9; P = 0.7) and failed first intubation attempts (succinylcholine 32/200; rocuronium 36/201; P = 1.0) did not differ between the groups.ConclusionsIn critically ill patients undergoing emergent RSI, incidence and severity of oxygen desaturations, the quality of intubation conditions, and incidence of failed intubation attempts did not differ between succinylcholine and rocuronium.Trial RegistrationClinicalTrials.gov, number NCT00355368.

Use of remifentanil and alfentanil in endotracheal intubation: a comparative study.

Background:Opioids, such as alfentanil, are used to facilitate endotracheal intubation without the use of neuromuscular blocking agents in patients undergoing elective surgery.Objectives:The goal of this study was to evaluate the endotracheal intubation conditions when remifentanil or alfentanil was used with propofol without the application of neuromuscular blocking agents.Patients and Methods:One hundred American Society of Anesthesiologists (ASA) grade I patients scheduled for elective surgery were enrolled in this prospective, randomized, triple-blinded study. The patients were randomized to group A (alfentanil) or R (remifentanil). In group A, alfentanil (50 mcg/kg) was intravenously injected over 10 seconds, and after 45 seconds or at the occurrence of apnea, propofol (2 mg/kg) was intravenously injected over 5 seconds. Thirty seconds after the administration of propofol, laryngoscopy and endotracheal intubation were attempted. In group R, remifentanil (5 mcg/kg) was administered instead of alfentanil. Intubation conditions, including ease of laryngoscopy, patency of the vocal cords, jaw relaxation, limb movement (1-4 score), and also, demographic data were evaluated.Results:There were no demographic data differences between groups (age, weight, and sex). Further, laryngoscopy, jaw relaxation, and limb movement scores were similar in the R and A groups and there were no significant differences, but vocal cords were significantly more patent in group R than those in group A (P = 0. 028).Conclusions:The results of this study showed that remifentanil, similar to alfentanil, provided excellent conditions for endotracheal intubation when used with propofol for the induction of anesthesia; however, remifentanil improved the patency of the vocal cords to a greater extent than alfentanil.

The optimal succinylcholine dose for intubating emergency patients: retrospective comparative study

Background: Succinylcholine remains the drug of choice for satisfactory rapid-sequence tracheal intubation. It is not clear from the literature why the 1 mg/kg dose of succinylcholine has been traditionally used. The effective dose (ED95) of succinylcholine is less than 0.3 mg/kg. The dose of 1 mg/kg represents 3.5 to 4 times the ED95.Objectives: To compare the effect of the traditionally used 1 mg/kg of succinylcholine with lower doses of 0.6 mg/kg and 0.45 mg/kg on intubation condition regarding the onset time, duration of action, duration of abdominal fasciculation, and the intubation grading.Methods: This retrospective comparative study was carried into three groups of ASA III & IV (American Society of Anesthesiologist's Physical Status III and IV) non-prepared emergency patients who were intubated at emergency department of Hamad General Hospital, Doha, Qatar during January 1st 2007 to August 31, 2010. The Institutional Research Board (IRB) approval was obtained. This study was limited to 88 patients who received fentanyl 1 µg/kg followed by etomidate 0.3 mg/kg intravenously as induction agents and succinylcholine as a muscle relaxant agent in doses of 0.45 mg/kg, 0.6 mg/kg, or 1 mg/kg.Results: Increasing the succinylcholine dosage shortened the onset time, prolonged the duration of action, and prolonged the duration of abdominal fasciculation significantly (P<.001). Tracheal intubation was 100% successful in the three groups of patients.Conclusion: Succinylcholine dose of 0.45 mg/kg provides an optimal intubation condition in ASA III & IV emergency non-prepared patients. Duration of action of succinylcholine is dose dependent; reducing the dose allows a more rapid return of spontaneous respiration and airway reflexes.

Failed rapid sequence induction in an achondroplastic dwarf

Achondroplasia, a common cause of short limbed type of dwarfism is due to quantitative decrease in rate of endochondral ossification. This abnormal bone growth leads to disproportionate body and head structure, thus placing them under high risk for anaesthetic management. There is paucity in literatures, regarding appropriate drug dosage selection in these patients. Use of drugs as per standard dosage recommendations based on body weight or body surface area, may not be adequate in these patients owing to discrepancies in overall body weight and lean body weight, especially during rapid sequence induction. Here, we report a case of failed rapid sequence induction due to abnormal response to administered drugs in an adult achondroplastic dwarf. Standard doses of thiopentone and rocuronium had to be repeated thrice to achieve adequate conditions for intubation.

Bispectral Index Monitoring (BIS) as a Guide for Intubation Without Neuromuscular Blockade in Office‐Based Pediatric General Anesthesia: A Retrospective Evaluation

The Bispectral Index System is a useful guide for timing of adequate intubation conditions in office-based pediatric general anesthesia without neuromuscular blockade. As the number of cases in the office-based setting increase, many clinicians opt to intubate patients without neuromuscular blockade to avoid airway complications associated with skeletal muscle relaxation. Conventionally, this technique is conducted using the traditional monitoring criteria of vital signs, end-tidal inhalation agents, as well as anesthesiologist timing and knowledge of the pharmacodynamics of the anesthetic agent to help determine the proper depth of anesthesia for adequate intubating conditions. This study retrospectively assesses the use of the Bispectral Index System (BIS) as a guide for timing of nonparalytic tracheal intubation in pediatric office-based general anesthesia. Anesthetic records for 168 children, American Society of Anesthesiology physical status I and II, and ranging in age from 18 months to 17 years were retrospectively analyzed. Intubation outcomes were based on 6 preset criteria to reflect the adequacy of the technique. The mean BIS value during the time of intubation was 34.7. There were no complications encountered. A BIS mean value of 34.7 provided adequate intubation conditions without muscle relaxation in office-based pediatric anesthesia without complications.