General Anesthesia Intubation Research Articles

Comparative study of intubating condition between rocuronium and vecuronium for endotracheal intubation in general anesthesia

Comparative study of intubating condition between rocuronium and vecuronium for endotracheal intubation in general anesthesia

Melatonin versus gabapentin as premedication for anxiolysis and attenuation of hemodynamic response to laryngoscopy and intubation in general anesthesia

Melatonin versus gabapentin as premedication for anxiolysis and attenuation of hemodynamic response to laryngoscopy and intubation in general anesthesia

Randomised control trial of bispectral index with propofol induction 2 mg/kg versus 1.5 mg/kg during endotracheal intubation in general anaesthesia

Randomised control trial of bispectral index with propofol induction 2 mg/kg versus 1.5 mg/kg during endotracheal intubation in general anaesthesia

Randomised control trial comparing hemodynamic response of propofol induction 2 mg/kg versus 1.5 mg/kg during endotracheal intubation in general anaesthesia

Randomised control trial comparing hemodynamic response of propofol induction 2 mg/kg versus 1.5 mg/kg during endotracheal intubation in general anaesthesia

Combined hypoglossal and lingual nerve palsy: An unrecognized complication after orotracheal intubation for general anaesthesia. A case report of a day surgery patient and a literature review

Cranial nerve injury after orotracheal intubation is a rare complication, which has varied etiology. We present a case of combined unilateral hypoglossal and lingual nerve palsy after orotracheal intubation. The current literature was reviewed for the diagnostic, treatment, follow-up, and preventive measures of this complication.

Retromolar intubation for the general anesthesia of maxillofacial fracture patients

BackgroundEvaluate the possibility of retromolar intubation for general anesthesia in patients with maxillofacial fractures.MethodsThe medical records of 54 patients with maxillofacial fractures who visited the Oral and Maxillofacial Surgery Department of Nantong First People’s Hospital from January 2020 to August 2022 were collected. The retromolar areas of each patient were measured from the coronal CT images, and correlated with the patient’s age, sex, type of fracture (i.e., maxillary fracture, mandibular fracture, or complex fracture of multiple maxillofacial bones), and the presence of the third molar (verified from 3D CT). The dimensions of the retromolar areas were finally compared with the outer diameter (OD) of standard endotracheal tubes (ETTs), most importantly the size 7.5 ETT (OD 10.3 mm) for male and the size 7.0 ETT (OD 9.8 mm) for female.ResultsThe survey included 38 male and 16 female patients, with an average age of 44.1 and 54.3 years, respectively. The dimensions of the retromolar area (height × width) were as follows: male, (9.39 ± 1.77) mm × (12.08 ± 0.98) mm on the left and (9.81 ± 2.23) mm × (11.77 ± 1.08) mm on the right; female, (8.82 ± 1.53) mm × (10.51 ± 1.00) mm on the left and (9.73 ± 1.60) mm × (10.63 ± 1.58) mm on the right. The width was always larger than the OD of the routinely used ETT, but the height could be smaller by less than 1 mm. However, the oral mucosa can be compressed to allow the ETT to fit in the retromolar area.ConclusionsThe retromolar area provided appropriate space to place a reinforced ETT for patients with maxillofacial fractures needing general anesthesia that must not interfere with intermaxillary ligation. Retromolar intubation can help maxillofacial fracture surgeries that focus on occlusal restoration.

Intravenous ketorolac versus intravenous dexmedetomidine for postoperative analgesia after hypospadias repair

ABSTRACT Hypospadias repair surgery, though necessary, can be painful after the procedure, especially for children. Effective pain management is essential in all surgeries, but particularly in pediatric procedures. The current study was conducted to evaluate the analgesic efficacy of intravenous ketorolac versus dexmedetomidine after hypospadias repair surgery. Patients and methods A total of 60 children aged between 2 and 7 years old undergoing hypospadias repair under general anesthesia enrolled in the study. Those children were randomly divided into either group Ketorolac (group A) or Dexmedetomidine group (group B). Group (A) included 30 patients who received IV ketorolac in a dose 0.9 mg/kg after intubation for general anesthesia while group (B) included 30 patients who received IV dexmedetomidine in a dose 1 μg/kg after intubation. Pain scores (FLACC), sedation and emergence agitation (EA) scores, 1st analgesic dose, hemodynamics, and any side events were recorded. Results The main finding in this study was that group (B) had significantly lower FLACC at different postoperative times compared to group n(A)with p < 0.05; with exception at 4th and 12th hours. It was found that FLACC was zero in group (B) till the 6th hour postoperatively. All patients in the studied groups had sedation scale was 3 starting from the 4th postoperative hour. Immediate and 2-hour postoperatively, the score was significantly higher among the dexmedetomidine group.Two patients developed EA in group A but non in group B. Conclusion Adjuvant intravenous dexmedetomidine is more effective than intravenous ketorolac in postoperative analgesia children after hypospadias repair surgery under general anaesthesia.

Intraoperative pain prediction of percutaneous kyphoplasty under local anesthesia by preoperative experimental pain assessment.

Percutaneous kyphoplasty (PKP) is the preferred treatment for osteoporotic vertebral compression fractures (OVCF) Currently, the preoperative anesthesia methods for PKP are mainly local anesthesia and tracheal intubation general anesthesia. To assess whether patient sensitivity to pain measured preoperatively could predict the patients' pain response during PKP treatment under local anesthesia, to facilitate the development of an optimal preoperative anesthesia plan for patients. Fifty-five female patients diagnosed with osteoporotic single vertebral fracture who were treated with PKP under local anesthesia were selected. The patients' pain sensitivities, including pain threshold and pain tolerance threshold, were evaluated with a pain test device on the day before the operation in the ward. Heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) were recorded before anesthesia, post-anesthesia, after needle puncture, and after balloon dilatation. At the same time, blood was drawn at the above time points to determine the level of norepinephrine (NA) as an indicator of intraoperative pain stress response. The numerical rating scale (NRS) during surgery was recorded at the end of the surgery. The preoperative pain tolerance threshold of 55surgical patients was correlated with the intraoperative NRS score (r=-0.768, P< 0.001), as well as with the preoperative and intraoperative changes in HR (r=-0.791, P< 0.001), MAP (r=-0.819, P< 0.001), and NA (r=-0.553, P< 0.001). Thus, the lower the preoperative pain tolerance threshold, the more severe the patient's response to pain during PKP treatment under local anesthesia, and the greater the hemodynamic changes. Consequently, the intraoperative experience becomes worse. However, there was no correlation between preoperative pain threshold and NRS scores (r=-0.069, P= 0.616) nor between the preoperative and intraoperative changes in HR (r= 0.103, P= 0.453), MAP (r= 0.086, P= 0.535), and NA (r=-0.058, P= 0.674). The results indicated that preoperative pain assessment could predict the level of pain response in OVCF patients during PKP surgery under local anesthesia.

A randomized comparison of three intubation techniques/tube materials for nasotracheal intubation.

We sought to compare three intubation methods using different intubation techniques/tube materials for tube advancement from the nasal cavity into the oral cavity during nasotracheal intubation. We conducted a randomized clinical trial with adult patients scheduled to undergo elective surgery requiring nasotracheal intubation for general anesthesia. Participants were randomly allocated to a polyvinyl chloride (PVC) tube group (group P), PVC tube attached to a rubber catheter group (group PR), or velvet-soft PVC tube group (group V). Tracheal intubation was then performed based on group allocation. The primary outcome was the first-attempt success rate of tube advancement into the oral cavity; secondary outcomes included the time required for tube advancement into the oral cavity, total intubation time, and the incidence of epistaxis. A total of 149 patients were included in the study. The first-attempt success rate in group V (90%) was significantly higher than that in group P (58%) (odds ratio, 6.5; 95% confidence interval [CI], 2.2 to 19.2), but similar to that in group PR (100%). The mean (standard deviation) time required for tube advancement into the oral cavity was significantly shorter in group V (16 [13] sec) than in group PR [40 (10) sec; 95% CI of mean difference, 17 to 30] and group P (26 [16] sec; 95% CI of mean difference, 3 to 16). Total intubation time was longest in group PR. Epistaxis occurred the least in group V. Among the three intubation techniques/tube materials for nasotracheal intubation, the velvet-soft PVC tube provided the highest first-attempt success rate, most expeditious advancement into the oral cavity, and lowest incidence of epistaxis. ClinicalTrials.gov (NCT04695444); first submitted 30 December 2020.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room

Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. ClinicalTrials.gov Identifier: NCT04701762.

A Case of Gastric Contents Reflux Aspiration during General Anesthesia Induction in A Patient with Femoral Vein Atrial Septal Defect Closure

Background: Aspiration of gastric contents during the induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. We report an 18-year-old patient with a closed atrial septal defect who developed gastric content reflux aspiration and severe aspiration pneumonia despite abstaining from drinking and fasting for more than 12 hours. Case Presentation: An 18-year-old female patient with congenital heart disease (atrial septal defect) had no previous history of gastroesophageal reflux. After fully abstaining from drinking and fasting (more than 12h), conventional anesthesia was induced, and after the patient’s spontaneous breathing and consciousness disappeared, the patient was assisted with mandibular support with both hands and mask pressure. The induction process was smooth. When preparing for intubation, a large amount of yellow fluid was found in the patient’s mouth. Intubation was performed immediately after suction. Aspiration pneumonia still occurs after the operation even if the patient is treated promptly. Conclusions: As the incidence of perioperative pulmonary aspiration is relatively low, precautions to prevent aspiration tend to be overlooked. We should be alert to the complications of gastric contents regurgitation aspiration in patients with sufficient abstention and fasting during general anesthesia intubation.

Nasotracheal intubation with the aid of nasopharyngeal airway

Introduction &amp; objective: Oral and maxillofacial surgeries commonly require nasotracheal intubation (NTI) to overcome difficulty of work in the oropharyngeal space. Several variables affect intubation difficulty and complications and include tube type or design, topical vasoconstrictors, lubricating the endotracheal tube (ETT), selecting smaller diameter ETT, using urethral catheter to assist NTI, using some catheters etc. We aimed to explore the effectiveness of nasopharyngeal airway (NPA) as a factor facilitating the passage of ETT in the nasopharynx and diminishing trauma and bleeding during NTI. Methodology: One hundred-forty patients undergoing surgery in the oral and maxillofacial area were divided into groups of 70 each; NPA group, in which an NPA was used as an assist device, and non-NPA group with non-NPA use. Before intubation, the more patent nostril was identified, topical nasal vasoconstrictor was used, lubricant jelly applied and thermo softening of the ETT achieved. In NPA group, nasal cavity dilatation was done with an NPA before NTI. The ease of ETT passage and any nasopharyngeal bleeding were assessed by a scale of four grades. Results: About 95.71% patients had easy (grade 0 or 1) passage of ETT in the NPA group compared to 81.43% in the non-NPA group (P &lt; 0.0001, P = 0.006), and the remaining grades also showing significant differences between groups. About 98.57% patients had grade 0 to 1 bleeding (no or traces of blood) in the NPA group, compared to 97.14% in the non-NPA group (P = 0.001) and the remaining grades also showed significant differences between the groups. NPA minimized difficulties in passage of the ETT and complications. Conclusion: Application of nasopharyngeal airway in patients undergoing nasotracheal intubation for general anesthesia proved to be effective in increasing nasal cavity space and minimizing difficulties faced in the passage of the endotracheal tube through the nasal passages and diminishing the resulting complications. Abbreviations: ETT- Endotracheal Tube; NPA- Nasopharyngeal Airway; NTI- Nasotracheal Intubation Keywords: Endotracheal Tube; Lubricating Gel; Maxillofacial; Nasopharyngeal Airway; Nasotracheal Intubation; Surgery, Oral; Surgery Citation: Abd Al-Qader BK, Abdulahad SA, Mohammad HM. Nasotracheal intubation with the aid of nasopharyngeal airway. Anaesth. pain intensive care 2024;28(1):50−54; DOI: 10.35975/apic.v28i1.2263 Received: July 09, 2023; Reviewed: December 10, 2023; Accepted: December 30, 2023

The use of dexmedetomidine in suppressing cardiovascular response due to intubation in general anesthesia

Endotracheal intubation is commonly used to maintain a safe airway during general anesthesia. This intubation action can trigger a dangerous response for the patient, one of which is the cardiovascular system. Increases in arterial blood pressure, plasma catecholamine levels, and heart rate are responses that can occur during intubation. Therefore, various methods and treatments have been used to control this cardiovascular response, including dexmedetomidine. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist that has analgesic, sympatholytic, and sedative effects with minimal depression of ventilation. Much research has been done on how well dexmedetomidine works to stop the cardiovascular response to intubation. Dexmedetomidine was significantly associated with reductions in heart rate, systolic blood pressure, and MAP.

Observation of the validity of the upper lip bite test in predicting difficult intubation

The upper lip bite test (ULBT) is considered an effective method for predicting difficult airways, but data on the ULBT for predicting difficult tracheal intubation are lacking. This study aimed to examine the clinical utility of the ULBT in predicting difficult endotracheal intubation. We conducted an observational case-cohort study of adult patients undergoing elective surgery and requiring endotracheal intubation for general anesthesia. Difficult airway assessment was performed on the recruited patients before the operation, including the ULBT, mouth opening, thyromental distance, modified Mallampati test, and body mass index. The primary outcome was the incidence of difficult tracheal intubation. The receiver operating characteristic curve analysis was used to compare the performance of variables in predicting difficult tracheal intubation. We successfully recruited 2522 patients for analysis and observed 64 patients with difficult tracheal intubation. When predicting difficult tracheal intubation, grade 2 ULBT had a sensitivity of 0.75 and a specificity of 0.54, and grade 3 had a sensitivity of 0.28 and a specificity of 0.75. Compared with mouth opening, the area under the receiver operating characteristic curve of the ULBT was lower in predicting difficult tracheal intubation (0.69 [95% confidence interval: 0.67–0.71] vs. 0.84 [95% confidence interval: 0.82–0.87], P < 0.05).Clinical Trials Registry: ChiCTR-ROC-16009050, principal investigator: Weidong Yao.

Effect of Traditional Chinese medicine acupressure on Sore Throat in Patients After Tracheal Intubation General Anesthesia: A Randomized Trial

Effect of Traditional Chinese medicine acupressure on Sore Throat in Patients After Tracheal Intubation General Anesthesia: A Randomized Trial

Iatrogenic uvular injury after endotracheal intubation: recommendations for clinical practice

BackgroundUvular injury is a rare complication of endotracheal intubation. It presents as a triad of sore throat, foreign body sensation in pharynx, and halitosis.Case presentationA 26-year-old male who underwent endotracheal intubation for general anesthesia developed sore throat and foreign body sensation after the procedure. The patient was diagnosed as a case of iatrogenic uvular necrosis (grade III uvular injury) leading to auto-amputation (grade IV uvular injury) attributed to compression of the uvula due to the endotracheal tube placement. The patient was counseled regarding the etiology of the disease and was treated conservatively.ConclusionsUvular injury is a rare complication that can easily be prevented by corrections in technique and experience. This report emphasizes the establishment of principles of diagnosis, prevention, and treatment of uvular injury.

Post-extubation use of high-flow nasal oxygenation induces upper airway leak and intrathoracic sepsis after successful Bentall procedure: A case report.

In recent few years, high-flow nasal oxygenation (HFNO) has been widely used for management of acute hypoxemic respiratory failure and during postextubation periods, including after endotracheal intubation general anesthesia (ETGA). However, HFNO generates positive pressure in the injured airway following removal of endotracheal tube may cause airway leaks. This is the first case report of severe airway leak syndrome following postextubation use of HFNO in surgical patients. This case report describes a 75-year-old female with critical aortic stenosis who underwent an emergency Bentall procedure. HFNO (flow rate of 45 L/min) was applied after weaning from mechanical ventilation and removal of the endotracheal tube. At 6 hours after HFNO application, subcutaneous emphysema in the neck bilaterally and face was noted, and the emphysema extended into the supraclavicular regions. The HFNO cannula was removed soon after and the patient was re-intubated with an endotracheal tube the following day due to progressive respiratory insufficiency. Unfortunately, the patient general condition deteriorated, as the subcutaneous air collections progressed into deep tissue infections of the neck, mediastinal abscesses, and left-sided empyema. Patient received surgical interventions repeatedly to drain the mediastinal abscess and empiric antimicrobial therapy was given. The patient passed away about 2 months later due to uncontrollable sepsis. Air leaks in the upper airway can occur during the use of post-extubation HFNO use, and the resulting subcutaneous emphysema can progress to severe intrathoracic infections in surgical patients who have a sternotomy wound. Therefore, HFNO-induced subcutaneous emphysema should be treated more aggressively in open thoracic or sternotomy surgeries to prevent the development of intrathoracic sepsis.

A case of safe airway management by fiber-optic nasotracheal intubation in general anesthesia in a pediatric patient with Hajdu-Cheney syndrome: a case report

BackgroundHajdu-Cheney syndrome (HCS) is an extremely rare disorder characterized by progressive acro-osteolysis. A unique facial structure and deformity of the cervical spine are associated with a difficult airway. Although several reports describe general anesthesia with orotracheal intubation for patients with HCS, there have been no reports of nasotracheal intubation with a risk of skull base fracture. We describe nasotracheal intubation for oral surgery in a patient with HCS.Case presentationA 13-year-old girl with HCS was scheduled for dental surgery. Preoperative computed tomography revealed no abnormalities including fractures in the skull base or cervical spine. After confirming a lack of vocal cord paralysis by bronchofiberscopic inspection from the nose, general anesthesia was induced with sevoflurane, remifentanil, and rocuronium. Fiber-optic nasotracheal intubation was successfully performed without complications such as depletion of oxygen saturation and massive epistaxis, and the surgery was completed uneventfully. She was discharged the day after surgery with no anesthesia-related complications.ConclusionsWe were able to safely manage the airway of a patient with HCS by nasotracheal intubation under general anesthesia.

Comparison of preoxygenation efficiency measured by the oxygen reserve index between high-flow nasal oxygenation and facemask ventilation: a randomised controlled trial

BackgroundHigh-flow nasal oxygenation and the oxygen reserve index (ORI), which is a non-invasive and innovative modality that reflects the arterial oxygen content, are used in general anaesthesia. This study compares the preoxygenation efficiency (measured by the ORI) of high-flow nasal oxygenation and facemask ventilation during the induction process.MethodsThis single-centre, two-group, randomised controlled trial included 197 patients aged ≥ 20 years who underwent orotracheal intubation for general anaesthesia for elective surgery. The patients were randomly allocated to receive preoxygenation via facemask ventilation or high-flow nasal oxygenation. The ORI was measured and compared between both groups.ResultsThe ORI increased during preoxygenation in all patients. At 1 min of preoxygenation, the ORI was significantly higher in the high-flow nasal oxygenation group (0.34 ± 0.33) than in the facemask ventilation group (0.21 ± 0.28; P = 0.003). The highest ORI was not significantly different between the two groups (0.68 ± 0.25 in the high-flow nasal oxygenation group vs. 0.70 ± 0.28 in the facemask ventilation group; P = 0.505).ConclusionsHigh-flow nasal oxygenation results in an oxygenation status similar to that provided by facemask ventilation during the induction process of general anaesthesia; therefore, high-flow nasal oxygenation is a feasible preoxygenation method.Trial RegistrationClinicaltrials.gov (NCT04291339).

Learning curve of i-gel insertion in novices using a cumulative sum analysis

The i-gel, a popular second-generation supraglottic airway device, has been used in a variety of airway management situations, including as an alternative to tracheal intubation for general anesthesia, rescue in difficult airway settings, and out-of-hospital cardiac arrest resuscitation. We aimed to investigate the number of experiences needed to achieve a rapid, highly successful first attempt i-gel insertion in novices with a cumulative sum analysis. We also looked at how learning affected success rates, insertion time, and bleeding and reflex (limb movement, frowning face, or coughing) incidences. This prospective observational study included 15 novice residents from March 2017 to February 2018 in a tertiary teaching hospital. Finally, 13 residents with 35 [30–42] (median [interquartile range]) cases of i-gel insertion were analyzed. The cumulative sum analysis showed that 11 of 13 participants had an acceptable failure rate after 15 [8–20] cases. With increasing experience, success rate (P = 0.004), insertion time (P < 0.001), and incidence of bleeding (P = 0.006) all improved. However, the incidence of reflex did not change (P = 0.43). Based on our results, we suggest that 20 cases are preferable for novices to develop skills in using the i-gel in airway management.