General Anesthesia Intubation Research Articles

Efficacy of a Bolus Dose of Esmolol and Bolus Dose of Lignocaine for Attenuating the Pressor Response to Laryngoscopy and Endotracheal Intubation in General Anesthesia: A Comparative Study.

Context:Laryngoscopy and endotracheal intubation result in an increase in heart rate and blood pressure; they evoke life-threatening complications. The esmolol is short-acting cardioselective beta-blocker and brings advantages to the perioperative management of tachycardia and hypertension.Aims:The aim of this study was to compare the efficacy of a bolus dose of esmolol and bolus dose of lignocaine for attenuation of the pressor response to laryngoscopy and intubation.Settings and Design:Sixty patients of both sex, aged 20–50 years, belonging to the American Society of Anesthesiologists physical Status I and II randomly allocated into two groups (n = 30).Materials and Methods:The study drugs diluted in 10-ml normal saline. Group I received esmolol 1.5 mg/kg and Group II received lignocaine 1.5 mg/kg 2 min before inducing the patients with thiopentone 5 mg/kg and suxamethonium 1.5 mg/kg. The heart rate, systolic blood pressure, and diastolic blood pressure were measured at basal, during intubation, and 1, 2, 3, and 5 min after intubation, and based on these values, the mean arterial pressure (MAP) and rate pressure product (RPP) was calculated.Statistical Analysis Used:The Student's t-test and data were represented by mean standard deviation and graphs.Results:The mean pulse rate, mean of MAP, and mean of RPP at intubation and at 1, 2, 3, and 5 min after intubation in lignocaine group showed a significant rise in these values but in esmolol group it remained nearer to or less than baseline values.Conclusions:Esmolol 1.5 mg/kg is effective in attenuating the pressor response in comparison with lignocaine 1.5 mg/kg during laryngoscopy and intubation.

Evaluation and Comparison of Fentanyl versus Nalbuphine for Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation in General Anesthesia.

Background:General anesthesia administration involves laryngoscopy and endotracheal intubation which are associated with the pressor response and can lead to tachycardia, hypertension, and arrhythmias, which can be deleterious in compromised patients and hence, this response needs to be suppressed.Aims:The aim of the study is to compare the effectiveness of intravenous (i.v) fentanyl and nalbuphine on the suppression of hemodynamic response in patients undergoing surgery under general anesthesia.Setting and Design:This prospective comparative study was conducted in the department of anesthesiology of a tertiary care center, and patients posted for elective surgery under general anesthesia were included.Methods:A total of 100 patients of either sex in the age group of 20–50 years, belonging to the American Society of Anesthesiologists physical status classes I and II undergoing surgery under general anesthesia, were divided into two groups: Group N (n = 50) – who received injection nalbuphine 0.2 mg/kg diluted in 10 mL normal saline i.v and Group F (n = 50) – who received injection fentanyl 2 μg/kg diluted in 10 mL of normal saline i.v over 1 min, 5 min prior to intubation. Technique of anesthesia was standardized for all the patients in the study. Heart rate (HR), blood pressure (systolic, diastolic, and mean arterial pressure [SBP, DBP, and MAP]), and oxygen saturation were recorded at baseline, induction, and at 1, 3, 5, and 10 min after intubation.Statistical Analysis:Descriptive statistics were done using mean with standard deviation for quantitative variables, and categorical variables were presented in frequencies along with respective percentages. The statistical comparisons for quantitative variables were done using Student's t-test and for categorical variables, Chi-square was used according to the data. All statistical analyses were performed using SPSS software (Version 22, SPSS Inc., Chicago, IL, USA). All analyses were two tailed, and results were discussed on 5% level of significance, i.e., P < 0.05 was considered statistically significant.Results:The demographic characteristics were comparable in both groups. HR was statistically insignificant between the two groups at all intervals. Comparing SBP, DBP, and MAP between the two groups, there was a significant increase in nalbuphine group than fentanyl group postintubation and was statistically significant at all intervals of time. Maximum rise in SBP, DBP, and MAP was 5.49%, 6.03%, and 5.80% for fentanyl group and 12.88%, 9.37%, and 10.86% for nalbuphine group, respectively. Comparison of oxygen saturation in two groups was statistically insignificant.Conclusion:Fentanyl is better than nalbuphine in blunting the pressor response of laryngoscopy and endotracheal intubation.

The influence of high-dose intraoperative remifentanil on postoperative sore throat: a prospective randomized study: A CONSORT compliant article.

Background:Endotracheal intubation for general anesthesia causes postoperative sore throat (POST). This study is designed to evaluate the effect of high-dose remifentanil on the incidence of POST in patients after general anesthesia.Methods:Ninety-two patients scheduled for orthopedic lower extremity surgery under general anesthesia were randomly assigned into 1 of 2 groups. In the high-dose remifentanil (HR) group (n = 46), remifentanil was infused at a rate of 0.25 μg/kg/min and subsequently increased or decreased by 0.05 μg/kg/min per clinical demand. In the low-dose remifentanil (LR) group (n = 46), remifentanil was infused at a rate of 0.05 μg/kg/min. The incidence of POST was monitored at 0, 2, 4, and 24 hours postoperatively. Complications regarding opioids were compared between groups.Results:The overall incidence of POST was higher in the HR group compared with that in the LR group [33 (72%) vs 18 (39%), P = .022]. The incidence of POST at 0, 2, and 24 hours after surgery was higher in the HR group compared with that in the LR group (P < .001, P = .001, and P = .001, respectively). The incidence of postoperative nausea, vomiting, drowsiness, and headache was similar between the groups. The incidence of postoperative shivering was higher in the HR group than in the LR group [10 (22%) vs 2 (4%), difference 17%, 95% CI 2%–33%, P = .027].Conclusion:A relatively large dose of intraoperative remifentanil increased the incidence of POST in patients for orthopedic surgery under general anesthesia.Trial Registration:Clinicaltrials.gov Identifier: NCT03173339.

Characterizing post-extubation negative pressure pulmonary edema in the operating room\u2014a retrospective matched case-control study

BackgroundPost-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesia-related emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices. This study investigated the incidence and associated risk factors for post-extubation NPPE during emergence.MethodsThis retrospective, matched case-control study was conducted by reviewing the post-anesthesia records in Tzu Chi General Hospital, Taiwan. Patients reported of having acute hypoxemia (SpO2 < 92%) shortly after the removal of the endotracheal tube or supraglottic airway, associating with radiographic evidence of pulmonary edema and/or pink frothy sputum, were identified as definite NPPE cases. The potential risk factors were compared with the matched controls, who were randomly selected from the same database.ResultsA total of 85,561 patients received general anesthesia with airway instrumentation during the 8.5-year study period. A total of 16 patients were identified as definite cases of NPPE. Compared with the matched controls (n = 131), males, active smokers, emergency operation, endotracheal intubation, use of desflurane, and prolonged operation time carried significantly higher risks of developing NPPE (P < 0.05). Multivariate logistic regression analysis illustrated that active smoking (AOR 7.66, 95% CI 1.67–35.3; P = 0.009) and endotracheal intubation (AOR 10.87, 95% CI 1.23–100; P = 0.03) were the two most significant independent variables of post-extubation NPPE.ConclusionWe present the first clinical comparative study demonstrating that the overall incidence of NPPE immediately after extubation in the operating room is 0.019%. Our results highlight that active smokers and patients receiving endotracheal intubation general anesthesia are associated with significantly higher risks of developing NPPE following extubation in the operating room.

Topical application of licorice for prevention of postoperative sore throat in adults: A systematic review and meta-analysis

Study objectivePostoperative sore throat negatively affects patient satisfaction and recovery. It may be related to inflammation of the mucosa caused by injury during intubation. Licorice, derived from the root of Glycyrrhiza glabra, contains active anti-inflammatory ingredients. The efficacy and safety of topical licorice for preventing postoperative sore throat in adults undergoing tracheal intubation for general anesthesia were assessed by a systematic review and meta-analysis. DesignA systematic review and meta-analysis of randomized controlled trials. SettingTrials conducted in perioperative settings. MeasurementsPubMed, EMBASE, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 21, 2018. All randomized, controlled trials (RCTs) that assessed the efficacy and safety of topical licorice in adults undergoing elective surgery under general anesthesia were eligible. The risk of bias was evaluated using the Cochrane risk of bias assessment tool. Data were pooled using a random-effects model. We conducted a trial sequential analysis (TSA) on the incidence of postoperative sore throat. Primary outcomes were the incidence and severity of sore throat 24 h after surgery/extubation and adverse events. Main resultsFive randomized controlled trials involving 609 patients were included. Compared with non-analgesic control, topical licorice was associated with a reduced incidence (risk ratio, 0.44; 95% confidence interval (CI), 0.28–0.69; P < 0.001) and severity (standardized mean difference, −0.69; 95% CI, −0.96, −0.43; P < 0.001) of postoperative sore throat. Four trials reported adverse events; there were no significant adverse events related to topical licorice. The findings of sensitivity analyses excluding trials at high or unclear risk of each type of bias were consistent with these findings. TSA confirmed the evidence for postoperative sore throat was adequate. ConclusionsPreoperative topical application of licorice appears significantly more effective than nonanalgesic methods for preventing postoperative sore throat.

Effects of fascia iliaca compartment block combined with general laryngeal mask airway anesthesia in children undergoing femoral fracture surgery: a randomized trial.

BackgroundPostoperative agitation after general anesthesia is a common complication in children; however, pain or uncomfortable feeling is the main reason of emergence agitation. Here, we have investigated the effects of fascia iliaca compartment block (FICB) combined with general laryngeal mask airway (LMA) anesthesia in children undergoing femoral surgery.MethodsEighty children undergoing femoral surgery were randomly divided into two groups: FICB + LMA group and control group (n=40). The FICB + LMA group received FICB combined with general LMA anesthesia, and the control group received tracheal intubation general anesthesia alone. Anesthesia was maintained with nitrous oxide and sevoflurane. Hemodynamic parameters were monitored, and pain was assessed by verbal numeric score within 24 hours postoperatively. Time to extubation, time to discharge from the postanesthesia care unit and postoperative complications were recorded.ResultsHemodynamic parameters were more stable in the FICB + LMA group than in the control group during anesthesia induction (P<0.05). Verbal numeric score values were lower in the FICB + LMA group than in the control group at 2–8 hours postoperatively (P>0.05). Compared with the control group, the time to extubation and time to discharge from postanesthesia care unit were shorter in the FICB + LMA group (P<0.05). Additionally, postoperative complications were less in the FICB + LMA group.ConclusionThe FICB combined with general LMA anesthesia may provide intra- and postoperative analgesia, shorten emergence time and reduce postoperative agitation in children undergoing femoral surgery.Trial registrationThis study is registered at http://www.chictr.org.cn (registration number: ChiCTR-IOR-17012725).

Peritonsillar Abscess (PTA) Management: A Literature Review Comparing Different Approaches of PTA Drainage

Background: Peritonsillar abscess (PTA) is the most common deep infection of neck space that occurs in adults and is potentially life threatening if not treated appropriately. The surgical treatment of peritonsillar abscess that is not complicated with upper airway obstruction still remains controversial. Objectives: This review attempts to explore the controverseries between different types of management and compare the efficacy of needle aspiration, tonsillectomy and/or incision and drainage. Methodology: This study was done in King Abdulaziz University. All researches, between 1988 to 2015 were recruited and reviewed in this study. Results and conclusion: Studying the three accepted methods of draining: incision and drainage, abscess tonsillectomy, or needle aspiration, Incision and drainage is an efficient and safe procedure to treat peritonsillar abscess. As well as it is superior to Needle aspiration in terms of the post-procedure pain score. It can be performed as the first-line treatment of peritonsillar abscess. Quinsy tonsillectomy can offer several advantages, by allowing full evacuation of the abscess cavity, effectively relieving symptoms, but holds risk in general anesthesia intubation. and also higher post-operative complication like Peritonsillar abscess make it not a favorable step.

The impact of prophylactic dexamethasone on postoperative sore throat: an updated systematic review and meta-analysis.

Background/AimsAn updated systematic review and meta-analysis was conducted to assess the effect of prophylactic dexamethasone for tracheal intubation of general anesthesia on postoperative sore throat (POST).MethodsComprehensive literature search of databases for randomized controlled trials (RCTs), including Embase, PubMed, and Cochrane Library, which evaluate the effect of prophylactic dexamethasone on POST was conducted. RevMan 5.0 and STATA 12.0 software were used to perform meta-analyses.ResultsFourteen RCTs totaling 1,837 patients were included for analysis. Compared with placebo, a significant reduction in the incidence of POST (OR 0.44, 95% CI 0.33–0.58, P<0.00001), hoarseness (OR 0.42, 95% CI 0.31–0.58, P<0.00001), and postoperative nausea and vomiting (PONV) (OR 0.06, 95% CI 0.03–0.14, P<0.00001) and a comparable incidence of cough (OR 0.59, 95% CI 0.19–1.89, P=0.38) was described in patients receiving dexamethasone, with or without concomitant drugs. Dexamethasone ≥0.2 mg/kg had a statistically greater impact on reducing the incidence of POST than dexamethasone 0.1–0.2 mg/kg, while dexamethasone ≤0.1 mg/kg did not. Dexamethasone was as effective as other drugs such as ondansetron, magnesium sulfate, ketamine gargle, betamethasone gel, and ketorolac for reducing POST (OR 0.70, 95% CI 0.46–1.07, P=0.10). Dexamethasone plus a different drug was more effective than dexamethasone alone for reducing the incidence of POST at 24 hours (OR 0.40, 95% CI 0.21–0.77, P=0.006). Compared with controls, a statistically higher blood glucose level was the only adverse event during the immediate postoperative period in patients receiving dexamethasone.ConclusionsIntravenous dexamethasone ≥0.2 mg/kg within 30 minutes before or after induction of general anesthesia should be recommended as grade 1A evidence with safety and efficacy in reducing the incidence of POST, hoarseness, and PONV in patients without pregnancy, diabetes mellitus, or contraindications for corticosteroids.

Time to recovery after general anesthesia at hospitals with and without a phase I post-anesthesia care unit: a historical cohort study

There is little knowledge about how hospitals can best handle disruptions that reduce post-anesthesia care unit (PACU) capacity. Few hospitals in Japan have any PACU beds and instead have the anesthesiologists recover their patients in the operating room. We compared postoperative recovery times between a hospital with (University of Iowa) and without (Shin-yurigaoka General Hospital) a PACU. This historical cohort study included 16 successive patients undergoing laparoscopic gynecologic surgery with endotracheal intubation for general anesthesia, at each of the hospitals, and with the hours from OR entrance until the last surgical dressing applied ≥ two hours. Postoperative recovery times, defined as the end of surgery until leaving for the surgical ward, were compared between the hospitals. The median [interquartile range] of recovery times was 112 [94-140] min at the University of Iowa and 22 [18-29] min at the Shin-yurigaoka General Hospital. Every studied patient at the University of Iowa had a longer recovery time than every such patient at Shin-yurigaoka General Hospital (Wilcoxon-Mann-Whitney, P < 0.001). The ratio of the mean recovery times was 4.90 (95% confidence interval [CI], 4.05 to 5.91; P < 0.001) and remained comparable after controlling for surgical duration (5.33; 95% CI, 3.66 to 7.76; P<0.001). The anesthetics used in the Iowa hospital were a volatile agent, hydromorphone, ketorolac, and neostigmine compared with the Japanese hospital where bispectral index monitoring and target-controlled infusions of propofol, remifentanil, acetaminophen, and sugammadex were used. This knowledge can be generally applied in situations at hospitals with regular PACU use when there are such large disruptions to PACU capacity that it is known before a case begins that the anesthesiologist likely will need to recover the patient (i.e., when there will not be an available PACU bed and/or nurse). The Japanese anesthesiologists have no PACU labour costs but likely greater anesthesia drug/monitor costs.

Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation.

Background Nasotracheal intubation is a blind procedure that may lead to complications; therefore, several tests were introduced to assess a suitable nostril for nasotracheal intubation. However, the value of simple tests in clinical practice was insufficient to evaluate. Method A diagnostic prospective study was conducted in 42 patients, ASA classes I–III, undergoing surgery requiring nasotracheal intubation for general anesthesia. Two simple methods for assessing the patency of nostrils were investigated. Firstly, the occlusion test was evaluated by asking for the patient's own assessment of nasal airflow during occlusion of each contralateral nostril while in a sitting posture. Secondly, patients breathed onto a spatula held 1 cm below the nostrils while in a sitting posture. All patients were assessed using these two simple tests. Nasal endoscopic examination of each patient was used as a gold standard. Results The diagnostic value of the occlusion test (sensitivity of 91.7%, specificity of 61.1%, PPV of 75.9%, NPV of 84.6%, LR+ of 2.36, and LR− of 0.14) seemed better than that of the spatula test (sensitivity of 95.8%, specificity of 25.0%, PPV of 63.0%, NPV of 81.8%, LR+ of 1.28, and LR− of 0.17). When both tests were combined in series, the diagnostic value increased (sensitivity of 87.9%, specificity of 70.8%, PPV of 80.1%, NPV of 81.4%, LR+ of 3.01, and LR− of 0.17). Conclusion and Recommendations The simple occlusion test is more useful than the spatula test. However, combining the results from both tests in series helped to improve the diagnostic value for selecting a suitable nostril for nasotracheal intubation.

Tracheobronchopathia osteochondroplastica discovered during tracheal intubation for general anesthesia

Tracheobronchopathia osteochondroplastica discovered during tracheal intubation for general anesthesia

Neck haematoma after carotid endarterectomy: risks, rescue, and prevention

Objective: This study was performed to identify risk factors for neck haematoma requiring re-exploration after carotid endarterectomy. Neck haematoma is a well-known complication after carotid endarterectomy, but there has been little discussion about intraoperative techniques for its prevention. We also investigated an intraoperative neck flexion technique for prevention of neck haematoma. Methods: A retrospective study reviewed 384 carotid endarterectomies performed at our institution from 2003 to 2016. The endpoint was neck haematomas requiring re-exploration after carotid endarterectomy. Endpoint predictors (general factors, preoperative medication, and intraoperative factors) were identified by univariate analysis. Our intraoperative neck flexion technique involved changing the neck and head position from extension to flexion during carotid endarterectomy. In patients with neck haematoma, we assessed the interval from carotid endarterectomy to re-exploration, the source of bleeding, and the method of airway rescue. Results: There was one major and three minor perioperative strokes (1.1%). Neck haematoma occurred in 9 patients (2.4%). Univariate analysis (odds ratio [95% confidence interval]) identified preoperative clopidogrel therapy (4.19 [1.03–17.06], P = .04) and not using protamine sulfate after heparin (4.13 [1.02–25.06], P = .04) as risk factors for haematoma. We used the intraoperative neck flexion technique in 87 patients and no neck haematomas occurred. There was no additional morbidity and no mortality in the patients who required re-exploration. The interval between carotid endarterectomy and re-exploration ranged from 0 to 30 hours. Intubation before re-exploration was often difficult. We recommend using a laryngeal mask and performing minor wound re-exploration under local anesthesia before tracheal intubation for general anesthesia. Haematomas were mainly caused by venous bleeding or capillary oozing. Conclusions: This study showed that neck haematoma is uncommon after carotid endarterectomy, but requires emergency airway rescue and re-exploration.

Peritonsillar Abscess (PTA) Management: A Literature Review Comparing Different Approaches of PTA Drainage

Background: Peritonsillar abscess (PTA) is the most common deep infection of neck space in adults and potentially life-threatening if not treated appropriately. The surgical treatment of peritonsillar abscess that is not complicated with upper airway obstruction remains controversial. Objectives: This review attempts to explore the controversies between different types of management and compare the efficacy of needle aspiration, tonsillectomy, and/or incision and drainage. Methodology: This study was done at King Abdulaziz University. All researchers, between 1988 to 2015 were recruited and reviewed in this study. Results and conclusion: Studying the three accepted methods of draining: incision and drainage, abscess tonsillectomy, or needle aspiration, incision, and drainage is an efficient and safe procedure to treat the peritonsillar abscess. As well as it is superior to Needle aspiration in terms of the post-procedure pain score. It can be performed as the first-line treatment of a peritonsillar abscess. Quinsy tonsillectomy can offer several advantages, by allowing full evacuation of the abscess cavity, effectively relieving symptoms, but holds risk in general anesthesia intubation. and also higher post-operative complications like Peritonsillar abscess make it not a favorable step.

Proseal LMA vs. Endotracheal Intubation in General Anaesthesia for Abdominal Surgeries

Proseal LMA vs. Endotracheal Intubation in General Anaesthesia for Abdominal Surgeries

Comparison of the effects of different doses of oxycodone on endotracheal intubation during general anesthesia induction period

Objective To compare the clinical effect of different doses of oxycodone on endotracheal intubation during general anesthesia induction period. Methods Ninety-five patients with endotracheal intubation general anesthesia were selected as the research subjects, and the patients were randomly divided into group A, group B and group C. 31 patients in group A received intravenous administration of oxycodone 0.20mg/kg, 32 patients in group B received intravenous administration of oxycodone 0.25mg/kg, and 32 patients in group C received intravenous administration of oxycodone 0.30mg/kg.The adrenaline, norepinephrine, dopamine concentration, as well as mean arterial pressure and heart rate at different time points were compared among the three groups. Results The mean arterial pressure and heart rate at T0 time point were decreased to varying extent compared with those at T1 time point(t=23.618, 7.412; 22.928, 9.063; 32.636, 9.422, P=0.000, 0.000; 0.000, 0.000; 0.000, 0.000). The heart rate, mean arterial pressure at T2, T3 and T4 time points in group A were increased compared with T0 time point(t=13.834, 6.506, 7.015; 17.604, 14.796, 16.323, P=0.000, 0.000, 0.000; 0.000, 0.000, 0.000). The adrenaline, norepinephrine and dopamine at T2, T3 and T4 time points in group A were increased compared with T0 time point(t=121.662, 64.533, 15.687; 31.498, 16.933, 9.286; 39.712, 116.049, 147.102, P=0.000, 0.000, 0.000; 0.000, 0.000, 0.000; 0.000, 0.000, 0.000). The heart rate, mean arterial pressure, adrenaline, norepinephrine and dopamine at T2, T3 and T4 time points in group B and group C were decreased significantly compared with those in group A(t=19.586, 31.972, 16.844, 27.087; 14.046, 14.822, 15.377, 23.826; 7.756, 14.396, 13.268, 23.342, 100.573, 104.010, 37.612, 38.892, 107.377, 117.969; 56.135, 56.757, 24.223, 25.300, 95.057, 82.088; 22.878, 25.731, 5.532, 5.934, 134.763, 83.628, P=0.000, 0.000, 0.000, 0.000, 0.000, 0.000; 0.000, 0.000, 0.000, 0.000, 0.000, 0.000; 0.000, 0.000, 0.000, 0.000, 0.000, 0.000; 0.000, 0.000, 0.000, 0.000; 0.000, 0.000, 0.000, 0.000; 0.000, 0.000, 0.000, 0.000), and the differences were statistically significant(all P<0.05). Conclusion During the induction of general anesthesia, the appropriate dose of oxycodone in patients with endotracheal intubation was 0.25mg/kg, which could effectively maintain the hemodynamic stability, such as mean arterial pressure, and could reduce the stress response. Key words: Anesthesia, intratracheal; Dose-response relationship, drug; Oxycodone

Effectiveness of an Interdisciplinary Medical Hospital Admission Center: The Role of the Dental Section in the Interdisciplinary System for Perioperative Management of Patients Awaiting Surgery.

Perioperative oral functional management (POFM) involves total oral management of a patient before surgery. Considerable benefits have been reported, but POFM remains scarce in medical settings. An interdisciplinary Medical Hospital Admission Center (MHAC) opened in our hospital in December 2014, and has since provided unified perioperative management for patients. This study reports on the clinical system and contributions of the systematized, standardized POFM applied through the MHAC. Patients awaiting surgery undergo oral screening before admission, with patients classified into three groups: red, needing surgical oral management (tooth extraction or other oral surgery) before surgery; yellow, needing non-surgical oral management before surgery, due to the planned surgery or the risk of tooth injury in connection with general anesthesia; or green, patients with good oral hygiene considered capable of suitable oral self-management. Patients categorized as red or yellow undergo POFM in the dental section of the MHAC before surgery. Almost all patients (88.8%) awaiting surgery now undergo preoperative oral screening, excluding emergent surgeries. In addition, oral screening is important for preventing tooth injury during endotracheal intubation for general anesthesia, and a need for preventive measures was identified in 6.1% of patients. No traumatic injuries of the teeth in connection with general anesthesia have occurred since the opening of the MHAC. Standardized POFM through an interdisciplinary MHAC thus seems extremely useful.

Determination of the appropriate oropharyngeal airway size in adults: Assessment using ventilation and an endoscopic view

IntroductionSize 9 and 8 airways for men and women, respectively, have been proposed as most appropriate based on endoscopy. However, a limitation of this guideline is that ventilation was not assessed. MethodsIn this retrospective review of prospectively collected data, 149 patients requiring tracheal intubation for general anesthesia were included. The adequacy for manual and pressure-controlled mechanical ventilation and views at the distal end of each airway was assessed using a fiber-optic bronchoscope with various airway sizes (7, 8, 9, 10, and 11). ResultsFor men, size 9, 10, and 11 airways permitted clear manual and adequate mechanical ventilation; size 7 and 8 airways caused partially obstructed manual and inadequate mechanical ventilation. On endoscopy, size 7 and 8 airways caused complete obstruction by the tongue; size 10 and 11 airways either touched or passed beyond the tip of the epiglottis. For women, the size 7 airway caused partially obstructed manual and inadequate mechanical ventilation; size 9 and 10 airways provided clear manual and adequate mechanical ventilation. The size 8 airway permitted clear manual ventilation, though mechanical ventilation was inadequate in one patient. On endoscopy, the size 7 airway caused complete obstruction in >50% of women; size 9, 10, and 11 airways either touched or passed beyond the tip of the epiglottis. ConclusionsWith respect to adequate ventilation in conjunction with an acceptable endoscopic view, size 9 and size 8 oropharyngeal airways appear to be the most appropriate sizes for clinical use in men and women, respectively.

A comparison of the video laryngoscopes with Macintosh laryngoscope for nasotracheal intubation

Nasotracheal intubation (NTI) is usually required in patients undergoing maxillofacial surgery. Though video-scopes have been demonstrated to perform well in oral endotracheal intubation, limited information is available concerning NTI. The aim of the study is to compare the efficiency of video-scopes and the traditional direct laryngoscopy in NTI. One hundred and eight patients scheduled for elective oro-maxillofacial surgery under nasotracheal intubation general anesthesia were randomly allocated into one of 3 groups of GlideScope, Pentax AirWay Scope, or Macintosh laryngoscope respectively. The primary outcome measures were total intubation time and each separate time interval (time A: for placement for the nasotracheal tube from selected nostril to oropharynx; time B: for use of devices to view the glottic opening; time C: for advancing nasotracheal tube from oropharynx into trachea and removing the scope from the oral cavity). The secondary outcomes were measurement of scores of modified naso-intubation difficulty scale (MNIDS) and attempts at intubation. ResultsMean total intubation time and time C interval were taken with GlideScope (33.1 s and 9.7 s), Pentax (38.4 s and 12.9 s), and Macintosh (42.2 s and 14.9 s) respectively. There was a significant difference among the groups (total time, P = 0.03; time C, P = 0.02). The median score of MNIDS was significantly lower using GlideScope or Pentax compared with using Macintosh in NTI (P = 0.037) and difficult intubation grading by MNIDS presented as easier in the GlideScope group than in the Macintosh group (0.016). Using GlideScope, intubation was successful at the first attempt in 80% patients whereas only 65% and 72.5% with the Pentax and Macintosh (P = 0.02). ConclusionAs compared with the Macintosh laryngoscope, the GlideScope video laryngoscope facilitated nasotracheal intubations with shortened intubation time and reduced intubation difficulty in patients undergoing oromaxillofacial surgery.

End-tidal capnography and upper airway ultrasonography in the rapid confirmation of endotracheal tube placement in patients requiring intubation for general anaesthesia.

Background and Aims:Confirmation of correct endotracheal tube placement is essential immediately after intubation for general anaesthesia. In this study, we have compared upper airway ultrasonography (USG) with reference to capnography for rapid confirmation of endotracheal tube placement after general anaesthesia.Methods:A prospective, single centre, observational study was conducted on 100 patients requiring tracheal intubation for general anaesthesia. Both capnography and upper airway USG were performed immediately after intubation to confirm the endotracheal tube (ETT) placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. Agreement between the methods and time required to determine ETT placement by the two methods were assessed with kappa statistics and Student's t-test.Results:Upper airway USG detected all five cases of oesophageal intubation, but could not detect five patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.84% (95% confidence interval [CI]: 94.25%–96.84%), specificity of 100% (95% CI: 50.6%–100%), positive predictive value of 100% (95% CI: 97.3%–100%) and negative predictive value of 62.5% (95% CI: 31.6%–62.5%). Kappa value was found to be 0.76, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 8.989 ± 1.043 s vs. 12.0 ± 1.318 s for upper airway USG (P < 0.001).Conclusion:Both capnography and upper airway USG may be used as primary procedures for the confirmation of ETT placement.

Comparison of efficacy and cost-effectiveness of 0.55% ortho-phthalaldehyde and 2% glutaraldehyde for disinfection of laryngoscopes: A prospective pilot study.

Background and Aims:The laryngoscope is a potential source of cross-infection as it involves contact with the mucous membrane, saliva and occasionally blood. This study compared efficacy and cost-effectiveness of two Centre for Disease Control approved agents for disinfection of laryngoscope blades.Methods:One hundred and sixty patients requiring laryngoscopy and intubation for general anaesthesia were randomly allocated into two groups. After tracheal intubation, used laryngoscope blades were cleaned with tap water. The blades were then immersed in either 2% w/v glutaraldehyde for a contact time of 20 min or 0.55% w/v ortho-phthalaldehyde (OPA) for 10 min. The handles were wiped with 0.5% w/v chlorhexidine wipes. Samples were collected using sterile cotton swabs from the tip, flange and light bulb area of the laryngoscope blade and one from the handle. They were cultured aerobically on blood and McConkey agar.Results:In 2% glutaraldehyde group, of 240 samples sent from the blades, 2 (0.8%) showed the growth of methicillin-resistant coagulase-negative staphylococci (MRCONS) and Enterobacter. In OPA group, of 240 samples, 2 (0.8%) showed growth of MRCONS. Thus, 2% glutaraldehyde and 0.55% OPA were comparable in terms of efficacy of disinfection. Growth was seen on 4 out of 160 handles.Conclusions:We suggest OPA for high-level disinfection of laryngoscope blades as it is equally efficacious as compared to glutaraldehyde, with a shorter contact time and available as a ready to use formulation.