Total Intubation Time Research Articles

Difficult Airway Simulation for Novice Physicians: A Randomized Trial Comparing Traditional and Video‐Assisted Laryngoscopy

Objectives: Detect a difference in intubation success and total intubation times between novice physicians using either a Macintosh laryngoscope or a video-assisted laryngoscope (Glidescope®) on a difficult airway manikin simulator. Methods: This prospective randomized trial was performed in June 2012. 40 first year residents with less than five total live intubations were recruited. Training was provided by both faculty otolaryngologists and anesthesiologists using both laryngoscope types on a manikin airway simulator in a standard intubation scenario. This was followed by randomization to use one of the aforementioned laryngoscopes in a difficult intubation scenario. The difficult airway simulation entailed oral cavity/oropharyngeal obstruction using tongue inflation, with rigid cervical spine immobilization preventing extension and elevation of the head and limiting oral cavity opening. Success was defined as a confirmed endotracheal intubation by the instructor in 120 seconds or less. Results: The Macintosh laryngoscope group (n=19) had an intubation success rate of 52.63% with a mean intubation time of 69.0 (95% CI: 52.7, 85.2) seconds. The video-assisted group (n=21) demonstrated a significantly higher success rate of 100% (p<0.0001) and a decreased mean intubation time of 23.1 (95% CI: 18.4, 27.8) seconds (p<0.0001). Conclusions: Novice physicians with little to no prior intubation experience showed significantly higher intubation success with lower intubation times using a video assisted laryngoscope in a difficult airway manikin simulator.

Lightwand-guided nasotracheal intubation in oromaxillofacial surgery patients with anticipated difficult airways: a comparison with blind nasal intubation

In oromaxillofacial surgery patients, the incidence of difficult airways is up to 15.4–16.9%. Blind nasal intubation remains a safe technique for difficult airway management in some remote areas where a fibreoptic bronchoscope is not always available. The lightwand is an easy-to-use, highly economical device, and can facilitate endotracheal intubation through illumination in the neck. The study aims to evaluate the efficacy of nasotracheal intubation using lightwand in oromaxillofacial surgery patients with difficult airways. One hundred and sixteen patients with difficult airways requiring nasotracheal intubation were randomly divided into a lightwand group and a blind group, with 58 cases in each group. The first attempt and overall success rates of lightwand intubation were 84.5% and 93.1%, respectively, which were higher than those of blind intubation (65.5% and 75.9%, respectively; P<0.05). The total intubation time was 91.4±27.7s in the lightwand group and 130.7±33.4s in the blind group (P<0.001). Patients in the lightwand group also experienced more stable haemodynamic responses and less pharyngalgia. In conclusion, lightwand-guided nasotracheal intubation is superior to blind intubation in patients with difficult airways, with a higher success rate, more stable haemodynamic responses, and fewer postoperative complications.

Learning Curve for Transoral Robotic Surgery&lt;subtitle&gt;A 4-Year Analysis&lt;/subtitle&gt;&lt;alt-title&gt;Learning Curve for Transoral Robotic Surgery&lt;/alt-title&gt;

As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve. To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes. Prospective case study. A single tertiary care academic institution. A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months). Transoral robotic surgery. Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications. Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required. This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.

Residual pulmonary hypertension after retrograde pulmonary embolectomy: long-term follow-up of 30 patients with massive and submassive pulmonary embolism

Pulmonary hypertension is a major cause of morbidity and mortality in patients following acute pulmonary embolism. Although thrombolytic therapy decreases pulmonary arterial pressure, compared with anticoagulation alone, it has the propensity for haemorrhagic complications, distal embolization and incomplete recanalization, with the potential risk of late pulmonary hypertension. Surgical embolectomy-once performed solely on critically-ill patients-has now gained favour in a wider range of patients. In this paper we present the outcomes of patients who underwent surgical embolectomy complemented with retrograde technique and follow-up systolic pulmonary arterial pressure (SPAP). From January 2004 to December 2010, 30 consecutive patients with a mean age of 58±15 years underwent pulmonary embolectomy at our centre. The patients were followed for a mean period of 30.5±12 months. Their New York Heart Association (NYHA) classifications were assessed and their SPAPs were measured by echocardiography. The overall mortality rate was 13.2% (4/30). Of the remaining patients, 19 patients (73.1%) were in NYHA classes I and II, 7 patients (26.9%) in class III and no patient in class IV. The patients' preoperative and postoperative mean SPAPs were 44.9±5.7 and 34.9±7.1 mmHg, respectively, which showed a significant reduction (P<0.001). The mean SPAP in the follow-up was 29.4±11.5 mmHg, which again showed significant reduction compared with early postoperation values (P<0.001). No significant correlations were found between the level of SPAP reduction in patients' follow-up with age (P=0.727) and total days of ICU admission (P=0.700), but weak correlations with sex (P=0.016) and total intubation time were noticed (P=0.035). This is the first series reporting the long-term outcome of patients undergoing surgical embolectomy complemented by retrograde embolectomy technique, demonstrating the safety and favourable long-term outcome of this technique. It is also a new element in the growing body of evidence regarding the relevance of surgical embolectomy in patients with acute pulmonary embolism. We concluded that, following surgery, not only does the pulmonary arterial pressure drop immediately, but also the trend toward normalization continues long after operation.

The disposable Ambu aScope vs. a conventional flexible videoscope for awake intubation – a randomised study

A new disposable flexible videoscope, the Ambu® aScope, has several potential advantages compared with reusable devices, but it is a prerequisite for its widespread use that it functions sufficiently well in the management of patients in whom difficulty with airway management is anticipated and awake intubation is indicated. In a pilot study, 20 patients with normal airways were intubated with the aScope. Subsequently, 40 patients with predicted difficult tracheal intubation were randomly assigned to be intubated awake with either the aScope or the reusable Olympus BF videobronchoscope. All patients were successfully intubated awake. The median total intubation time, including the administration of local anaesthesia, was 278 vs. 234 s in the aScope and Olympus groups, respectively (P = 0.03). In two cases in the aScope group, the image became blurred immediately after the first injection of lidocaine via the injection channel, and the time that it took to replace the scopes was included in the intubation times. Both the disposable aScope and the reusable Olympus videoscope allowed safe awake intubation in our elective patients with severely difficult, but uncompromised, airways. The occasional need to employ a spare scope because of malfunctioning would make the disposable aScope less suitable in patients with acutely compromised airways.

Comparison of Intubation Success Rate and Times Required for Intubation by Glottic Exposure Methods with Glidescope®

Background: The glottis can be exposed by a Glidescope ® during endotracheal intubation using either the epiglottis or valleculae ele- vation method. We compared the epiglottis and valleculae elevation methods for endotracheal intubations performed with a Glidescope ® using differences in success rate, time spent for tracheal intubation and percent of glottic opening. Methods: Forty medical students without experience using a Glidescope ® participated in this prospective, randomized study in which they intubated a tracheal tube into a manikin. All participants performed tracheal intubation using the 2 forementioned methods. Twenty students exposed the vocal cord by placing the blade tip in the valleculae (valleculae elevation method; VEM). The other 20 students di- rectly elevated the epiglottis with the blade (epiglottis elevation method; EEM). We separated intubating time into 3 parts: turnaround time to exposing the vocal cord, tube passing time and first ventilating time. Results: The success rate of tracheal intubation using VEM (86.7%, 104/120) was higher than that using EEM (65.8%, 79/120) (p < 0.001). VEM resulted in a lower total intubation time (VEM vs. EEM, 23.5 ± 5.3 vs. 29.0 ± 8.7, p = 0.001). The key factor of this differ- ence was the tube passing time (VEM vs. EEM, 7.4 ± 2.5 vs. 12.8 ± 7.4, p < 0.001). Conclusions: Exposing the vocal cord by using VEM during tracheal intubation with a Glidescope

Comparison of the Laryngeal Mask Airway (CTrach(TM)) and Direct Coupled Interface-Video Laryngoscope for Endotracheal Intubation: a Prospective, Randomized, Clinical Study.

Video laryngoscopy was developed to facilitate tracheal intubation of difficult airways. We aimed to compare the efficacy of CTrach™ (CT) and Direct Coupled Interface-Videolaryngoscope (DCI-VL) in patients with normal airways. Sixty ASA I-II (American Society of Anesthesiologists) adult patients admitted for elective surgery were enrolled in this prospective study. The patients were randomly assigned to two groups, where intubation was performed via CT or DCI-VL. Time to obtain a good glottic view, total intubation time, success rates and the number of patients who required maneuvers for a good glottic view were recorded. The mean time to obtaining a good glottic view was significantly longer with CT than with DCI-VL (29.4±20.3 seconds vs. 12.8±1.9 seconds, respectively; p=0.01). Intubation was achieved on the first attempt in 28 patients in the CT group (93.3%) and in 24 in the DCI-VL group (80%) (p=0.77). The total intubation time for CT was significantly longer compared to DCI-VL (99.9±36.0 seconds vs. 39.2±21.4 seconds, respectively; p=0.01). Optimization maneuvers were required in eight and two patients in the CT and DCI-VL groups, respectively (p=0.03). Although the normal airway endotracheal intubation success rates were similar in both groups, the time to obtain a good glottic view and the total intubation time were significantly shorter with DCI-VL.

The success rate of nasotracheal intubation using lightwand does not depend on the laryngoscopic view

The purpose of this study was to evaluate the usefulness of Trachlight (TL) for nasotracheal intubation and to determine the relationship between the grade of laryngeal view and the subsequent ease of nasotracheal intubation using TL. Patients requiring nasotracheal intubation were enrolled in this study. Laryngoscopy was performed in all patients under topical anesthesia, with 8% lidocaine spray applied to the supraglottic region and the vocal cords. Glottic visualization during laryngoscopy was assessed using the Cormack and Lehane classification. Patients were allocated to four groups according to this classification. If the TL intubation was unsuccessful after three attempts, intubation was carried out using direct laryngoscopy. Intubation difficulty was assessed by the original 6-point scale and the total intubation time was also recorded. Trachlight intubation was successful in 89.1% of the 110 patients enrolled in the study. There was no observed correlation between the original 6-point scale and glottic visualization. The total intubation time and the ratio of "unsuccessful" cases were not significantly different among the four groups. No relationship was found between the ease of nasotracheal intubation using TL and glottic visualization.

A comparison of the Glidescope® to the McGrath® videolaryngoscope in patients

BackgroundThe Glidescope® videolaryngoscope is a new device for tracheal intubation that provides an improved view of the larynx. This study was performed to compare the Glidescope with the McGrath videolaryngoscope in terms of time to intubation (TTI) and number of attempts.MethodsPatients were randomly allocated to one of two groups, Glidescope or McGrath group, by using computer-generated numbers. Tracheal intubation was attempted by an anesthesiologist with extensive experience using these two devices. The operator recorded ease of visualization of glottic structures based on the classification described by Cormack and Lehane. Number of failures, number of attempts and their duration, total intubation time, and events during the whole procedure were recorded. The duration of one attempt was defined as the time elapsed between picking up the endotracheal tube and verification of tracheal intubation with visualization of three expiratory carbon dioxide waveforms. TTI was defined as the sum of the duration of all intubation attempts (as many as three), excluding preoxygenation procedures.ResultsTTI was significantly shorter for the Glidescope® compared to the McGrath® laryngoscope (40.5 vs. 53.3 s, respectively, P < 0.05). However, glottic views obtained at intubation were similar between the two groups. Number of intubation attempts was not significantly different between the two groups (1.03 ± 0.19 vs 1.10 ± 0.32, respectively) (mean ± SD).ConclusionsStudy results demonstrated that the Glidescope reduced total intubation time in comparison with the McGrath, in terms of TTI in patients with normal airways.

A randomized Comparison of C-MAC Videolaryngscope Versus Macintosh Laryngoscope for Tracheal Intubation

Purpose: The present study compared the C-MAC videolaryngoscope (C-MAC) with Macintosh laryngoscope with regard to the laryngoscopic view, laryngoscopic time and time required to complete the tracheal intubation. We aimed to investigate any disadvantages that the C-MAC laryngoscope may have when used in routine clinical practice. Methods: Ninety patients undergoing elective surgery requiring general anaesthesia and tracheal intubation were randomly allocated to receive tracheal intubation using the C-MAC or the Macintosh laryngoscope. Following a standardised general anaesthetic, data were collected during laryngoscopy and endotracheal intubation. Results: The median laryngoscopic time (IQR) for the C-MAC and Macintosh laryngoscope respectively were 9.8 (4) and 8.1 (3.3) seconds (p = 0.037). The median total intubation time (IQR) for the C-MAC and Macintosh laryngoscope respectively were 29.2 (18.6) and 23.5 (9.4) seconds, (p = 0.011). There were no significant differences in the laryngoscopic view, additional airway manoeuvres and success rate of tracheal intubation between the two groups. Conclusion: Although the differences in the laryngoscopic time and intubation time were statistically significant, they did not achieve clinical significance. Therefore we conclude that the C-MAC videolaryngoscope may be used in routine clinical practice for tracheal intubation.

Repeated attempts improve tracheal tube insertion time using the intubating laryngeal airway in a mannequin

Study Objective To determine if repeated performance of endotracheal tube insertion via the intubating laryngeal airway (ILA) would shorten insertion time in mannequins. Design Prospective study. Setting Clinical Skills Laboratory, Department of Anesthesia, Toronto Western Hospital. Participants 65 department anesthesiologists. Measurements After a video training session, anesthesiologists with no previous experience with the ILA performed 5 consecutive ILA-guided tracheal tube intubations on a mannequin. Each participant completed Task 1: insertion of an ILA; Task 2: blind insertion of a tracheal tube through the ILA, and Task 3: removal of the ILA. The time required for each task and the total intubation time for the three tasks over the 5 attempts were recorded. These times were compared using repeated-measures analysis of variance. The success rate among the 5 attempts was compared using Chi-Square analyses. Main Results A total of 65 anesthesiologists performed 5 ILA-guided tracheal intubations each. Total intubation time decreased from the first to the fifth attempt (92.6 ± 22.7 sec, 74.5 ± 19.2 sec, 66.5 ± 16.5 sec, 65.9 ± 19.9 sec, and 60.8 ± 16.3 sec; P < 0.001). Significant differences in intubation times were noted between the first and second, and the second and third attempts ( P < 0.001 and P = 0.02, respectively). The success rate did not change over the 5 attempts (84.6%, 89.2%, 84.6%, 89.2%, and 90.8%; P = 0.737). Conclusions Total intubation time decreased by 34% (92.6 to 60.8 sec) over the 5 attempts in mannequins. The success rate ranged from 84.6% to 90.8% and did not differ significantly over the 5 attempts.

The LMA CTrach™ in morbidly obese and lean patients undergoing gynecological procedures: a comparative study

The tracheas of obese patients may be more difficult to intubate than those of normal-weight patients. The aim of this study was to compare the airway management quality in morbidly obese and lean patients with use of the LMA CTrach. After Ethics Committee approval, 60 adult patients (30 morbidly obese patients with body mass index >40 kg/m² and 30 lean patients with body mass index <30 kg/m²) scheduled to undergo gynecological surgery were enrolled in this prospective study. The induction of anesthesia was standardized using propofol, fentanyl, and rocuronium. Ventilation and intubation success rates, time taken to achieve successful ventilation, and intubation through the CTrach and airway complications were recorded. The CTrach was successfully inserted and adequate ventilation through the CTrach was achieved in 59 patients (98%). Only 1 patient in the lean group was not able to ventilate through the CTrach. We were successful in endotracheal intubation, either under vision or blind, in 56 patients (93%). We were able to view the larynx in 51 patients (85%). Total intubation time was significantly longer in morbidly obese patients, 69 (311) s, than in lean patients, 33 (107) s [median (range)] (P < 0.001). We concluded that the time to intubate the trachea in obese patients was significantly longer than in lean patients when the LMA CTrach was used.

Fibreoptic intubation through the laryngeal mask airway: effect of operator experience*

In a randomised crossover study, we compared times and success rates for tracheal placement of a fibrescope and railroading of a tracheal tube through the classic laryngeal mask airway by anaesthetists with limited experience in fibreoptic intubation (trainees) and those who were experts. Thirty-two patients, 32 trainees and three experts took part. The median (IQR [range]) times to fibrescope placement for trainees and experts were 21 (18-30 [12-58]) s and 17 (14-24 [9-55]) s, respectively (95% CI for the difference 2-8 s; p = 0.023). There were no significant differences between trainees and experts in the times to placement of the laryngeal mask airway (41 (33-47 [31-105]) s and 36 (33-43 [30-52]) s, respectively; p = 0.24), railroading times (43 (40-58 [33-87]) s and 44 (38-57 [31-83]) s, respectively; p = 0.96) and total intubation time (114 (97-127 [80-213]) s and 95 (89-116 [74-139]) s, respectively; p = 0.13). There was no significant difference in the number of attempts needed for successful placement of the fibrescope (p = 0.12) and railroading the tracheal tube (p = 0.22). The differences between experts and trainees when using fibrescope assisted intubation via the classic laryngeal mask airway were not clinically important.

Heart rate/blood pressure response and airway morbidity following tracheal intubation with direct laryngoscopy, GlideScope and Trachlight: a randomized control trial

Haemodynamic response to tracheal intubation might be detrimental in high-risk patients. Minimizing oropharyngo-laryngeal stimulation or avoiding laryngoscopy may attenuate this response. We hypothesized that intubations performed with GlideScope or Trachlight would generate a lesser haemodynamic response than the conventional method of direct laryngoscopy. The objective of this study was to compare the haemodynamic response following tracheal intubation, using three different techniques of intubation. We also examined postoperative airway morbidities as our secondary outcome. This was a prospective randomized control trial, conducted at Mount Sinai Hospital of Toronto. After Ethics Board approval, 60 adult ASA status I and II patients, scheduled for elective surgery requiring general anaesthesia with orotracheal intubation, were randomly allocated into three groups. Intubation was performed by a single experienced anaesthesiologist, using direct laryngoscopy, GlideScope or Trachlight. The haemodynamic variables were measured noninvasively at specific time intervals. We also recorded the number of attempts and total time for intubation. Postoperative airway symptoms following surgery were assessed using a questionnaire. There was no significant difference in blood pressure and heart rate between the groups. Direct laryngoscopy intubation times were significantly lower than those of the other techniques (both P<0.0001). The occurrence of sore-throat symptoms in recovery was significantly higher in the Trachlight group (P=0.0033). There was no benefit of using any of the three intubation techniques for attenuation of haemodynamic changes. There was a higher incidence of airway symptoms associated with Trachlight intubation.

The Pentax-AWS is particularly suitable for facilitating intubation in edentulous geriatric patients

tion, the percentage of glottic opening (POGO) score [1], the intubation diffi culty scale (IDS) [2], and the number of intubation attempts were recorded. The time for intubation was defi ned as the time taken from the blade fi rst passing the incisors until passage of the tracheal tube was completed. Data were analyzed using the unpaired t-test and the χ 2 test, and P < 0.05 was considered signifi cant. Patient profi les were not different between the groups, except for the inter-incisor distance (IID). There was a signifi cant difference between the groups in the anatomical structure observed after the initial blade rotation maneuver; the vocal cords were more frequently observed in the FD group. The total time for intubation was signifi cantly less in the FD group than the NT group. The POGO score, IDS, and number of intubation attempts did not differ between the groups (Table 1). Our result showed that intubation with the AWS was facilitated when the patients were edentulous. It seems that the increased IID in the edentulous patients may have been responsible for this result. As a consequence of the lack of teeth, the working space necessary for AWS manipulation was increased. This may have facilitated the insertion of the blade tip behind the epiglottis after blade rotation, resulting in faster laryngeal exposure and subsequent faster intubation.

Treatment of Chest Wall Implosion Injuries Without Thoracotomy: Technique and Clinical Outcomes

Chest wall implosion injuries secondary to side impact are unusual but devastating injuries. The purpose of this series is to describe the clinical entity, present a surgical technique to reduce and repair the thoracic cage deformity without thoracotomy, and report outcomes in nine patients. Institutional review board approved retrospective case series, surgical technique. Level I Trauma Center. Twenty-two patients were admitted during 7-year period with thoracic cage implosion injuries and multiple segmental rib fractures from a side impact mechanism. All patients' required mechanical ventilation and had an implosion deformity along the posterolateral thoracic cage, pulmonary contusion, and clavicular fractures. Nine patients underwent repair of rib fractures through a paramidline posterior approach without thoracotomy using standard 2.4-mm titanium plates. Seven patients with similar fracture pattern treated nonoperatively were used as a historical control. Total intubation time, intensive care unit (ICU) length of stay (LOS), and final shoulder function using the Constant Murley scoring system were compared between the two groups. Average age, male to female ratio, and injury severe score were comparable for both cohorts (p > 0.6). Average follow-up was 16 months versus 12 months for the operative and nonoperative groups, respectively, (p = 0.11). In the operative group, 8 of 9 (89%) patients were extubated within 24 hours of surgery; 3 of 9 (33%) were extubated in the operating room. In the operative group, seven patients underwent internal fixation of the clavicle and progressed to union with a mean Constant score of 93. Nine patients had nonoperative treatment of the clavicle with a mean Constant score of 75 (p = 0.04). Total intubation time (1.9 days) was significantly shorter in the operative group than the nonoperative controls at 13.3 days (p < 0.01) and length of ICU stay was also shortened at 5.7 (4-8) days versus 16.7 (10-26) days, respectively, (p < 0.01). Chest wall implosion injuries with fixed deformities of the thoracic cage, multiple segmental rib fractures, and clavicular injury are a distinct clinical entity, which can be effectively managed with a posterior paramidline approach without thoracotomy. Reduction of the deformity and repair of the rib fractures led to a dramatic reduction in time to extubation, ICU LOS, and in-hospital complications including pneumonia and sepsis. Repair of the clavicular fracture appeared to be beneficial.

Comparisons of the GlideScope and Macintosh Laryngoscope in Tracheal Intubation by Medical Students on Fresh Human Cadavers

Objective The GlideScope Video Laryngoscope (GS) is an intubating device that provides equal or better glottic views than conventional laryngoscopes, but correct tube placement is more time-consuming, even when performed by experienced operators. The aim of this study was to investigate the use of the GS compared with the more conventional Macintosh laryngoscope in easy and difficult tracheal intubation when performed by inexperienced medical students on fresh human cadavers Patients and Methods Forty-one medical students were assigned to perform tracheal intubation using the direct Macintosh laryngoscope (DL) and the GS. Each student was given four attempts, with a maximum of 180 seconds for each attempt, to successfully intubate the trachea with a 6.5-mm tracheal tube in each of two scenarios, one with an easy airway and the other with a difficult airway cadaver. Results The total time of intubation for the easy airway cadaver was significantly longer in the GS group (61.4 ± 4.8 seconds vs. 40.6 ± 5.3 seconds; p < 0.001) despite the modified Cormack-Lehane scores showing no difference between the two groups. In the difficult airway cadaver, total time of intubation was significant shorter in the GS group (64.3 ± 6.5 seconds vs. 98.7 ± 10.2 seconds; p < 0.001) Conclusion Most inexperienced operators found the GS to be more time-consuming for tracheal intubation than DL in the easy airway cadaver. However, an obvious advantage was demonstrated when the GS was used for the difficult airway.

A modified lightwand-guided nasotracheal intubation technique for oromaxillofacial surgical patients

Study Objective To investigate the efficiency of a double curve nasotracheal tube on lightwand-guided nasotracheal intubation. Design Prospective, randomized, controlled trial. Setting University medical center hospital. Patients 60 ASA physical status I and II patients undergoing oromaxillofacial surgery. Interventions and Measurements Patients undergoing surgery with nasotracheal intubation and general anesthesia were randomly enrolled in the laryngoscopy group or the lightwand group. The same type of double curve nasotracheal tube was used in both groups. In the laryngoscopy group, intubation was assisted with a Macintosh No. 3 standard curved blade and Magill forceps. In the lightwand group, intubation was aided with a flexible lightwand device (without the inner stiff stylet). Intubation time was divided into two parts: Part one, from selected naris to oropharynx; Part two, from oropharynx into trachea. Part one, Part two, and total intubation time, hemodynamic responses to nasotracheal intubation, and adverse events or complications were recorded. Main Results Total intubation times in the lightwand group and the laryngoscopy group were 22.8 ± 8.0 sec vs 30.3 ± 8.2 sec ( P < 0.001), respectively. The lightwand group had comparable hemodynamic responses to those of the laryngoscopy group. Adverse events and complications were all self-limited, with similar occurrence in both groups. Conclusion For patients undergoing oromaxillofacial surgery, modified lightwand-guided nasotracheal intubation is feasible with a double curve nasotracheal tube and is an efficient alternative technique.

Effect of Female Gender and Hysterectomy on Colonoscopy Procedure Time

Purpose: Some feel that female anatomy and post-surgical changes with hysterectomy affect colonoscopy by increasing cecal intubation time. However, there are no studies directly comparing females to males. We sought to prospectively determine the effect of female gender and hysterectomy on colonoscopy procedure time. Methods: We enrolled and compared the 1st consecutive 60 males (Grp 1), 40 females w/o hysterectomy (Grp 2), and 20 females w/hysterectomy (Grp 3) undergoing screening colonoscopy, starting from October 1, 2007. We collected data on patient characteristics (age, BMI, ethnicity, previous colonoscopy, co-morbid medical conditions) and endoscopy characteristics (level of experience of endoscopist, # biopsies/polypectomies performed, dose of versed/fentanyl used). We collected data on total procedure, cecal intubation, scope withdrawal, and recovery times. Results: In our study, pts were comparable for age, BMI, prev colonoscopy, % co-morbid medical conditions, % 1st yr GI fellow performing procedure, and total dose of versed/fentanyl given. There was a significantly higher proportion of Caucasian pts in the male group compared to female groups. There was no significant difference between the 3 groups for cecal intubation time. On univariate analysis, women w/o hysterectomy had significantly shorter total procedure times; however, this group had significantly fewer polypectomies and biopsies performed during their procedure. Recovery time was significantly shorter in male pts. Total procedure time was predicted by formula: total colonoscopy procedure time (min) = 22.9 + 4.8 (if 1st yr GI fellow as endoscopist) + 7.2 (# polypectomies) + 2.3 (# biopsies). Female gender and history of hysterectomy were not found to be independent predictors of total procedure time. Conclusion: In our study, there was no difference between the 3 groups for cecal intubation time. We found that the level of experience of the endoscopist, # polypectomies performed, and # biopsies performed were independent predictors of total colonoscopy procedure time. Female gender and history of hysterectomy were not independent predictors of total colonoscopy procedure time. Larger studies are needed.Table: Results.

High-Frequency Oscillatory Ventilatory Support During CT-Guided Percutaneous Cryotherapy of Renal Masses

Computed tomography (CT)-guided percutaneous procedures are often made more difficult due to the movement of the kidney during respiration. Here we examine the use of high-frequency oscillatory ventilation (HFOV), which eliminates the movement of the kidney, potentially making cryoprobe access to the kidney simpler and possibly more efficient. We compared seven CT-guided percutaneous procedures using a single cryoprobe and either standard mechanical ventilation (MV) (n=4) or HFOV (n=3). The variables studied included: total time of patient intubation, operative time, overall duration of interventional radiology (IR) suite time, change in hematocrit, narcotic use, and complications. The ease of the procedure was rated on a subjective scale from 1 to 3. The total intubation time remained nearly identical at 210 minutes for HFOV and 208 minutes for MV, but surgeon procedural time decreased by 31 minutes in the HFOV group (HFOV=99 minutes and MV=130 minutes) (P=0.40). Total IR time was 225 minutes for HFOV compared to 212 minutes for the MV group (P=0.63). There were no significant differences in the postoperative hematocrit, creatinine, or narcotic use between the two groups. There were no complications related to the procedure or anesthesia in either group. Both urology attending physicians and the interventional radiologist noted that the procedure seemed easier with HFOV. HFOV may shorten the actual procedural time required to perform cryoablation, likely due to the elimination of renal movement during the procedure, thereby facilitating targeting and access to the renal mass. In this initial experience, patients tolerated HFOV without incident, and the operating surgeons found it easier to perform the procedures.