Tracheal Intubation For General Anesthesia Research Articles

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.

Efficacy and safety of ciprofol versus propofol for the induction of anesthesia in adult patients: a multicenter phase 2a clinical trial

BackgroundCiprofol is a novel 2, 6-disubstituted phenolic derivative anesthetic that binds to the gamma-aminobutyric acid-A receptor.AimTo determine the equally potent dose of ciprofol compared with propofol as an induction agent for general anesthesia in patients undergoing selective surgery, and to assess its safety.MethodA total of 109 patients undergoing selective non-emergency, non-cardiothoracic or non-neurosurgical surgery requiring tracheal intubation for general anesthesia were enrolled. Ten patients per group were assigned to ciprofol-0.3, 0.4 and 0.5 mg/kg, and propofol-2.0 or 2.5 mg/kg groups, respectively to receive an intravenous bolus dose. An additional 20 patients were enrolled in the ciprofol-0.3, 0.5 or propofol-2.0 mg/kg groups. The primary outcome was the success rate of induction defined as a Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) ≤ 1 after the initial bolus dose. The secondary outcomes included the time to reach MOAA/S ≤ 1, the time to loss of the eyelash reflex, the incidences and severity of adverse events (AEs).ResultsThe success rates were 100% for all 5 groups. The mean time to MOAA/S ≤ 1 and the time to loss of the eyelash reflex were not different among the 5 groups, regardless of whether a top-up dose was needed. There were no significant differences in the incidences and severity of AEs in the dose ranges investigated of ciprofol vs. propofol.ConclusionThe efficacy and safety of a single bolus dose of ciprofol-0.5 mg/kg for the general anesthesia induction in selective surgery patients was comparable to that of propofol-2.0 mg/kg.Trial registrationClinicaltrials.gov, NCT03698617, retrospectively registered.

A Comparison of Air-Q and I-Gel in Terms of Insertion Conditions and as Intubating Aids for Elective Surgeries under General Anaesthesia

BACKGROUND&#x0D; Supraglottic airway devices (SAD) like air Q and I-Gel are widely used in place of tracheal intubation for general anaesthesia. The present study was undertaken to compare the insertion conditions of these two supraglottic airway devices and as conduits for endotracheal tube (ETT) insertion in adult patients undergoing elective surgeries.&#x0D; METHODS&#x0D; 100 patients belonging to American Society of Anaesthesiologists (ASA) grade 1 and 2 between 18 to 70 years were randomly divided into 2 groups of 50 each. In group A, Air-Q was used and in group B, I-gel. The following parameters were compared while inserting SAD and endotracheal tube (ETT): number of insertion attempts, insertion time, ease of insertion, intraoperative and postoperative complications.&#x0D; RESULTS&#x0D; Insertion in first attempt was 90 % in air- Q and 72 % in I-gel. The mean time of insertion for air-Q was 7.28 1.46 seconds which was shorter as compared to I-gel which was 8.46 2.18 seconds (p = 0.002). Air Q was easy to insert in 93 % cases and I-Gel in 52 % cases. ETT insertion through Air-Q was easy when compared to I-Gel .Complications occurred in some patients in both the groups.&#x0D; CONCLUSIONS&#x0D; We concluded that Air-Q has better efficacy than I-gel in terms of insertion conditions and as a conduit for endotracheal intubation.

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.

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.

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.

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.

Intravenous dexamethasone versus ketamine gargle versus intravenous dexamethasone combined with ketamine gargle for evaluation of post-operative sore throat and hoarseness: A randomized, placebo-controlled, double blind clinical trial.

Background:Sore throat and hoarseness are the most frequent subjective complaints after tracheal intubation for general anesthesia. We conducted a prospective, randomized, double-blind, placebo controlled study to evaluate the efficacy of intravenous (IV) dexamethasone plus ketamine gargle for reducing the incidence and severity of post-operative sore throat (POST) and hoarseness.Materials and Methods:140 patients (aged 16-65 year) scheduled for elective surgery were enrolled. Patients were randomly allocated into four groups of 35 subjects each: Group K, gargled 40 mg ketamine in 30 ml saline; Group D, were infused 0.2 mg/kg IV dexamethasone; Group KD, gargled 40 mg ketamine in 30 ml saline plus 0.2 mg/kg IV dexamethasone; Group P (placebo) that received saline (gargle and IV). POST was graded at 0, 2, 4, 8, 16 and 24 h after operation on a four-point scale (0-3).Results:The incidence and severity of POST were significantly lower in Group KD, compared with the other groups at all times after tracheal extubation for up to 24 h (P < 0.05). Also the incidence and severity of hoarseness were significantly lower in each Groups of KD and K and D compared with group placebo (P < 0.05).Conclusion:The prophylactic use of 0.2 mg/kg of IV dexamethasone plus ketamine gargle significantly reduced the incidence and severity of POST compared with using each of these drugs alone or using placebo.

RETRACTED ARTICLE: Different anesthesia methods for laparoscopic cholecystectomy

The aim of the study was to compare the possibility of performing laparoscopic cholecystectomy using two different anesthesia procedures (spinal anesthesia versus general anesthesia). The study included 68 patients with symptoms of cholelithiasis examined in the 309th Hospital of PLA from 2006 to 2009. Patients were randomly selected to undergo laparoscopic cholecystectomy with low tension pneumoperitoneum with CO(2) under general anesthesia (n=33) or spinal anesthesia (n=35). The study used propofol, fentanyl, rocuronium, sevoflurane and tracheal intubation for general anesthesia and hyperbaric 15mg bupivacaine and 20µg fentanyl were used to achieve a sensorial level of T(3) for spinal anesthesia. Intraoperative parameters, postoperative pain, complications, recovery, patient satisfaction and cost were compared between both groups. All surgical procedures were completed with the chosen method with the exception of one case, in which spinal anesthesia was converted to general anesthesia. Shoulder pain was significantly less frequent in the spinal anesthesia group (6%) compared with the general anesthesia group (24%). The level of pain at 2, 4, and 6h after the procedure under spinal anesthesia was significantly lower than that under general anesthesia. At 12h both groups had the same evaluation in the visual analogue scale. In the spinal anesthesia group all patients recovered 6h after surgery, while patients in the general anesthesia group spent more time in recovery. All patients were discharged from hospital after 24h. In the postoperative evaluation all patients were satisfied with the spinal anesthesia and would recommend this procedure, while only 78.9% of patients were very satisfied in the general anesthesia group. The cost of spinal anesthesia was significantly lower than that of general anesthesia. Laparoscopic cholecystectomy with low pressure pneumoperitoneum with CO(2) can be safely performed under spinal anesthesia. Spinal anesthesia was associated with an extremely low level of postoperative pain, better recovery and lower cost than general anesthesia.

Tracheal intubation by non-anesthesia residents using the Pentax-AWS airway scope and Macintosh laryngoscope

Study Objective To evaluate the performance of the Pentax-AWS airway scope for tracheal intubation compared with the Macintosh laryngoscope by non-anesthesia residents. Design Prospective, randomized, cohort study. Setting University-affiliated hospital. Patients 520 patients who underwent tracheal intubation for general anesthesia. Interventions 48 non-anesthesia residents performed tracheal intubation using either the Pentax-AWS or the Macintosh laryngoscope. Measurements Time to complete tracheal intubation, number of attempts until successful intubation, and number of intubations of the esophagus were recorded. Results Time to secure the airway (sec; mean ± SD) was shorter with the Pentax-AWS than with the Macintosh laryngoscope (44 ± 19 vs. 71 ± 44 sec; P < 0.001). Of the 264 tracheal intubations with the Pentax-AWS, 239 (91%) were completed within 60 seconds, while only 148 (58%) of the 256 tracheal intubations performed with the Macintosh laryngoscope were completed within the same period. The rate of successful intubations on the first attempt was higher with the Pentax-AWS than the Macintosh laryngoscope ( P < 0.001). No esophageal intubation was experienced with the Pentax-AWS approach, while 18 occurred with the Macintosh laryngoscope ( P < 0.001). Conclusion The Pentax-AWS appears to require less operator skill than the Macintosh laryngoscope. Use of the Pentax-AWS may reduce the time to secure the airway and the incidence of failed tracheal intubation by non-anesthesia residents.

Lymphocyte contamination of laryngoscope blades – a possible vector for transmission of variant Creutzfeldt‐Jakob disease

Variant Creutzfeldt-Jakob disease (vCJD) is associated with extensive prion infection of lymphoreticular tissues during the prolonged asymptomatic incubation period. Instruments exposed to infected tissues of preclinically infected individuals during medical or surgical procedures represent a potential risk of iatrogenic transmission of vCJD prions. We assessed the frequency of contamination with lymphoid tissue of single-use laryngoscope blades used for tracheal intubation for general anaesthesia. Using a cyto-centrifugation technique, lymphocytes were detected from 30% of laryngoscope blades studied. As prions resist routine sterilisation procedures, the use of non-disposable laryngoscope blades poses a risk of transmitting vCJD from patient to patient. The use of such instruments should be abandoned and disposable alternatives used.

Complaints of sore throat after tracheal intubation

Sore throat and hoarseness rank, besides pain and nausea, among the most frequent subjective complaints after tracheal intubation for general anaesthesia. Our intention was to determine the incidence of postoperative sore throat from a large sample of patients and thus to identify the most important associated factors. We prospectively followed up 809 adult patients who underwent elective surgical interventions and examined their history, the applied anaesthetic techniques, perioperative course and the occurrence, intensity and duration of postoperative throat complaints. The assignment and professional experience of the involved intubators were also assessed. The influence of a multitude of variables on postoperative throat complaints was statistically analysed. Postoperative sore throat was present in 40% overall being significantly higher in female than in male (44% vs. 33%; P = 0.001). The mean pain intensity in the affected patients (n = 323) was 28+/-12 mm on a visual analogue scale where 0 = no pain and 100 = extreme pain. The average duration was 16+/-11 h. Main factors associated with throat complaints were female sex; history of smoking or lung disease, duration of anaesthesia, postoperative nausea, bloodstain on the endotracheal tube and natural teeth. We could find no influence on the occurrence or intensity of throat complaints by the professional assignment or the length of professional experience of the personnel involved. Postoperative throat complaints frequently arise after tracheal intubation for general anaesthesia in the first 2 postoperative days, but they are of limited intensity and duration.

Widespread Application of Topical Steroids to Decrease Sore Throat, Hoarseness, and Cough After Tracheal Intubation

Widespread Application of Topical Steroids to Decrease Sore Throat, Hoarseness, and Cough After Tracheal Intubation

Does Urapidil Attenuate the Blood Pressure Response to Tracheal Intubation for General Anaesthesia?

Tracheal intubation for general anaesthesia usually induces an increase in blood pressure (BP). This well-documented phenomenon (Fox 1977; MillarForbes & Dally 1970) is transitory and of variable intensity, but is more marked in older patients or patients with arterial hypertension or coronary artery disease. It may result in myocardial ischaemia or infarction, cerebral oedema or haemorrhage. The pressure response elicited by intubation of the trachea may be limited by minimising the duration of direct laryngoscopy to 15 secondsor less (Stoelting 1978a), or by administration of laryngotracheal lidocaine (lignocaine) 2 mg/kg immediately before placement of the tube (Stoelting 1977). When it is suspected that the duration of direct laryngoscopy will exceed 15 seconds, intravenous nitroprusside I to 2 Jlg/kg (Stoelting 1978b) or intravenous lidocaine 1.5 rng/kg (Stoelting 1977), administered just before direct laryngoscopy, may have a protective effect. Urapidil, a new antihypertensive agent, is a postsynaptic ,q-adrenoceptor blocker and agonist of cerebral serotonin IA receptors. The purpose of the study is to evaluate whether urapidil may attenuate this potentially deleterious pressure response to tracheal intubation. 1. Study Design

Laryngeal Edema after Tracheal Intubation for General Anesthesia: Report of 3 Cases

Laryngeal Edema after Tracheal Intubation for General Anesthesia: Report of 3 Cases