Tracheal Intubation In Patients Research Articles

Comparison of Effects of Nalbuphine and Tramadol on Cardiovascular Response to Tracheal Intubation in Patients Undergoing Emergency Appendectomy

Objectives: To compare the effects of Nalbuphine with Tramadol on cardiovascular response (change in heart rate and blood pressure) to tracheal intubation in patients undergoing emergency appendectomy. Material and methods: This randomized controlled trial was conducted at the Department of Anaesthesiology, CMH Mardan from January 1, 2022, to June 30, 2022. A total of 100 patients who were undergoing emergency appendectomy under general anaesthesia, with ASA grade I, aged between 30-50 years, and weighing between 50-80 kg were selected. Patients were either male or female and had normal blood pressure. They were divided into two groups: the Nalbuphine group and the Tramadol group. The study focused on analyzing the cardiovascular response (changes in heart rate and blood pressure) to tracheal intubation in both groups. Results: Most of the patients in both Group A and Group B were females, with a female to male ratio of 3.54:1 and 2.57:1, respectively. The mean age of patients in Group A was 37.90±5.41, while in Group B it was 40.10±6.39. After laryngoscopy and tracheal intubation, patients in Group A had a significantly less increase in heart rate and blood pressure as compared to those in Group B. Conclusion: The Nalbuphine is better than Tramadol in attenuating the cardiovascular response to laryngoscopy and tracheal intubation. Keywords: Nalbuphine, Tramadol, Cardiovascular Response, Tracheal Intubation, Laryngoscopy, Heart Rate and Blood Pressure.

Head elevation during preoxygenation can delay desaturation time: A randomized-controlled trial

BackgroundPreoxygenation before anesthesia induction is an important part of airway management to reduce the risk of hypoxemia when the patient is apneic. The effectivity of preoxygenation is influenced by several things such as patient's head position. This study aimed to compare preoxygenation between various degrees of head elevation (20°, 30°, and 45°) and 0° or no elevation position towards desaturation time before tracheal intubation in patients undergoing general anesthesia. MethodThis was a single-blinded randomized clinical trial of 48 patients, assigned into four groups (0°, 20°, 30°, and 45° head elevation group). All subjects were preoxygenated for 3 min with 100% oxygen. Induction of anesthesia was started with fentanyl and propofol, followed by rocuronium after the patient lost consciousness. Time was recorded from the beginning of induction until the oxygen saturation decreased to 93% or a time limit of 5 min was reached. ResultThe desaturation time in 45° head elevation group was significantly the longest, followed by 30°, 20°, and 0° group (224,0 ± 49,4; 196,4 ± 41,7; 187,2 ± 29,8; and 166,1 ± 51,3 s, respectively; P < 0.05). ConclusionsPatients with 45° head elevation had significant longer mean desaturation time compared to 0° and 20° head elevation group. In patients undergoing general anesthesia, preoxygenation with head elevation slowed down the time for desaturation before tracheal intubation compared to the conventional position. Clinical trial registrationNCT05688722.

Emergency endotracheal intubation in critically ill patients with COVID-19: management and clinical characteristics

PurposesSARS-CoV-2 have become widespread worldwide since the outbreak. Respiratory function deteriorates rapidly in critically ill patients infected with SARS-CoV-2. Endotracheal intubation is an indispensable therapeutic measure during the development of the disease. This study was intended to describe the experience of endotracheal intubation from front-line anesthesiologists and clinical prognosis of patients infected with Coronavirus disease-19 (COVID-19).MethodsFourteen critical patients infected with COVID-19 who underwent endotracheal intubation were included in this study. We collate and analyze the blood gas results before and after tracheal intubation of patients and clinical prognostic indicators such as length of stay and. mortality. The experience of anesthesiologists who intubated patients has also been recorded in detail.ResultsPatients had a mean time of 10.6 days from initial symptoms to endotracheal intubation. Most intubated patients had one or more underlying conditions: hypertension (8, 57.14%), diabetes (5, 35.71%), and cardiovascular and cerebrovascular diseases (2, 14.29%). The oxygenation index increased significantly after intubation compared with before intubation (148.80 ± 42.25 vs 284.43 ± 60.17 p < 0.001). 85.72% of patients required extra-corporeal membrane oxygenation (ECMO) due to inability to maintain oxygen saturation with standard therapeutic measures. Two patients underwent lung transplantation because their lungs were essentially nonfunctional, and they recovered well after surgery. As of this writing, all patients were discharged after satisfactory recovery.ConclusionsReasonable selection of intubation timing is particularly important. It is crucial to increase the patient's oxygen supply and reduce oxygen consumption as much as possible during endotracheal intubation. In addition, the personal protective measures of medical personnel participating in treatment should be scientific and standardized.Graphical

Effectiveness of C-MAC video-stylet versus C-MAC D-blade video-laryngoscope for tracheal intubation in patients with predicted difficult airway: Randomized comparative study

ABSTRACT Background This prospective study was done on patients with suspected difficult airway to compare between C-MAC video-stylet (VS) and D-blade video-laryngoscope for tracheal intubation. Patients and methodology Randomization was done on 160 adult patients with anticipated difficulty in intubation for different causes to divide them into two equal groups (VS group and D group). Patients in each group were divided into five categories according to the cause of anticipated intubation difficulty. Duration of intubation, number of attempts, and success intubation rate were recorded. Hemodynamics parameters were measured before intubation as baseline, then after intubation at 1 and 5 min. Results In VS group, intubation time ranged between 23 and 166 s with mean of 53.2 ± 24.19 s and in D group it ranged between 30 and 279 s with mean of 65.5 ± 40.63 s (P-value 0.021). This shorter intubation time was not constant in different patient’s categories. The first attempt intubation was successfully done in 68 patients (85%) in VS group versus 61 patients (76.3%) in D group. Hemodynamically, HR and MABP showed significant increase in D group more than in VS group at 1 and 5 min after intubation (P-value = 0.001). Conclusion Both devices are helpful when there is a risk of difficult intubation. C-MAC VS is a better choice in cases of limited mouth opening and obesity, but in cases of limited cervical motility, the use of C-MAC D-blade is a better choice with a faster intubation time.

Controversies Concerning Emergency Tracheal Intubation in Patients with COVID-19

Should we still worry about coronavirus disease 2019 (COVID-19) in 2023? Mandatory restrictions of many activities due to COVID-19 have been largely relaxed across the country. We’ve dealt with COVID-19, haven’t we? However, concerning levels of COVID-19 infections have still been reported in many metropolitan areas. China’s Joint Prevention and Control Mechanism of the State Council reported that from December 8, 2022 to January 12, 2023, 59,938 hospital deaths related to COVID-19 occurred in healthcare facilities across the country, among whom 5503 were due to respiratory failure caused by COVID-19. Early and appropriate management with invasive mechanical ventilation is crucial in critically ill patients with COVID-19. Tracheal intubation still plays an important role in the successful treatment of these patients. We updated the pertinent information and new understanding on several controversial topics regarding emergency tracheal intubation in patients with COVID-19.

Effect of gabapentin on pressor response to laryngoscopy and tracheal intubation in patients undergoing elective cholecystectomy

Effect of gabapentin on pressor response to laryngoscopy and tracheal intubation in patients undergoing elective cholecystectomy

695: EVALUATING AIRWAY MANAGEMENT IN PATIENTS WITH TRISOMY 21 IN THE PEDIATRIC INTENSIVE CARE UNIT

Introduction: Children with Trisomy 21 (T21) are known to have anatomic and physiologic abnormalities that may complicate tracheal intubation. However, current tracheal intubation (TI) practice in critically ill children with T21 is not well described. We sought to describe TI practice in critically ill children with T21. We hypothesize the Adverse Airway Outcomes: AAOs (adverse TI associated events: TIAEs and/or peri-intubation hypoxemia: >20% decrease in SpO2) are higher in children with T21 as compared to those without T21. Methods: Multicenter airway management quality improvement database (NEAR4KIDS) was queried. In addition, we collected patient’s T21 status, cervical spine and cardiac conditions. The association between T21 status and occurrence of AAOs was evaluated using Chi2 and multivariable logistic regression adjusting for patient, provider, and practice covariates. Results: Of the 8401 TI encounters from 15 pediatric general/cardiac ICUs between 2014-2020, 274 (3.3%) were TIs in patients with T21. Among those with T21, 84% had congenital heart disease, and 4% had atlantoaxial instability with cervical spine protection used in 6%. Patients with T21 were smaller (median (IQR) weight 7.8 (4.5-14.7) kg vs 10.6 (5.2-25) kg, p< 0.001). Patients with T21 (vs without) were more commonly urgently intubated for oxygenation (46% vs 32%, p< 0.001) and ventilation failure (41% vs 35%, p=0.04) as opposed to elective procedural intubations. Patients with T21 had more difficult airway features (35% vs 25%, p=0.001), including upper airway obstruction (14% vs 8%, p=0.001). Patients with T21 were more likely to receive atropine (34% vs 26%, p=0.004) and less likely intubated with video laryngoscopy (30% vs 37%, p=0.023). AAOs occurred similarly between those with T21 vs without (26% vs. 24%, p=0.669); adverse TIAEs occurred less in T21 (9% vs 14%, p=0.02), but hypoxemia occurred more frequently (23% vs 18%, p=0.046). After adjusting for age, indication, provider, device, paralytic, and apneic oxygenation, T21 condition was not associated with increased AAOs (OR 0.91, 95% CI 0.69-1.21, p=0.53). Conclusions: T21 condition was not associated with higher adverse airway outcomes. Patients with T21 were intubated more frequently for respiratory failure and with atropine and less frequently with video laryngoscopy.

Effectiveness of non-invasive respiratory support strategies in patients with COVID-19: A systematic review and meta analysis.

BackgroundThe effectiveness of non-invasive respiratory strategies, namely CPAP and HFNO, in reducing the risk of mortality and tracheal intubation in patients with severe COVID-19 is not well established. A thorough literature search was conducted across 3 electronic databases (Medline, EMBASE and Cochrane Central) from inception through July 2022. Randomized controlled trials (RCTs) and observational studies assessing the impact of CPAP or HFNO on clinical outcomes in patients infected with COVID-19 were considered for inclusion. End-points included all-cause mortality and risk of tracheal intubation. Evaluations were reported as risk ratios (RRs) with 95% confidence intervals (CI) and analysis was performed using a random effects model. I2 index was used to assess heterogeneity. From the 1041 articles retrieved from initial search, 7 potentially relevant studies (n=2831 patients) were included in the final analysis. Compared to conventional oxygen therapy, non-invasive respiratory strategies reduced the risk of tracheal intubation (RR=0.84, [95% CI 0.72, 0.98]; p=0.02, I2=43%) and all-cause mortality (RR=0.83, [95% CI 0.71-0.97]; p=0.02, I2=0%) in patients infected with COVID-19 However, reduction in length of hospital stay was not significant between the non-invasive respiratory group and conventional oxygen therapy (MD=-0.60, [95% CI -2.17 - 0.98]; p=0.46, I2=26%). This meta-analysis supports the application of non-invasive respiratory strategy is feasible as it can delay the start of tracheal intubation and reduce mortality rates among patients infected with COVID-19.

Comparison of ultrasonography, clinical method and capnography for detecting correct endotracheal tube placement- A prospective, observational study.

In emergency airway management, unstable haemodynamics of the patients calls for the early need to detect correct endotracheal tube (ETT) placement. Ultrasonography has an advantage of being readily available along with being non-invasive and providing real time images. We aimed to study the usefulness of tracheal ultrasonography and use it as a tool to assess correct tracheal intubation in patients in the intensive care unit. This was a hospital-based observational study. The study included 92 patients who needed and were taken up for endotracheal intubation. Tube placement was confirmed simultaneously by three different observers with their respective method, i.e., ultrasonography, clinical method and capnography. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography against capnography were 100% each with P value of 1. However, for clinical method against capnography, the sensitivity was 96.5%, specificity 28.6%, PPV 94.3% and NPV 40% with P value of 0.727. Mean time taken to detect correct placement of the ETT by ultrasonography, capnography and clinical method was 4.93 s, 15.39s and 17.80s, respectively. Out of 92 intubations, 85 were tracheal and 7 were oesophageal. All intubations were detected accurately with ultrasonography and capnography, ultrasonography being faster. Clinical method correctly detected 82 out of 85 tracheal intubations and 2 out of 7 oesophageal intubations, and was therefore less accurate than the other two methods. The study shows that ultrasonography is as reliable a method for confirmation of endotracheal intubation as capnography and is more reliable than clinical method. Besides, ultrasonography is faster than the other two methods.

Опыт выполнения респираторной поддержки у пострадавших с тяжелыми травмами в ходе проведения санитарно-авиационной эвакуации вертолетами легкого класса

The aim of the study was to determine the optimal types of respiratory support for acute respiratory failure in patients with severe trauma during medical evacuation by light-class helicopters. Materials and research methods. The materials of the study are the data on the performance of respiratory support in patients with various types of trauma and acute respiratory failure for 2016-2021, contained in the automated information-analytical system “Disaster Medicine of Moscow” of the State Budget Institution “Moscow Territorial Scientific and Practical Center for Disaster Medicine of the Moscow City Health Department”. When performing the study, historical, statistical and analytical methods were used. Study results and their analysis. The results of the analysis showed: – proportion of victims with various traumas received in the emergency situations in Moscow constitutes 31,9% of all sanitary losses in emergencies. Of them 12.9% were in an extremely severe and serious condition, including 1.1% who needed artificial lung ventilation and tracheal intubation; – severe acute respiratory distress requiring ventilation and tracheal intubation was caused in 49.7% of cases by polytrauma, in 38.4 cases — by isolated trauma, in 8.7 cases — by thermal trauma, and in 3.2% of cases — by combined trauma. The indications and peculiarities of artificial ventilation with tracheal intubation in patients with various traumas to be medically evacuated by a light-class ambulance helicopter have been determined.

Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis.

Background:Although minimization of cervical spine motion by using a neck collar or manual in-line stabilization is recommended for urgent tracheal intubation (TI) in patients with known or suspected cervical spine injury (CSI), it may worsen glottic visualization. The overall performance of video-stylets during TI in patients with neck immobilization remains unclear. The current meta-analysis aimed at comparing the intubation outcomes of different video-stylets with those of conventional laryngoscopes in patients with cervical immobilization.Method:The databases of Embase, Medline, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2021 to identify trials comparing intubation outcomes between video-stylets and conventional laryngoscopes. The primary outcome was first-pass success rate, while secondary outcomes included overall success rate, time to intubation, the risk of intubation-associated sore throat, or tissue damage.Results:Five randomized controlled trials published between 2007 and 2013 involving 487 participants, all in an operating room setting, were analyzed. The video-stylets investigated included Bonfils intubation fiberscope, Levitan FPS Scope, and Shikani optical stylet. There was no difference in first-pass success rate (risk ratio [RR] =1.08, 95% confidence interval [CI]: 0.89–1.31, P = .46], overall success rate (RR = 1.06, 95% CI: 0.93–1.22, P = .4), intubation time [mean difference = 4.53 seconds, 95% CI: –8.45 to 17.51, P = .49), and risk of tissue damage (RR = 0.46, 95% CI: 0.16–1.3, P = .14) between the 2 groups. The risk of sore throat was lower with video-stylets compared to that with laryngoscopes (RR = 0.45, 95% CI: 0.23–0.9, P = .02).Conclusion:Our results did not support the use of video-stylets as the first choice for patients with neck immobilization. Further studies are required to verify the efficacy of video-stylets in the nonoperating room setting.

Airway Management of Patients with Suspected or Confirmed COVID-19: Survey Results from Physicians from 19 Countries in Latin America.

Airway management during the COVID-19 pandemic has been one of the most challenging aspects of care that anesthesiologists and intensivists face. This study was conducted to evaluate the management of tracheal intubation in patients with suspected or confirmed COVID-19 infection. This is a cross-sectional and international multicenter study based on a 37-item questionnaire. The survey was available to physicians who had performed intubations and tracheostomies in patients with suspected or confirmed COVID-19 and had provided informed consent to participate. The primary outcome is the preference to use a specific device for tracheal intubation. Secondary outcomes are clinical practice variables, use of video laryngoscopes, difficult airway management, and safety features to prevent cross-infection. This study included 2411 physicians who performed an average of 11.90 and 20.67 tracheal intubations in patients diagnosed or suspected of having COVID-19 disease, respectively. Physicians were mainly from the specialties of Anesthesiology (61.2%) and Intensive Care (7.4%). COVID-19 infection diagnosed by positive PCR or serology in physicians participating in intubation in this study was 15.1%. Respondents considered preoxygenation for more than three minutes very useful (75.7%). The preferred device for tracheal intubation was the video laryngoscope (64.8%). However, the direct laryngoscope (57.9%) was the most commonly used, followed by the video laryngoscope (37.5%). The preferred device to facilitate intubation was the Eschmann guide (34.2%). Percutaneous tracheostomy was the preferred technique (39.5%) over the open tracheostomy (22%). The predicted or unpredicted difficult airway management in these patients was preferably performed with a video laryngoscope (61.7% or 63.7, respectively). Intubation was mostly performed by two or more expert airway physicians (61.6%). The use of personal protective equipment increased the practitioners’ discomfort during intubation maneuvers. The video laryngoscope is the preferred device for intubating patients with COVID-19, combined with the Eschmann guide, flexible stylet within the endotracheal tube, or Frova guide to facilitate intubation. The sub-analysis of the two groups of physicians by the level of intubation experience showed a higher use of the video laryngoscope (63.4%) in the experts group and no significant differences between the two groups in terms of cross-infection rates in physicians, in their preference for the use of the video laryngoscope or in the number of intubations performed in confirmed or suspected COVID-19 patients.

Comparison of Effects of Intravenous Lignocaine and Magnesium Sulphate on the Cardiovascular Response to Laryngoscopy and Intubation

Background and Objective: The patient's heart rate, blood pressure, pulmonary arterial pressure, and capillary wedge pressure will all rise during laryngoscopy and tracheal intubation. These hemodynamic alterations are less noticeable in those with normal blood pressure but have been linked to several diseases. They are well tolerated by those with normal blood pressure. The study's goal is to compare the cardiovascular effects of lignocaine and magnesium sulfate during laryngoscopy and intubation. Methodology: The objective of this randomized controlled trial was to examine the effects of lignocaine and magnesium sulfate on cardiovascular and respiratory responses after endotracheal intubation in ASA I patients. The 60 participants' ages ranged from 15 to 45, and they were all classed as "grade I" by the ASA. Each of these patients underwent elective surgery under general anesthesia voluntarily. The sixty people were divided into two groups of thirty using a random selection method. Neither group was significantly different from the other in terms of demographics or blood-flow parameters. Group L was administered 1.5 mg/kg intravenously of lidocaine three minutes before to induction. Group M received an intravenous injection of magnesium sulfate at a rate of 40 mg/kg over the course of one minute. Results: In both the Magnesium and Lignocaine groups, heart rates increased, but the Lignocaine group's increase was far more dramatic (p value 0.01). Both groups experienced an increase in systolic blood pressure following medication administration (p value 0.05). The results of Group M remained statistically significant for the first minute after the insertion of the tube, but by the fifth minute, they had returned to pre-insertion levels. In Group L, blood pressure increased significantly at 1 and 3 minutes after tube insertion, but by 5 minutes, blood pressure had returned to pre-insertion levels. The SBP of group L individuals increased significantly greater than that of group M participants. (p 0.05). Immediately following intubation, there was a statistically significant (p 0.01) increase in DBP in both groups; however, three minutes later, DBP had returned to pre-intubation levels in both groups (p 0.01). It is five percent as important. (p 0.05). The results revealed that the growth rate of group L members was significantly higher than that of group M members. In the presented situation, p equals 0.01 Conclusion: When it comes to preventing a rise in heart rate, blood pressure, and blood pressure during laryngoscopy and tracheal intubation for patients with an ASA grade I, magnesium sulfate is more beneficial than lidocaine.

Abstract No.: ABS2070: Comparative evaluation of intubating Laryngeal Mask Airway (Fastrach) and Blockbuster Laryngeal Mask Airway for blind tracheal intubation in general surgical operations

Background & Aims:Supraglottic devices fill a niche between the facemask and tracheal tube. The aim of this study was to compare the insertion characteristics (ease of insertion), insertion time, number of attempts, haemodynamic changes and complications (if any)following blind tracheal intubation.Methods:The comparative study was conducted by dividing 70 patients of age 18-60 years, ASA grade I and II into two groups of 35 patients each who were scheduled for general surgical operations. Group F underwent blind tracheal intubation usingFastrach LMA whereas Group B underwent blind tracheal intubation using Blockbuster LMA. The two groups were thencompared for the efficacy and overall success rate of blind tracheal intubation in patients undergoing surgeries under general anaesthesia.Association of cough, vocal cord movement and patient’s reaction with groups Group D (DEXEM)Group P (PROPOFOL)Totalχ2, P No.%No.%No.%Cough None2893.32893.35693.3χ2=0.000, P=1.000 Slight26.726.746.7Vocal Cord Movement Open2583.32893.35388.3χ2=1.456, P=0.228 Moving516.726.7711.7Patient Reaction No reaction826.72066.72846.7χ2=10.410, P=0.015 Slight grimacing1033.36201626.7 Severe grimacing1136.7413.31525 Defensive movement of head, hands or feet13.30011.7 Total301003010060100 Comparison of Intubation Score among both Groups Group D Group P P Mean SD Mean SD Intubation Score4.41.33.61.00.007Results:Both devices were inserted in first attempt only. The first time successful ETT insertion following Blockbuster LMA was in 33/35 patients (94.29%) as compared to 26/35 patients (74.29%) of FT LMA. The mean time taken by Group B was13.57±3.48 seconds as compared to 18.82±5.09 seconds of Group F. The complications (sore throat, dysphagia, dysphonia) were significant for Group F as compared to Group B. The haemodynamic parameters were insignificant for both the groups.Group FGroup B No.% ageNo.% ageFirst time successYes2674.293394.29No925.7125.71Total35100.0035100.00Χ2: 5.285; P=0.002Conclusion:Although both supraglottic devices are feasible for blind tracheal intubation, Blockbuster LMA is a better option as it provides higher first pass success rate with less complications like sore throat, dysphagia and dysphonia.

Relationship between tracheal intubation and the drugs used by patients with drug overdose due to self-harm

BackgroundTracheal intubation may be performed in patients with drug overdose due to self-harm; however, the details of the causative drug are unknown. The purpose of this study was to clarify the relationship between drugs or its blood levels of patients with drug overdose and the need for tracheal intubation based on the actual measurement results.MethodsFrom October 2018 to March 2020, 132 patients with drug overdose due to self-harm who were transported to the emergency department (ED) were studied. Patient drugs were measured using gas chromatography–mass spectrometry (GC-MS) and were analyzed on the basis of the GC/MS Forensic Toxicological Database. Logistic analysis was performed by combining patient information and GC-MS information.ResultsThe Glasgow Coma Scale (GCS) and Japan Coma Scale (JCS) efficiently predicted tracheal intubation in patients with drug overdose during transport triage; GCS (cut-off value: 12, area under the curve (AUC): 0.81, 95% confidence interval (CI): 0.71–0.88, sensitivity: 0.85, specificity: 0.71, P < 0.05) and JCS (cut-off value: 3, AUC: 0.74, 95% CI: 0.60–0.84, sensitivity: 0.60, specificity: 0.84, P < 0.05). The drugs detected in all patients with drug overdose in order were benzodiazepine receptor agonists (BZs; 43.9%), anticonvulsants (38.6%), antipsychotics (25.0%), and antidepressants (9.8%). In univariate logistic analysis, antipsychotics (odds ratio (OR) 2.46, 95% CI 1.19–5.20, P < 0.05), anticonvulsants (OR 2.71, 95% CI 1.26–5.98, P < 0.05), and anticonvulsants above alert blood levels (OR 27.8, 95% CI 2.92–264.1, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose, but not BZs and antidepressants. Also, in multivariate logistic analysis, antipsychotics (OR 2.27, 95% CI 1.07–4.83, P < 0.05), anticonvulsants (OR 2.50, 95% CI 1.14–5.64, P < 0.05) and in multivariate logistic analysis of blood levels, anticonvulsants above the alert blood levels (OR 24.9, 95% CI 2.56–241.6, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose respectively.ConclusionsLogistic analysis revealed that the use of anticonvulsants and antipsychotics were significantly associated with an increased OR in the tracheal intubation of patients with drug overdose due to self-harm.

Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain.

BackgroundWe explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients.MethodsAn software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.Results1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.ConclusionsMost physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

A disposable envelope for video-assisted intubating stylet during tracheal intubation in COVID-19 pandemic.

DEAR EDITOR, Tracheal intubation of patients with coronavirus disease-19 (COVID-19) is a potentially aerosol-generating procedure that requires a careful and efficient approach to ensure the safety of both patients and healthcare providers.1 Many guidelines recommend the use of video-assisted intubating devices (VAIDs) to increase the operator’s distance from the patient’s airway and the chance of first-pass success.2 When donned with personal protective equipment (PPE), the first-pass success rate and intubation time with VAIDs are not affected when compared with a direct laryngoscope.3 A VAID is usually a video laryngoscope or video intubating stylet. It mainly composes of four parts: monitor, main body, handle and its cable, and a blade or stylet. Compared with the traditional direct laryngoscope, VAIDs can be expensive to use and maintain with concerns for cost-effectiveness, quality, and environmental impact from the disposable blades or stylets. Moreover, the nondisposable parts of the equipment such as the handle, cable, and main body can be potential sources of cross-contamination if strict decontamination is not followed.4 An innovative and economic approach is to cover the entire VAID device with a disposable envelope, including the optic stylet, handle, and monitor during airway management. We explored this concept using a video optic intubating stylet (disposcope endoscope). An elastic, flexible heat-shrunk tube was designed and manufactured, which the optic style can be inserted easily without any lubricant. The end tip of the heat-shrunk tube consists of a transparent acrylic lens that does not block or in any way compromise the light and camera of the optic stylet. The handle is then covered by a disposable plastic drape. This setup ensures the video optic stylet is fully shielded during airway management or tracheal intubation. The demonstration is provided by supplementary appendix (https://youtu.be/XBh1W5Rki8k). After each procedure, the heat-shrunk tube and the plastic handle drape can be removed and disposed of. The heat-shrunk tube is very thin (thickness in 1.5 mm). After its fitting over the optic stylet, it still allows the loading of endotracheal tube equal to or larger than 5.5 ID in size. A pediatric optic stylet with a matching heat-shrunk tube is also developed, and it can be loaded with an endotracheal tube equal to or larger than 3 ID in size. The COVID-19 pandemic is not likely going to disappear and can potentially become a seasonal or endemic foe. Furthermore, infected asymptomatic and mildly symptomatic still confer a high risk of transmission. Routine and emergent airway management thus poses the risk of potential exposure and infection to healthcare workers during the procedure and postoperative decontamination.5 An affordable and practical disposable barrier method to the video-assisted airway device to protect the operators and reduce the associated cost.

Diabetes Mellitus Olan Hastalarda C-MAC Video Laringoskop ve Macintosh Laringoskopun Elektif Trakeal Entübasyon İçin Karşılaştırılması: Randomize Kontrollü Çalışma

Objective: C-MAC video laryngoscope and Macintosh direct laryngoscope were compared in terms of intubation conditions, during elective tracheal intubation in patients with diabetes mellitus (DM) who have a high risk for difficult airway. Material and Methods: One hundred and ten American Society of Anesthesiologist physical class II-III patients with DM undergoing elective surgery were randomized to be intubated using C-MAC video laryngoscope or Macintosh laryngoscope. Glottic view Cormack Lehane (CL) score, intubation time, intubation difficulty scale (IDS) score, and first attempt intubation success were compared. Results: Similar intubation times were detected [Macintosh laryngoscope: 39.6±30.1 seconds; C-MAC: 46.7±35.4 seconds (p=0.098). C-MAC provided significantly better CL scores]. Grade 1 CL laryngeal view was observed in 37 (68%) C-MAC vs. 26 (47.3%) Macintosh laryngoscope intubations (p=0.04). An IDS score of >5 was determined in 11 (20.4%) patients with C-MAC and in 10 (18.2%) with Macintosh laryngoscope (p=0.04), indicating an overall 20.1% moderate-to-severe intubation difficulty (p=0.536). The mean IDS score was 3.2±2.9 and 2.4±3.3 with C-MAC and Macintosh laryngoscopes, (p=0.04). First-attempt intubation success was 83.3% vs. 87.0% with C-MAC vs. Macintosh laryngoscope (p=0.786). Conclusion: In patients with DM, CMAC provided improved glottis visualization, similar intubation time and first-attempt intubation success as a first-attempt intubation device compared with the Macintosh laryngoscope. However IDS scores were higher with the C-MAC. The incidence of actual intubation difficulty was found 20.1% in this diabetic study population.

Comparison of Airtraq with Macintosh Laryngoscope for Endotracheal Intubation in Paediatric Patients: A Randomised Controlled Trial

Introduction: The Airtraq is a new intubation device that has been developed to facilitate tracheal intubation in patients with normal or difficult airway. The available paediatric sizes are 0, 1 and 2 and are of grey, purple, green colour. These can insert endotracheal tube of size 2.0-3.5/4-5.5/6-7.5, respectively. Aim: To evaluate the clinical efficacy of Airtraq laryngoscope in comparison with Macintosh by experienced anaesthesiologist for intubation in paediatric patients. Materials and Methods: The randomised controlled trial was conducted at Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, from December 2015 to August 2017. Fifty healthy children, aged 2-10 years of American Society of Anesthesiologists (ASA) grades I/II, presenting for elective surgery were randomly allocated in two equal groups. Endotracheal intubation was done either using Airtraq or Macintosh laryngoscope. Duration of intubation (primary variable), number of attempts, ease of intubation, oesophageal intubation, optimisation maneuvers, Percentage Of Glottic Opening (POGO) scoring and haemodynamic parameters were compared between two groups. Patients’ demographic data, intubation time, haemodynamic variables were analysed by Unpaired t-test. While number of attempts for intubation, ease of intubation, optimisation maneuvers and POGO scoring were analysed by Fisher’s-exact test. Data was presented as mean (SD) with categorical data presented as number (%) and as frequencies. The p-value of &lt;0.05 was considered as significant. Results: There was no difference in demographic variables and duration of surgery between two groups. Intubation time, which was taken as primary variable, was found to be significantly longer in Macintosh (56.28±6.02 sec) as compared to Airtraq (25.60±3.73 sec) (p-value &lt;0.0001). In terms of ease of intubation and POGO scoring Airtraq was better as compared to Macintosh. Haemodynamically, Airtraq was found to be better as compared to Macintosh reflected by postintubation heart rate which was 110±7.84 beats/min with Airtraq while 119.32±10.61 beats/min with Macintosh (p-value=0.0028). The two groups were statistically comparable in terms of number of attempts, optimisation maneuvers and mean blood pressure changes. Conclusion: It can be concluded that Airtraq is a reliable and promising alternative to Macintosh for endotracheal intubation in paediatric patients as seen by duration of intubation, better Laryngeal view, ease of intubation and haemodynamic changes.

Comparative Study of Safety and Efficacy of Three Different Doses of Fentanyl on Hemodynamic Response to Laryngoscopy and Tracheal Intubation in Patients under General Anaesthesia

Aim of Study: Laryngoscopy and endotracheal intubation are the commonest method for securing a definitive airway for general anaesthesia. It is one of the most invasive and painful stimuli in anaesthesia producing clinically relevant changes in the hemodynamic variables.&#x0D; This study has been designed to compare the safety and efficacy of three different doses of fentanyl (2µg/kg, 3µg/kg and 4µg/kg) in attenuating hemodynamic response, following laryngoscopy and endotracheal intubation.&#x0D; Materials and Methods: In this observational study, three groups of 90 patients belonging to ASA grade I and II, aged between 18 to 65&#x0D; years, including either gender, posted for elective surgery under GA with informed consent. Baseline vital hemodynamic parameters and the serial heart rate, arterial pressures, SpO2 and respiratory rate were noted at five minutes after intravenous fentanyl administration, during laryngoscopy &amp; intubation and at 1-, 3-, 5-, 10- and 20-minutes after laryngoscopy. Ramsay sedation scores were also noted at five minutes after intravenous fentanyl administration, during extubation and at 10-, 20- and 30-minutes after extubation.&#x0D; Results: There was substantial difference in mean HR, SBP, DBP &amp; MAP values post 5 minutes after intravenous fentanyl administration, during laryngoscopy, at 1, 3-, 5-, 10- and 20-minutes following laryngoscopy and intubation between the three groups. Patients’ behaviour belonging to group C (IV fentanyl 4µg/kg), followed by the patients of group B (IV fentanyl 3µg/kg) presented considerable amount of attenuation of all the hemodynamic stress parameters effectively, with statistically significant results when compared to group A (IV fentanyl 2µg/kg).&#x0D; Conclusion: Intravenous fentanyl 4µg/kg and 3µg/kg are better at attenuating the laryngo-tracheal stress response, in comparison to intravenous fentanyl 2µg/kg.