Ullah, M A; Rahman, M A; Chowdhury, L H; Mohammed, S; Hasan, M I
Nasogastric intubation is a common procedure with both merits and demerits. Controversies exist about the routine use of nasogastric intubation following upper gastrointestinal surgery. Good numbers of literatures were published in favour of selective nasogastric intubation pointing out some complications of routine use of nasogastric tube. In 1995, Cheatham et al. concluded in a meta-analysis that although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of hospital stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. In July 2004, Cochrane database of systemic review published the result of their systemic review on the prophylactic decompression after abdominal surgery, that review was revised and updated in 2007. According to this database, routine nasogastric intubation should be abandoned in favour of selective use of nasogastric tube. In our country some surgeons are practicing it routinely and some are not. This observation prompted us to conduct this study in order to see and compare the outcome of upper gastrointestinal surgery with and without nasogastric intubation. This will help us to make decision whether nasogastric intubation will be done routinely or not following upper gastrointestinal surgery.
Jestin N. Carlson
Full Text Available Introduction: Video laryngoscopy (VL has been advocated for several aspects of emergency airway management; however, there are still concerns over its use in select patient populations such as those with large volume hematemesis secondary to gastrointestinal (GI bleeds. Given the relatively infrequent nature of this disease process, we sought to compare intubation outcomes between VL and traditional direct laryngoscopy (DL in patients intubated with GI bleeding, using the third iteration of the National Emergency Airway Registry (NEARIII. Methods: We performed a retrospective analysis of a prospectively collected national database (NEARIII of intubations performed in United States emergency departments (EDs from July 1, 2002, through December 31, 2012. All cases where the indication for intubation was “GI bleed” were analyzed. We included patient, provider and intubation characteristics. We compared data between intubation attempts initiated as DL and VL using parametric and non-parametric tests when appropriate. Results: We identified 325 intubations, 295 DL and 30 VL. DL and VL cases were similar in terms of age, sex, weight, difficult airway predictors, operator specialty (emergency medicine, anesthesia or other and level of operator training (post-graduate year 1, 2, etc. Proportion of successful first attempts (DL 261/295 (88.5% vs. VL 28/30 (93.3% p=0.58 and Cormack-Lehane grade views (p=0.89 were similar between devices. The need for device change was similar between DL [2/295 (0.7% and VL 1/30 (3.3%; p=0.15]. Conclusion: In this national registry of intubations performed in the ED for patients with GI bleeds, both DL and VL had similar rates of success, glottic views and need to change devices.
Carlson, Jestin N.; Crofts, Jason; Walls, Ron M.; Brown, Calvin A.
Introduction Video laryngoscopy (VL) has been advocated for several aspects of emergency airway management; however, there are still concerns over its use in select patient populations such as those with large volume hematemesis secondary to gastrointestinal (GI) bleeds. Given the relatively infrequent nature of this disease process, we sought to compare intubation outcomes between VL and traditional direct laryngoscopy (DL) in patients intubated with GI bleeding, using the third iteration of the National Emergency Airway Registry (NEARIII). Methods We performed a retrospective analysis of a prospectively collected national database (NEARIII) of intubations performed in United States emergency departments (EDs) from July 1, 2002, through December 31, 2012. All cases where the indication for intubation was “GI bleed” were analyzed. We included patient, provider and intubation characteristics. We compared data between intubation attempts initiated as DL and VL using parametric and non-parametric tests when appropriate. Results We identified 325 intubations, 295 DL and 30 VL. DL and VL cases were similar in terms of age, sex, weight, difficult airway predictors, operator specialty (emergency medicine, anesthesia or other) and level of operator training (post-graduate year 1, 2, etc). Proportion of successful first attempts (DL 261/295 (88.5%) vs. VL 28/30 (93.3%) p=0.58) and Cormack-Lehane grade views (p=0.89) were similar between devices. The need for device change was similar between DL [2/295 (0.7%) and VL 1/30 (3.3%); p=0.15]. Conclusion In this national registry of intubations performed in the ED for patients with GI bleeds, both DL and VL had similar rates of success, glottic views and need to change devices. PMID:26759653
Full Text Available Background and Objective: The optimal treatment strategy for patients with gastric cancer is gastrectomy. Typically, nasogastric intubation is used after this type of surgery to feed patients; however, there seems to be no unanimity of opinion on this topic. Therefore, this study aimed to evaluate the effect of nasogastric intubation on gastrointestinal function after gastrectomy in gastric cancer patients. Materials and Method: This clinical trial was conducted on gastric cancer patients, admitted to the general ward of Imam Reza Hospital in Mashhad, Iran in 2015. In total, 68 patients were selected through randomized convenience sampling and divided into two intervention and control groups of 34 individuals. Nasogastric tube insertion was applied for the intervention group after the surgery. Patients of the study groups were fasted for three days after the surgery, which was followed by the removal of nasogastric tubes and initiation of oral feeding. Gastrointestinal function of all the participants was evaluated six hours after transferring to the ward up to seven days after the surgery on a daily basis using nausea and vomiting assessment tools and researcher-made questionnaire of gastrointestinal function. Data analysis was performed in SPSS version 16 using Fisher’s exact test, Chi-square, Mann-Whitney U, repeated measures ANOVA and paired t-test. Results: In this study, the severity of nausea and vomiting, the first time of passing gas and severity of flatulence Intensity were less observed in the control group, compared to the intervention group. Moreover, postoperative food tolerance was higher in the patients of the control group, compared to the other study group (P<0.05. Conclusion: According to the results of this study, nasogastric intubation can delay normal gastrointestinal function after gastrectomy. Therefore, it is not recommended to use this method after gastrectomy.
Cappell, Mitchell S
Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be
Sheykhol Islami V
Full Text Available The incidence of failed intubation is higher in obstetric than other surgical patients. Failed intubation was the 2nd commonest cause of mortality during anesthesia. Bearing in mind that failre to intubate may be unavoidable in certain circumstances, it is worth reviewing. The factors, which may contribute to a disastrous out come. Priorities of subsequent management must include maintaining oxygenation and preventing aspiration of gastric contents. Fiber optic intubation is now the technique of choice with a high success rate and with least trauma to the patient.
Difficult endotracheal intubation techniques include, use of fiberoptic bronchoscope, intubating laryngeal mask airway, tracheostomy, blind nasotracheal and retrograde intubation. According to the Difficult Airway Society guidelines, intubating with the aid of a fiberoptic scope has taken its place as the standard adjuvant for.
Weingart, Scott D; Trueger, N Seth; Wong, Nelson
assessed. RESULTS: A total of 62 patients were enrolled: 19 patients required delayed sequence intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV, and 4 patients required it for nasogastric tube placement. Saturations increased from a mean of 89.9% before delayed sequence...
with an ante-grade or retrograde approach for traction. In the latter cases railroading was done. Following placement, the tube was anchored with one or two stitches through the tube and the abdominal oesophagus. Results. Thirty-four patients were intubated during a twenty- four month study period (1988-1990). Eighteen ...
The UKCC's 'Scope of Professional Practice' validly points out that, 'Practice takes place in a context of continuing change and development' partly 'as a result of new approaches to professional practice'. Consequently, demands are made on educational institutions to prepare professionals for new practice. One of the new skills, which is now being taught to nurses on the Anaesthetic Nursing Course at the Eastern Area College, is that of endotracheal intubation. Bearing in mind the all-important proviso that 'As a registered nurse, midwife or health visitor, you are personally accountable for your practice', it is essential that post registration education 'equips practitioners with additional and more specialist skills necessary to meet the special needs of patients and clients'. This article is therefore designed as an introduction to the basic rationale, anatomy and procedural skills necessary for safe intubation.
Ben-Ami-Lozover, S; Benbassat, J
For critically ill patients on assisted respiration caring behavior is particularly important. In this paper we review the literature on patient satisfaction with medical care and with their communication with the nursing staff. Communication skills of staff of intensive respiratory care units were studied by direct observation, debriefing of hospitalized patients and by interview of discharged patients. Direct observation showed that nurses spent only a small proportion of their time talking to patients. The interactions dealt with technical rather than emotional matters and consisted mostly of negative and discouraging comments rather than positive and supporting messages. Debriefing of hospitalized intubated patients revealed a high degree of overall satisfaction with care on the one hand, and complaints of communication problems, anxiety and anger on the other. Lastly, interviews with discharged patients revealed that as many as a quarter of those who could remember their hospitalization reported feelings of anxiety, anger, distrust in the staff and difficulty in communication. These findings suggest that the nursing staff needs improved communication skills. There is evidence that the judicious use of communication techniques may improve patient satisfaction, reduce anxiety and reduce duration of treatment.
The authors report the case of a primary small bowel lymphoma discovered incidentally in a 33-year-old male following ileal intubation at colonoscopy. The patient subsequently underwent curative treatment with chemotherapy. This case not only highlights the importance of routine ileoscopy but also the successful use of chemotherapy in a disease for which the optimal treatment modality has not been well characterized.
MacIntyre, N.R.; Silver, R.M.; Miller, C.W.; Schuler, F.; Coleman, R.E.
To study the effects of respiratory failure and mechanical ventilation on aerosol delivery to the lungs, nuclear scans were performed after aerosolization of 5 to 9 mCi of Tc-99m diethylenetriamine pentaacetic acid in seven stable, intubated, and mechanically ventilated patients. The radioactivity reaching the lungs was 2.9 +/- .7% (mean +/- SD) of the administered dose, an amount significantly less than that in three healthy nonintubated subjects and also less than what would be expected in nonintubated subjects from other published reports. A subsequent study was performed in 15 additional mechanically ventilated patients who were receiving aerosolized bronchodilators through their endotracheal tube. In these patients, heart rate and lung mechanical function values before and after treatment were not significantly different. It is concluded from these studies that aerosol delivery in mechanically ventilated patients is significantly reduced and that this is probably due to a combination of suboptimal breathing pattern, intrinsic airway disease, and the endotracheal tube functioning as both a site for aerosol deposition through impaction as well as a barrier to gastrointestinal absorption
Aris, A M; Elegbe, E O; Krishna, R
Intubation was difficult and traumatic in a 40-year-old patient presented for emergency oesophagoscopy because the diagnosis of stylohyoid ligament calcification was not suspected. High probability of stylohyoid ligament calcification should be suspected when there is difficulty in lifting the epiglottis and fibre-optic laryngoscopy is suggested as the best way to tackle this problem to prevent trauma and possible risk of regurgitation and aspiration especially in emergency situation.
Full Text Available Background: Prolonged endotracheal intubation is a growing method for supporting ventilation in patients who require intensive care. Despite considerable advancement in endotracheal intubation, this method still has some complications; the most important is laryngo-tracheal injuries. Methods: Over a 2-year period, this retrospective study was conducted on 57 patients with history of prolonged intubation who were referred to the ENT Department of Amir Alam Hospital. For each patient, a complete evaluation including history, physical examination, and direct laryngoscopy and bronchoscopy was done under general anesthesia. Results: Fifty-seven patients (44 male; mean age, 23.014.7 years were studied. Mean intubation period was 15.88 days. The most common presenting symptom was dyspnea (62%. Head trauma was responsible for most cases of intubation (72.4%. The most common types of tracheal and laryngeal lesions were tracheal (56.9% and subglottic (55.2% stenosis, respectively. Mean length of tracheal stenosis was 0.810.83 cm. There was a statistically significant relationship between length of tracheal stenosis and intubation period (P=0.0001 but no relation was observed between tracheal stenosis and age, sex, and etiology of intubation (All P=NS. Among the glottic lesions, inter- arytenoids adhesion was the most common lesion (25.9%. No statistically significant relation was found between glottic and subglottic lesions and age, sex and intubation period (all P=NS. Length of stenosis and intubation period was significantly greater in tracheal/ subglottic lesions than those in glottic/ supraglottic lesions (all P=NS. Conclusion: After prolonged endotracheal intubation, laryngo-tracheal lesions had no relation with patient’s age, sex, and cause of intubation.There was direct relation between length of tracheal stenosis and intubation period. Glottic lesions were more commonly observed in head trauma patients. Lesion length and intubation
Haffejee, A A; Angorn, I B
The nutritional status of 15 patients suffering from unresectable carcinoma of the midthoracic esophagus was evaluated before and after palliative pulsion intubation. All patients showed evidence of protein-calorie malnutrition, prior to intubation. Oral alimentation using a formulated hospital ward diet with an elemental dietary supplement reversed the nutritional deficit. A mean daily positive nitrogen balance of seven grams was achieved three weeks following intubation. No episode of tube blockage was observed and the elemental diet supplement was well tolerated. PMID:74985
the trauma victim with an unstable cervical spine. Ann Emerg Med 17: 25- 29, 1988 4. Cormack RS, Lehane J: Difficult tracheal intubation in...optimal airway view was scored according to Cormack .4 The Malampati Grade, ease or difficulty of intubation, and Cormack scores for each patient are...Malampati and Cormack scores for individual patients and specific events. 13 Median Distraction at each stage of intubation for different methods of
Ydemann, Mogens; Rovsing, Marie Louise; Lindekaer, A L
Several potential problems can arise from airway management in morbidly obese patients, including difficult mask ventilation and difficult intubation. We hypothesised that endotracheal intubation of morbidly obese patients would be more rapid using the GlideScope(®) (GS) (Verathon Inc Corporate...
Introduction: Airway management is one of the most important medical priorities. Despite its benefits, intubation can be sometimes associated with many complications and hardships. Hard intubation can have dangerous consequences, including hypoxia, increased intracranial pressure, cardiac collapse-vascular, traumatic ...
A total of 46.8% of nasal trauma were inferior turbinate trauma involving the inferior medial aspect. Conclusion: The use of untreated cuffed polyvinyl chloride tube for nasotracheal intubation in unprepared nostrils is associated with a high incidence of epistaxis and nasal trauma. Keywords: nasotracheal intubation, epistaxis ...
Full Text Available Abstract Background The “Rusch” intubation stylet is used to make endotracheal tube intubation easy. We designed this study to evaluate the usage of this equipment in the guidance of nasogastric tube (NGT insertion. Methods A total of 103 patients, aged 23 to 70 years, undergoing gastrointestinal or hepatic surgeries that required intraoperative NGT insertions were enrolled into our study. The patients were randomly allocated to the control group (Group C or the stylet group (Group S according to a computerized, random allocation software program. In the control group, the NGT was inserted with the patient’s head in an intubating position. In the stylet group, the NGT was inserted with the assistance of a “Rusch” intubation stylet tied together at the tips by a slipknot. The success rates of the two methods, the durations of the insertions, and the occurrences of complications were recorded. All of the failed cases in the control group were subjected to the new technique used in the stylet group, and the successful rescue rate was also evaluated. Results Successful insertions were recorded for 52/53 patients (98.1% in Group S and for 32/50 patients (64% in Group C. The mean insertion times were 39.5 ± 19.5 seconds in Group C and 40.3 ± 23.2 seconds in Group S. Successful rescues of failure cases in Group C were achieved in 17/18 patients (94.4% with the assistance of a “Rusch” intubation stylet. Conclusions The “Rusch” intubation stylet-guided method is reliable with a high success rate of NGT insertion in anesthetized and intubated patients. Trial registration Institutional Review Board of Chang Gung Memorial Hospital (IRB: 98-2669B and Australian New Zealand Clinical Trials Registry (ACTRN12611000423910
Background The “Rusch” intubation stylet is used to make endotracheal tube intubation easy. We designed this study to evaluate the usage of this equipment in the guidance of nasogastric tube (NGT) insertion. Methods A total of 103 patients, aged 23 to 70 years, undergoing gastrointestinal or hepatic surgeries that required intraoperative NGT insertions were enrolled into our study. The patients were randomly allocated to the control group (Group C) or the stylet group (Group S) according to a computerized, random allocation software program. In the control group, the NGT was inserted with the patient’s head in an intubating position. In the stylet group, the NGT was inserted with the assistance of a “Rusch” intubation stylet tied together at the tips by a slipknot. The success rates of the two methods, the durations of the insertions, and the occurrences of complications were recorded. All of the failed cases in the control group were subjected to the new technique used in the stylet group, and the successful rescue rate was also evaluated. Results Successful insertions were recorded for 52/53 patients (98.1%) in Group S and for 32/50 patients (64%) in Group C. The mean insertion times were 39.5 ± 19.5 seconds in Group C and 40.3 ± 23.2 seconds in Group S. Successful rescues of failure cases in Group C were achieved in 17/18 patients (94.4%) with the assistance of a “Rusch” intubation stylet. Conclusions The “Rusch” intubation stylet-guided method is reliable with a high success rate of NGT insertion in anesthetized and intubated patients. Trial registration Institutional Review Board of Chang Gung Memorial Hospital (IRB: 98-2669B) and Australian New Zealand Clinical Trials Registry (ACTRN12611000423910) PMID:22853453
Foglia, Julena; Archer, David; Pytka, Saul; Baghirzada, Leyla; Duttchen, Kaylene
To determine if an endotracheal (ET) tube will distort the laryngeal view obtained with direct laryngoscopy measuring with the modified Cormack-Lehane scale (MCL). Observational single-arm study. The University of Calgary teaching hospitals. Patients between 18 and 86 years of age undergoing elective surgical procedures. A total of 173 patients were enrolled and analyzed. Direct laryngoscopy view obtained before ET intubation and directly after intubation. The MCL scales were described for each view obtained and compared to each other with each patient serving as their own control. The primary objective was a change in the best obtainable view by direct laryngoscopy from an acceptable view (MCLS 1 or 2a) to an unacceptable view (MCLS 2b, 3, or 4) or changing from an unacceptable view (MCLS 2b, 3, or 4) to an acceptable view (MCLS 1 or 2a). The main finding of this study was that the ET tube altered the MCL in 58 (33%) of 173 patients, "worsening" the grade in 30 patients (17.34%) and "improving" the grade in 28 patients (16.18%). We performed a prospective observational study to address the predictive value of postintubation laryngoscopy grade in adults. The presence of the ET tube both increased visualization of the glottis and worsened the view in different subjects. The important outcome was that the presence of the ET tube did in fact change the view obtained of the larynx during direct laryngoscopy. In conclusion, postintubation MCL grades may not be reliable to predict laryngeal grade and should be used with caution in the right clinical context. Copyright © 2016 Elsevier Inc. All rights reserved.
Geier, J; Orlando, B
A pregnant woman at 25weeks of gestation was diagnosed with laryngeal tuberculosis following a failed intubation for upper gastrointestinal endoscopy. Laryngeal tuberculosis represents approximately 1% of all cases of tuberculosis in the United States and presents a unique diagnostic challenge, because accompanying laryngeal changes are both varied and nonspecific. This report highlights both the challenges of the pregnant airway and the diagnosis and treatment of laryngeal tuberculosis. Copyright © 2017 Elsevier Ltd. All rights reserved.
Strøm, C; Barnung, S; Kristensen, M S
assessed for eligibility. Patients were intubated using Boedeker intubation forceps and MVL. The primary endpoint was time to intubation. The secondary endpoints were intubation success rate, number of intubation attempts, intubation conditions and post-operative hoarseness. RESULTS: Thirty-three patients......BACKGROUND: Videolaryngoscopes with sharp angulated blades improve the view of the vocal cords but this does not necessarily result in higher success rates of intubation The aim of this study was to evaluate the efficacy of using Boedeker intubation forceps in conjunction with McGrath Series 5...
Nicholas Thomas A
Lower gastrointestinal endoscopy findings included 7 cases of polyps, 3 cases of colorectal cancer and 2 cases of diverticulosis. Commonest lesion on lower GI endoscopy was haemorrhoids (41.7%). Adjusted caecal intubation was 81.4% for colonoscopies performed. Overall adenoma detection rate for male and female ...
We compared heart rate and blood pressure changes to intubation produced by conventional laryngoscopic-guided intubation to those produced by blind intubation through the intubating laryngeal mask (ILM) in normotensive adults with normal airways. Forty paralysed, anaesthetised adults undergoing elective surgery ...
Esra Yildiz Sut
Full Text Available Abstract Purpose: In this study, we evaluated the effectiveness of intubations by way of "Gum Elastic Bougie" and "Intubating Laryngeal Mask Airway" in endotracheal intubation of patients with simulated cervical trauma. Method: 134 patients were included in the study. All patients were placed cervical collar for a simulated cervical trauma. Patients were allocated randomly into three groups: Group NI (n = 45 intubation with Macintosh laryngoscopy, Group GEB (n = 45 intubation with Gum Elastic Bougie, and Group ILMA (n = 44 intubation with Intubating Laryngeal Mask Airway. The number of intubation attempts, success of intubation, duration of complete visualization of the larynx, duration of intubation, user's performance score, hemodynamic changes and the observed complications were recorded. Results: Success of intubation in the first attempt was highest in Group GEB while it was lowest in Group ILMA. Regarding the intubation success, rates of successful intubation were 95.6%, 84.4% and 65.9% in Groups GEB, NI, and ILMA, respectively. Durations of visualization of larynx and intubation were shorter in Groups NI and GEB than in Group ILMA. This difference was statistically significant (p < 0.05 while there was no significant difference between Groups NI and GEB. The number of patients with "good" intubation performance was significantly higher in Group GEB while the number of patients with "poor" intubation performance was significantly higher in Group ILMA (p < 0.05. Conclusions: We conclude that GEB, which is cheap and easily accessible, should be an advantageous choice in cervical trauma patients for both the easeness of intubation and patient morbidity and mortality.
In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage. The need for urgent endoscopy before 6-12 h after the onset of upper gastrointestinal bleeding episode may be beneficial in patients with hemodynamic instability and high risk for comorbidity. It is confirmed that in Western but not in Japanese populations, gastrointestinal bleeding episodes admitted to hospital during weekend days are associated with a worse prognosis associated with delays in the clinical management of the events. The strategy of a restrictive policy on blood transfusions during an upper GI bleeding event has been challenged. Several studies have shown the benefit of identifying the bleeding vessel in non varicose underlying gastric lesions by Doppler ultrasound which allows direct endoscopic therapy in the patient with upper GI bleeding. Finally, it has been reported that lower gastrointestinal bleeding diverticula band ligation or hemoclipping are both safe and have the same long-term outcomes. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Turner, Joseph S; Ellender, Timothy J; Okonkwo, Enola R; Stepsis, Tyler M; Stevens, Andrew C; Eddy, Christopher S; Sembroski, Erik G; Perkins, Anthony J; Cooper, Dylan D
There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.
Mota, Luiz Alberto Alves
Full Text Available Introduction: The injuries caused for the orotracheal intubation are common in our way and widely told by literature. Generally the pipe rank of or consequence of its permanence in the aerial ways of the patient is caused by accidents in. It has diverse types of larynx injuries, caused for multiple mechanisms. Objective: To verify, in literature, the main causes of laryngeal complications after- orotracheal intubation and its mechanisms of injury. Revision of Literature: The searched databases had been LILACS, BIREME and SCIELO. Were updated, books and theses had been used, delimiting itself the period enters 1953 the 2009. The keywords used for the search of articles had been: complications, injuries, larynx, intubation, endotracheal, orotracheal, granulomas, stenosis. 59 references had been selected. The used criteria of inclusion for the choice of articles had been the ones that had shown to the diverse types of injuries caused for the orotracheal intubation and its pathophysiology. Final Considerations: This revision of literature was motivated by the comment in the practical clinic of a great number of laryngeal sequels in patients submitted to the orotracheal intubation. Of that is ahead important the knowledge, for the professionals of the area of health, the types of complications and its causes, with intention to prevent them, adopting measured of prevention of these injuries.
Reid, Lindsay A; Dunn, Mark; Mckeown, Dermot W; Oglesby, Angela J
To determine the frequency of and primary indication for surgical airway during emergency department intubation. Prospectively collected data from all intubations performed in the emergency department from January 1999 to July 2007 were analysed to ascertain the frequency of surgical airway access. Original data were collected on a structured proforma, entered into a regional database and analysed. Patient records were then reviewed to determine the primary indication for a surgical airway. Emergency department intubation was undertaken in 2524 patients. Of these, only five patients (0.2%) required a surgical airway. The most common indication for a surgical airway was trauma in four of the five patients. Two patients had attempted rapid sequence induction before surgical airway. Two patients had gaseous inductions and one patient received no drugs. In all five patients, surgical airway was performed secondary to failed endotracheal intubation attempt(s) and was never the primary technique used. In our emergency department, surgical airway is an uncommon procedure. The rate of 0.2% is significantly lower than rates quoted in other studies. The most common indication for surgical airway was severe facial or neck trauma. Our emergency department has a joint protocol for emergency intubation agreed by the Departments of Emergency Medicine, Anaesthesia and Critical Care at the Edinburgh Royal Infirmary. We believe that the low surgical airway rate is secondary to this collaborative approach. The identified low rate of emergency department surgical airway has implications for training and maintenance of skills for emergency medicine trainees and physicians.
Full Text Available Background : Endotracheal intubations performed in the Emergency Department. Aims : To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI on ease of intubation. Settings and Design : A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months. Materials and Methods : Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed. Statistical Analysis : Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups. Results : Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4. Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations. Conclusions : An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.
Jepson, Mark A.; Bouwmeester, Hans
The epithelial lining of the gastrointestinal tract (GIT) acts as a barrier to uptake of potentially dangerous material while allowing absorption of processed food. The gut may be exposed to a diverse range of engineered nanomaterials due to their deliberate addition to food and consumer products
Conclusion: In conclusion, our study showed that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during blind nasotracheal intubation; however it could not facilitate blind nasotracheal intubation.
Blind intubation through the ILM using a straight silicone tracheal tube manufactured for specific use with the ILM; 2. Intubation with a size 3 macintosh laryngoscope ... such as in patients with ischaemic heart disease. Key Words: Equipment:intubating laryngeal mask airway; Airway,complications: haemodynamic response ...
over a two-year period. Each patient required maxillomandibular fixation following trauma.Acommon feature in these patients was depressed fracture of the frontonasal bone which could not permit nasal intubation. These patients were reluctant to have tracheostomy if there was an alternative option of securing their airway.
The use of nasogastric tubes, throat pack, duration of intubation and status of the anaesthetists were also noted. The presence of sore throat and other throat complications were determined within 24 - 36 hours after surgery. Results: One hundred twenty six (63%) patients experienced throat complications. The incidence of ...
Treatment of hypertension following endotracheal intubation. A study comparing the efficacy of labetalol, practolol and placebo. R. J. MAHARAJ, M. THOMPSON, J. G. BROCK-UTNE,. J. W. DOWNING. R. WI LLlAMSON,. Summary. Labetalol, a new adrenergic receptor antagonist, has both a- and B-blocking properties.
Hoffmann, Clifford O; Samuels, Paul J; Beckman, Eileen; Hein, Elizabeth A; Shackleford, T Michael; Overbey, Evelyn; Berlin, Richard E; Wang, Yu; Nick, Todd G; Gunter, Joel B
We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation. Optimum airway management during EGD in children remains undecided. Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi-square contingency tables or Fisher's exact test as appropriate. Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD. Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.
Full Text Available BACKGROUND & AIMS Several pre-operative screening tools are used in adult. Wide range of pediatric anatomical & developmental differences (especially with infants makes uses of adult clinical predictors in challenge. The aim of our study is to assess various measurements of intubation in infants and their correlation with difficult laryngoscopy. MATERIAL AND METHODS This prospective randomized study conducted in 100 infants. We assessed the usefulness of neck length (NL, neck circumference (NC, Head Circumference, (HC ratio of NC/NL and introduced length of laryngoscope blade as predictors of difficult laryngoscopy and intubation. RESULT NC, NL, HC and ratio of NC/NL were significantly associated with incidence of difficult laryngoscopy and intubation. As this ratio increases difficulty at laryngoscopy increases (p<.001. Difficult laryngoscopy was assessed using Cormack Lehane grading. We found as age increases laryngoscopy becomes easier. (p<0.05 CONCLUSION There is no single anatomical measurement of intubation in infants in our study we measured NC, NL, NC/NL, HC and introduced length of laryngoscope blade which were found to be important predictors of difficult laryngoscopy and intubation. Statistical significant correlation was found between age and Cormack Lehane grades. In infants, various congenital malformations are highly associated with difficult laryngoscopy and intubation.
Ti, Lian K; Chen, Fun-Gee; Tan, Gee-Mei; Tan, Wah-Tze; Tan, Jacqueline M J; Shen, Liang; Goy, Raymond W L
Simulators provide an effective platform for the learning of clinical motor skills such as endotracheal intubation, although the optimal learning technique remains unidentified. We hypothesised that, for novices, experiential learning would improve the learning and retention of endotracheal intubation compared with guided learning. Year 4 medical students were randomised to either guided or experiential learning. Students in the guided group were taught using the conventional step-by-step technique. Students in the experiential group had to work out the correct technique for intubation on their own. Both groups had further opportunities to intubate manikins and patients during their postings. The students were recalled 3, 6, 9 and 12 months later, and their intubation skills assessed in four major categories: equipment preparation; intubation technique; successful intubation, and placement confirmation. A total of 210 students (107 guided, 103 experiential) participated in the study. At 3 months, 64.5% of the students in the experiential group successfully intubated the manikin, compared with 36.9% in the guided group (P experiential group also had higher overall scores, signifying quality of intubation attempts, at 3 months (79% versus 70%; P experiential group at 12 months. Success rates improved with time, reaching 86% at 12 months. Novices learned and retained the skill of endotracheal intubation better with experiential learning. This study suggests that experiential learning should be adopted for the teaching of endotracheal intubation and that refresher tuition at 3-monthly intervals will prevent the decay of this skill in infrequent users.
Moliner-Martínez, Y; Prima-Garcia, Helena; Ribera, Antonio; Coronado, Eugenio; Campíns-Falcó, P
We report a new in-tube solid phase microextraction approach named magnetic in-tube solid phase microextraction, magnetic-IT-SPME. Magnetic-IT-SPME has been developed, taking advantage of magnetic microfluidic principles with the aim to improve extraction efficiency of IT-SPME systems. First, a magnetic hybrid material formed by Fe(3)O(4) nanoparticles supported on SiO(2) was synthesized and immobilized in the surface of a bared fused silica capillary column to obtain a magnetic adsorbent extraction phase. The capillary column was placed inside a magnetic coil that allowed the application of a variable magnetic field. Acetylsalicylic acid, acetaminophen, atenolol, diclofenac, and ibuprofen were tested as target analytes. The application of a controlled magnetic field resulted in quantitative extraction efficiencies of the target analytes between 70 and 100%. These results demonstrated that magnetic forces solve the low extraction efficiency (10-30%) of IT-SPME systems, which is one of their main drawbacks.
Walsh, M E
Fiberoptically guided tracheal intubation represents one of the most important advances in airway management to occur in the past thirty years. Perhaps its most important role is in management of the anticipated difficult airway. This is a situation in which the dangers of encountering the life-threatening "can\\'t intubate, can\\'t ventilate" situation can be avoided by placement of an endotracheal tube while the patient is awake. Although skill at the procedure of endoscopy is obviously necessary in this setting, these authors hold that success or failure of the technique frequently depends on the adequacy of preparation. These measures include 1) pre-operative assessment of the patient; 2) careful explanation of what lies in store; 3) "setting the stage"; 4) preparing the equipment to be used; and 5) preparing the patient (antisialogue, sedation, application of topical anesthesia to the upper airway). If these preparatory measures are carried out meticulously, the likelihood of performing a successful and comfortable awake fiberoptic tracheal intubation is greatly increased.
Koh, Wonuk; Kim, Hajung; Kim, Kyongsun; Ro, Young-Jin; Yang, Hong-Seuk
An unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS. We retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed. For the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure. Unexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation.
Marston, Alexander P; Lander, Timothy A; Tibesar, Robert J; Sidman, James D
To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population. Case series and retrospective chart review at a tertiary children's hospital. PRS newborns who underwent endotracheal intubation or other airway intervention before 3 months of age between January 2000 and July 2011 were identified from a pediatric otolaryngology practice database. Indications for airway intervention, anesthetic management, method of intubation, and comorbid conditions were collected. Thirty-three PRS newborns were identified. Twenty had isolated PRS, and 13 had PRS related to a coexisting syndrome. Thirteen of 35 (37%) endotracheal intubations performed in PRS newborns prior to mandibular distraction osteogenesis were accomplished with direct laryngoscopy. The remaining 22 of 35 (63%) who failed intubation with direct laryngoscopy were intubated over a flexible fiberoptic bronchoscope. No significant difference was observed between the isolated and syndromic PRS newborns with regard to technique utilized for intubation. No patient required rescue laryngeal mask airway or emergent tracheotomy, and no case resulted in death. This series demonstrates that endotracheal intubation is safe and effective in PRS newborns. In patients who failed intubation with direct laryngoscopy, intubation over a flexible fiberoptic bronchoscope provided a reliable alternative method. Although airway management in PRS newborns poses a significant challenge, experienced otolaryngologists and anesthesiologists can successfully manage these difficult airway cases. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.
Garne, Ester; Loane, Maria; Dolk, Helen
The aim of the study was to analyse the degree to which gestational age (GA) has been shortened due to prenatal diagnosis of gastrointestinal malformations (GIM). The data source for the study was 14 population-based registries of congenital malformations (EUROCAT). All liveborn infants with GIMs...... malformations, although not statistically significant for gastroschisis. There was little difference in median birthweight by GA for the pre- and postnatally diagnosed infants. The difference in GA at birth between prenatally and postnatally diagnosed infants with GIMs is enough to increase the risk...... of mortality for the prenatally diagnosed infants. Clinicians need to balance the risk of early delivery against the benefits of clinical convenience when making case management decisions after prenatal diagnosis. Very few studies have been able to show benefits of prenatal diagnosis of congenital...
Cheong, Yuseon; Kang, Seong Sik; Kim, Minsoo; Son, Hee Jeong; Park, Jaewoo; Kim, Jeong-Mo
Airway management in patients with complex maxillofacial injuries is a challenge to anesthesiologists. Submental intubation is a useful technique that is less invasive than tracheostomy in securing the airways where orotracheal and nasotracheal intubation cannot be performed. This procedure avoids the use of tracheostomy and bypasses its associated morbidities. A flexible and kink-resistant reinforced endotracheal tube with detachable universal connector is commonly used for submental intubation. Herein, we report cases involving submental intubation using a reinforced endotracheal tube with a non-detachable universal connector in patients with complex maxillofacial injuries. PMID:27924286
Biro, P; Fried, E; Schlaepfer, M
This single-centre, prospective trial was designed to assess the efficacy of a new retrograde transillumination device called the 'Infrared Red Intubation System' (IRRIS) to aid videolaryngoscopic tracheal intubation. We included 40 adult patients, who were undergoing elective urological surgery......-10])), credibility (10 (8-10 [5-10])) and ease of use (10 (9-10 [8-10])). Tracheal intubation with the system lasted 26 (16-32 [6-89]) s. No alternative technique of securing the airway was necessary. The lowest SpO2 during intubation was 98 (97-99 [91-100])%. We conclude that this method of retrograde...
Nowakowski, Michal; Williams, Stephan; Gallant, Jason; Ruel, Monique; Robitaille, Arnaud
Endotracheal intubation is commonly performed via direct laryngoscopy (DL). However, in certain patients, DL may be difficult or impossible. The Bonfils Rigid Fiberscope® (BRF) is an alternative intubation device, the design of which raises the question of whether factors that predict difficult DL also predict difficult BRF. We undertook this study to determine which demographic, morphologic, and morphometric factors predict difficult intubation with the BRF. Four hundred adult patients scheduled for elective surgery were recruited. Patients were excluded if awake intubation, rapid sequence induction, or induction without neuromuscular blocking agents was planned. Data were recorded, including age, sex, weight, height, American Society of Anesthesiologist classification, history of snoring and sleep apnea, Mallampati class, upper lip bite test score, interincisor, thyromental and sternothyroid distances, manubriomental distances in flexion and extension, neck circumference, maximal neck flexion and extension, neck skinfold thickness at the cricoid cartilage, and Cormack and Lehane grade obtained via DL after paralysis was confirmed. Quality of glottic visualization (good or poor), as well as the number of intubation attempts and time to successful intubation with the BRF, was noted. Univariate analyses were performed to evaluate the association between patient characteristics and time required for intubation. Variables that exhibited a significant correlation were included in a multivariate analysis using a standard least squares model. A P 1 attempt; 4 patients could not be intubated by using the BRF alone. These 4 patients were intubated by using a combination of DL and BRF (2 patients), DL and a Frova bougie (1 patient), and DL and an endotracheal tube shaped with a semirigid stylet (1 patient). Mean time for successful intubation was 26 ± 13 seconds. Multivariate analysis showed that decreased mouth opening (P = 0.008), increased body mass index (P = 0
James, R.D.; Pointon, R.C.S.
At the time of writing, radiotherapy is of only minor use in the management of adenocarcinoma of the gastrointestinal tract, for a number of reasons. First, an exploratory laparotomy is generally needed for diagnosis, and if possible the tumour is resected or by-passed. Second, radiotherapy planning in the upper abdomen is complicated by the proximity of small bowel, kidneys, and spinal cord. Third, it has been assumed that these tumours cause death largely as a result of distant metastases, so that local radiotherapy, even if effective, would contribute little to survival. The continued interest in radiotherapy for this group of tumours arises out of the poor survival rates following surgery, which have not changed for many years, and the morbidity associated with their resection. It was hoped that the addition of cytotoxic agents to radical surgery would improve survival rates in carcinoma of the stomach and intraperitoneal colon. Despite a large number of well-organised prospective trials, using a variety of cytotoxic drugs, there is so far no evidence that the addition of chemotherapy to radical surgery improves survival for either tumour site. The authors are therefore faced with a group of tumours which are not only common, but commonly fatal and many surgeons would accept that a new approach using modern radiotherapy techniques may well be justified. There is evidence that this movement is already taking place for carcinoma of the rectum, and the indications for radiotherapy in this condition will be dealt with below. Before considering these it is worth dwelling briefly on recent changes in surgical and radiological practices which, if they fulfil expectations, might allow radiotherapy to be used for carcinoma of the colon, stomach, and pancreas as it is now used for rectal cancer
Patients with 'difficult endotracheal intubation' may present for elective or emergency surgery. We present a case of a 29 year old female patient who required general anaesthesia for resection of a large mandibular osteosarcoma where the blind nasoendotracheal intubation technique was used.
Full Text Available Molar intubation is a technique of laryngoscopy that can be used for anticipated difficult intubation in cases where standard laryngoscopy technique is difficult due to presence of any intraoral mass that anatomically hampers laryngoscopy or that bleeds on touch. This technique is very easy, reliable and rewarding but should be practiced on normal patients for easy application in actual difficult cases.
Evaluation of the Intubating Laryngeal Mask Airway (ILMA) as an intubation conduit in patients with a cervical collar simulating fixed cervical spine. The page number in the footer is not for bibliographic referencing .... their use in patients with suspected cervical spine injury.1. Removal of the front portion of the collar before ...
Nov 12, 2013 ... by a target‑controlled infusion (TCI) of 3.0 μg/mL propofol (AstraZeneca UK Limited, London, UK) and. 5.0 ng/mL remifentanil hydrochloride (Humanwell. Pharmaceutical Co., Ltd., Yichang, China) using a TCI syringe pump ... intubation condition assessment, number of intubation attempts, ease of ...
Jung, Ye-Ryung; Taek Jeong, Joon; Kyu Lee, Myoung; Kim, Sang-Ha; Joong Yong, Suk; Jeong Lee, Seok; Lee, Won-Yeon
Post-intubation tracheal stenosis accounts for the greatest proportion of whole-cause tracheal stenosis. Treatment of post-intubation tracheal stenosis requires a multidisciplinary approach. Surgery or an endoscopic procedure can be used, depending on the type of stenosis. However, the efficacy of cryotherapy in post-intubation tracheal stenosis has not been validated. Here, we report a case of recurring post-intubation tracheal stenosis successfully treated with bronchoscopic cryotherapy that had previously been treated with surgery. In this case, cryotherapy was effective in treating web-like fibrous stenosis, without requiring more surgery. Cryotherapy can be considered as an alternative or primary treatment for post-intubation tracheal stenosis. PMID:27853078
Caruana, Emmanuel; Duchateau, François-Xavier; Cornaglia, Carole; Devaud, Marie-Laure; Pirracchio, Romain
Prehospital tracheal intubation (TI) is associated with morbidity and mortality, particularly in cases of difficult intubation. The goal of the present study was to describe factors associated with TI related complications in the prehospital setting. This was a prospective cohort study including all patients intubated on scene in a prehospital emergency medical service over a 4 year period. TI related complications included oxygen desaturation, aspiration, vomiting, bronchospasm and/or laryngospasm, and mechanical complications (mainstem intubation, oesophageal intubation and airway lesion- that is, dental or laryngeal trauma caused by the laryngoscope). Difficult intubation was defined as >2 failed laryngoscopic attempts, or the need for any alternative TI method. A multivariate logistic regression was used to identify the risk factors for TI related complications. 1251 patients were included; 208 complications occurred in 165 patients (13.1%). Among the 208 complications, the most frequent were oesophageal intubation (n=69, 29.7%), desaturation (n=58, 25.0%) and mainstem intubation (n=37, 15.9%). In multivariate analysis, difficult intubation (OR=6.13, 3.93 to 9.54), Cormack and Lehane grades 3 and 4 (OR=2.23, 1.26 to 3.96 for Cormack and Lehane grade 3 and OR=2.61, 1.28 to 5.33 for Cormack and Lehane grade 4 compared with Cormack and Lehane grade 1) and a body mass index >30 kg/m(2) (OR=2.22, 1.38 to 3.56) were significantly associated with TI related complications. Despite specific guidelines, TI related complications are more frequent in the prehospital setting when intubation is deemed difficult, the Cormack and Lehane grade is greater than grade 1 and the patient is overweight. In such situations, particular attention is needed to avoid complications. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Hiestand, Brian; Cudnik, Michael T; Thomson, David; Werman, Howard A
It is not known how rocuronium compares with succinylcholine in its effect on intubation success during air medical rapid-sequence intubation (RSI). To examine the impact of succinylcholine use on the odds of successful prehospital intubation. We performed a retrospective analysis of a critical care transport service administrative database containing patient encounters from 2004 to 2008. Rotor transports of patients ≥ 18 years old, requiring airway management (intubation or backup airway: laryngeal mask airway, Combitube, or cricothyrotomy), and receiving either rocuronium or succinylcholine were included in the analysis. Patients receiving both drugs were excluded. Multiple imputation was used to account for records that were missing data elements. A propensity score based on patient and encounter characteristics was calculated to control for the effect of clinical factors on the choice of drug by air medical personnel. Logistic regression was used to assess the impact of succinylcholine use on the odds of first-attempt intubation. Ordinal logistic regression was used to assess the impact of succinylcholine on the number of attempts required to intubate (1, 2, or ≥ 3 or backup airway). A total of 1,045 patients met the criteria for analysis; 761 (73%) were male, and the median age was 41 years (interquartile range 26-56). Eight hundred seventy-six (84%) were transported from the scene, and 484 (46%) received succinylcholine. Six hundred twelve (59%) were intubated on the first attempt, 322 (31%) required two attempts, 69 required three or more attempts (7%), and 42 required a backup airway (4%). After propensity score adjustment, succinylcholine was associated with a higher incidence of first-attempt intubation (odds ratio 1.4, 95% CI 1.1-1.8), as well as improved odds for requiring fewer attempts to intubate (odds ratio 1.5, 95% CI 1.2-1.9), as compared with rocuronium. Rapid-sequence intubation was more successful with fewer attempts in patients intubated
Taboada, M; Calvo, A; Doldán, P; Ramas, M; Torres, D; González, M; Rodríguez, A; Lombardía, M; Fernandez, Cr; Baluja, A; Otero, P; Álvarez, J
To compare the complications and the difficulty of orotracheal intubation procedures performed in the Intensive Care Unit during the off-hours period and the on-hours period. A prospective, observational and non-interventional cohort study covering a period of 27 months was carried out. Working days between 8:00 a. m. and 7:59 p. m. were considered «on-hours», while the remaining shifts were regarded as «off-hours». An 18-bed surgical in a Intensive Care Unit of a third-level hospital. All orotracheal intubation patients admitted to the ICU from January 2015 to March 2017 were included. Patients were stratified into 2groups according to whether intubation was performed on-hours or off-hours. Non-interventional study. The reason for intubation, time and day on which intubation was performed, degree of intubation difficulty (number of attempts, Cormack-Lehane laryngoscopic vision, need for accessory material) and complications during intubation. A total of 252 patients were intubated; of these, 132 were included in the on-hours group and 120 patients in the off-hours group. In the off-hours group we observed a greater percentage of urgent and emergent intubations compared to the on-hours group. However, no differences were found between the 2groups in relation to the other variables studied. During the off-hours period, orotracheal intubation was not associated to a greater number of complications or to greater difficulty of the technique in our Unit. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Andrade, Rebeca Gonelli Albanez da Cunha; Lima, Bruno Luís Soares; Lopes, Douglas Kaíque de Oliveira; Couceiro Filho, Roberto Oliveira; Lima, Luciana Cavalcanti; Couceiro, Tania Cursino de Menezes
Since anesthesia complications associated with unexpected difficult airway are potentially catastrophic, they should be avoided. The modified Mallampati test and jaw-thrust maneuver enable the identification of difficult airway. The aim of this study was to associate the modified Mallampati test and the jaw-thrust maneuver with laryngoscopy (Cormack-Lehane) in an attempt to identify a better predictor of difficult airway in an adult population undergoing elective surgery. A cross-sectional study in which 133 adult patients undergoing elective surgery requiring tracheal intubation were analyzed. The accuracy and specificity of the modified Mallampati test and jaw-thrust maneuver were assessed by correlating them with difficult laryngoscopy (Cormack-Lehane Degrees 3 and 4). In the 133 patients evaluated the difficult intubation rate found was 0.8%; there was association between the two predictive tests proposed (p=0.012). The values of 94.5% for specificity and 95.4% for accuracy were found for the jaw-thrust maneuver and for the modified Mallampati test, the values found were 81.1% and 81.2%, respectively. Kappa agreement identified a result of 0.240 between jaw-thrust maneuver and Cormarck-Lehane, which was considered reasonable. On the other hand, a poor agreement (κ=0.06) was seen between modified Mallampati test and Cormarck-Lehane test. The jaw-thrust maneuver presented superior accuracy and agreement than the modified Mallampati test, showing the ability to identify a difficult airway. It is necessary to emphasize the association of tests in the evaluation of patients, emphasizing their complementarity to minimize the negative consequences of repeated laryngoscopies. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph
In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation. Retrospective observational cohort. Level I trauma center. Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008. Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality. Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP. Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.
Kim, Hyae-Jin; Lee, Hyeon Jeong; Cho, Hyun-Jun; Kim, Hae-Kyu; Cho, Ah-Reum; Oh, Narae
A nasogastric tube (NGT) is commonly inserted into patients undergoing abdominal surgery to decompress the stomach during or after surgery. However, for anatomic reasons, the insertion of NGTs into anesthetized and intubated patients may be challenging. We hypothesized that the use of a tube exchanger for NGT insertion could increase the success rate and reduce complications. One hundred adult patients, aged 20-70 years, who were scheduled for gastrointestinal surgeries with general anesthesia and NGT insertion were enrolled in our study. The patients were randomly allocated to the tube-exchanger group or the control group. The number of attempts, the time required for successful NGT insertion, and the complications were noted for each patient. In the tube-exchanger group, the success rate of NGT insertion on the first attempt was 92%, which is significantly higher than 68%, the rate in the control group (P = 0.007). The time required for successful NGT insertion in the tube-exchanger group was 18.5 ± 8.2 seconds, which is significantly shorter than the control group, 75.1 ± 9.8 seconds (P tube-exchanger group. There were many advantages in using a tube-exchanger as a guide to inserting NGTs in anesthetized and intubated patients. Compared to the conventional technique, the use of a tube-exchanger resulted in a higher the success rate of insertion on the first attempt, a shorter procedure time, and fewer complications.
Artime, Carlos A; Altamirano, Alfonso; Normand, Katherine C; Ferrario, Lara; Aijazi, Hassan; Cattano, Davide; Hagberg, Carin A
This study was designed to compare the Ambu Aura-i to the single-use LMA Fastrach regarding time to intubation, success rate, and airway morbidity in patients undergoing elective surgery requiring general anesthesia. Prospective, randomized controlled trial. Academic medical center. Sixty-five adult patients scheduled for elective surgery requiring general anesthesia. Patients were randomized into 2 groups. Group A (n=33) were intubated using Ambu Aura-i and the Ambu aScope 2, a disposable flexible intubating scope, whereas those in group B (n=33) were blindly intubated using the Intubating Laryngeal Mask Airway (ILMA). First-attempt intubation success rate, overall intubation success rate, time to intubation, incidence of airway morbidity. The data demonstrated that time for endotracheal intubation in the ILMA group was significantly shorter than in the Ambu Aura-i group (PAura-i=26/33, 78.8%; ILMA=27/33, 81.8%; P=.757) or the overall intubation success rate (Aura-i=29/33, 87.9%; ILMA=31/33, 93.9%; P=.392) between the groups. Four patients (12%) in the Ambu Aura-i group had a failed intubation; 1 was due to a failure of the aScope monitor, whereas 3 were due to inability to visualize the glottis. Two patients (7%) in the ILMA group had a failed intubation due to esophageal intubation. There was no statistically significant difference in airway morbidity between the 2 groups. The data suggest that intubation with the ILMA is faster but that first-attempt and overall intubation success rates were comparable in both groups. The results suggest that although the flexible intubating scope-guided Aura-i does not outperform blind intubation via the ILMA, the technique is comparable in terms of first-attempt and overall intubation success rate. Copyright © 2016 Elsevier Inc. All rights reserved.
Background Tracheal intubation with Macintosh laryngoscope is taught to medical students as it is a lifesaving procedure. However, it is a difficult technique to learn and the consequences of intubation failure are potentially serious. The Airtraq optical laryngoscope is a relatively novel intubation device, which allows visualization of the glottic plane without alignment of the oral, pharyngeal, and tracheal axes, possessing advantages over Macintosh for novice personnel. We introduced a teaching mode featured with a progressive evaluation scheme for preparation and performance of tracheal intubation with medical students in this prospective randomized crossover trial who had no prior airway management experience to find the superior one. Methods Twenty-six medical students of the 8-year programme in the 6th year participated in this trial, when they did their one-week rotation in the department of anaesthesiology. Each of the students intubated 6 patients, who were scheduled for surgeries under general anaesthesia, each laryngoscope for 3 patients respectively. One hundred and forty-nine consecutive patients scheduled for surgical procedures requiring tracheal intubation were enrolled. Patients were randomly allocated to undergo tracheal intubation using Macintosh (n = 75) or Airtraq (n =74) laryngoscope. The progressive evaluation scheme was applied to each intubation attempt. Results Intubation success rate was significantly higher in Airtraq group than Macintosh group (87.8% vs. 66.7%, P Cormack and Lehane glottic view was obtained in 94.6% of patients in the Airtraq group versus 32% of patients in the Macintosh group (P <0.001). Duration of intubation in Airtraq group was significantly shorter (68 ± 21 s vs. 96 ± 22 s, P < 0.05) compared to Macintosh group. Conclusions Airtraq laryngoscope is easier to master for novice personnel with a higher intubation success rate and shorter intubation duration compared with the Macintosh
Full Text Available The use of supraglottic airways as rescue devices in failed intubation and resuscitation has become well accepted in emergency practice. Many offer or advertise the possibility of intubation through the device, but techniques and success rates vary greatly. Intubation can be achieved blindly, with the use a bougie or introducer, or with fiberoptic guidance. In this review, I examine the evidence behind different devices with various techniques, present the data from our on-going research, suggest further research directions and propose practical guidelines for clinical use in emergencies.
Chen, Y H; Chen, J Y; Hsu, C S; Huang, C T; So, E
Epistaxis is one of the common complications of nasotracheal intubation. Clinical patterns of all nasal bleeding are mild and may stop spontaneously in most patients. Serious nasal bleeding requiring hospitalization are rare. Nasal bleeding occurs more frequently in children than in adults. Among adults, men have a higher incidence than women. Although numerous publications have reported the cases of initial epistaxis caused by nasotracheal intubation, recurrent epistaxis was reported rarely. We experienced a case of recurrent epistaxis occurring in the 6th, 8th, 15th and 18th day after nasotracheal intubation. Herein, we describe the clinical events and discuss the causes of epistaxis.
Grove, Erik Lerkevang; Würtz, Morten; Schwarz, Peter
Clopidogrel prevents cardiovascular events, but has been linked with adverse gastrointestinal (GI) complications, particularly bleeding events.......Clopidogrel prevents cardiovascular events, but has been linked with adverse gastrointestinal (GI) complications, particularly bleeding events....
Sanders, Ronald C; Nett, Sholeen T; Davis, Katherine Finn; Parker, Margaret M; Bysani, G Kris; Adu-Darko, Michelle; Bird, Geoffrey L; Cheifetz, Ira M; Derbyshire, Ashley T; Emeriaud, Guillaume; Giuliano, John S; Graciano, Ana Lia; Hagiwara, Yusuke; Hefley, Glenda; Ikeyama, Takanari; Jarvis, J Dean; Kamat, Pradip; Krishna, Ashwin S; Lee, Anthony; Lee, Jan Hau; Li, Simon; Meyer, Keith; Montgomery, Vicki L; Nagai, Yuki; Pinto, Matthew; Rehder, Kyle J; Saito, Osamu; Shenoi, Asha N; Taekema, Hester Christianne; Tarquinio, Keiko M; Thompson, Ann E; Turner, David A; Nadkarni, Vinay M; Nishisaki, Akira
Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated. To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs. Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs. Family presence and no FP during TI in the PICU. The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level. A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR
Thomas, Joanna L; Dumouchel, Justin; Li, Jinghong; Magat, Jenna; Balitzer, Dana; Bigby, Timothy D
Mice, both wildtype and transgenic, are the principal mammalian model in biomedical research currently. Intubation and mechanical ventilation are necessary for whole animal experiments that require surgery under deep anesthesia or measurements of lung function. Tracheostomy has been the standard for intubating the airway in these mice to allow mechanical ventilation. Orotracheal intubation has been reported but has not been successfully used in many studies because of the substantial technical difficulty or a requirement for highly specialized and expensive equipment. Here we report a technique of direct laryngoscopy using an otoscope fitted with a 2.0 mm speculum and using a 20 G intravenous catheter as an endotracheal tube. We have used this technique extensively and reliably to intubate and conduct accurate assessments of lung function in mice. This technique has proven safe, with essentially no animal loss in experienced hands. Moreover, this technique can be used for repeated studies of mice in chronic models.
Basaranoglu, Gokcen; Columb, Malachy; Lyons, Gordon
Difficult tracheal intubation following induction of general anaesthesia for caesarean section is a cause of morbidity and mortality. Our aim was to evaluate five bedside predictors that might identify women with potential intubation difficulty immediately prior to emergency caesarean section. Women requiring emergency caesarean section with general anaesthesia and tracheal intubation who had been assessed by the same experienced anaesthesiologist preoperatively were included in this study. Mallampati score, sternomental distance, thyromental distance, interincisor gap and atlantooccipital extension were all measured. The same anaesthesiologist performed laryngoscopy and graded the laryngeal view according to Cormack and Lehane. Exact logistic regression was used to identify significant independent predictors for difficult intubation (Cormack and Lehane grades ≥ 3) with two-sided P value less than 0.05 considered as significant. In 3 years, 239 women were recruited. Cormack and Lehane grades of 2 or less (easy) were found in 225 and grade of at least 3 (difficult) in 14 women. Patients' characteristics (age, height, weight, BMI or weight gain) were not significantly associated with difficulty of intubation. The incidence of difficult intubation was 1/17 women [95% confidence interval (CI) from 1/31 to 1/10]. A positive result from any of the five predictors combined had a sensitivity of 0.21 (95%CI 0.05-0.51), a specificity of 0.92 (95%CI 0.88-0.96), a positive predictive value of 0.15 (95%CI 0.032-0.38) and a negative predictive value of 0.95 (95%CI 0.91-0.97) for a Cormack and Lehane grade of at least 3 at laryngoscopy. Airway assessment using these tests cannot be relied upon to predict a difficult intubation at emergency caesarean section as the low sensitivity means that 79% (95%CI 49-95) of difficult intubations will be missed.
Gümüş, Nevzat; Dilek, Ahmet; Ülger, Fatma; Köksal, Ersin; Çetinoğlu, Erhan Çetin; Özkan, Fatih; Güldoğuş, Fuat
Objective In this study, our objective was to compare the Cormack and Lehane (C-L) sight scores of direct laryngoscopy in endotracheal intubation with the endoscopic sight scores of the LMA CTrach and video laryngoscope. We also compared the success of endoscopy with the LMA CTrach and video laryngoscopy, intubation time, and its effects on haemodynamic and stress responses. Methods The study included 100 patients, with American Society of Anesthesiologists (ASA) scores I–III and aged 18–65, who will undergo elective surgery. Patients were randomly divided into two groups: Group C and Group V. The patients in both groups underwent direct laryngoscopy with a Macintosh laryngoscope, and their C-L scores were recorded. In Group C, the patients were intubated with the LMA CTrach, and in Group V, the patients were intubated with a video laryngoscope. Patients’ haemodynamic parameters, oxygen saturation, end-tidal carbondioxide, and endoscopic sight scores were recorded. Results The demographic characteristics and the ASA classifications of the groups were similar. When endoscopic sight scores were compared with C-L, better sight was obtained in the LMA CTrach group; no significant difference was detected in Group V. Regarding the success of the intubation, no significant difference was detected between groups. However, when intubation times were compared, there was a significant difference between groups. The intubation time was longer in Group C. There was no difference between groups in terms of the percentage changes of haemodynamic parameters, oxygen saturation, and end-tidal carbondioxide values of the patients. Conclusion In this study, when endoscopic sight scores were compared, better visualization was obtained in the LMA CTrach group. Therefore, in cases where intubation is difficult to apply in patients, the LMA CTrach can be an alternative application. PMID:27366431
Dyson, Kylie; Bray, Janet E; Smith, Karen; Bernard, Stephen; Straney, Lahn; Nair, Resmi; Finn, Judith
Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Linh T. Nguyen
Full Text Available Despite recent advances in airway management, perianesthetic dental injury remains one of the most common anesthesia-related adverse events and cause for malpractice litigation against anesthesia providers. Recommended precautions for prevention of dental damage may not always be effective because these techniques involve contact and pressure exerted on vulnerable teeth. We describe a novel approach using the retromolar space to insert a flexible fiberscope for tracheal tube placement as a reliable method to achieve atraumatic tracheal intubation. Written consent for publication has been obtained from the patient.
Cagnazzi, Elena; Mosca, Alessandro; Pe, Federico; Togazzari, Tiziana; Manenti, Ottavia; Mittempergher, Francesco; Raffetti, Elena; Donato, Francesco; Latronico, Nicola
Unpredicted Difficult Tracheal Intubation (DTI) with Macintosh occurs frequently in obese patients. We investigated the incidence of DTI using an algorithm based on preoperative assessment with the El-Ganzouri Risk Index (EGRI) and Glidescope® routine use. We prospectively enrolled morbidly obese patients undergoing abdominal surgery. Patients were scheduled for Glidescope® intubation under general anesthesia if EGRI was Cormack and Lehane grades ≥III, Intubation Difficulty Scale >5 and modified Intubation Difficulty Scale >5. Secondary outcomes included intubation success on the first attempt, the Time to Cormack, the time to intubation, failure to intubate, oxygen desaturation and difficult ventilation. Of the 214 patients enrolled, 212 (99%) were intubated with Glidescope® and 2 (1%) with awake Flexible Fiber-optic Intubation (one electively, one after a Glidescope® failure). There were no cases of DTI assessed using Cormack and Lehane and Intubation Difficulty Scale, and 3 cases (1.4%; 95% CI 0.45-4.29%) assessed using modified Intubation Difficulty Scale. Of the 213 patients intubated with Glidescope®, 185 (87%) had successful intubation on the first attempt. Mean Time to Cormack and time to intubation were 13.1 (SD 9.6) and 38.1 seconds (SD 21.1) respectively. We had one case (0.5%) of failed Glidescope® intubation and no cases of clinically significant complications. The incidence of DTI and Intubation Failure was reduced to near-zero using Glidescope® and the Besta Airway Algorithm in this sample of morbidly obese patients.
Li-Chun Wang; Hung-Chang Lee; Chun-Yan Yeung; Wai-Tao Chan; Chuen-Bin Jiang
Gastrointestinal polyps are common in children. The purpose of this study was to review the clinical manifestations, diagnostic procedures, endoscopic findings, management, pathology, and recurrence of gastrointestinal polyps in children at Mackay Memorial Hospital. Methods: We retrospectively reviewed the charts of 50 children with a diagnosis of gastrointestinal polyps managed at Mackay Memorial Hospital between January 1984 and April 2007. Demographic data; clinical features; polyp size...
Fan, Luo; Liu, Qin; Gui, Li
To prospectively identify the effect of the nonswallow procedure of nasogastric tube insertion. Nasogastric intubation is one of the most important and basic skills in treatment and nursing. Patients generally experience discomfort and encounter complications during this procedure. Thus, practitioners need a more convenient, effective, quicker and safer method to improve the performance of this procedure. This prospective randomised controlled trial was conducted from March to May 2014 in the four units of Gansun Province Hospital in Lanzhou, China. A total of 80 participants were randomly assigned to an experimental group (n = 40) and a control group (n = 40). Participants in the experimental group underwent a nonswallow procedure for nasogastric tube insertion. There were statistically significant differences in nasogastric tube insertion between the study groups. A marked increase in the success rate at first intubation as well as a markedly reduced occurrence of nausea, tearing, mucosal injury and changes in vital signs (i.e. heart rate, breath, systolic pressure) were observed compared with the control group. No differences in the success rates at second and third intubation were observed between the groups. The nonswallow procedure of nasogastric tube intubation relieves discomfort and ensures the safety of patients. Patients subjected to nasogastric intubation are more likely to benefit from the nonswallow procedure when nasogastric tube insertion is performed. © 2016 John Wiley & Sons Ltd.
Khan, Imran; Sybil, Deborah; Singh, Anurag; Aggarwal, Tarun; Khan, Rizwan
Successful management of airway in complex maxillofacial injuries is quite challenging. The complications and the post-operative care associated with tracheotomy makes it an unpopular choice for airway management meant solely for surgery in these patients. A retrospective analysis of 12 patients from June 2008 to December 2011, seeking treatment for pan facial fractures who underwent transmylohyoid oroendotracheal (submental) intubation is discussed here. The stepwise procedure is explained along with problems of intubation in pan facial fractures. The advantages, disadvantages and complications of transmylohyoid intubation are discussed and compared with alternative methods of air way management in such cases. This reliable, safe and easy method of airway management gives sterile surgical field without a change of tube.
Costa, D L; Lehmann, J R; Harold, W M; Drew, R T
A fiberoptic laryngoscope which allows direct visualization of the deep pharynx and epiglottis has been developed for transoral tracheal intubation of small laboratory mammals. The device has been employed in the intubation and instillation of a variety of substances into the lungs of rats, and with minor modification, has had similar application in mice, hamsters, and guinea pigs. The simplicity and ease of handling of the laryngoscope permits one person to intubate large numbers of enflurane anesthetized animals either on an open counter top or in a glove-box, as may be required for administration of carcinogenic materials. Instillation of 7Be-labeled carbon particles into the lungs of mice, hamsters, rats, and guinea pigs resulted in reasonably consistent interlobal distribution of particles for each test animal species with minimal tracheal deposition. However, actual lung tissue doses of carbon exhibited some species dependence.
Jang, Minyoung; Basa, Krystyne; Levi, Jessica
Intubation has been associated with laryngeal injury that often resolves spontaneously without complication. We present a case of a child intubated for less than 48 hours, who presented with dysphonia and intermittent dyspnea two months after intubation due to epiglottic and vocal process granulomas. This is unusual in that multiple granulomas were found in the posterior glottis and supraglottis after short-term intubation. Our objective was to determine if there are risk factors for developing persistent post-intubation sequelae, including the delayed presentation and unusual location of post-intubation granulomas in our case. Case report and systematic literature review. Pubmed database, which is inclusive of MEDLINE, was used to perform a literature review with the search terms ((pediatric OR children OR neonatal OR infant) AND (laryngeal OR supraglottic) AND intubation AND (granuloma OR injury OR complication)). Only English language results were reviewed. Titles and abstracts from 379 results were reviewed. Full text was reviewed from all original studies which included human pediatric subjects and endoscopic examinations after endotracheal intubation. In our case, laryngeal granuloma size reduced significantly after starting anti-reflux medications. The remainder was removed with laryngeal microdebrider with no recurrence at 3 weeks and 2.5 years post-operatively. Overall, 28 of the 379 studies reviewed identified evidence of laryngeal trauma due to intubation, however only 6 studies documented any type of supraglottic injury. Risk factors identified for developing post-intubation sequelae included intubation duration greater than 24 h; trauma to the larynx via various mechanisms including traumatic intubation, need for reintubation and tube changes, and increased movement while intubated; and presence of respiratory tract infection during intubation. Trauma to the larynx during intubation should be avoided to minimize post-intubation injury in pediatric
Full Text Available Background and Aims: Pentax airway scope (AWS has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation. Methods: We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade, total dose of local anaesthetic used, anaesthetists rating and patient′s tolerance of the procedure were recorded. Results: The procedure was successful in 25 out of the 30 patients (83%. The mean (standard deviation intubation time and total time to complete the tracheal intubation was 5.4 (2.4 and 13.9 (3.7 min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS. Conclusion: Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route.
The main innovations of the latest meeting of the Gastroenterological Association (2016) concerning upper gastrointestinal bleeding from the clinician's perspective can be summarised as follows: a) The Glasgow-Blatchford scale has the best accuracy in predicting the need for surgical intervention and hospital mortality; b) Prognostic scales for non-variceal upper gastrointestinal bleeding are also useful for lower gastrointestinal bleeding; c) Preliminary data suggest that treatment with hemospray does not seem to be superior to current standard treatment in controlling active peptic ulcer bleeding; d) Either famotidine or a proton pump inhibitor may be effective in preventing haemorrhagic recurrence in patients taking aspirin, but this finding needs to be confirmed in further studies; e) There was confirmation of the need to re-introduce antiplatelet therapy as early as possible in patients with antiplatelet-associated gastrointestinal bleeding in order to prevent cardiovascular mortality; f) Routine clinical practice suggests that gastrointestinal or cardiovascular complications with celecoxib or traditional NSAIDs are very low; g) Dabigatran is associated with an increased incidence of gastrointestinal bleeding compared with apixaban or warfarin. At least half of the episodes are located in the lower gastrointestinal tract; h) Implant devices for external ventricular circulatory support are associated with early gastrointestinal bleeding in up to one third of patients; the bleeding is often secondary to arteriovenous malformations. Copyright Â© 2016 Elsevier España, S.L.U. All rights reserved.
Conclusion: Gastrointestinal polyps in children are usually benign. Pediatricians treating a child with a gastrointestinal polyp should pay attention to the immediate complications of the polyps, such as intussusception or bleeding, the extraintestinal manifestations and long-term risk for malignancy.
Oliveira, Ana Carolina Martins de; Friche, Amélia Augusta de Lima; Salomão, Marina Silva; Bougo, Graziela Chamarelli; Vicente, Laélia Cristina Caseiro
Lesions in the oral cavity, pharynx and larynx due to endotracheal intubation can cause reduction in the local motility and sensitivity, impairing the swallowing process, resulting in oropharyngeal dysphagia. To verify the predictive factors for the development of oropharyngeal dysphagia and the risk of aspiration in patients with prolonged orotracheal intubation admitted to an intensive care unit. This is an observational, analytical, cross-sectional and retrospective data collection study of 181 electronic medical records of patients submitted to prolonged orotracheal intubation. Data on age; gender; underlying disease; associated comorbidities; time and reason for orotracheal intubation; Glasgow scale on the day of the Speech Therapist assessment; comprehension; vocal quality; presence and severity of dysphagia; risk of bronchoaspiration; and the suggested oral route were collected. The data were analyzed through logistic regression. The level of significance was set at 5%, with a 95% Confidence Interval. The prevalence of dysphagia in this study was 35.9% and the risk of aspiration was 24.9%. As the age increased, the altered vocal quality and the degree of voice impairment increased the risk of the presence of dysphagia by 5-; 45.4- and 6.7-fold, respectively, and of aspiration by 6-; 36.4- and 4.8-fold. The increase in the time of orotracheal intubation increased the risk of aspiration by 5.5-fold. Patients submitted to prolonged intubation who have risk factors associated with dysphagia and aspiration should be submitted to an early speech-language/audiology assessment and receive appropriate and timely treatment. The recognition of these predictive factors by the entire multidisciplinary team can minimize the possibility of clinical complications inherent to the risk of dysphagia and aspiration in extubated patients. Copyright © 2017. Published by Elsevier Editora Ltda.
Estela T Rodrigues
Full Text Available Estela T Rodrigues1, Iván C Suazo2, Antonio S Guimarães31Centro de Pós Graduação em Odontologia São Leopoldo Mandic, Campinas, Brasil; 2Department of Morphology. Universidad de Talca, Talca, Chile; 3Centro de Pós Graduação em Odontologia São Leopoldo Mandic, Campinas, BrasilAbstract: The aim of this study was to analyze the temporomandibular joint (TMJ disc displacement and articular sounds incidence after orotracheal intubation. A prospective cohort study was conducted in the Hospital Universitário do Oeste do Paraná (HUOP, in Cascavel, Brazil. 100 patients (aged 14–74 years, mean 44 years, 34 male and 66 female, in need of surgical procedure with orotracheal intubation were evaluated. The anterior disc displacement with reduction incidence and the nonclassifiable sounds incidence by the Research Diagnostic Criteria Axis I was evaluated in all patients after orotracheal intubation. The patients was evaluated one day before and until two days after the procedure. Eight percent present with anterior disc displacement with reduction and 10% presented nonclassifiable sounds after the orotracheal intubation. There was no correlation of any kind regarding gender related influence in the incidence of disc dislocations (P = 0.2591 and TMJ sounds (P = 0.487. Although anterior disc dislocations and TMJ sounds after anesthetic with orotracheal intubation presented a low incidence (8%–10%, it is recommended that the evaluation of TMJ signs and symptoms be done before the anesthetic procedure to take care with susceptible patients manipulation.Keywords: orotracheal intubation, TMJ sounds, TMJ dislocations, TMJ disorders, disc displacement, surgical procedure
Developing from the intubation and performing of small bowel enteroclysis a consultant radiographer led service expanded to include problematic gastric, enteric and colonic intubations for diagnostic, therapeutic and interventional purposes. The radiographer led service has also extended to include 'hot reporting' chest images taken to check siting of ward placed nasogastric tubes as well as resiting those tubes that were misplaced. The service has demonstrated itself to be safe and efficient. It has also proven to be both cost and clinically effective. The protracted discomfort and distress to the patient are reduced by minimizing the delay in correctly relocating misplaced tubes
Öztürk, Muhammed Beşir; Barutca, Seda Asrufoğlu; Keskin, Elif Seda; Atik, Bekir
The parotid duct can be damaged in traumatic injuries and surgical interventions. Early diagnosis and treatment of a duct injury is of great importance because complications such as sialocele and salivary gland fistula may develop if the duct is not surgically repaired. We think the cuff of an intubation tube is an ideal material in parotid duct repair, because of its technical characteristics, easiness of availability, and low-cost. In this paper, we described the use of the cuff cannula of an intubation tube for the diagnosis and treatment of parotid duct laceration, as a low-cost and easy to access material readily available in every operating room. PMID:28713751
Full Text Available We are presenting a case report on the anaesthetic management of a case of ankylosis of temporomandibular joint for corrective surgery in a 7 year old child. Anticipated difficult airway in paediatric population has always been a perplexing problem, awake fibreoptic intubation almost impossible due to obvious difficulties with co-operation. Here we are describing a new approach to this problem, in which the patients were kept under GA with spontaneous ventilation while retrograde intubation was done quite comfortably by the conventional method.
Maharaj, Chrisen H
The Airtraq laryngoscope (Prodol Ltd., Vizcaya, Spain) is a novel single-use tracheal intubation device. The authors compared ease of intubation with the Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization in a randomized, controlled clinical trial.
Malik, M A
The purpose of this study was to determine the potential for the Pentax AWS and the Glidescope to reduce the difficulty of tracheal intubation in patients at increased risk for difficult tracheal intubation, in a randomized, controlled clinical trial.
Nishisaki, Akira; Turner, David A; Brown, Calvin A; Walls, Ron M; Nadkarni, Vinay M
To characterize the landscape of process of care and safety outcomes for tracheal intubation across pediatric intensive care units Procedural process of care and safety outcomes of tracheal intubation across pediatric intensive care units has not been described. We hypothesize that the novel National Emergency Airway Registry for Children registry is a feasible tool to capture tracheal intubation process of care and outcomes. Prospective, descriptive. Fifteen academic PICUs in North America. Critically ill children requiring tracheal intubation in PICUs. Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubation in 15 PICUs from July 2010 to December 2011 using the National Emergency Airway Registry for Children tool with explicit site-specific compliance plans and operational definitions including adverse tracheal intubation associated events. One thousand seven hundred fifteen tracheal intubation encounters were reported (averaging 1/3.4 days, or 1/86 bed days). Ninety-eight percent of primary tracheal intubation were successful; 86% were successful with less than or equal to two attempts. First attempt was by pediatric residents in 23%, pediatric critical care fellows in 41%, and critical care attending physicians in 13%: first attempt success rate was 62%, first provider success rate was 79%. The first method was oral intubation in 1,659 (98%) and nasal in 55 (2%). Direct laryngoscopy was used in 96%. Ninety percent of tracheal intubation were with cuffed tracheal tubes. Adverse tracheal intubation associated events were reported in 20% of intubations (n = 372), with severe tracheal intubation associated events in 6% (n = 115). Esophageal intubation with immediate recognition was the most common tracheal intubation associated events (n = 167, 9%). History of difficult airway, diagnostic category, unstable hemodynamics, and resident provider as first airway provider were associated with occurrence of tracheal
Kullnig, P.; Steiner, H.; Porsch, G.; Smolle, J.
A case of Cowden disease (multiple hamartoma syndrome) with marked gastrointestinal polyposis is presented. The differential diagnosis of gastrointestinal polyposis syndromes is discussed. (orig.) [de
Joseph, Thomas T; Gal, Jonathan S; DeMaria, Samuel; Lin, Hung-Mo; Levine, Adam I; Hyman, Jaime B
Awake intubation is the standard of care for management of the anticipated difficult airway. The performance of awake intubation may be perceived as complex and time-consuming, potentially leading clinicians to avoid this technique of airway management. This retrospective review of awake intubations at a large academic medical center was performed to determine the average time taken to perform awake intubation, its effects on hemodynamics, and the incidence and characteristics of complications and failure. Anesthetic records from 2007 to 2014 were queried for the performance of an awake intubation. Of the 1,085 awake intubations included for analysis, 1,055 involved the use of a flexible bronchoscope. Each awake intubation case was propensity matched with two controls (1:2 ratio), with similar comorbidities and intubations performed after the induction of anesthesia (n = 2,170). The time from entry into the operating room until intubation was compared between groups. The anesthetic records of all patients undergoing awake intubation were also reviewed for failure and complications. The median time to intubation for patients intubated post induction was 16.0 min (interquartile range: 13 to 22) from entrance into the operating room. The median time to intubation for awake patients was 24.0 min (interquartile range: 19 to 31). The complication rate was 1.6% (17 of 1,085 cases). The most frequent complications observed were mucous plug, endotracheal tube cuff leak, and inadvertent extubation. The failure rate for attempted awake intubation was 1% (n = 10). Awake intubations have a high rate of success and low rate of serious complications and failure. Awake intubations can be performed safely and rapidly.
Ertürk, Tuna; Deniz, Süleyman; Şimşek, Fatih; Purtuloğlu, Tarık; Kurt, Ercan
Objective Endotracheal intubation of patients is an effective method for controlling airway and breathing. However, laryngoscopy and endotracheal intubation is not easy in every case. There is a recent abundance of equipment used for controlling ventilation and intubation. Airtraq is one of those equipments. In this study, our main objective is to compare the success rates of the Airtraq and Macintosh (direct and classic) laryngoscopes in endotracheal intubation. Methods In this single-center, prospective, randomized, clinical study was performed on 80 patients who were operated under general anesthesia, ASA I–II, 18–65 years old. Patients were intubated using two different endotracheal intubation tools. Group A was intubated using the Macintosh (direct and classic) laryngoscope, meanwhile Group B was intubated using the Airtraq laryngoscope. Patients’ snoring complaints, modified Mallampati scores, sternomental distances, thyromental distances, interincisor distance measurements and Cormack-Lehane (C-L) laryngoscopic classification, upper lip bite test results, intubation time, number of intubation attempts, maneuvers and techniques used for facilitating intubation and complications arising from intubation were recorded. Results There was a statistically significant difference between the groups in terms of C-L scores (p=0.041). In all, 8 patients in the Macintosh group, and 2 patients in the Airtraq group were C-L grade III. In intubation of the Airtraq group, only 3 patients required facilitating techniques, meanwhile in intubation of the Macintosh group 15 patients we had to use one or more facilitating maneuver. The rate of Mallampati scoring “difficult” was 4/6 in the Macintosh and 2/11 in Airtraq laryngoscopy groups (p=0.553). Conclusion In cases with seemingly difficult intubations, we believe the Airtraq laryngoscope has an advantage over the Macintosh laryngoscope, owing to its better view of the oropharyngeal and glottic areas in addition to
Rosenstock, Charlotte Vallentin; Thøgersen, Bente; Afshari, Arash
Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients...
Jones, Peter; Dauger, Stéphane; Denjoy, Isabelle; Pinto da Costa, Nathalia; Alberti, Corinne; Boulkedid, Rym; Peters, Mark J
Our objectives were to describe the prevalence of arrhythmia and conduction abnormalities before critical care intubation and to test the hypothesis that atropine had no effect on their prevalence during intubation. Prospective, observational study. PICU and pediatric/neonatal intensive care transport. All children of age less than 8 years intubated September 2007-2009. Subgroups of intubations with and without atropine were analyzed. None. A total of 414 intubations were performed in the study period of which 327 were available for analysis (79%). Five children (1.5%) had arrhythmias prior to intubation and were excluded from the atropine analysis. Atropine was used in 47% (152/322) of intubations and resulted in significant acceleration of heart rate without provoking ventricular arrhythmias. New arrhythmias during intubation were related to bradycardia and were less common with atropine use (odds ratio, 0.14 [95% CI, 0.06-0.35], p arrhythmia was junctional rhythm. Acute bundle branch block was observed during three intubations; one Mobitz type 2 rhythm and five ventricular escape rhythms occurred in the no-atropine group (n = 170). Only one ventricular escape rhythm occurred in the atropine group (n = 152) in a child with an abnormal heart. One child died during intubation who had not received atropine. Atropine significantly reduced the prevalence of new arrhythmias during intubation particularly for children over 1 month of age, did not convert sinus tachycardia to ventricular tachycardia or fibrillation, and may contribute to the safety of intubation.
Hansen, Tom Giedsing; Joensen, Henning; Henneberg, Steen Winther
Endotracheal intubation in infants with the Pierre Robin syndrome may sometimes be impossible to accomplish by conventional means. To aid difficult tracheal intubation many different techniques have been described. We present a case, in which we successfully intubated a small-for-date newborn boy...
Bauquier, S H; Golder, F J
Anaesthesia requires maintenance of a patent airway. Nasotracheal intubation of a red kangaroo (Macropus rufus) was performed when the inability to open the animal’s mouth prevented orotracheal intubation. Nasotracheal intubation was easy to perform, secured the airway and permitted delivery of supplemental oxygen, isoflurane and intermittent positive pressure ventilation.
Full Text Available Background: Despite strong evidence of the benefits of rapid sequence intubation in neonates, it is still infrequently utilized in neonatal intensive care units (NICU, contributing to avoidable pain and secondary procedure-related physiological disturbances. Objectives: The primary objective of this cross-sectional survey was to assess the practice of premedication and regimens commonly used before elective endotracheal intubation in NICUs in Saudi Arabia. The secondary aim was to explore neonatal physicians′ attitudes regarding this intervention in institutions across Saudi Arabia. Methods: A web-based, structured questionnaire was distributed by the Department of Pediatrics, Umm Al Qura University, Mecca, to neonatal physicians and consultants of 10 NICUs across the country by E-mail. Responses were tabulated and descriptive statistics were conducted on the variables extracted. Results: 85% responded to the survey. Although 70% believed it was essential to routinely use premedication for all elective intubations, only 41% implemented this strategy. 60% cited fear of potential side effects for avoiding premedication and 40% indicated that the procedure could be executed more rapidly without drug therapy. Treatment regimens varied widely among respondents. Conclusion: Rates of premedication use prior to non-emergent neonatal intubation are suboptimal. Flawed information and lack of unified unit policies hampered effective implementation. Evidence-based guidelines may influence country-wide adoption of this practice.
Du Toit-Prinsloo L, Dippenaar JM, Honey EM. Case report of sudden death in a child with Williams syndrome following administration of anaesthesia. S Afr J Anaesth Analg. 2015;21(1):75–8. 2. Cook T. Williams syndrome: was intubation rather than anaesthetic drug choice a cause of cardiac arrest? S Afr J Anaesth Analg.
Linda van Deventer
Aug 20, 2014 ... Intubation and mechanical ventilation: knowledge of medical officers at a South African secondary hospital. 184. Thirty-two medical officers (72.4%) could not identify the appropriate initial tidal volume per kg of ideal body weight for a patient with acute respiratory distress syndrome (ARDS). Seventeen ...
Objective and Aim: The objective of the following study is to examine the effectiveness and safety of suspension laryngoscopy under intubation with propofol and remifentanil alone for vocal fold nodule (VFN) excision. Materials and Methods: A total of 40 patients were equally and randomly assigned to elective VFN excision ...
with the use of a Miller laryngoscope blade (straight blade) and paraglossal technique, achieving Cormack and Lehane views superior to those seen using Macintosh blades.7 As early as 1997,. Henderson8 questioned the role of curved blades for di cult airway intubation and proposed that paraglossal straight blade.
Akinyemi, O O; Elegbe, E O
Two cases of difficult laryngoscopy and tracheal intubation caused by calcified stylohyoid ligaments are presented. Neither patient exhibited a skin crease over the hyoid bone. It is suggested that inability to lift up the epiglottis from the posterior pharyngeal wall be taken as a more useful sign of this condition than the presence of the skin crease.
sequence tracheal intubation. It is not clear from the literature why the 1 mg/kg dose of succinylcholine has been traditionally used. The effective dose (ED95) of succinylcholine is less than 0.3 mg/kg. The dose of 1 mg/kg represents 3.5 to 4 times ...
Kastl, Sigrid; Kotschenreuther, U; Hille, B; Schmidt, J; Gepp, H; Hohenberger, W
Small-animal intubation is often necessary during inhalation anesthesia to allow steady-state conditions for large operations and in vivo experiments in all fields of experimental surgery. In rats, placing an orotracheal tube is technically difficult primarily because of the small size of the subject and the lack of equipment specifically designed for this task. We describe a simple rat intubation technique in which the animal is suspended in dorsal recumbency on an inclined metal plate. The animal, anesthetized with ether, is fixed to a 70 degrees-inclined metal plate in a dorsal position by means of a Mersilene ribbon hooked around the upper incisors. This method of positioning the animal is the most important step in the intubation process and further facilitates the technique already described by other authors. A human otoscope was used as a laryngoscope, intubation was performed using the Seldinger technique, and a 14-gauge intravenous catheter served as an endotracheal tube. This inexpensive technique is quickly learned and can be used in any laboratory. Safe and reliable airway management can thus be achieved, permitting in vivo examinations and operations.
Jigeeshu V Divatia
Full Text Available Tracheal intubation (TI is a routine procedure in the intensive care unit (ICU, and is often life saving. However, life-threatening complications occur in a significant proportion of procedures, making TI perhaps one the most common but underappreciated airway emergencies in the ICU. In contrast to the controlled conditions in the operating room (OR, the unstable physiologic state of critically ill patients along with underevaluation of the airways and suboptimal response to pre-oxygenation are the major factors for the high incidence of life-threatening complications like severe hypoxaemia and cardiovascular collapse in the ICU. Studies have shown that strategies planned for TI in the OR can be adapted and extrapolated for use in the ICU. Non-invasive positive-pressure ventilation for pre-oxygenation provides adequate oxygen stores during TI for patients with precarious respiratory pathology. The intubation procedure should include not only airway management but also haemodynamic, gas exchange and neurologic care, which are often crucial in critically ill patients. Hence, there is a necessity for the implementation of an Intubation Bundle during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.
6 days ago ... induced with 8% sevoflurane with eight deep breaths via a face mask and the patient was maintained on 4% end-tidal sevoflurane, fentanyl. 2 µg/kg and rocuronium 0.6 mg/kg. NTI was achieved 2 min after rocuronium injection. The more patent nostril was selected for intubation. An experienced anesthetist.
Shah, Prerana N; Sundaram, Vimal
This study is aimed to determine the incidence and predictors of difficult and impossible mask ventilation. Information like age, snoring history, obstructive sleep apnea, dental and mandibular abnormalities, macroglossia, grading like SLUX, Mallampatti, Cormack Lehanne, atlantooccipital extension, presence of beard or moustache, mouth opening were collected. During mask ventilation, the information related to the ventilation and intubation was collected. All variables found to be significant in univariate analysis were subjected to the multivariate logistic regression model to identify independent predictors of measured outcome. Difficult mask ventilation (DMV) was observed in 30 male patients and 9 female patients. Of the 40 patients who had difficult intubation (DI), 7 patients had both DMV and intubation and 1 patient was of impossible mask ventilation/ intubation. Snoring was the lone significant risk factor for DMV. The risk factors identified for DI were snoring, retrognathia, micrognathia, macroglossia, short thick neck, Mallampatti grade [III/IV], abnormal SLUX grade, Cormack Lehanne grade [II,III/IV], abnormal atlantooccipital extension grading, flexion/extension deformity of neck, protuberant teeth, cervical spine abnormality, mouth opening 26 kg/m(2). BMI > 26 kg/m(2) and atlantooccipital extension grade > 3 were independent risk factors for DI and the presence of two of the variables made the sensitivity and specificity of 43% and 99% respectively with a positive predictive value of 74%. The predictive score may lead to a better anticipation of difficult airway management, potentially deceasing the morbidity and mortality resulting from hypoxia or anoxia with failed ventilation.
Full Text Available This study compared remifentanil and dexmedetomidine as awake fiberoptic intubation (AFOI anesthetics. Thirty-four adult ASA I-III patients were enrolled in a double-blinded randomized pilot study to receive remifentanil (REM or dexmedetomidine (DEX for sedation during AFOI (nasal and oral. Thirty patients completed the study and received 2 mg midazolam IV and topical anesthesia. The REM group received a loading dose of 0.75 mcg/kg followed by an infusion of 0.075 mcg/kg/min. The DEX group received a loading dose of 0.4 mcg/kg followed by an infusion of 0.7 mcg/kg/hr. Time to sedation, number of intubation attempts, Ramsay sedation scale (RSS score, bispectral index (BIS, and memory recall were recorded. All thirty patients were successfully intubated by AFOI (22 oral intubations/8 nasal. First attempt success rate with AFOI was higher in the REM group than the DEX group, 72% and 38% (P=0.02, respectively. The DEX group took longer to attain RSS of ≥3 and to achieve BIS <80, as compared to the REM group. Postloading dose verbal recall was poorer in the DEX group. Dexmedetomidine seems a useful adjunct for patients undergoing AFOI but is dependent on dosage and time. Further studies in the use of dexmedetomidine for AFOI are warranted.
Evans, Heather L; Warner, Keir; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph
We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.
Britton, Robert A.; Versalovic, James
Gastrointestinal infections are a major cause of morbidity and mortality worldwide, particularly in developing countries. The use of probiotics to prevent and treat a variety of diarrheal diseases has gained favor in recent years. Examples where probiotics have positively impacted gastroenteritis will be highlighted. However, the overall efficacy of these treatments and the mechanisms by which probiotics ameliorate gastrointestinal infections are mostly unknown. We will discuss possible m...
Comparative randomised study of GlideScope®video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation.
Mahran, Essam Abd El-Halim; Hassan, Mohamed Elsayed
Awake flexible fibre-optic bronchoscope (FFS) is the standard method of intubation in difficult airway in oral cancer patients. We decided to evaluate GlideScope ® video laryngoscope (GL) for intubation as compared to the standard FFS for nasal intubation in such patients. After the ethical committee approval, we included 54 oropharyngeal cancer patients divided randomly into two equal groups: Group G and Group F. After pre-medication and pre-oxygenation, awake nasal intubation was performed using GL in Group G and FFS in Group F. In both groups, we compared intubation time in seconds (mean ± standard deviation) (primary outcome), success rate of the first intubation attempt, percentage of Cormack and Lehane glottic score and incidence of complications. We assumed that GL could be a suitable alternative for the standard FFS in nasal intubation of patients with oropharyngeal cancer. Success rate of the first attempt and Cormack and Lehane glottic score were compared using Chi-square test. Intubation time in seconds was significantly shorter in Group G (70.85 ± 8.88 S) than in Group F (90.26 ± 9.41 S) with ( P Cormack and Lehane glottic Score I and II showed insignificant difference between both Group G (92.6%) and Group F (96.3%). We detected three cases of sore throat in each group. GlideScope ® could be a suitable alternative to FFS in nasal intubation of oropharyngeal cancer patients.
Maharaj, C H
The Airtraq, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope.
Hussain khan Z
Full Text Available Background: Failed endotracheal intubation is one of the principal causes of morbidity and mortality in anesthetized patients. If the anesthetist can anticipate which patients may be more difficult to intubate, can reduce the risks of anesthesia greatly and be more prepared for any difficulties that may occur. The aim of this study was to investigate the inability of patients to protrude the lower jaw in predicting difficult intubation.Methods: In this prospective study, we enrolled 300 patients, above 16 years of age or older, who were scheduled for elective surgery. For all of the patients, before each operation, a single anesthesiologist measured the temporomandibular mobility, which was defined as the difference between the distances, from the lower incisors to the upper incisors in a neutral position and at maximum mandibular protrusion. At the time of intubation, another anesthesiologist, blinded to the preoperative airway assessment test, performed a laryngoscopy in which the laryngoscopic view of the larynx was determined according to the Cormack and Lehane scoring system. Difficult intubation was defined as laryngoscopic views of grade III and IV.Results: Twenty-one patients were identified as having difficult intubation. Only one patient could not be intubated. The forward movement of the mandible was significantly greater in patients with easy intubation compared to those with difficult intubation (6.42±1.95 mm vs. 3.58±1.26 mm respectively, P<0.001. The use of a cut-off point of less than 5 mm for prediction of difficult intubation showed a sensitivity of 92.86% and a specificity of 70.43%.Conclusion: The forward movement of the mandible is significantly greater in patients with easy intubation compared those with difficult intubation Although infrequent difficulties may arise, most patients that do not have indicators of difficult intubation will be easy to intubate under anesthesia.
Romanowski, Kathleen S; Palmieri, Tina L; Sen, Soman; Greenhalgh, David G
Advanced Burn Life Support emphasizes endotracheal intubation for patients with facial burns before transfer to a burn center to prevent airway obstruction. Many patients are intubated before transport and are often extubated shortly after burn center arrival. We hypothesize that many intubations performed before burn center transport are unnecessary. We conducted a retrospective review of all adults who were intubated before burn transfer and survived to discharge from August 2003 to June 2013. Intubations that had 2 or fewer ventilator days (i.e., potentially unnecessary intubations) were compared with those lasting longer than 2 days. Data collected included age, ventilator days, length of stay, % TBSA burn, % second degree, % third degree, % second degree face burn, % third degree face burn, and origin of burns. A total of 416 patient met inclusion criteria. Of these, 129 patients (31.0%) were intubated less than or equal to 1 day, and a total of 171 (40.1%) patients remained intubated for less than or equal to 2 days. Patients who were intubated less than or equal to 2 days differed from those intubated more than 2 days with respect to % TBSA burn (10.2 ± 8.1 vs 30.8 ± 19.7, P third degree burn (2.84 ± 5.6 vs 22.5 ± 19.6, P third degree face burn (0.14 ± 0.7 vs 0.94 ± 1.9, P burn center setting (74.9% vs 51.8%, P burned outdoors (42.1% vs 24.9%; P burn. There were no reintubations in patients who were intubated 2 days or less. As a burn community, we have emphasized early intubation before transfer for those who have sustained significant burns, inhalational injury, or facial burns. Unfortunately, this has led to many potentially unnecessary intubations that expose patients to unnecessary complications. Although early intubation is a lifesaving intervention for many burn patients, criteria should be developed to determine when intubation is not needed.
Wang, Li-Chun; Lee, Hung-Chang; Yeung, Chun-Yan; Chan, Wai-Tao; Jiang, Chuen-Bin
Gastrointestinal polyps are common in children. The purpose of this study was to review the clinical manifestations, diagnostic procedures, endoscopic findings, management, pathology, and recurrence of gastrointestinal polyps in children at Mackay Memorial Hospital. We retrospectively reviewed the charts of 50 children with a diagnosis of gastrointestinal polyps managed at Mackay Memorial Hospital between January 1984 and April 2007. Demographic data; clinical features; polyp size, number and location; endoscopic findings; management; pathology; and information on recurrences were extracted from the clinical records. The distribution of polyps in the 50 patients included gastric (4 patients), duodenal (2), ileocecal (4) and colorectal polyps (40). All patients with gastric polyps presented with vomiting, and three of the four patients with ileocecal polyps presented with intussusception. The mean age of the 40 patients with colorectal polyps was 6.8 years. The majority of those polyps were in the rectosigmoid colon; 36 patients presented with hematochezia. Solitary polyps were identified in 33 patients and multiple polyps were identified in seven patients. Most of the colorectal polyps were less than 2cm in diameter. Histologically, the most frequent type was juvenile polyp. Gastrointestinal polyps in children are usually benign. Pediatricians treating a child with a gastrointestinal polyp should pay attention to the immediate complications of the polyps, such as intussusception or bleeding, the extraintestinal manifestations and long-term risk for malignancy.
Dohrn, Niclas; Sommer, Thorbjørn; Bisgaard, J.
index (BMI) 2, ASA scores > 2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra......Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess...... the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients...
Laaks, Jens; Jochmann, Maik A.; Schilling, Beat; Schmidt, Torsten C.
Microextraction techniques, especially dynamic techniques like in-tube extraction (ITEX), can require an extensive method optimization procedure. This work summarizes the experiences from several methods and gives recommendations for the setting of proper extraction conditions to minimize experimental effort. Therefore, the governing parameters of the extraction and injection stages are discussed. This includes the relative extraction efficiencies of 11 kinds of sorbent tubes, either commerci...
Sakles, John C; Deacon, John M; Bair, Aaron E; Keim, Samuel M; Panacek, Edward A
Airway management is a critical procedure performed frequently in emergency departments (EDs). Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs). All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9%) were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI), stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period. The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553). Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553) of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 - 8.5%]) developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 - 5.1%]) had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway management. Three patients (0.5% [95% CI 0
Keim, Samuel M
Full Text Available OBJECTIVES: Airway management is a critical procedure performed frequently in emergency departments (EDs. Previous studies have evaluated the complications associated with this procedure but have focused only on the immediate complications. The purpose of this study is to determine the incidence and nature of delayed complications of tracheal intubation performed in the ED at an academic center where intubations are performed by emergency physicians (EPs.METHODS: All tracheal intubations performed in the ED over a one-year period were identified; 540 tracheal intubations were performed during the study period. Of these, 523 charts (96.9% were available for review and were retrospectively examined. Using a structured datasheet, delayed complications occurring within seven days of intubation were abstracted from the medical record. Charts were scrutinized for the following complications: acute myocardial infarction (MI, stroke, airway trauma from the intubation, and new respiratory infections. An additional 30 consecutive intubations were examined for the same complications in a prospective arm over a 29-day period.RESULTS: The overall success rate for tracheal intubation in the entire study group was 99.3% (549/553. Three patients who could not be orally intubated underwent emergent cricothyrotomy. Thus, the airway was successfully secured in 99.8% (552/553 of the patients requiring intubation. One patient, a seven-month-old infant, had unanticipated subglottic stenosis and could not be intubated by the emergency medicine attending or the anesthesiology attending. The patient was mask ventilated and was transported to the operating room for an emergent tracheotomy. Thirty-four patients (6.2% [95% CI 4.3 - 8.5%] developed a new respiratory infection within seven days of intubation. Only 18 patients (3.3% [95% CI 1.9 - 5.1%] had evidence of a new respiratory infection within 48 hours, indicating possible aspiration pneumonia secondary to airway
Rehder, Kyle J; Giuliano, John S; Napolitano, Natalie; Turner, David A; Nuthall, Gabrielle; Nadkarni, Vinay M; Nishisaki, Akira
Adverse tracheal intubation-associated events are common in PICUs. Prior studies suggest provider and practice factors are important contributors to tracheal intubation-associated events. Little is known about how the incidence of tracheal intubation-associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. We hypothesize that tracheal intubations occurring during nights and weekends are associated with a higher frequency of tracheal intubation-associated events. Retrospective observational cohort study. Twenty international PICUs. Critically ill children requiring tracheal intubation. None. We analyzed 5,096 tracheal intubation courses from July 2010 to March 2014 from the prospective multicenter National Emergency Airway Registry for Children. Frequency of a priori-defined tracheal intubation-associated events was the primary outcome. Occurrence of any tracheal intubation-associated events and severe tracheal intubation-associated events were more common during nights (19:00 to 06:59) and weekends compared with weekdays (19% vs 16%, p = 0.01; 7% vs 6%, p = 0.05, respectively). This difference was significant in emergent intubations after adjusting for site-level clustering and patient factors: for any tracheal intubation-associated events: adjusted odds ratio, 1.20; 95% CI, 1.02-1.41; p = 0.03; but not significant in nonemergent intubations: adjusted odds ratio, 0.94; 95% CI, 0.63-1.40; p = 0.75. For emergent intubations, PICUs with home-call attending coverage had a significantly higher frequency of tracheal intubation-associated events during nights and weekends (adjusted odds ratio, 1.29; 95% CI, 1.01-1.66; p = 0.04), and this difference was attenuated in PICUs with in-hospital attending coverage (adjusted odds ratio, 1.12; 95% CI, 0.91-1.39; p = 0.28). Higher occurrence of tracheal intubation-associated events was observed during nights and weekends. This difference was primarily attributed to
Endotracheal intubation (ETI) is a valuable procedure which must be learnt and practised, and performing ETI on cadavers is probably the best way to do this, although lesser alternatives do exist. Performing ETI on a cadaver is viewed with a real and reasonable repugnance and if it is done without proper authorisation it might be illegal. Some form of consent is required. Presumed consent would preferably be governed by statute and should only occur if the community is well informed and therefore in a position of being able to decline. Currently neither statute nor adequate informing exists. Endotracheal intubation on the newly dead may be justifiable according to a Guttman scale if the patient has already consented to organ donation and if further research supports the relevance of the Guttman scale to this question. A "mandated choice" with prior individual consent as a matter of public policy is the best of these solutions, however until such a solution is in place we may not practise endotracheal intubation on the newly dead.
Prerana N. Shah
Full Text Available Background. Video laryngoscopes provide better view and can improve ease of intubation compared with standard laryngoscopes. Methods. A prospective randomized study was done on 60 patients, 18 to 65 years old, comparing McGrath video laryngoscope and Macintosh laryngoscope. The aim was to compare the ease, efficacy, and usability of them during routine airway management. The primary endpoint was duration of intubation and the secondary endpoints were Cormack and Lehane grade of laryngoscopic view, number of intubation attempts, and incidence of complications. Results. There was an increase in total duration of intubation with McGrath video laryngoscope with 42.9 ± 19.5 seconds compared to Macintosh laryngoscope with 17.9 ± 4.6 seconds. In Macintosh group, 73.3% had grade I, 20% had grade II, and 6.7% had grade III Cormack Lehane view, while in McGrath group, 83.3% had grade I, 13.3% had grade II, and 3.3% had grade III. In McGrath group, 6 patients (20% required more than 120 seconds to get intubated and only 73.3% were intubated in 1 attempt, while patients in Macintosh group had 100% successful intubation in 1 attempt. Pharyngeal trauma was seen with McGrath videolaryngoscopy. Conclusion. Duration of laryngoscopy, intubation, and total duration of intubation were significantly higher in McGrath group than in Macintosh group. McGrath group required a higher number of intubation attempts.
Full Text Available Purpose: Airtraq™ is an optical laryngoscope that allows viewing of the vocal cords without a direct line of sight. The main objective of this prospective, randomized, controlled trial was to evaluate Airtraq intubation characteristics, mainly intubation time and cardiovascular changes in the pediatric patients. Methods: Fifty children of American Society of Anesthesiologists class I, 2-10 years of age were divided into 2 groups using sealed envelope technique. Children were premedicated with midazolam. Anesthesia was induced with sevoflurane, fentanyl, and atracurium. Patients were randomly allocated to be intubated with either Airtraq (Airtraq group or Macintosh laryngoscope (Macintosh group. Intubation time, number of intubation attempts, optimization maneuvers, and ease of intubation were recorded. Hemodynamic variables were recorded before and after anesthetic induction, 1, 3, and 5 min after tracheal intubation. Results: The mean age of children was 6.1 years. Compared with Macintosh group, the use of Airtraq was associated with shorter intubation time (51.6±26.7 s vs 22.8±6.1 s, respectively, P=0.001, less median number of intubation attempts 2 (1-2 versus 1 (1-1, P=0.001, more ease of intubation [2 (1-3 versus 1 (1-1, P=0.001] and less increase in the heart rate 5 min after intubation (P=0.007. No optimization maneuvers required for Airtraq laryngoscope (P=0.001. Conclusion: Airtraq decreases intubation time, number of attempts, and optimization maneuvers, less heart rate changes during intubation compared with Macintosh laryngoscope.
Saasouh, W; Laffey, K; Turan, A; Avitsian, R; Zura, A; You, J; Zimmerman, N M; Szarpak, L; Sessler, D I; Ruetzler, K
The role of obesity as a risk factor for difficult intubation remains controversial. We primarily assessed the association between body mass index (BMI) and difficult tracheal intubation. We analysed electronic records of more than 67 000 adults having elective non-cardiac surgery requiring tracheal intubation at the Cleveland Clinic between 2011 and 2015. The association between BMI and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression adjusting for pre-specified confounders. Amongst 40 183 patients with BMI <30 kg m -2 and 27 519 with BMI ≥30 kg m -2 , 9% required more than one intubation attempt. Increasing BMI up to 30 kg m -2 was significantly associated with increased odds of more than one intubation attempt [odds ratio (OR): 1.03; 97.5% confidence interval (CI): 1.02, 1.04] per unit increase in BMI, P < 0.001. However, the odds of difficult intubation remained unchanged once BMI exceeded 30 kg m -2 (P = 0.08). The results were similar when analysis was restricted to patients without history of airway abnormalities in whom intubation was attempted using a standard direct laryngoscope (OR: 1.03; 99.4% CI: 1.01, 1.04) per kg m -2 increase in BMI <30 kg m -2 ). Increasing BMI was associated with increasing odds of difficult intubation in the lean range. At higher BMI, the odds of difficult intubation remain elevated, but there is no additional increase in odds with further increase in BMI. Obese patients were thus harder to intubate than lean ones, but difficult intubation was no more likely in morbidly obese patients than in those who were only slightly obese. Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
Larsen, R.P.; Oldham, R.D.; Bhattacharyya, M.H.; Moretti, E.S.; Austin, D.J.
An investigation has been made of the effect of the oxidation state of plutonium on its absorption from the gastrointestinal tract. For mice and rats that have been starved prior to gastrointestinal administration, there is no significant difference between the absorption factors for Pu(IV) and Pu(VI). The value obtained for Pu(VI) is an order of magnitude lower than that reported previously. The value obtained for Pu(IV) is two orders of magnitude higher than those reported previously for nitrate solutions and the same as those reported for citrate solutions
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of video-assisted laryngoscopy for tracheal intubation. Video-assisted, rigid laryngoscopes have been recently introduced that allow for the illumination of the airway and the accurate placement of the endotracheal tube. Two such devices are available in Canada: the Bullard® Laryngoscope that relies on fibre optics for illumination and the GlideScope® that uses a video camera and a light source to illuminate the airway. Both are connected to an external monitor so health professionals other than the operator can visualize the insertion of the tube. These devices therefore may be very useful as teaching aids for tracheal intubation. The objective of this review was to examine the effectiveness of the most commonly used video-assisted rigid laryngoscopes used in Canada for tracheal intubation. According to the Medical Advisory Secretariat standard search strategy, a literature search for current health technology assessments and peer-reviewed literature from Medline (full citations, in-process and non-indexed citations) and Embase for was conducted for citations from January 1994 to January 2004. Key words used in the search were as follows: Video-assisted; video; emergency; airway management; tracheal intubation and laryngoscopy. Two video-assisted systems are available for use in Canada. The Bullard® video laryngscope has a large body of literature associated with it and has been used for the last 10 years, although most of the studies are small and not well conducted. The literature on the GlideScope® is limited. In general, these devices provide better views of the airway but are much more expensive than conventional direct laryngoscopes. As with most medical procedures, video-assisted laryngoscopy requires training and skill maintenance for successful use. There seems to be a discrepancy between the seeming advantages of these devices in the
Fevang, Espen; Perkins, Zane; Lockey, David; Jeppesen, Elisabeth; Lossius, Hans Morten
Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8-94%), compared to 29% (range 6-67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding.
Comparative randomised study of GlideScope® video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation
Essam Abd El-Halim Mahran
Full Text Available Background and Aims: Awake flexible fibre-optic bronchoscope (FFS is the standard method of intubation in difficult airway in oral cancer patients. We decided to evaluate GlideScope® video laryngoscope (GL for intubation as compared to the standard FFS for nasal intubation in such patients. Methods: After the ethical committee approval, we included 54 oropharyngeal cancer patients divided randomly into two equal groups: Group G and Group F. After pre-medication and pre-oxygenation, awake nasal intubation was performed using GL in Group G and FFS in Group F. In both groups, we compared intubation time in seconds (mean ± standard deviation (primary outcome, success rate of the first intubation attempt, percentage of Cormack and Lehane glottic score and incidence of complications. We assumed that GL could be a suitable alternative for the standard FFS in nasal intubation of patients with oropharyngeal cancer. Success rate of the first attempt and Cormack and Lehane glottic score were compared using Chi-square test. Results: Intubation time in seconds was significantly shorter in Group G (70.85 ± 8.88 S than in Group F (90.26 ± 9.41 S with (P < 0.001. The success rate of the first attempt intubation was slightly higher in Group G (81.5% than Group F (78.8%. Cormack and Lehane glottic Score I and II showed insignificant difference between both Group G (92.6% and Group F (96.3%. We detected three cases of sore throat in each group. Conclusion: GlideScope® could be a suitable alternative to FFS in nasal intubation of oropharyngeal cancer patients.
Burjek, Nicholas E; Nishisaki, Akira; Fiadjoe, John E; Adams, H Daniel; Peeples, Kenneth N; Raman, Vidya T; Olomu, Patrick N; Kovatsis, Pete G; Jagannathan, Narasimhan; Hunyady, Agnes; Bosenberg, Adrian; Tham, See; Low, Daniel; Hopkins, Paul; Glover, Chris; Olutoye, Olutoyin; Szmuk, Peter; McCloskey, John; Dalesio, Nicholas; Koka, Rahul; Greenberg, Robert; Watkins, Scott; Patel, Vikram; Reynolds, Paul; Matuszczak, Maria; Jain, Ranu; Khalil, Samia; Polaner, David; Zieg, Jennifer; Szolnoki, Judit; Sathyamoorthy, Kumar; Taicher, Brad; Riveros Perez, N Ricardo; Bhattacharya, Solmaletha; Bhalla, Tarun; Stricker, Paul; Lockman, Justin; Galvez, Jorge; Rehman, Mohamed; Von Ungern-Sternberg, Britta; Sommerfield, David; Soneru, Codruta; Chiao, Franklin; Richtsfeld, Martina; Belani, Kumar; Sarmiento, Lina; Mireles, Sam; Bilen Rosas, Guelay; Park, Raymond; Peyton, James
The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.
Vleugels, Jasper L. A.; Hazewinkel, Yark; Dekker, Evelien
In the era of spreading adoption of gastrointestinal endoscopy screening worldwide, endoscopists encounter an increasing number of complex lesions in the gastrointestinal tract. For decision-making on optimal treatment, precise lesion characterization is crucial. Especially the assessment of
Knudsen, Kati; Högman, Marieann; Larsson, Anders; Nilsson, Ulrica
To facilitate evaluation of the airway before endotracheal intubation, different scores have been developed, mainly to predict difficult airways. However, in anesthesia clinical practice in Sweden, scores would be more useful if they could also predict an easy airway, so that the correct category of anesthesia personnel can be allocated. Therefore, we evaluated whether scoring systems commonly used to predict difficult airways could also predict easy endotracheal intubation. This prospective observational study included patients who were scheduled for general anesthesia and required endotracheal intubation. Airways were evaluated preoperatively by two independent variables, namely Mallampati classification and thyromental distance. After anesthesia induction, the Cormack and Lehane grade was assessed. Mallampati scores yielded the highest specificity in predicting easy intubation, and Cormack and Lehane grades yielded the highest positive predictive value for predicting easy intubation. Mallampati classification is an appropriate screening test for predicting easy intubation. Copyright © 2014 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Full Text Available Purpose:To analysis clinical experience of applying recurrent laryngeal monitoring endotracheal tube (NIM EMG Endotracheal Tube in the surgery of thyroid. Method: A retrospective analysis of 84 patients who underwent endotracheal intubation laryngeal nerve monitoring by thyroid surgery in the Chinese-Japanese Friendship Hospital of Jilin University from March to December in 2015. To summarize the experience of intubation with NIM EMG Endotracheal Tube. Result 77 (91.7%had initial intubation achievement in the 84 patients.FROM the 77 cases we had gotten s atisfactory nerve monitoring signal.Whereas there are 7 cases (8.3% appear abnormal EMG or signal missing, in the 7 cases there is one which being intubated too deep, 3 cases which being intubated too shallow and 3 cases with malrotation intubation.Conclusion: We got the satisfactory signals after adjust1ing the tube by using the visual laryngoscope.
Won Young Kim
Full Text Available OBJECTIVES: Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED. The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication. METHODS: A matched case-control study with a case to control ratio of 1:3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities. RESULTS: Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7% had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%. Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001. Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤ 90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58-8.55], p = 0.01. CONCLUSION: Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.
Acar, H V; Yarkan Uysal, H; Kaya, A; Ceyhan, A; Dikmen, B
A close relationship between obstructive sleep apnea (OSA) and difficult intubation has been suggested. We hypothesized that the STOP-Bang questionnaire, a screening tool for obstructive sleep apnea (OSA), can predict difficult intubation. In this prospective cohort study, 200 adult surgical patients undergoing surgery under general anesthesia were studied to evaluate the usefulness of the STOP-Bang questionnaire for predicting difficult intubation. STOP-Bang questionnaire results, Mallampati score and tonsil size, as well as demographic data, were recorded preoperatively. Cormack & Lehane grading and difficulty of intubation (Cormack & Lehane grade III or IV, need of an intubation aid, or need of three or more intubation attempts) were also evaluated. Eighty-three out of 200 patients had a high risk of OSA based on the STOP-Bang questionnaire. The occurrence of difficult intubation was higher in the patients at a high risk of OSA (i.e., a STOP-Bang score of ≥ 3) than in the patients at a low risk (13.3% vs. 2.6%) (p = 0.004). Higher age, greater weight, higher body mass index, greater neck circumference, male gender, presence of comorbidities, lower preoperative SpO2, longer extubation times, higher Mallampati score, higher Cormack & Lehane grading, tonsil size and difficult intubation were significantly correlated with a high risk of OSA (p < 0.001). Fourteen out of 200 patients had difficulty in intubation. A STOP-Bang score of ≥ 3 was seen more frequently in the difficult intubation patients (78.6% vs. 38.7%) (p = 0.009). Greater weight, greater neck circumference, greater Mallampati score, a STOP-Bang score ≥ 3 and male gender were significantly correlated with difficult intubation (p < 0.05). A STOP-Bang score of ≥ 3 was a predictor for difficult intubation.
Wan, Li; Liao, Mingfeng; Li, Li; Qian, Wei; Hu, Rong; Chen, Kun; Zhang, Chuanhan; Yao, Wenlong
Abstract Background: Many studies have shown Airtraq videolaryngoscope provided faster tracheal intubation and a higher success rate than other videolaryngoscopes. Recently, different types of videolaryngoscopes have been reported for use in double-lumen tube (DLT) intubation. However, the advantages and disadvantages between them remain undetermined for DLT intubation. In this study, we compared the Airtraq DL videolaryngoscope with the McGrath Series 5 videolaryngoscope for DLT intubation by experienced anesthesiologists. Methods: Ninety patients with expected normal airways were randomly allocated to either the Airtraq or McGrath group. The primary outcome was DLT intubation time. The secondary outcomes were glottic view, success rate, subjective ease of intubation (100-mm visual analog scale, 0 = easy; 100 = difficult), incidence of DLT malposition, and postoperative intubation-related complication. Results: The airway characteristics were comparable between the 2 groups. Cormack and Lehane grades significantly improved with the use of the McGrath and Airtraq videolaryngoscopes, compared with the Macintosh laryngoscope. The intubation success rate on the first attempt was 93% in the Airtraq group and 95% in the McGrath group (P > 0.05). The intubation time in the McGrath group is longer than that in the Airtraq group (39.9 [9.1]s vs 28.6 [13.6]s, P 0.05). Conclusions: When using videolaryngoscopes for DLT intubation, the Airtraq DL is superior to the McGrath Series 5 in intubation time, but it does not decrease intubation difficulty. PMID:28002347
Hansen, T G; Joensen, H; Henneberg, S W
Endotracheal intubation in infants with the Pierre Robin syndrome may sometimes be impossible to accomplish by conventional means. To aid difficult tracheal intubation many different techniques have been described. We present a case, in which we successfully intubated a small-for-date newborn boy...... with the Pierre Robin syndrome by using a modified laryngeal mask airway (no. 1) as a guide for the endotracheal tube. The technique is easy to perform, less traumatic and less time-consuming than multiple attempts at laryngoscopy or blind tracheal intubation....
Girgis, Karim K; Youssef, Maha M I; ElZayyat, Nashwa S
One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients. A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications. Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat. Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.
Full Text Available Objective: to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. Methods: patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. Results: thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016 but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936 for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248. Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p <0.001. Conclusions: intubation using intravenous diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs.
Sullivan, Bradley P.; El-Gendy, Nashwa; Kuehl, Christopher; Berkland, Cory
Antibiotic multi-resistant pneumonia is a risk associated with long term mechanical ventilation. Vancomycin is commonly prescribed for methicillin-resistant staphylococcus aureus infections; however, current formulations of vancomycin are only given intravenously. High doses of vancomycin have been associated with severe renal toxicity. In this study we characterized dry powder vancomyin as a potential inhaled therapeutic aerosol and compared pharmacokinetic profiles of i.v. and pulmonary administered vancomycin in intubated rabbits using a novel endotracheal tube catheter system. Cascade Impaction studies indicated that using an endotracheal tube, which bypasses deposition the mouth and throat, increased the amount of drug entering the lung. Drug deposition in the lung was further enhanced by using an endotracheal tube catheter, which did not alter the aerosol fine particle fraction. Interestingly, intubated rabbits administered 1 mg/kg vancomycin via inhalation had similar AUC to rabbits that were administered 1 mg/kg vancomycin via a single bolus i.v. infusion; however, inhalation of vancomycin reduced Cmax and increased Tmax, suggesting that inhaled vancomycin resulted in more sustained pulmonary levels of vancomycin. Collectively, these results suggested that dry powder vancomycin can successfully be delivered by pulmonary inhalation in intubated patients. Furthermore, as inhaled vancomycin is delivered locally to the site of pulmonary infection, this delivery route could reduce the total dose required for therapeutic efficacy and simultaneously reduce the risk of renal toxicity by eliminating the high levels of systemic drug exposure required to push the pulmonary dose to therapeutic thresholds during i.v. administration. PMID:25915095
Hassanian-Moghaddam, Hossein; Soltaninejad, Kambiz; Shadnia, Shahin; Kabir, Ali; Movahedi, Mitra; Mirafzal, Amirhossein
This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose. © 2015 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).
Sameer Sethi; Souvik Maitra; Vikas Saini; Tanvir Samara
Background: This study has been designed to compare the performance of Ambu® AuraGain™ laryngeal mask with the air-Q™ as a conduit for blind tracheal intubation in adult patients. Methods: In this prospective randomized controlled trial blind endotracheal intubation success rates were compared between Ambu® AuraGain™ and air-Q™ intubating laryngeal airway in 90 adult patients. Patients were randomized in two equal groups: Group Ambu® AuraGain™ (n = 45) and Group air-Q™ (n = 45). Results...
Polanco Allué, I
The bacterial colonisation is established immediately after birth, through direct contact with maternal microbiota, and may be influenced during lactation. There is emerging evidence indicating that quantitative and qualitative changes on gut microbiota contribute to alterations in the mucosal activation of the immune system, leading to intra- or extra-intestinal diseases. A balance between pathogenic and beneficial microbiota throughout childhood and adolescence is important to gastrointestinal health, including protection against pathogens, inhibition of pathogens, nutrient processing (synthesis of vitamin K), stimulation of angiogenesis, and regulation of host fat storage. Probiotics can promote an intentional modulation of intestinal microbiota favouring the health of the host. A review is presented on the modulation of intestinal microbiota on prevention, and adjuvant treatment of some paediatric gastrointestinal diseases. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Full Text Available Gastrointestinal stromal tumors are the most frequent mesenchymal tumors of the gastrointestinal tract. The discovery that these tumors, formerly thought of smooth muscle origin, are indeed better characterized by specific activating mutation in genes coding for the receptor tyrosine kinases CKIT and PDGFRA and that these mutations are strongly predictive for the response to targeted therapy with receptor tyrosine kinase inhibitors has made GISTs the typical example of the integration of basic molecular knowledge in the daily clinical activity. The information on the mutational status of these tumors is essential to predict (and subsequently to plan the therapy. As resistant cases are frequently wild-type, other possible oncogenic events, defining other entities, have been discovered (e.g. succinil dehydrogenase mutation/dysregulation, insuline growth factor expression, mutations in the RAS-RAF-MAPK pathway. The classification of disease must nowadays rely on the integration of the clinico-morphological characteristics with the molecular data.
Lakatos, Gábor; Tulassay, Zsolt
Probiotics are preparations containing viable microorganisms that confer potential health benefits for the host. Alteration of bacterial flora both in terms of specific content and concentration may be beneficial in many gastrointestinal disorders. Probiotics are widely used for the management of these conditions in many countries. However, mechanisms of probiotics are incompletely understood. Benefits observed clinically with one species or combinations of species can not be generalized. The optimal dose of treatment has to be determined. Although probiotics are generally regarded safe, caution is needed when using these supplements routinely. It has been proved, that severe adverse events can occur as a complication of probiotic treatment. This review summarizes the recent knowledge concerning the use of probiotics in gastrointestinal disorders.
Kim, Sang Gyun; Yang, Chang-Hun
Gastrointestinal (GI) stent has been developed for palliation of obstructive symptoms in various diseases causing obstruction of GI tract. Self-expanding metal stent (SEMS) has replaced old type of plastic stent, and endoscopic insertion of stent has replaced fluoroscopy-guided insertion. Nowadays, newly-designed SEMSs have been developed for prevention of complications such as stent migration and re-obstruction, and indications of stent recently have been widened into benign conditions as we...
Blutt, Sarah E; Broughman, James R; Zou, Winnie; Zeng, Xi-Lei; Karandikar, Umesh C; In, Julie; Zachos, Nicholas C; Kovbasnjuk, Olga; Donowitz, Mark; Estes, Mary K
Gastrointestinal diseases are a significant health care and economic burden. Prevention and treatment of these diseases have been limited by the available human biologic models. Microphysiological systems comprise organ-specific human cultures that recapitulate many structural, biological, and functional properties of the organ in smaller scale including aspects of flow, shear stress and chemical gradients. The development of intestinal microphysiological system platforms represents a critical component in improving our understanding, prevention, and treatment of gastrointestinal diseases. This minireview discusses: shortcomings of classical cell culture models of the gastrointestinal tract; human intestinal enteroids as a new model and their advantages compared to cell lines; why intestinal microphysiological systems are needed; potential functional uses of intestinal microphysiological systems in areas of drug development and modeling acute and chronic diseases; and current challenges in the development of intestinal microphysiological systems. Impact statement The development of a gastrointestinal MPS has the potential to facilitate the understanding of GI physiology. An ultimate goal is the integration of the intestinal MPS with other organ MPS. The development and characterization of nontransformed human intestinal cultures for use in MPS have progressed significantly since the inception of the MPS program in 2012, and these cultures are a key component of advancing MPS. Continued efforts are needed to optimize MPS to comprehensively and accurately recapitulate the complexity of the intestinal epithelium within intestinal tissue. These systems will need to include peristalsis, flow, and oxygen gradients, with incorporation of vascular, immune, and nerve cells. Regional cellular organization of crypt and villus areas will also be necessary to better model complete intestinal structure.
Heine, Ralf G
Gastrointestinal food allergies present during early childhood with a diverse range of symptoms. Cow's milk, soy and wheat are the three most common gastrointestinal food allergens. Several clinical syndromes have been described, including food protein-induced enteropathy, proctocolitis and enterocolitis. In contrast with immediate, IgE-mediated food allergies, the onset of gastrointestinal symptoms is delayed for at least 1-2 hours after ingestion in non-IgE-mediated allergic disorders. The pathophysiology of these non-IgE-mediated allergic disorders is poorly understood, and useful in vitro markers are lacking. The results of the skin prick test or measurement of the food-specific serum IgE level is generally negative, although low-positive results may occur. Diagnosis therefore relies on the recognition of a particular clinical phenotype as well as the demonstration of clear clinical improvement after food allergen elimination and the re-emergence of symptoms upon challenge. There is a significant clinical overlap between non-IgE-mediated food allergy and several common paediatric gastroenterological conditions, which may lead to diagnostic confusion. The treatment of gastrointestinal food allergies requires the strict elimination of offending food allergens until tolerance has developed. In breast-fed infants, a maternal elimination diet is often sufficient to control symptoms. In formula-fed infants, treatment usually involves the use an extensively hydrolysed or amino acid-based formula. Apart from the use of hypoallergenic formulae, the solid diets of these children also need to be kept free of specific food allergens, as clinically indicated. The nutritional progress of infants and young children should be carefully monitored, and they should undergo ongoing, regular food protein elimination reassessments by cautious food challenges to monitor for possible tolerance development. © 2015 S. Karger AG, Basel.
Full Text Available Objectives: Endoscopic examinations have great potential in early diagnosis of colorectal adenomas and carcinomas with reducing to colorectal cancer incidence and mortality. We aimed to evaluate for diagnostic purposeful lower gastrointestinal endoscopic procedures in the second step state hospital retrospectively Methods: Between June 2010 and June 2013, we evaluated 278 patients with rectal bleeding, constipation and abdominal pain detected by lower gastrointestinal endoscopic procedures retrospectively. Results: The mean age of the patients was 54.8 ± 16.8 (15-90 year, respectively. 172 (61.9% of the patients were male and 106 (38.1% of the patients were female. 116 (41.7% of the patients was performed rectosigmoidoscopy and 162 (58.3% of the patients was performed colonoscopy. 51(18.3% of our patients were normal. 10 (3.6% of patients had colorectal cancer, 11(3.9% of patients had inflammatory bowel disease, 8 (2.9% of patients had parasitosis, 31(11.1% of patients had colorectal polyps, 12 (4.3% , in patients had diverticular disease, 2 (0.7% patients had rectal ulcer, 25 (9% patients had anal fissure and 159 (57.2% of the patients had hemorrhoidal disease. Conclusion: Lower gastrointestinal endoscopy is a method been the gold standard with a low complication rate and that can be easily applied in the evaluation to pathology of colorectal and anal canal. J Clin Exp Invest 2014; 5 (4: 580-582
Baccari, M C
Orexin A (OXA) and orexin B (OXB) are recently discovered neuropeptides that appear to play a role in various distinct functions such as arousal and the sleep-wake cycle as well as on appetite and regulation of feeding and energy homeostasis. Orexins were first described as neuropeptides expressed by a specific population of neurons in the lateral hypothalamic area, a region classically implicated in feeding behaviour. Orexin neurons project to numerous brain regions, where orexin receptors have been shown to be widely distributed: both OXA and OXB act through two subtypes of receptors (OX1R and OX2R) that belong to the G protein-coupled superfamily of receptors. Growing evidence indicates that orexins act in the central nervous system also to regulate gastrointestinal functions: animal studies have indeed demonstrated that centrally-injected orexins or endogenously released orexins in the brain stimulates gastric secretion and influence gastrointestinal motility. The subsequent identification of orexins and their receptors in the enteric nervous system (including the myenteric and the submucosal plexuses) as well as in mucosa and smooth muscles has suggested that these neuropeptides may also play a local action. In this view, emerging studies indicate that orexins also exert region-specific contractile or relaxant effects on isolated gut preparations. The aim of the proposed review is to summarize both centrally- and peripherally-mediated actions of orexins on gastrointestinal functions and to discuss the related physiological role on the basis of the most recent findings.
Basak Ceyda Meco
Full Text Available BACKGROUND AND OBJECTIVES: Preoperative ultrasonographic evaluation of the thyroid gland done by surgeons could let us foresee airway management challenges. The aim of this observational study was to evaluate the effects of thyroid-related parameters assessed preoperatively by surgeons via ultrasonography and chest X-ray on intubation conditions. METHODS: Fifty patients undergoing thyroid surgery were enrolled. Thyromental distance, Mallampati score, neck circumference and range of neck movement were evaluated before the operation. Thyroid volume, signs of invasion or compression and tracheal deviation on chest X-ray were also noted. The intubation conditions were assessed with Cormack and Lehane score and the intubation difficulty scale. Statistical analyses were done with SPSS 15.0 software. RESULTS: The mean thyroid volume of the patients was 26.38 ± 14 mL. The median intubation difficulty scale was 1 (0-2. Thyromental distance (p = 0.011; r = 0.36; 95% CI 0.582-0.088, Mallampati score (p = 0.041; r = 0.29; 95% CI 0.013-0.526, compression or invasion signs (p = 0.041; r = 0.28; 95% CI 0.006-0.521 and tracheal deviation on chest X-ray (p = 0.041; r = 0.52; 95% CI 0.268-0.702 were correlated with intubation difficulty scale. Also patients were classified into two groups related to their intubation difficulty scale (Group I, n = 19: intubation difficulty scale = 0; Group II, n = 31: 1 < intubation difficulty scale ≤ 5 and difficult intubation predictors and thyroid-related parameters were compared. Only Mallampati score was significantly different between groups (p = 0.025. CONCLUSION: The thyroid volume is not associated with difficult intubation. However clinical assessment parameters may predict difficult intubation.
Full Text Available Tomasz Gaszynski Department of Emergency and Disaster Medicine, Medical University of Lodz, Lodz, Poland Background: Super-obese patients are at increased risk of difficult mask ventilation and difficult intubation. Therefore, devices that allow for simultaneous ventilation/oxygenation during attempts to visualize the entrance to the larynx, increase patient safety. TotalTrack video intubating laryngeal mask is a new device that allows for ventilation during intubation efforts. Patients and methods: Twenty-four super-obese patients (body mass index >50 kg/m2 were divided into two subgroups: intubation efforts using 1 TotalTrack and 2 Macintosh blade standard laryngoscope in induction of general anesthesia. Visualization and successful intubation was evaluated for both groups with ventilation and post-mask complications additionally evaluated for TotalTrack. Results: In all cases in the TotalTrack group, the Cormack-Lehane score was 1, ventilation and intubation was successful in 11/12 patients. No hypoxia during intubation efforts was recorded. No serious complications of use of TotalTrack were observed. In the Macintosh blade laryngoscope group, all patients were intubated, but the Cormack-Lehane score was 2 in four cases, and 3 in three cases. Conclusion: TotalTrack video intubating laryngeal mask is a device that allows for better visualization of the larynx compared to the standard Macintosh blade laryngoscope, it provides effective ventilation/oxygenation and intubation in super-obese patients. Keywords: super-obese, intubation, ventilation, laryngeal mask, standard laryngoscope, video laryngoscope
Carroll, Christopher L; Smith, Sharon R; Collins, Melanie S; Bhandari, Anita; Schramm, Craig M; Zucker, Aaron R
Status asthmaticus is a common cause of admission to a pediatric intensive care unit (PICU). Children unresponsive to medical therapies may require endotracheal intubation; however, this treatment carries significant risk, and thresholds for intubation vary. Our hypothesis was that children who sought care at community hospitals received less aggressive treatment and more frequent intubation than children who sought care at a children's hospital. Retrospective cohort study. A university-affiliated children's hospital PICU. We retrospectively examined data from all children older than 2 yrs admitted to the PICU with status asthmaticus between April 1997 and July 2005. None. Of the 251 children admitted to the PICU with status asthmaticus, 130 initially presented to the emergency department of a children's hospital and 116 presented to the emergency department of a community hospital. Despite similar illness severity, children presenting to a community hospital were significantly more likely to be intubated than those presenting to a children's hospital (17% vs. 5%; p = .004). In addition, those children intubated at community hospitals were intubated sooner after presentation (2.4 +/- 5.2 vs. 7.5 +/- 5.8 hrs; p = .009), had shorter durations of intubation (71 +/- 73 vs. 151 +/- 81 hrs; p = .02), and had shorter PICU length of stays (129 +/- 82 vs. 230 +/- 84 hrs; p = .01). Children with status asthmaticus are more likely to be intubated, and intubated sooner, at a community hospital. The shorter duration of intubation suggests that some children may not have been intubated had they presented to a children's hospital or received more aggressive therapy at their community hospital.
Dhanger, Sangeeta; Gupta, Suman Lata; Vinayagam, Stalin; Bidkar, Prasanna Udupi; Elakkumanan, Lenin Babu; Badhe, Ashok Shankar
Background: Unanticipated difficult intubation can be challenging to anesthesiologists, and various bedside tests have been tried to predict difficult intubation. Aims: The aim of this study was to determine the incidence of difficult intubation in the Indian population and also to determine the diagnostic accuracy of bedside tests in predicting difficult intubation. Settings and Design: In this study, 200 patients belonging to age group 18–60 years of American Society of Anesthesiologists I and II, scheduled for surgery under general anesthesia requiring endotracheal intubation were enrolled. Patients with upper airway pathology, neck mass, and cervical spine injury were excluded from the study. Materials and Methods: An attending anesthesiologist conducted preoperative assessment and recorded parameters such as body mass index, modified Mallampati grading, inter-incisor distance, neck circumference, and thyromental distance (NC/TMD). After standard anesthetic induction, laryngoscopy was performed, and intubation difficulty assessed using intubation difficulty scale on the basis of seven variables. Statistical Analysis: The Chi-square test or student t-test was performed when appropriate. The binary multivariate logistic regression (forward-Wald) model was used to determine the independent risk factors. Results: Among the 200 patients, 26 patients had difficult intubation with an incidence of 13%. Among different variables, the Mallampati score and NC/TMD were independently associated with difficult intubation. Receiver operating characteristic curve showed a cut-off point of 3 or 4 for Mallampati score and 5.62 for NC/TMD to predict difficult intubation. Conclusion: The diagnostic accuracy of NC/TM ratio and Mallampatti score were better compared to other bedside tests to predict difficult intubation in Indian population. PMID:26957691
Kwon, Min A; Song, Jaegyok; Kim, Seokkon; Ji, Seong-Mi; Bae, Jeongho
Various complications may occur during nasotracheal intubation. This may include epistaxis and damage to the nasopharyngeal airway. We tested the hypothesis that the use of fiberoptic bronchoscopy (FOB)-guided intubation is superior to endotracheal tube (ETT) obturated with an inflated esophageal stethoscope. Patients were randomly assigned to 1 of 2 groups (n=22 each): either an FOB-guided intubation group or ETT obturated with an inflated esophageal stethoscope group. After the induction of general anesthesia, patients in the FOB group received an FOB inspection through the nostril without advancement of ETT. Then, after confirming the placement of the bronchoscope tip in the trachea, the lubricated ETT was advanced via the nostril to the trachea along the bronchoscope. In the obturated ETT insertion group, the proximal opening of the ETT was blunted with an inflated esophageal stethoscope. The ETT was inserted into the selected nostril and advanced blindly into the posterior oropharynx. Then, the esophageal stethoscope was removed and tracheal intubation was performed with the bronchoscope. The number of attempts for successful tracheal intubation, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. Another anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5minutes after the intubation and postoperative complications. The FOB group had significantly less epistaxis during bronchoscopy, better navigability, and fewer intubation attempts and redirections. Fiberoptic-guided nasotracheal intubation was associated with less epistaxis. It also showed better navigability and less redirection rate. Therefore, FOB as an intubation guide is superior to ETT with an inflated esophageal stethoscope when intubating a patient via the nasotracheal route. Copyright © 2016 Elsevier Inc. All rights reserved.
Slater, E A; Weiss, S J; Ernst, A A; Haynes, M
Maintenance of an airway in the air medically transported patient is of paramount importance. The purpose of this study is to compare preflight versus en route rapid sequence intubation (RSI)-assisted intubations and to determine the value of air medical use of RSI. This study is a 31-month retrospective review of all patients intubated and transported by a large city air medical service. Subgroup analysis was based on whether patients were transported from a hospital or a scene and whether they were intubated preflight or en route. Information on age, Glasgow Coma Scale score, type of scene, ground time, and previous attempts at intubation was recorded. Complications included failures, multiple attempts at intubation, arrhythmias, and need for repeated paralytic agents. Comparisons were made using a confidence interval analysis. An alpha of 0.05 was considered significant; Bonferroni correction was used for multiple comparisons. Three hundred twenty-five patients were intubated and transported by Lifeflight during the study period. Two hundred eighty-eight patients were intubated using RSI (89%). The success rate was 97%. Preflight intubations were performed on 100 hospital calls and 86 scene calls. En route intubations were performed on 40 hospital cases and 62 scene calls. Patients who underwent preflight intubations were significantly younger than those who underwent en route intubations for both the hospital group (34 +/- 11 vs. 44 +/- 24 years, p < 0.05) and the scene group (27 +/- 13 vs. 32 +/- 16 years,p < 0.05). Otherwise, the demographic characteristics of the four groups were similar. Trauma accounted for 60 to 70% of hospital transfers and almost 95 to 100% of scene calls. Compared with preflight intubations, there was a significant decrease in ground time for hospital patients who were intubated en route (26 +/- 10 vs. 34 +/- 11 minutes, p < 0.05) and for scene patients who were intubated en route (11 +/- 8 vs. 18 +/- 9 minutes, p < 0.05). There were
Kociszewski, C; Thomas, S H; Harrison, T; Wedel, S K
The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.
Gonçalves, Roberta Lins; Tsuzuki, Lucila Midori; Carvalho, Marcos Giovanni Santos
Evidence-based practices search for the best available scientific evidence to support problem solving and decision making. Because of the complexity and amount of information related to health care, the results of methodologically sound scientific papers must be integrated by performing literature reviews. Although endotracheal suctioning is the most frequently performed invasive procedure in intubated newborns in neonatal intensive care units, few Brazilian studies of good methodological quality have examined this practice, and a national consensus or standardization of this technique is lacking. Therefore, the purpose of this study was to review secondary studies on the subject to establish recommendations for endotracheal suctioning in intubated newborns and promote the adoption of best-practice concepts when conducting this procedure. An integrative literature review was performed, and the recommendations of this study are to only perform endotracheal suctioning in newborns when there are signs of tracheal secretions and to avoid routinely performing the procedure. In addition, endotracheal suctioning should be conducted by at least two people, the suctioning time should be less than 15 seconds, the negative suction pressure should be below 100 mmHg, and hyperoxygenation should not be used on a routine basis. If indicated, oxygenation is recommended with an inspired oxygen fraction value that is 10 to 20% greater than the value of the previous fraction, and it should be performed 30 to 60 seconds before, during and 1 minute after the procedure. Saline instillation should not be performed routinely, and the standards for invasive procedures must be respected. PMID:26465249
Romualdo Del Buono
Conclusions: According to the literature, our results confirmed that there is still no single element that can predict a difficult intubation. Although no statistical significance was found, the AFV and FV have shown to have a potential predictive role for difficult intubation. Further studies with bigger samples are advisable to confirm this encouraging result.
Maharaj, C H
Direct laryngoscopic tracheal intubation is a potentially lifesaving manoeuvre, but it is a difficult skill to acquire and to maintain. These difficulties are exacerbated if the opportunities to utilise this skill are infrequent, and by the fact that the consequences of poorly performed intubation attempts may be severe. Novice users find the Airtraq laryngoscope easier to use than the conventional Macintosh laryngoscope. We therefore wished to determine whether novice users would have greater retention of intubation skills with the Airtraq rather than the Macintosh laryngoscope. Twenty medical students who had no prior airway management experience participated in this study. Following brief didactic instruction, each took turns performing laryngoscopy and intubation using the Macintosh and Airtraq devices in easy and simulated difficult laryngoscopy scenarios. The degree of success with each device, the time taken to perform intubation and the assistance required, and the potential for complications were then assessed. Six months later, the assessment process was repeated. No didactic instruction or practice attempts were provided on this latter occasion. Tracheal intubation skills declined markedly with both devices. However, the Airtraq continued to provide better intubating conditions, resulting in greater success of intubation, with fewer optimisation manoeuvres required, and reduced potential for dental trauma, particularly in the difficult laryngoscopy scenarios. The substantial decline in direct laryngoscopy skills over time emphasise the need for continued reinforcement of this complex skill.
Full Text Available Background and objective: Prediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro-hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation. Method: The consecutive 500 ASA (I, II adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, Specificity, Positive and Negative Predictive Values were also reported. Results: Cormack-Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack-Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications. Conclusion: Friedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre-anesthetic prediction of difficult intubation where its involvement in Multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway.
Full Text Available Background : Fiberoptic intubation is the gold standard technique for difficult airway management in patients of temporomandibular joint. This study was aimed to evaluate the clinical efficacy and safety of dexmedetomidine as premedication with propofol infusion for fiberoptic intubation. Methods: Consent was obtained from 46 adult patients of temporomandibular joint ankylosis, scheduled for gap arthroplasty. They were enrolled for thisdouble-blind, randomized, prospective clinical trial with two treatment groups - Group D and Group P, of 23 patients each. Group D patients had received premedication of dexmedetomidine 1 μg/kg infused over 10 min followed by sedative propofol infusion and the control Group P patients were given only propofol infusion to achieve sedation. Condition achieved at endoscopy, intubating conditions, hemodynamic changes and postoperative events were evaluated as primary outcome. Results : The fiberoptic intubation was successful with satisfactory endoscopic and intubating condition in all patients. Dexmedetomidine premedication has provided satisfactory conditions for fiberoptic intubation and attenuated the hemodynamic response of fiberoptic intubation than the propofol group. Conclusion : Fiberoptic intubation was found to be easier with dexmedetomidine premedication along with sedative infusion of propofol with complete amnesia of the procedure, hemodynamic stability and preservation of patent airway.
Full Text Available Airway management is essential for safe anesthesia and endotracheal intubation is the most important procedure by which critically ill patients can be better managed, especially if done quickly and successfully. This study aimed to compare the techniques of intubation through laryngeal mask airway (LMA using a bougie versus video laryngoscopy (VL regarding to intubation success and the quality of intubation indices in patients with difficult airways. This randomized clinical trial was performed on 96 patients aged 16–76 years with Mallampati class 3 or 4 who underwent elective surgery. Once the demographics were recorded, patients were randomly divided into two groups and the first group intubated with VL, and the second group intubated through laryngeal mask using a bougie. Then vital signs, arterial oxygen saturation, the time required for successful intubation, and ease of intubation were recorded. Here t-tests, chi-square, Fisher exact tests, and analysis of variance for repeated measurement were used to analyze the data in SPSS software. The overall success rates of intubation in VL and LMA groups were 46 (96% and 44 (92%, respectively. The mean duration of intubation for the LMA and VL groups was 18.70 ± 6.73 and 14.21 ± 4.14 seconds, respectively (P < 0.001. Moreover, visual analogue scale score for pain in throat was significantly lower in VL group than LMA (1.65 ± 0.76 vs. 1.33 ± 0.52. Moreover, easy intubation in bougie group was 50%, while the easy intubation in VL was 73% (P = 0.023. In addition, incidence of cough was 31% in the LMA with bougie group and 9% in VL group (P = 0.005. The VL technique is an easier method and has a shorter intubation time than LMA using bougie, and causes a lower incidence of coughing, laryngospasm in patients that need intubation. Moreover, cough and discomfort in the throat tend to be less in VL, and the LMA could be used as replacement of VL in hard situations.
Pažur, Iva; Maldini, Branka; Hostić, Vedran; Ožegić, Ognjen; Obraz, Melanija
D-blade is a relatively new device in the field of videolaryngoscopy, designed for airway management by enabling indirectoscopic glottic view. In our study, we investigated efficiency of D-blade in comparison with direct Macintosh laryngoscope (gold standard). Fifty-two adult patients with normal airway scheduled for elective surgery in general anesthesia were randomly assigned in D-blade video or direct Macintosh group. In the first video group, patients were laryngo-scoped and intubated by D-blade, and in the second group laryngoscopy and intubation were performed by Macintosh laryngoscope. Glottic view was evaluated according to Cormack Lehane grading system (C-L), while duration of intubation and easiness of intubation were evaluated according to the intubation difficulty score (IDS). Additionally, hemodynamic parameters were recorded before and after induction. There were no statistically significant between-group differences in time to intubation, easiness of endotracheal tube insertion, C-L, and IDS. In comparison with direct Macintosh laryngoscope, D-blade showed similar but still favorable characteristics. In our opinion, D-blade is a useful device in airway management and should be used in daily anesthesiologist work.
Li, Simon; Rehder, Kyle J; Giuliano, John S; Apkon, Michael; Kamat, Pradip; Nadkarni, Vinay M; Napolitano, Natalie; Thompson, Ann E; Tucker, Craig; Nishisaki, Akira
Advanced airway management in the pediatric intensive care unit (PICU) is hazardous, with associated adverse outcomes. This report describes a methodology to develop a bundle to improve quality and safety of tracheal intubations. A prospective observational cohort study was performed with expert consensus opinion of 1715 children undergoing tracheal intubation at 15 PICUs. Baseline process and outcomes data in tracheal intubation were collected using the National Emergency Airway Registry for Children reporting system. Univariate analysis was performed to identify risk factors associated with adverse tracheal intubation-associated events. A multidisciplinary quality improvement committee was formed. Workflow analysis of tracheal intubation and pilot testing were performed to develop the Airway Bundle Checklist with 4 parts: (1) risk factor assessment, (2) plan generation, (3) preprocedure time-out to ensure that providers, equipment, and plans are prepared, (4) postprocedure huddle to identify improvement opportunities. The Airway Bundle Checklist developed may lead to improvement in airway management. © The Author(s) 2014.
Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the digestive tract. Better understanding of the molecular characteristics of GISTs led to the clinical development of imatinib for treating patients with this disease. New immuno markers and mechanisms of primary and secondary resistance were discovered. Adjuvant imatinib in intermediate or high risk GIST has improved the recurrence-free survival. Sunitinib in patients with intolerance or progression on imatinib demonstrated significant improvements in progression-free and overall survival versus placebo. Second-generation tyrosine kinase inhibitors, such as sorafenib, dasatinib, and nilotinib, have shown activity in patients with imatinib- and sunitinib-resistant GIST. (author)
Graham, R.N.J.; Perriss, R.W.; Scarsbrook, A.F.
This is the fifth in the series of short reviews of internet-based radiological learning resources and will focus on gastrointestinal (GI) and hepatobiliary radiology. Below are details of a few of the higher quality resources currently available. Most of the sites cater for medical students and trainee or non-specialist radiologists, but may be also be of interest to specialists, especially for use in teaching. Hyperlinks are available in the electronic version of this article and were all active at the time of going to press (May 2006)
Vargas, Maria; Pastore, Antonio; Aloj, Fulvio; Laffey, John G; Servillo, Giuseppe
Videolaryngoscopy has become increasingly attractive for the routine management of the difficult airway. Glidescope® is well studied in the literature while imago V-Blade® is a recent videolaryngoscope. This is a feasibility study with 1:1 case-control sequential allocation comparing Imago V-Blade ® and Glidescope® in predicted difficult airway settings. Two senior anesthesiologists with no clinical experience in video assisted intubation but previously trained in a simulated scenario, performed the endotracheal intubations with Imago V-Blade® and Glidescope®. A third experienced anesthesiologist supervised the procedures. Forty-two patients, 21 for each group, with the presence of predicted difficult airway according to the Italian guideline were included. The primary end point is the feasibility of intubation. The secondary end-points are the success to intubate in the first attempt, the intubation time, the Cormack and Lehane score view, the comparison of the intubation difficulty scale (IDS) score and the need for maneuvers to aid the endotracheal intubation comparing Imago V-Blade® and Glidescope®. The intubation was achieved in 100% of cases in both groups. No differences were found in the first-attempt success rate (p = 0.383), intubation time (p = 0.280), Cormack and Lehane score view (p = 0.799) and IDS score (p = 0.252). Statistical differences were found in external laryngeal pressure (p = 0.005), advancement of the blade (p = 0.024) and use of increasing lifting force (p = 0.048). This feasibility study showed that the intubation with the newly introduced Imago V-Blade® is feasible. Further randomized and/or non-inferiority trials are needed to evaluate the benefit of Imago V-Blade® in this procedure. Clinicaltrials.gov NCT02897518 . Retrospectively registered 25 August 2016.
Manning, B J
BACKGROUND: The routine use of nasogastric tubes in patients undergoing elective abdominal operation is associated with an increased incidence of postoperative fever, atelectasis, and pneumonia. Previous studies have shown that nasogastric tubes have no significant effect on the incidence of gastroesophageal reflux or on lower esophageal sphincter pressure in healthy volunteers. We hypothesized that nasogastric intubation in patients undergoing laparotomy reduces lower esophageal sphincter pressure and promotes gastroesophageal reflux in the perioperative period. METHODS: A prospective randomized case-control study was undertaken in which 15 consenting patients, admitted electively for bowel surgery, were randomized into 2 groups. Group 1 underwent nasogastric intubation after induction of anesthesia, and Group 2 did not. All patients had manometry and pH probes placed with the aid of endoscopic vision at the lower esophageal sphincter and distal esophagus, respectively. Nasogastric tubes, where present, were left on free drainage, and sphincter pressures and pH were recorded continuously during a 24-hour period. Data were analyzed with 1-way analysis of variance. RESULTS: The mean number of reflux episodes (defined as pH < 4) in the nasogastric tube group was 137 compared with a median of 8 episodes in the group managed without nasogastric tubes (P =.006). The median duration of the longest episode of reflux was 132 minutes in Group 1 and 1 minute in Group 2 (P =.001). A mean of 13.3 episodes of reflux lasted longer than 5 minutes in Group 1, with pH less than 4 for 37.4% of the 24 hours. This was in contrast to Group 2 where a mean of 0.13 episodes lasted longer than 5 minutes (P =.001) and pH less than 4 for 0.2% of total time (P =.001). The mean lower esophageal sphincter pressures were lower in Group 1. CONCLUSIONS. These findings demonstrate that patients undergoing elective laparotomy with routine nasogastric tube placement have significant gastroesophageal
Cystic fibrosis has historically been considered a pulmonary disease, but with the increasing life expectancy of these patients, gastrointestinal manifestations are becoming more important. Furthermore, nutritional status is closely linked to pulmonary function and, thus, overall mortality. This article discusses gastrointestinal manifestations (which involve nutritional, pancreatic, hepatobiliary, and, in particular, gastrointestinal tract issues) of cystic fibrosis as well as management of the disease. In addition, the article discusses studies that have been critical to our understanding of gastrointestinal manifestations of cystic fibrosis. PMID:27330503
Andersen, L H; Rovsing, Marie Louise; Olsen, K S
Morbidly obese patients are at increased risk of hypoxemia during tracheal intubation because of increased frequency of difficult and impossible intubation and a decreased apnea tolerance. In this study, intubation with the GlideScope videolaryngoscope (GS) was compared with the Macintosh direct...
Radiological imaging is an important part of the evaluation and management of neonates with suspected anomalies of the gastrointestinal tract. Clinical presentation is often non-specific, commonly with abdominal distension and vomiting for which the underlying cause may or may not be clinically apparent. In a proportion of patients, the clinical assessment alone may suffice in providing the diagnosis and no further imaging is necessary. The reader must have an understanding of the normal radiographic appearances of the gastrointestinal tract in neonates and appreciate normal variants and differences to adults. In certain cases, the abdominal radiograph alone is diagnostic. In others, sonography and contrast studies are useful adjunct investigations and the indications for CT and MRI are few, but specific. Appropriate radiological investigation will help to establish the diagnosis and guide surgical intervention whilst also avoiding unnecessary radiation. Some of the conditions require transfer to specialist paediatric institutions for care. Thus, in some circumstances it is appropriate for imaging to be delayed and performed at the specialist centre with early referral often essential for the continued well being of the child
Leardi, S; Altilia, F; Pietroletti, R; Risetti, A; Schietroma, M; Simi, M
The diagnosis-related-groups (DRG) is the cost-based system for hospital reimbursement. However, the proceeds does not coincide with the costs. Aim of the study was to identify the profit, which we could gained with 147, 155, 158, 162, 165, 198 gastrointestinal surgery DRG. 30 consecutive patients, undergone to surgery in Clinica Chirurgica of L'Aquila University, had been studied. We had calculated the daily costs of medical and nursing practice, diagnostic tests, drugs, hospitalization, surgical instruments for every patient's therapy. The DRG-proceeds had been correlated with the DRG-costs. The "major gastrointestinal surgery" had not profit (147 DRG: anterior resection of rectum = -354428 Pounds, Miles = -94020 Pounds; 155 DRG: total gastrectomy = -1920641 Pounds). On the contrary, "minimal surgery" had good profits (158 DRG: hemorroidectomy with local anestesia = 1469605 Pounds;162 DRG: sutureless groin hernioplasty = 1561200 Pounds; 198 DRG: videolaparochole-cystectomy: 1208807 Pounds). The study seems to demonstrate the disparity of the reimbursement system related to DRG. However, the surgeons, as managers, must employ warily the resources for producing DRG.
Ritesh R Kalaskar
Full Text Available Avulsion is serious injury that may encounter during endotracheal intubation and its management often presents a challenge. Replantation of the avulsed tooth can restore esthetic appearance and occlusal function shortly after the injury. The present article describes the management of air-dried maxillary permanent incisors that have been avulsed due to direct laryngoscopy during the induction of general anesthesia for tonsillectomy procedure. The replanted maxillary central incisors had maintained its function and esthetic for 1 year after replantation. Children in a mixed dentition phase are high-risk group children for traumatic dental injury during laryngoscopy; therefore, Anesthetic Departments should have local protocols to refer patients for dental treatment postoperatively in the event of trauma.
Nilsson, Philip M; Russell, Lene; Ringsted, Charlotte
: Twenty-three anaesthesia residents in their first year of training in anaesthesiology with no experience in FOI, and 10 anaesthesia consultants experienced in FOI. INTERVENTIONS: The novices to FOI were allocated randomly to receive either part-task or whole-task training of FOI on virtual reality......BACKGROUND: Flexible fibreoptic intubation (FOI) is a key element in difficult airway management. Training of FOI skills is an important part of the anaesthesiology curriculum. Simulation-based training has been shown to be effective when learning FOI, but the optimal structure of the training...... is debated. The aspect of dividing the training into segments (part-task training) or assembling into one piece (whole-task training) has not been studied. OBJECTIVE: The aims of this study were to compare the effect of training the motor skills of FOI as part-task training or as whole-task training...
Carlson, Jestin N; Das, Samarjit; De la Torre, Fernando; Frisch, Adam; Guyette, Francis X; Hodgins, Jessica K; Yealy, Donald M
Adequate visualization of the glottic opening is a key factor to successful endotracheal intubation (ETI); however, few objective tools exist to help guide providers' ETI attempts toward the glottic opening in real-time. Machine learning/artificial intelligence has helped to automate the detection of other visual structures but its utility with ETI is unknown. We sought to test the accuracy of various computer algorithms in identifying the glottic opening, creating a tool that could aid successful intubation. We collected a convenience sample of providers who each performed ETI 10 times on a mannequin using a video laryngoscope (C-MAC, Karl Storz Corp, Tuttlingen, Germany). We recorded each attempt and reviewed one-second time intervals for the presence or absence of the glottic opening. Four different machine learning/artificial intelligence algorithms analyzed each attempt and time point: k-nearest neighbor (KNN), support vector machine (SVM), decision trees, and neural networks (NN). We used half of the videos to train the algorithms and the second half to test the accuracy, sensitivity, and specificity of each algorithm. We enrolled seven providers, three Emergency Medicine attendings, and four paramedic students. From the 70 total recorded laryngoscopic video attempts, we created 2,465 time intervals. The algorithms had the following sensitivity and specificity for detecting the glottic opening: KNN (70%, 90%), SVM (70%, 90%), decision trees (68%, 80%), and NN (72%, 78%). Initial efforts at computer algorithms using artificial intelligence are able to identify the glottic opening with over 80% accuracy. With further refinements, video laryngoscopy has the potential to provide real-time, direction feedback to the provider to help guide successful ETI.
Gehrke, Lísia; Oliveira, Roselaine P; Becker, Maicon; Friedman, Gilberto
to compare clinical and cost effectiveness of midazolam and diazepam for urgent intubation. patients admitted to the Central ICU of the Santa Casa Hospital Complex in Porto Alegre, over the age of 18 years, undergoing urgent intubation during 6 months were eligible. Patients were randomized in a single-blinded manner to either intravenous diazepam or midazolam. Diazepam was given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute. Midazolam was given as an intravenous bolus of 5 mg with further aliquots of 2.5 mg each minute. Ramsay sedation scale 5-6 was considered adequate sedation. We recorded time and required doses to reach adequate sedation and duration of sedation. thirty four patients were randomized, but one patient in the diazepam group was excluded because data were lost. Both groups were similar in terms of illness severity and demographics. Time for adequate sedation was shorter (132 ± 87 sec vs. 224 ± 117 sec, p = 0.016) but duration of sedation was similar (86 ± 67 min vs. 88 ± 50 min, p = 0.936) for diazepam in comparison to midazolam. Total drug dose to reach adequate sedation after either drugs was similar (10.0 [10.0-12.5] mg vs. 15.0 [10.0-17.5] mg, p = 0.248). Arterial pressure and sedation intensity reduced similarly overtime with both drugs. Cost of sedation was lower for diazepam than for midazolam (1.4[1.4-1.8] vs. 13.9[9.4-16.2] reais, p diazepam and midazolam is effective and well tolerated. Sedation with diazepam is associated to a quicker sedation time and to lower costs.
Matyja, Maciej; Pasternak, Artur; Szura, Mirosław; Pędziwiatr, Michał; Major, Piotr; Rembiasz, Kazimierz
Colonoscopy plays a critical role in colorectal cancer (CRC) screening and has been widely regarded as the gold standard. Cecal intubation rate (CIR) is one of the well-defined quality indicators used to assess colonoscopy. To assess the impact of new technologies on the quality of colonoscopy by assessing completion rates. This was a dual-center study at the 2 nd Department of Surgery at Jagiellonian University Medical College and at the Specialist Center "Medicina" in Krakow, Poland. The CIR and cecal intubation time (CIT) in three different eras of technological advancement were determined. The study enrolled 27 463 patients who underwent colonoscopy as part of a national CRC screening program. The patients were divided into three groups: group I - 3408 patients examined between 2000 and 2003 (optical endoscopes); group II - 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); and group III - 13 650 patients examined between 2009 and 2014 (modern endoscopes). There were statistically significant differences in the CIR between successive eras. The CIR in group I (2000-2003) was 69.75%, in group II (2004-2008) was 92.32%, and in group III (2009-2014) was 95.17%. The mean CIT was significantly reduced in group III. Our study shows that the technological innovation of novel endoscopy devices has a great influence on the effectiveness of the CRC screening program. The new era of endoscopic technological development has the potential to reduce examination-related patient discomfort, obviate the need for sedation and increase diagnostic yields.
Luo, Hui; Zhang, Linhui; Liu, Xiaodong; Leung, Felix W; Liu, Zhiguo; Wang, Xiangping; Xue, Ling; Wu, Kaichun; Fan, Daiming; Pan, Yanglin; Guo, Xuegang
Colonoscopy is widely used for management of colorectal diseases. A history of abdominal or pelvic surgery is a well-recognized factor associated with difficult colonoscopy. Although water exchange colonoscopy (WEC) was effective in small groups of male U.S. veterans with such a history, its application in other cultural settings is uncertain. To investigate the application of WEC in such patients. Prospective, randomized, controlled, patient-blinded study. Tertiary-care referral center in China. Outpatients with prior abdominal or pelvic surgery undergoing unsedated diagnostic, screening, or surveillance colonoscopy. Patients were randomized to examination by either WEC or conventional air colonoscopy (AC). Cecal intubation rate. A total of 110 patients were randomized to the WEC (n = 55) or AC (n = 55) group. WEC significantly increased the cecal intubation rate (92.7% vs 76.4%; P = .033). The maximum pain scores (± standard deviation) were 2.1 ± 1.8 (WEC) and 4.6 ± 1.7 (AC), respectively (P WEC would be willing to have a repeat unsedated colonoscopy (90.9% vs 72.7%, P = .013). Single center; unblinded but experienced endoscopists. This randomized, controlled trial confirms that the water exchange method significantly enhanced cecal intubation in potentially difficult colonoscopy in unsedated patients with prior abdominal or pelvic surgery. The lower pain scores and higher proportion accepting repeat of the unsedated option suggest that WEC is promising. It may enhances compliance with colonoscopy in specific populations. ( NCT01485133.). Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
Cheong, Geraldine Pei Chin; Kannan, Anusha; Koh, Kwong Fah; Venkatesan, Kumaresh; Seet, Edwin
Airway management during anaesthesia has potential difficulties and risks. We aimed to investigate the utility of routine airway assessment for predicting difficult tracheal intubation, review the prevailing practice of videolaryngoscope use amongst anaesthetists in a teaching hospital and determine the incidence of intraoperative and postoperative airway-related complications. A prospective observational study of 1,654 patients undergoing general anaesthesia with endotracheal intubation over a seven-month period was performed. Data regarding airway and anaesthetic management was collected and analysed. Videolaryngoscopes were used as the first-choice equipment in 60.5% of the cohort. The incidence of difficult intubation was 2.1%, of which 45.7% of cases were unanticipated. The sensitivity of airway assessment was 54.3%, with a positive predictive value of 8.1%. When difficult intubation was anticipated, more videolaryngoscopes were used as the first equipment of choice compared to the Macintosh laryngoscope (p < 0.001). In the Macintosh group, more patients required a change of airway equipment (p = 0.015), but the number of intubation attempts was similar (p = 0.293). The incidence of intraoperative (p = 0.920) and postoperative complications (p = 0.380) were similar in both groups. Using the current predictors of difficult intubation, half of the difficult airways we encountered were unanticipated. Videolaryngoscopes were preferred when difficulty was anticipated and were also used in routine tracheal intubation. Copyright: © Singapore Medical Association.
Gleason, Joshua M; Christian, Bill R; Barton, Erik D
Patients requiring emergency airway management may be at greater risk of acute hypoxemic events because of underlying lung pathology, high metabolic demands, insufficient respiratory drive, obesity, or the inability to protect their airway against aspiration. Emergency tracheal intubation is often required before complete information needed to assess the risk of procedural hypoxia is acquired (i.e., arterial blood gas level, hemoglobin value, or chest radiograph). During pre-oxygenation, administering high-flow nasal oxygen in addition to a non-rebreather face mask can significantly boost the effective inspired oxygen. Similarly, with the apnea created by rapid sequence intubation (RSI) procedures, the same high-flow nasal cannula can help maintain or increase oxygen saturation during efforts to secure the tube (oral intubation). Thus, the use of nasal oxygen during pre-oxygenation and continued during apnea can prevent hypoxia before and during intubation, extending safe apnea time, and improve first-pass success attempts. We conducted a literature review of nasal-cannula apneic oxygenation during intubation, focusing on two components: oxygen saturation during intubation, and oxygen desaturation time. We performed an electronic literature search from 1980 to November 2017, using PubMed, Elsevier, ScienceDirect, and EBSCO. We identified 14 studies that pointed toward the benefits of using nasal cannula during emergency intubation.
Vadepally, Ashwant Kumar; Sinha, Ramen; Kumar, A V S S Subramanya
Patients with limited mouth opening (LMO) often associated with difficult intubation. Retrograde intubation is an alternative technique of establishing definitive airway in these patients when blind nasal intubation fails and fiberoptic bronchoscope is not available. We tested the retrograde intubation through nasal route in patients with LMO less than 2 cm. The procedure was performed with some modification with regard to retrograde guide on 18 patients requiring maxillofacial surgical procedures to increase mouth opening. Indications for this technique were mandibular fracture (n = 6), oral submucous fibrosis (OSMF; n = 6), temporomandibular joint (TMJ) ankylosis (n = 4) and internal derangement of TMJ (n = 2). All patients were assessed for preoperative interincisal opening; during intubation through specific parameters and; also postoperative findings were observed. Mean time taken for successful intubation was 5.6 min ± 1.66. One patient had subcutaneous emphysema which was managed conservatively. Postoperatively, four patients had sore throat which resolved in few days. No other complications were encountered. In conclusion, retrograde nasotracheal intubation is an effective and useful technique for airway control in patients with LMO and with only a small risk potential.
Kulkarni, Atul P; Tirmanwar, Amar S
Literature suggests glottic view is better with straight blades while tracheal intubation is easier with curved blades. To compare glottic view and ease of intubation with Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope. This prospective randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer centre after approval from the Institutional Review Board. We compared the Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope for glottic visualisation and ease of tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated. We recorded: Visualisation of glottis (Cormack Lehane grade), ease of intubation, number of attempts; need to change the blade and need for external laryngeal manipulation. Demographic data, Mallampati classification were compared using the Chi-square test. A P<0.05 was considered significant. Grade 1 view was obtained most often (87% patients) with Trueview(®) laryngoscope. Intubation was easier (Grade 1) with Trueview(®) and McCoy blades (93% each). Seven patients needed two attempts; one patient in Miller group needed three attempts. No patient in McCoy and Trueview(®) Groups required external laryngeal manipulation. We found that in patients with normal airway glottis was best visualised with Miller blade and Trueview(®) laryngoscope however, the trachea was more easily intubated with McCoy and Macintosh blades and Trueview(®) laryngoscope.
Maharaj, Chrisen H
The Airtraq laryngoscope is a novel intubation device that may possess advantages over conventional direct laryngoscopes for use by personnel that are infrequently required to perform tracheal intubation. We conducted a prospective study in 20 medical residents with little prior airway management experience. After brief didactic instruction, each participant took turns performing laryngoscopy and intubation using the Macintosh (Welch Allyn, Welch Allyn, NY) and Airtraq (Prodol Ltd. Vizcaya, Spain) devices, in 3 laryngoscopy scenarios in a Laerdal Intubation Trainer (Laerdal, Stavanger, Norway) and 1 scenario in a Laerdal SimMan manikin (Laerdal, Kent, UK). They then performed tracheal intubation of the normal airway a second time to characterize the learning curve. In all scenarios tested, the Airtraq decreased the duration of intubation attempts, reduced the number of optimization maneuvers required, and reduced the potential for dental trauma. The residents found the Airtraq easier to use in all scenarios compared with the Macintosh laryngoscope. The Airtraq may constitute a superior device for use by personnel infrequently required to perform tracheal intubation.
Bill R. Christian
Full Text Available Patients requiring emergency airway management may be at greater risk of acute hypoxemic events because of underlying lung pathology, high metabolic demands, insufficient respiratory drive, obesity, or the inability to protect their airway against aspiration. Emergency tracheal intubation is often required before complete information needed to assess the risk of procedural hypoxia is acquired (i.e., arterial blood gas level, hemoglobin value, or chest radiograph. During pre-oxygenation, administering high-flow nasal oxygen in addition to a non-rebreather face mask can significantly boost the effective inspired oxygen. Similarly, with the apnea created by rapid sequence intubation (RSI procedures, the same high-flow nasal cannula can help maintain or increase oxygen saturation during efforts to secure the tube (oral intubation. Thus, the use of nasal oxygen during pre-oxygenation and continued during apnea can prevent hypoxia before and during intubation, extending safe apnea time, and improve first-pass success attempts. We conducted a literature review of nasal-cannula apneic oxygenation during intubation, focusing on two components: oxygen saturation during intubation, and oxygen desaturation time. We performed an electronic literature search from 1980 to November 2017, using PubMed, Elsevier, ScienceDirect, and EBSCO. We identified 14 studies that pointed toward the benefits of using nasal cannula during emergency intubation.
Aida, Junko; Oda, Yutaka; Kasagi, Yoshihiro; Ueda, Mami; Nakada, Kazuo; Okutani, Ryu
We retrospectively reviewed the anesthesia records of infants 10 min for tracheal intubation) or records of Cormack-Lehane grade were included. Demographic data are median age 5 (range, 0-11) months, height 61 (33-84) cm, body weight 6.0 (1.1 - 11.8) kg. The number of cases with ASA physical status I, II, III and IV was 182 (36.6 %), 135 (27.3 %), 177 (35.5 %) and 3 (0.6 %), respectively. Cormack-Lehane grade 1, 2, 3 and 4 was seen in 450 (90.5 %), 32 (6.4 %), 6 (1.2 %) and 6 (1.2 %) cases, respectively. Document of difficult intubation was found in 12 cases (2.4 %, 10 different infants) with a lack of record of Cormack-Lehane grade in 3 cases. Of these 10 infants, nine had multiple congenital anomalies including heart diseases and cleft palate. Without premedication, general anesthesia was induced with intravenous midazolam or sevoflurane in the 12 cases. Tracheal intubation was performed after disappearance of spontaneous respiration except three cases who were intubated in the awake state or under sedation. Elapsed time from induction of anesthesia to intubation was 17 (14-29) min. Although mask ventilation was adequate in all cases, two cases (one infant) developed hypoxia and bradycardia during tracheal intubation. No remarkable decrease of SpO 2 or bradycardia less than 100 bpm was detected in other cases. In conclusion, we found difficult intubation in 2.4 % of infants undergoing general anesthesia. Although muscle relaxants are useful for facilitating tracheal intubation, it should be carefully used with the preparation of other airway devices in infants with predicted difficult intubation.
Staikou, Chryssoula; Tsaroucha, Athanassia; Paraskeva, Anteia; Fassoulaki, Argyro
The Intubating Laryngeal Mask Airway FastrachTM (ILMA) has been used with success in difficult intubation cases. The purpose of this study is to evaluate the effect of mouth opening, Mallampati classification, thyromental distance and Cormack-Lehane Grade, on the ease of ILMA use. Eighty one patients ASA I-II, were assessed preoperatively for mouth opening, Mallampati classification and thyromental distance. After induction with propofol and rocuronium, the first investigator recorded Cormack-Lehane Grade by direct laryngoscopy. Subsequently an appropriate size ILMAwas inserted by the second investigator and correct placement was confirmed by adequate ventilation and normal capnogram. A maximum of three ILMA insertion attempts were allowed and the number was recorded. Then blind intubation was attempted and classified as follows, according to Intubation Difficulty Grade (IDG): IDG-1: intubation succeeded: at first attempt requiring no or minor ILMA manipulations. IDG-2: intubation succeeded at second attempt requiring major ILMA manipulations or size change. IDG-3: intubation failed after the second attempt or oesophageal intubation occurred at either attempt. In failure of the technique direct laryngoscopy was the alternative approach. Success rates in insertion of ILMA and in blind intubation were 100% and 92.6% respectively. No difference was found between Cormack-Lehane Grade I-II and II-IV or Mallampati classification and number of ILMA insertion attempts or IDG. There was also no correlation between mouth opening, or thyromental distance and number of ILMA insertion attempts or IDG. It is concluded that easiness of ILMA use is irrelevant to mouth opening, thyromental distance, Mallampati classification or Cormack-Lehane Grade.
Full Text Available Background: Traditional Macintoch laryngoscopy is known to cause a rise in intraocular pressure (IOP, tachycardia and hypertension. These changes are not desirable in patients with glaucoma and open globe injury. GlideScope is a video laryngoscope that functions independent of the line of sight, reduces upward lifting forces for glottic exposure and requires less cervical neck movement for intubation, making it less stimulating than Macintosh laryngoscopy. Aim: The aim was to assess the variations in IOP and hemodynamic changes after GlideScope assisted intubation. Materials and Methods: After approval of the local Institutional Research and Ethical Board and informed patient consent, 50 adult American Society of Anesthesiologist I and II patients with normal IOP were enrolled in a prospective, randomized study for ophthalmic surgery requiring tracheal intubation. In all patients, trachea was intubated using either GlideScope or Macintoch laryngoscope. IOP of nonoperated eye, heart rate and blood pressure were measured as baseline, 1 min after induction, 1 min and 5 min after tracheal intubation. Results: IOP was not significantly different between groups before and after anesthetic induction and 5 min after tracheal intubation (P = 0.217, 0.726, and 0.110 respectively. The only significant difference in IOP was at 1 min after intubation (P = 0.041. No significant difference noted between groups in mean arterial pressure (P = 0.899, 0.62, 0.47, 0.82 respectively and heart rate (P = 0.21, 0.72, 0.07, 0.29, respectively at all measurements. Conclusion: GlideScope assisted tracheal intubation shown lesser rise in IOP at 1 min after intubation in comparison to Macintoch laryngoscope, suggesting that GlideScope may be preferable to Macintosh laryngoscope.
Hogan, A M
The concept that E2 exerts an effect on the gastrointestinal tract is not new and its actions on intestinal mucosa have been investigated for at least three decades. An attempt to consolidate results of these investigations generates more questions than answers, thus suggesting that many unexplored avenues remain and that the full capabilities of this steroid hormone are far from understood. Evidence of its role in esophageal, gastric and gallbladder cancers is confusing and often equivocal. The most compelling evidence regards the protective role conferred by estrogen (or perhaps ERbeta) against the development and proliferation of colon cancer. Not only has the effect been described but also many mechanisms of action have been explored. It is likely that, along with surgery, chemotherapy and radiotherapy, hormonal manipulation will play an integral role in colon cancer management in the very near future.
Minsky, Bruce D.
Objective: This refresher course will review the current knowledge as well as ongoing and future research strategies in lower gastrointestinal malignancies. Radiation therapy has a significant role in the adjuvant treatment of lower gastrointestinal malignancies. Furthermore, there are data to suggest that radiation therapy is an integral component of the conservative management (organ preservation) of rectal and anal cancers. 1. Colon cancer. The standard adjuvant treatment for node positive or high risk transmural colon cancer is postoperative 5-FU and Levamisole. There are retrospective data to suggest that certain subsets of high risk patients may benefit from postoperative radiation therapy. 2. Rectal cancer. Randomized trials have revealed an advantage of postoperative radiation therapy plus chemotherapy in transmural and/or node positive rectal cancer. In the adjuvant setting the use of continuous infusion 5-FU may be more beneficial compared with bolus 5-FU. Despite the improvement in survival, postoperative therapies are associated with an approximately 35% incidence of grade 3+ toxicity. Recent data suggest that the use of preoperative combined modality therapy may be associated with less toxicity as well as increase the chance of sphincter preservation. New Intergroup trials addressing these issues will be presented. In patients with locally advanced unresectable rectal cancer, the addition of intraoperative radiation therapy may further improve local control. 3. Anal cancer. The use of combined 5-FU/Mitomycin-C and pelvic radiation therapy is effective in the treatment of anal carcinoma. The RTOG has recently completed a randomized trial addressing the question of the effectiveness and toxicity of Mitomycin-C. The replacement Intergroup Phase III trial will be presented
Minsky, Bruce D.
Objective: This refresher course will review the current knowledge as well as ongoing and future research strategies in lower gastrointestinal malignancies. Radiation therapy has a significant role in the adjuvant treatment of lower gastrointestinal malignancies. Furthermore, there are data to suggest that radiation therapy is an integral component of the conservative management (organ preservation) of rectal and anal cancers. 1. Colon cancer. The standard adjuvant treatment for node positive or high risk transmural colon cancer is postoperative 5-FU and Levamisole. There are retrospective data to suggest that certain subsets of high risk patients may benefit from postoperative radiation therapy. 2. Rectal cancer. Randomized trials have revealed an advantage of postoperative radiation therapy plus chemotherapy in transmural and/or node positive rectal cancer. In the adjuvant setting the use of continuous infusion 5-FU may be more beneficial compared with bolus 5-FU. Despite the improvement in survival, postoperative therapies are associated with an approximately 35% incidence of grade 3+ toxicity. Recent data suggest that the use of preoperative combined modality therapy may be associated with less toxicity as well as increase the chance of sphincter preservation. New Intergroup trials addressing these issues will be presented. In patients with locally advanced unresectable rectal cancer, the addition of intraoperative radiation therapy may further improve local control. 3. Anal cancer. The use of combined 5-FU/Mitomycin-C and pelvic radiation therapy is effective in the treatment of anal carcinoma. The RTOG has recently completed a randomized trial addressing the question of the effectiveness and toxicity of Mitomycin-C. The replacement Intergroup Phase III trial will be presented
Margaret H. Collins
Full Text Available Eosinophilic gastrointestinal disorders (EGID are characterized pathologically by excess eosinophils in mucosal biopsies of one or multiple sites in the gastrointestinal (GI tract, simultaneously or sequentially. Eosinophilic esophagitis (EoE is the best characterized EGID, and in most patients it is an abnormal immune-mediated response to food antigens. Current recommendations for diagnosis include signs and symptoms of esophageal dysfunction that do not respond to proton-pump inhibitor therapy, and esophageal biopsies that exhibit at least 15 intraepithelial eosinophils in at least one high power field (HPF. Therapy consists of swallowed glucocorticoids or dietary elimination. Eosinophilic gastritis (EG is the second most common form of EGID, but like all forms of EGID except EoE consensus recommendations for either clinical or pathological diagnosis do not exist. EG may be associated clinically with peripheral blood eosinophilia, hypoalbuminemia, and anemia, and pathologically with marked expansion of lamina propria by dense eosinophilic infiltrates. Eosinophilic enteritis (EE may be subdivided into eosinophilic duodenitis, eosinophilic jejunitis, and eosinophilic ileitis. Most investigators believe that EE rarely, if ever, exists as a solitary form of EGID and is encountered only in patients who have at least one other affected portion of the GI tract. Eosinophilic colitis (EC is perhaps the most enigmatic EGID. Distinction of EC from inflammatory bowel disease may be problematic especially in children. Multiple possible etiologies for EGID include hypereosinophilic syndrome, drug reactions, etc. Currently, the only etiology that can be identified histologically is parasitic infestation, if a portion of an invasive parasite is found in mucosal biopsies. This review will provide guidelines for the pathologic diagnosis of the various forms of EGID.
Ghatak, Tanmoy; Samanta, Sukhen; Baronia, Arvind Kumar
Insertion of a nasogastric tube in an unconscious intubated patient may be difficult as they cannot follow the swallowing instructions, and therefore has a high first attempt failure rate. We describe here a new technique to insert nasogastric tube in an unconscious intubated patient by neck flexion and using angiography catheter as a stylet and manipulating the cricoid ring of trachea for easy passage of nasogastric tube. The technique is easy and helpful for nasogastric insertion in unconscious intubated patients. Additionally, it neither alters vital responses nor increases intracranial pressure like with laryngoscopy.
Full Text Available The aim of this study was to evaluate the efficiency of lightwand-guided endotracheal intubation (LWEI performed using either the right (dominant or left (nondominant hand. Two hundred and forty patients aged 21–64 years, with a Mallampati airway classification grade of I—II and undergoing endotracheal intubation under general anesthesia, were enrolled in this randomized and controlled study. Induction of anesthesia was initiated by intravenous administration of fentanyl (2 mg/kg and thiopentone (5mg/kg, and tracheal intubation was facilitated by intravenous atracurium (0.5 mg/kg. In the direct-vision laryngoscope group (group D; n = 80, the intubator held the laryngoscope in the left hand and inserted the endotracheal tube (ETT into the glottic opening with the right hand. In the group in which LWEI was performed with the right hand (group R; n = 80, the intubator lifted the patients' jaws with the left hand and inserted the ETT-LW unit into the glottic openings with the right hand. On the contrary, in the group in which LWEI was performed with the left hand (group L; n = 80, the intubator lifted the jaws with the right hand and inserted the ETT-LW unit with the left hand. Data including total intubation time, the number of intubation attempts, hemodynamic changes during intubation, and side effects following intubation, were collected. Regardless of whether lightwand manipulation was performed with the left hand (group L; 11.4 ± 9.3 s or the right-hand (group R; 12.4 ± 9.2 s, less time was consumed in the LWEI groups than in the laryngoscope group (group D; 17.9 ± 9.9s (p 95% on their first intubation attempts. The changes in mean arterial blood pressure and heart rate were similar among the three groups. A higher incidence of intubation-related oral injury and ventricular premature contractions (VPC was found in group D compared with groups L and R (oral injury: group D 8.5%, group L 1.3%, group R 0%, p = 0.005; VPC: group D 16
Full Text Available Morquio′s syndrome, also known as mucopolysaccharidosis type IV is an autosomal recessive disorder, caused by deficiency of n-acetylgalactosamine-6-sulphate. Anesthetic management of this syndrome is a great challenge, especially in pediatric age group as "cannot ventilate, cannot intubate" scenario can be encountered by anesthesiologist due to the possibility of total airway collapse. Herewith, we are reporting a case of child with Morquio′s syndrome where I-gel assisted fiber-optic intubation was used for safe endotracheal intubation.
Maharaj, C H
Direct laryngoscopic tracheal intubation is taught to many healthcare professionals as it is a potentially lifesaving procedure. However, it is a difficult skill to acquire and maintain, and, of concern, the consequences of poorly performed intubation attempts are potentially serious. The Airtraq Laryngoscope is a novel intubation device which may possess advantages over conventional direct laryngoscopes for use by novice personnel. We conducted a prospective trial with 40 medical students who had no prior airway management experience. Following brief didactic instruction, each participant took turns in performing laryngoscopy and intubation using the Macintosh and Airtraq devices under direct supervision. Each student was allowed up to three attempts to intubate in three laryngoscopy scenarios using a Laerdal Intubation Trainer and one scenario in a Laerdal SimMan Manikin. They then performed tracheal intubation of the normal airway a second time to characterise the learning curve for each device. The Airtraq provided superior intubating conditions, resulting in greater success of intubation, particularly in the difficult laryngoscopy scenarios. In both easy and simulated difficult laryngoscopy scenarios, the Airtraq decreased the duration of intubation attempts, reduced the number of optimisation manoeuvres required, and reduced the potential for dental trauma. The Airtraq device showed a rapid learning curve and the students found it significantly easier to use. The Airtraq appears to be a superior device for novice personnel to acquire the skills of tracheal intubation.
Full Text Available Background and Objective. The Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain is a novel tracheal intubation device. Studies, performed until now, have compared the Airtraq with the Macintosh laryngoscope, concluding that it reduces the intubation times and increase the success rate at first intubation attempt, decreasing the Cormack-Lehane score. The aim of the study was to evaluate if, in unskillful anesthesiology residents during the laryngoscopy, the Airtraq compared with the Macintosh laryngoscope improves the laryngeal view, decreasing the Cormack-Lehane score. Methods. A prospective, randomized, crossed-over trial was carried out on 60 patients. Each one of the patients were intubated using both devices by unskillful (less than two hundred intubations with the Macintosh laryngoscope and 10 intubations using the Airtraq anesthesiology residents. The Cormack-Lehane score, the success rate at first intubation attempt, and the laryngoscopy and intubation times were compared. Results. The Airtraq significantly decreased the Cormack-Lehane score (=0.04. On the other hand, there were no differences in times of laryngoscopy (=0.645; IC 95% 3.1, +4.8 and intubation (=0.62; C95% −6.1, +10.0 between the two devices. No relevant complications were found during the maneuvers of intubation using both devices. Conclusions. The Airtraq is a useful laryngoscope in unskillful anesthesiology residents improving the laryngeal view and, therefore, facilitating the tracheal intubation.
Ferrando, Carlos; Aguilar, Gerardo; Belda, F Javier
Background and Objective. The Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) is a novel tracheal intubation device. Studies, performed until now, have compared the Airtraq with the Macintosh laryngoscope, concluding that it reduces the intubation times and increase the success rate at first intubation attempt, decreasing the Cormack-Lehane score. The aim of the study was to evaluate if, in unskillful anesthesiology residents during the laryngoscopy, the Airtraq compared with the Macintosh laryngoscope improves the laryngeal view, decreasing the Cormack-Lehane score. Methods. A prospective, randomized, crossed-over trial was carried out on 60 patients. Each one of the patients were intubated using both devices by unskillful (less than two hundred intubations with the Macintosh laryngoscope and 10 intubations using the Airtraq) anesthesiology residents. The Cormack-Lehane score, the success rate at first intubation attempt, and the laryngoscopy and intubation times were compared. Results. The Airtraq significantly decreased the Cormack-Lehane score (P = 0.04). On the other hand, there were no differences in times of laryngoscopy (P = 0.645; IC 95% 3.1, +4.8) and intubation (P = 0.62; C95% -6.1, +10.0) between the two devices. No relevant complications were found during the maneuvers of intubation using both devices. Conclusions. The Airtraq is a useful laryngoscope in unskillful anesthesiology residents improving the laryngeal view and, therefore, facilitating the tracheal intubation.
Jitin N Trivedi
Full Text Available Video laryngoscope (VL provides excellent laryngeal exposure in patients when anaesthesiologists encounter difficulty with direct laryngoscopy. Videolaryngoscopy, like flexible fibreoptic laryngoscopy demands a certain level of training by practitioners to become dexterous at successful intubation with a given instrument. Due to their cost factors, VLs are not easily available for training purposes to all the students, paramedics and emergency medical services providers in developing countries. We tried to develop a cost-effective instrument, which can work analogous to various available VLs. An inexpensive and easily available instrument was used to create an Airtraq Model for VL guided intubation training on manikin. Using this technique, successful intubation of manikin could be achieved. The Airtraq Model mimics the Airtraq Avant ® and may be used for VL guided intubation training for students as well as paramedics, and decrease the time and shorten the learning curve for Airtraq ® as well as various other VLs.
Ching, Yiu-Hei; Socias, Stephanie M; Ciesla, David J; Karlnoski, Rachel A; Camporesi, Enrico M; Mangar, Devanand
Nasogastric tube intubation of a patient under general anesthesia with an endotracheal tube in place can pose a challenge to the most experienced anesthesiologist. Physiologic and pathologic variations in a patient's functional anatomy can present further difficulty. While numerous techniques to the difficult nasogastric tube intubation have been described, there is no consensus for a standard approach. Therefore, selecting the most appropriate approach requires a working knowledge of the techniques available, mindful consideration of individual patient and clinical factors, and the operator's experience and preference. This article reviews the relevant literature regarding various approaches to the difficult nasogastric tube intubation with descriptions of techniques and results from comparative studies if available. Additionally, we present a novel approach using a retrograde technique for the difficult intraoperative nasogastric tube intubation.
This study described the use of 120 mg nebulized lidocaine to attenuate the cardiovascular response to direct laryngoscopy and tracheal intubation in ASA I and ASA II patients undergoing various surgical procedures...
A. A. Ziganshina
Full Text Available Objective: to highlight the current concepts of gastrointestinal manifestations of mitochondrial dysfunction. The data available in Russian and foreign literature on the gastrointestinal manifestations of mitochondrial dysfunction were analyzed. Functional digestive diseases are common in pediatric practice; however, their etiopathogenesis has not been adequately explored today. According to the literature, impaired cellular energy metabolism may underlie gastrointestinal motility disorders in cyclic vomiting syndrome, gastroesophageal reflux, gastric stasis, chronic diarrhea, constipation, intestinal pseudoobstruction, malabsorption syndrome, irritable bowel syndrome, as well as diseases of the liver and pancreas.
Dhananjay Sampatrao Pote
Full Text Available BACKGROUND The aim of this study is to compare the McCoy blade laryngoscope and TruView laryngoscope in patients with anticipated difficult tracheal intubation with respect to ease of intubation, haemodynamic stress response and incidence of complications. MATERIALS AND METHODS Out of 120 patients anticipated to have difficult intubation using the standard criteria of airway assessment preoperatively including modified Mallampati classification, mouth opening, neck extension, SLUX, Upper Lip Bite Test (ULBT and thyromental distance. The patients are randomised into 2 groups using computer generated randomisation chart. Group T (n=60- intubation with TruView blade and Group M (n=60- intubation with McCoy blade. The two groups were studied using Chi-square tests. p<0.05 was considered statistically significant. RESULTS Overall, there was an improvement in the Cormack-Lehane grade (CL grade after using either McCoy or TruView laryngoscopes. The number of patients with CL grade I (85.0% in TruView group is significantly more as compared to grade I CL in McCoy group (50%, p=0.039, 13.3% of cases required ELM in the McCoy group, which was significantly more as compared to 3.3% cases in the TruView group. Mean total time taken for endotracheal intubation was 33.73 secs. in McCoy group, which was significantly less as compared to 64.03 secs. in TruView group. When compared between the groups, the increase in HR over the baseline was more in the McCoy group than the TruView group. CONCLUSION TruView laryngoscope provided excellent glottic view and showed better haemodynamic stability as compared to McCoy laryngoscope.
Nieman, Carolyn T; Merlino, James I; Kovach, Betty; Polk, J D; Mancuso, Charlene; Fallon, William F
We could not find any studies of nontertiary care facilities performing intubation for patients requiring transport to definitive pediatric care. The purpose of our study was to determine the current practices of pediatric airway management in the prehospital and transport environments. A retrospective analysis of all patients younger than 16 years transported by our flight program during a 2-year period served as the population of interest. The flight records (RN and MD documentation) for intubated patients were analyzed for medications, methods, outcomes, and other descriptive endpoints. As a matter of program policy, all pediatric transports are subjected to peer review in the performance improvement committee. During the review period, 732 patients younger than 16 years (range: 30 days to 15 years) were transported by our flight program. Of the 148 (20%) patients intubated for airway control, 81 were boys (55%), and 67 were girls (45%). Sixteen percent were younger than 1 year, 24% were 1 to 2 years old, 18% were 3 to 5, 20% were 6 to 11, and 22% were 12 to 15. Indicators for intubation included unresponsiveness or arrest, 42 (28%); seizures, 38 (26%); respiratory failure, 28 (19%); decreased level of consciousness (LOC), 14 (9%); airway protection, 13 (9%); combativeness, 11 (7%); and other, 2 (1%). Children were intubated most frequently by the referring physician (92 children, 62% of patients). The flight crew performed 49 (33%) intubations, and EMS staff performed seven (5%). Three children were nasally intubated. Significant variation occurred in medications used, endotracheal tube size and position, and nasogastric decompression. No single group performed better or worse than the others in our review. Variability exists in the application of pediatric airway management techniques, including pharmacologic modes and intubation indications.
Mustapha, Bensghir; Chkoura, K.; Elhassani, M.; Ahtil, R.; Azendour, H.; Kamili, N. Drissi
Anesthetic technique in parturient with syringomyelia and Arnold–Chiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq™ laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and Arnold–Chiari type I malformation. PMID:22144932
Andrew M. Mason
Full Text Available A case series of five patients is described demonstrating the utility of the intubating laryngeal mask airway in the prehospital setting, both as a primary airway rescue device and as a bridge to tracheal intubation. All patients were hypoxaemic, had sustained severe polytrauma and were trapped in their vehicles following road traffic collisions. A probability of survival study showed better-than-predicted outcomes for the group as a whole.
Mason, Andrew M.
A case series of five patients is described demonstrating the utility of the intubating laryngeal mask airway in the prehospital setting, both as a primary airway rescue device and as a bridge to tracheal intubation. All patients were hypoxaemic, had sustained severe polytrauma and were trapped in their vehicles following road traffic collisions. A probability of survival study showed better-than-predicted outcomes for the group as a whole. PMID:19718243
Rabadi, Daher; Baker, Ahmad Abu; Al-Qudah, Mohannad
Prediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro-hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation. The consecutive 500 ASA (I, II) adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, Specificity, Positive and Negative Predictive Values were also reported. Cormack-Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack-Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications. Friedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre-anesthetic prediction of difficult intubation where its involvement in Multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Ushakumary; Radha Korumbil; Bindu Mele
BACKGROUND AND AIMS In this era of high technology, we still face an ageless problem in anaesthesia – the difficult airway. In 1997, Smarajith Sur Roy of India introduced a new airway index to predict difficult intubation. Aim of the study is to compare the new airway index with modified Mallampati classification and also with Cormack and Lehane grading for predicting intubation difficulty. MATERIALS AND METHODS The study was conducted on 200 patients undergoing various surg...
Full Text Available BACKGROUND Direct laryngoscopy and endotracheal intubation elicits a haemodynamic response associated with increased heart rate and blood pressure. The aim of the study is to compare the efficacy of intravenous dexmedetomidine and fentanyl in attenuation of stress response to laryngoscopy and intubation. MATERIALS AND METHODS Study was carried out on 60 patients belonging to ASA grade I & II, aged 15 to 65 years including either gender scheduled for elective surgical procedures under general anaesthesia in Osmania General Hospital. Patients were randomly divided into two groups of 30 each. Group D received 0.6g/kg dexmedetomidine and Group F received 2 g/kg fentanyl diluted in 10 mL normal saline 10 minutes before laryngoscopy and intubation. Anaesthesia was standardised in both groups and vital parameters heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded preoperatively, during intubation and up to 10 minutes after intubation. RESULTS The groups were well matched for their demographic data. It was observed that increase in heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure after intubation was highly significant in fentanyl group as compared to dexmedetomidine. There was a statistically significant difference (P <0.05 between dexmedetomidine and fentanyl groups in heart rate, systolic, diastolic blood pressure and mean arterial pressure at all time points after tracheal intubation. CONCLUSION Both the drugs attenuated the pressor response. Among the two drugs administered dexmedetomidine 0.6 µg/kg provides reliable and effective attenuation of pressor response to laryngoscopy and tracheal intubation when compared to fentanyl in a dose of 2 µg/kg.
Zhang, Miao; Wang, Heng; Liu, Dong; Pan, Xuefeng; Wu, Wenbin; Hu, Zhengqun; Zhang, Hui
An asymptomatic patient was admitted as his chest photograph and computed tomography scans showed a giant Morgagni's hernia (MH). And it was repaired by laparoscopic approach under epidural anesthesia without endotracheal intubation. The hernia content of omentum was repositioned back into the abdominal cavity, and the diaphragmatic defect was repaired with composite mesh. Which indicated that non-intubated laparoscopic mesh repair via epidural anesthesia is reliable and satisfactory for MH.
Kumari, Indira; Naithani, Udita; Dadheech, Vinod Kumar; Pradeep, D S; Meena, Khemraj; Verma, Devendra
The role of nitro-glycerine (NTG) lingual spray for attenuation of the hemodynamic response associated with intubation is not much investigated. We conducted this study to evaluate the efficacy of NTG lingual pump or pen spray in attenuation of intubation induced hemodynamic responses and to elucidate the optimum dose. In a prospective randomized controlled trial, 90 adult patients of ASA I, II, 18-60 year posted for elective general surgery under general anesthesia with intubation were randomly allocated to three groups as Group C (control) - receiving no NTG spray, Group N1 - receiving 1 NTG spray and Group N2 - receiving 2 NTG spray one minute before intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate were recorded at baseline, just before intubation (i.e., 60 s just after induction and NTG spray), immediately after intubation, at 1, 2, 5 and 10 min after intubation. Incidence of hypertension was significantly higher in Group C (60%, n = 18) as compared to Group N1 and N2 (10%, n = 3 each), P N1 and N2. There was a trend toward fall in blood pressure in Group N2 (4.95% fall in SBP, 4.72% fall in MAP) 1-min following spray, which was clinically insignificant. Mean value of SBP, DBP and MAP was significantly higher in Group C than in Group N1, which was in turn greater than Group N2 (Group C > N1> N2), P N1 and 67.77% in Group N2, P > 0.05). We concluded that the NTG lingual spray in dose of 0.4 mg (1 spray) or 0.8 mg (2 sprays) was effective in attenuation of intubation induced hemodynamic response, in terms of preventing significant rise in SBP, DBP and MAP compared to control group.
Full Text Available Anesthetic technique in parturient with syringomyelia and Arnold-Chiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq™ laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and Arnold-Chiari type I malformation.
An easily prepared radiolabeled gastrointestinal scanning agent is described. Technetium-99m has ideal characteristics for imaging the upper and lower GI tract and determining stomach emptying and intestinal transit time when used with an insoluble particulate material. For example, crystalline and amorphous calcium phosphate particles can be effectively labeled in a one-step process using sup(99m)TcO 4 and SnCl 2 . These labeled particles have insignificant mass and when administered orally pass through the GI tract unchanged, without affecting the handling and density of the intestinal contents. Visualization of the esophageal entry into the stomach, the greater and lesser curvatures of the stomach, ejection into the duodenum, and rates of passage through the upper and lower GI tract are obtained. The slurry of sup(99m)TC particulate can be given rectally by enema. Good images of the cecum and the ascending, transverse, and descending colon are obtained. Mucosal folds and the splenic and hepatic flexures are visualized. The resilience of the large intestine is also readily visualized by pneumocolonographic techniques. (author)
Moon, Hyoung-Yong; Kim, Jin-Seo; Koo, Gill Hoi; Kim, Jin-Yun; Woo, Young-Cheol; Jung, Yong Hun; Kang, Hyun; Shin, Hwa-Yong; Yang, So-Young
Background We studied the differences in airway assessment factors among old, middle, and young age groups, and evaluated the frequency and causes of difficult intubation among these groups. Methods Patients were divided into young (Cormack-Lehane (C-L) grade were assessed. The differences in airway assessment factors between difficult (C-L grade 3, 4) and easy (C-L grade 1, 2) intubation were then examined. Logistic regression analysis was also carried out to identify the extent to which airway assessment factors reflected difficult intubation. Results As aging, head and neck movement, thyromental distance, and interincisor gap decreased, the grade of dentition, Mallampati score, cervical joint rigidity and the ratio of Arné score > 11 increased. In the old and middle group, the incidence of difficult intubation was increased compared with the young group. Dentition in the young group, Mallampati score and interinsisor gap in the middle group and Mallampati score, cervical joint rigidity in the old group respectively predicted difficult intubation. Conclusions Compared to young individuals, middle-aged or elderly adults are likely to experience more difficulty in endotracheal intubation and its predictive factors could vary by age group. PMID:23646239
Full Text Available Dental trauma during tracheal intubation mostly happens in case of poor dentition, restricted mouth opening, and/or difficult laryngoscopy. 57-year-old man undergoing laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma had his dental work detached at induction of anesthesia. Oropharyngeal direct view, manual inspection, fibreoptic nosendoscopy, tracheobronchoscopy, and fiberoptic inspection of the esophagus and stomach were unsuccessful in locating the dislodged bridge. While other possible exams were considered, such as lateral and AP x-ray of head and neck, further meticulous manual “sweepings” of the mouth were performed, and by moving the first and second fingers below the soft palate deep towards the posterolateral wall of the pharynx, feeling consistent with a dental prosthesis was detected in the right pharyngeal recess. Only after pulling the palatopharyngeal arch upward was it possible to grasp it and extract it out with the aid of a Magill Catheter Forceps. Even though the preexisting root and bridge deficits were well reported by the consultant dentist, the patient was fully reimbursed. The lack of appropriate documentation of the advanced periodontal disease in the anesthesia records, no mention of potential risks on anesthesia consent, and insufficient protective measures during airway instrumentation reinforced the reimbursement claim.
Santos, Ana Paula S Vieira; Mathias, Ligia Andrade S Telles; Gozzani, Judymara Lauzi; Watanabe, Marcelo
The concern of facing difficult airways brought the need of developing predictive testing for difficult intubation. Those tests were developed primarily for adult populations. In pediatric patients studies always focus on patients with congenital malformation, polytraumatized, and newborns. The objective of the present study was to determine the applicability of the predictive test used more often in adults, the Mallampati index, in patients 4 to 8 years old, correlating it with the Cormack-Lehane index. One hundred and eight patients 4 to 8 years of age, ASA I, without any type of congenital malformation, genetic syndromes or cognitive deficits were evaluated. The Mallampati index was applied to patients during the pre-anesthetic evaluation. Evaluation of the Cormack-Lehane index was performed after anesthetic induction. A pCormack-Lehane index. The sensitivity and specificity of the Mallampati index were 75.8% and 96.2% respectively, but the sensitivity showed a wide confidence interval. The Mallampati index was proven to be applicable in children 4 to 8 years old. Copyright © 2011 Elsevier Editora Ltda. All rights reserved.
Full Text Available AIM: To evaluate the effective and complications rate of silicone reverse-intubation in treating chronic dacryocystitis with different extubation time after surgery. METHODS: From December 2009 to December 2012, 56 patients(60 eyeswith chronic dacryocystitis were studied. Silicone tube was placed for 1.5 months(group Aor more than 3 months(group B, and the follow-up was 6 months after extubation. RESULTS: All eyes were successfully placed silicone tube. In group A(32 eyes, all lacrimal passage were unobstructed after extubation, after 6 months of postextubation, 21 eyes were cured(66%, 6 eyes were improved(19%, 5 eyes were failed(16%, the overall successful rate was 84%. In group B(28 eyes, 27 eyes of lacrimal passage were unobstructed after extubation, after 6 months of postextubation, 16 eyes were cured(57%, 5 eyes were improved(18%, 7 eyes were failed(25%, the overall successful rate was 75%. The difference between two groups had not statistically significance(P>0.05. Two eyes in group A and 5 eyes in group B had complications with no statistically significance(P>0.05.CONCLUSION: With the time of silicone tube in lacrimal passages before extubation, 1.5 months or more than 3 months, the effective rate were similar, the granulation tissue proliferation is less in the former group.
Feider, Laura L; Mitchell, Pamela; Bridges, Elizabeth
Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilator-associated pneumonia. To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the 2005 AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention. A descriptive, cross-sectional design with a 31-item Web-based survey was used to describe oral care practices reported by 347 randomly selected members of the American Association of Critical-Care Nurses. Oral care was performed every 2 (50%) or 4 (42%) hours, usually with foam swabs (97%). Oral care was reported as a high priority (47%). Nurses with 7 years or more of critical care experience performed oral care more often (P=.008) than did less experienced nurses. Nurses with a bachelor's degree in nursing used foam swabs (P=.001), suctioned the mouth before the endotracheal tube (P=.02), and suctioned after oral care (Ptoothpaste (40%), brushing with a foam swab (90%), using chlorhexidine gluconate oral rinse (49%), suctioning the oral cavity (84%), and assessing the oral cavity (73%). Oral care practices and policies differed for all those items. Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used.
Laaks, Jens; Jochmann, Maik A; Schilling, Beat; Schmidt, Torsten C
Microextraction techniques, especially dynamic techniques like in-tube extraction (ITEX), can require an extensive method optimization procedure. This work summarizes the experiences from several methods and gives recommendations for the setting of proper extraction conditions to minimize experimental effort. Therefore, the governing parameters of the extraction and injection stages are discussed. This includes the relative extraction efficiencies of 11 kinds of sorbent tubes, either commercially available or custom made, regarding 53 analytes from different classes of compounds. They cover aromatics, heterocyclic aromatics, halogenated hydrocarbons, fuel oxygenates, alcohols, esters, and aldehydes. The number of extraction strokes and the corresponding extraction flow, also in dependence of the expected analyte concentrations, are discussed as well as the interactions between sample and extraction phase temperature. The injection parameters cover two different injection methods. The first is intended for the analysis of highly volatile analytes and the second either for the analysis of lower volatile analytes or when the analytes can be re-focused by a cold trap. The desorption volume, the desorption temperature, and the desorption flow are compared, together with the suitability of both methods for analytes of varying volatilities. The results are summarized in a flow chart, which can be used to select favorable starting conditions for further method optimization.
Nassar, Mahmoud; Zanaty, Ola M; Ibrahim, Mohamed
To assess the efficacy of both Bonfils and GlideScope in obese patient with difficult airways for bariatric surgery using awake intubation. Comparative study. Operating room. The study was carried out on 60 patients, for laparoscopic bariatric surgery, after approval of the Medical Ethics Committee and having an informed written consent from each patient. Patients were randomly categorized into 2 equal groups 30 patients in each group. Awake intubation with either Retromolar Bonfils or GlideScope. Time to visualize the laryngeal inlet, time of intubation, time of scope manipulation, success rate at each attempt, the lowest oxygen saturation, hemodynamic parameters, and any complication. Regarding intubation criteria, GlideScope achieves shorter times compared with Retromolar for visualization of the vocal cords and intubation, in addition to less intubation attempts, but both without a statistically significant difference. Retromolar shows better patient satisfaction than does GlideScope, with statistically significant difference. Both Bonfils fiberscope and the GlideScope can be successfully used for awake intubation in morbidly obese patients with expected difficult airways. Bonfils intubating fiberscope was more tolerated by patients with statistical difference; on the other hand, GlideScope provided shorter intubation time and less intubation attempts but not statistically significant. Copyright © 2016 Elsevier Inc. All rights reserved.
The application of computerized tomography in gastrointestinal tract diseases are presented, including advantages in surgical belly that are: anatomic clarity, wide survey and rapid performance. (C.G.C.)
Haren, E.M. van; Sleight, J.W.; Pickkers, P.; Hoeven, J.G. van der
Septic shock is characterised by vasodilation, myocardial depression and impaired microcirculatory blood flow, resulting in redistribution of regional blood flow. Animal and human studies have shown that gastrointestinal mucosal blood flow is impaired in septic shock. This is consistent with
Khanijow, Vikesh; Prakash, Pia; Emsellem, Helene A; Borum, Marie L; Doman, David B
Sleep deprivation and impaired sleep quality have been associated with poor health outcomes. Many patients experience sleep disturbances, which can increase the risk of medical conditions such as hypertension, obesity, stroke, and heart disease as well as increase overall mortality. Recent studies have suggested that there is a strong association between sleep disturbances and gastrointestinal diseases. Proinflammatory cytokines, such as tumor necrosis factor, interleukin-1, and interleukin-6, have been associated with sleep dysfunction. Alterations in these cytokines have been seen in certain gastrointestinal diseases, such as gastroesophageal reflux disease, inflammatory bowel disease, liver disorders, and colorectal cancer. It is important for gastroenterologists to be aware of the relationship between sleep disorders and gastrointestinal illnesses to ensure good care for patients. This article reviews the current research on the interplay between sleep disorders, immune function, and gastrointestinal diseases.
Madsen, Jan Lysgård
intestinal and colonic transit. This article reviews current imaging techniques, methods for data processing and principles for evaluating results when scintigraphy is used to assess gastrointestinal motility. Furthermore, clinical indications for performing scintigraphy are reviewed........ Dysmotility in the different major segments of the gastrointestinal tract may give rise to similar symptoms; hence, localizing transit abnormalities to a specific segment is a valuable element of diagnostic evaluation. Scintigraphy is an effective noninvasive tool to assess gastric emptying as well as small...
Bjelakovic, G; Nikolova, D; Simonetti, R G
Oxidative stress may cause gastrointestinal cancers. The evidence on whether antioxidant supplements are effective in preventing gastrointestinal cancers is contradictory.......Oxidative stress may cause gastrointestinal cancers. The evidence on whether antioxidant supplements are effective in preventing gastrointestinal cancers is contradictory....
Ballinger, Anne; Farthing, M. J. G. (Michael J. G.)
... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Gastrointestinal bleeding Matthew R Banks, Peter D Fairclough . . . . . . . . . . . . . . . . . . . . 63 Inflammatory bowel...
Gorbach, S L
Evidence for positive health benefits of Lactobacilli applies to only a few strains used for commercial applications. It is generally agreed that a probiotic must be capable of colonizing the intestinal tract to influence human health; this requirement disqualifies many of the strains currently used in fermented dairy products. Lactobacillus GG, a variant of L. casei sps rhamnosus, has been studied extensively in adults and children. When consumed as a dairy product or as a lyophilized powder, LGG colonizes the gastrointestinal tract for 1-3 days in most individuals and up to 7 days in about 30% of subjects. Traveler's diarrhea, antibiotic-associated diarrhea, and relapsing Clostridium difficile colitis are improved with LGG. In infantile diarrhea, the severity and duration of the attack is reduced. LGG-fermented milk lessens the intestinal permeability defects caused by exposure to cows milk or rotavirus infection. LGG has proven beneficial effects on intestinal immunity. It increases the numbers of IgA and other immunoglobulin-secreting cells in the intestinal mucosa. LGG stimulates local release of interferon. It facilitates antigen transport to underlying lymphoid cells, which serves to increase antigen uptake in Peyer's patches. LGG also acts as an immunoadjuvant for oral vaccines. In an animal model of colon cancer, LGG reduced the incidence of chemically induced tumors in the large bowel of rodents. Extensive safety testing has shown no pathogenic potential in humans or animals. Probiotic cultures of Lactobacilli have the potential to bring substantial health benefits to the consumer. The purported benefits for any probiotic must pass the highest standards of scientific scrutiny before the claims can be accepted.
Krajewski, Paweł; Chudzik, Anita; Strzałko-Głoskowska, Barbara; Górska, Monika; Kmiecik, Magdalena; Więckowska, Katarzyna; Mesjasz, Anna; Sieroszewski, Piotr
Surfactant replacement therapy is crucial in the management of respiratory distress syndrome (RDS) in preterm infants. Classic strategies of surfactant administration required intubation. To reduce the need of intubation and mechanical ventilation (MV), we applied surfactant via a thin endotracheal catheter without intubation. We compared 26 preterm infants threatened by RDS treated with surfactant via a thin endotracheal catheter without intubation (studied group - SG) with a retrospective group of preterm infants managed on MV with early surfactant treatment using INtubation SURfactant Extubation (INSURE) method (control group - CG). Study had an approval from the ethics committee (RNN/6/14/KE). In the SG, 26 preterm infants were treated with one dose of surfactant (Curosurf®) administered via endotracheal catheter without intubation while receiving nasal continuous positive airway pressure (nCPAP)/SiPAP (Infant Flow). After surfactant administration, significantly less patients in SG required intubation and MV (19.2%) versus 65% necessity of second intubation in the CG. The median of time of MV in SG was 5 d versus 3.5 d in CG. Median time spent on nCPAP was 5.5 d versus 4.0 d in CG. The incidence of intraventricular hemorrhage (IVH) in the SG was 53.9%, including 50% with ≥ IVH II versus 36.7% (30% ≥ IVH II) in CG. The incidence of other complications of prematurity in the SG, such as necrotizing enterocolitis was 11.5% versus 23.3% in CG, the hemodynamically important patent ductus arteriosus was observed in 53.9% in SG versus 45% in CG. Bronchopulmonary dysplasia level in SG was significantly lower (15.4%) than in CG (40%), and the incidence of retinopathy of prematurity in SG was also lower (3.9%) versus 11.7% in MV group. Surfactant application via a thin endotracheal catheter without intubation seems to be a beneficial therapy for preterm infants with slight and mild degree of RDS. This new method of surfactant application was associated with a lower
Zhi, Juan; Deng, Xiao-Ming; Yang, Dong; Wen, Chao; Xu, Wen-Li; Wang, Lei; Xu, Jin
Objective To compare the Ambu Aura-i with the Air-Q intubating laryngeal airway for fiberoptic-guided tracheal intubation in ear deformity children.Methods Totally 120 children who were scheduled for elective auricular reconstruction surgery requiring general anaesthesia with tracheal intubation were enrolled in this prospective study. They were randomized to receive either the Ambu Aura-i (Aura-i group) or Air-Q (Air-Q group). The time for successful tracheal intubation was assessed. The attempts for successful device insertion, leak pressures, cuff pressures, fiberoptic grade of laryngeal view, time for removal of the device after endotracheal intubation, and complications were recorded. Results Device placement, endotracheal intubation, and removal after endotracheal intubation were successful in all patients. The Air-Q group required longer time than the Aura-i group in device placement[(14.1±7.2) s vs. (10.8±5.2) s, PAura-i group). The leak pressure was (20.5±4.8) cmH 2 O in the Air-Q group and (22.2±5.0) cmH 2 O in the Aura-i group (PAura-i group (PAura-i group. Conclusion Both Ambu Aura-i and Air-Q intubating laryngeal airway are effective conduits for beroptic-guided tracheal intubation, with advantages including simple operation, high success rate, and fewer complications, especially the Ambu Aura-i.
Full Text Available Interferon gamma release assays like Quantiferon Gold In-Tube (QFT are used to identify individuals infected with Mycobacterium tuberculosis. A dichotomous cut-off (0.35 IU/ml defines a positive QFT without considering test variability. Our objective was to evaluate the introduction of a borderline range under routine conditions.Results of routine QFT samples from Sweden (2009-2014 were collected. A borderline range (0.20-0.99 IU/ml was introduced in 2010 recommending a follow-up sample. The association between borderline results and incident active TB within 3 to 24 months was investigated through linkage with the national TB-register.Using the recommended QFT cut-off, 75.1% tests were negative, 21.4% positive and 3.5% indeterminate. In total, 9% (3656/40773 were within the borderline range. In follow-up samples, individuals with initial results between 0.20-0.34 IU/ml and 0.35-0.99 IU/ml displayed negative results below the borderline range (0.99 IU/ml, 65 (0.97% developed incident TB within 3-24 months.We recommend retesting of subjects with QFT results in the range 0.20-0.99 IU/ml to enhance reliability and validity of the test. Half of the subjects in the borderline range will be negative at a level <0.20 IU/ml when retested and have a very low risk of developing incident active TB.
Deepak Prakash Borde
Full Text Available Background and Aims: Safe airway management is the cornerstone of contemporary anaesthesia practice, and difficult intubation (DI remains a major cause of anaesthetic morbidity and mortality. The surgical category, particularly cardiac surgery as a risk factor for DI has not been studied extensively. The aim of this study was to test the hypothesis whether cardiac surgical patients are at increased risk of DI. Methods: During the study, 627 patients (329 cardiac and 298 non-cardiac surgical were enrolled. Pre-operative demographic and other variables associated with DI were assessed. Patients with Cormack Lehane grade III and IV or use of bougie in Cormack grade II were defined as DI. The incidence of anticipated and unanticipated DI was assessed. Factors associated with DI were described using univariate and multivariate logistic regression models. Results: The overall incidence of DI was 122/627 (19.46%. The incidence of DI was higher in cardiac surgery patients (24% as compared to non-cardiac surgery patients (14.4% P = 0.002. On multivariate analysis, factors independently associated with DI were greater age, male sex, higher Mallampati grade, and anticipated DI, but not cardiac surgery. The incidence of unanticipated DI was 48.1% and 53.4% in cardiac and non-cardiac surgery patients, respectively. Conclusion: Although there was a higher incidence of DI in cardiac surgical patients, cardiac surgery is not an independent risk factor for DI. Rather, other factors play more important role. About half of the DI both in cardiac and non-cardiac surgeries were unanticipated.
Hassanein, Ahmed Gaber; Abdel Mabood, Ahmed M A
During surgery for major maxillofacial fractures, orotracheal intubation can interfere with some surgical procedures and nasal intubation can be contraindicated or impossible. That is why tracheotomy is presented as a solution, although it carries a relatively high incidence of complications. In this study, the use of submandibular tracheal intubation is basically evaluated as an alternative to tracheotomy in such circumstances. This prospective study was performed in patients undergoing surgery for major maxillofacial fractures in which oral intubation and/or nasal intubation have been unsuitable, impossible, or contraindicated. The technique of submandibular intubation was assessed intraoperatively and in the postoperative period. The outcomes and complications are presented. The study included 26 patients aged between 14 and 57 years. All patients had mandibular fractures, with 19 midface fractures (73.1%), 11 nasal bone fractures (42.3%), 10 zygomatic bone fractures (38.5%), 9 naso-orbito-ethmoidal fractures (34.6%), and 9 frontobasilar fractures (34.6%). The procedure time ranged from 5 to 12 minutes (mean, 7 minutes 4.6 seconds). Delayed extubation was performed in 15 cases (57.7%) in which the tube was left in place for a period ranging from 8 to 50 hours (mean, 30 hours 24 minutes). The technique has proved to be straightforward and satisfactory. A postoperative superficial infection occurred in 2 patients, whereas hypertrophic scars occurred in another 2 patients. Submandibular endotracheal intubation is straightforward, safe, and quick to carry out. It can be an alternative to tracheotomy as it allows operative techniques and postoperative airway protection without the risks and side effects of tracheotomy. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Grgurich, Erin; Arnemann, Cynthia; Amon, Kim; Horton, Rose; Carlson, Jestin N
As neonatal endotracheal intubation (ETI) is a low-frequency, high-consequence event, it is essential that providers have access to resources to aid in ETI. We sought to determine the impact of video laryngoscopy (VL) with just-in-time training on intubation outcomes over direct laryngoscopy (DL) when performed by neonatal nurses. We conducted a prospective, randomized, crossover study with neonatal nurses employed at a level 2 neonatal intensive care unit (NICU). Nurses performed both DL and VL on a neonatal mannequin using a CMAC (Karl Storz Corp, Tuttlingen, Germany) either with the assistance of the screen (VL) or without (DL). Before performing the intubation, providers were given a just-in-time, brief education presentation and allowed to practice with the device. Each ETI attempt was reviewed to obtain the percentage of glottic opening (POGO) score, time to intubation (TTI, time from insertion of the blade into the mouth until the first breath was delivered), and time from blade insertion until the best POGO score. We enrolled 19 participants, with a median (interquartile range) of 20 (9-26) years of experience and having a median of 2 (1-3) intubations within the past year. None had used VL in the NICU previously. Median TTI did not differ between DL and VL: 19.9 (15.3-41.5) vs 20.3 (17.9-24.4) (P = 1). POGO scores and the number of attempts also did not differ between DL and VL. In our simulated setting, just-in-time VL training provided similar intubation outcomes compared with DL in ETI performed by neonatal nurses. Just-in-time VL education may be an alternative to traditional DL for neonatal intubations.
Hypes, Cameron; Sakles, John; Joshi, Raj; Greenberg, Jeremy; Natt, Bhupinder; Malo, Josh; Bloom, John; Chopra, Harsharon; Mosier, Jarrod
The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p 1 attempt is associated with 6.4 (95 % CI 4.4-9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.
Atul P Kulkarni
Full Text Available Context: Literature suggests glottic view is better with straight blades while tracheal intubation is easier with curved blades. Aims: To compare glottic view and ease of intubation with Macintosh, Miller, McCoy blades and the Trueview® laryngoscope. Settings and Design: This prospective randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer centre after approval from the Institutional Review Board. Methods: We compared the Macintosh, Miller, McCoy blades and the Trueview® laryngoscope for glottic visualisation and ease of tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated. We recorded: Visualisation of glottis (Cormack Lehane grade, ease of intubation, number of attempts; need to change the blade and need for external laryngeal manipulation. Statistical Analysis: Demographic data, Mallampati classification were compared using the Chi-square test. A P<0.05 was considered significant. Results: Grade 1 view was obtained most often (87% patients with Trueview® laryngoscope. Intubation was easier (Grade 1 with Trueview® and McCoy blades (93% each. Seven patients needed two attempts; one patient in Miller group needed three attempts. No patient in McCoy and Trueview® Groups required external laryngeal manipulation. Conclusions: We found that in patients with normal airway glottis was best visualised with Miller blade and Trueview® laryngoscope however, the trachea was more easily intubated with McCoy and Macintosh blades and Trueview® laryngoscope.
Dharmarajan, Harish; Liu, Yi-Chun Carol; Hippard, Helena Karlberg; Chandy, Binoy
Pediatric otolaryngologists are frequently called to assist in difficult airway management in newborns with Pierre Robin Sequence (PRS) who have microretrognathia, glossoptosis, and an anterior larynx. The Bonfils fiberscope (BF) is a curved rigid scope designed to provide superior visualization in the anterior larynx. (1) to assess whether BF provides an improvement in intubation success rate, time to intubation, or airway visualization as compared to rigid fiberscope (RF) in a difficult airway simulation setting and (2) to determine whether a training program for BF can improve time to intubation through practice trials. Six right-handed trainees completed five trials on each of the three following airway models using the BF and RF: normal anatomy, anterior larynx and PRS. The normal larynx model was intubated only with RF. Main outcome measures were the time needed for tracheal intubation and Cormack-Lehane classification (1-4). The majority of the intubation trials showed a statistically significant difference between first and last completion times (p Cormack-Lehane classification measures, laryngeal visualization by the BF was better than RF in the PRS manikin (p < .0022) while there was no significant difference in grade scores for the anterior larynx manikin (p < .45). All six trainees reported an improved visualization of the larynx with the BF compared to the RF for both the anterior larynx and PRS manikins; at the end of the trial runs, all participants noted an improvement in comfort level using the BF. The difficult airway simulation model is feasible for surgical training. BF adds superior visualization of the anterior larynx in PRS. Otolaryngology training programs may include BF as a supplemental tool in addition to RF as a part of the airway equipment training since there is significant improvement in time to intubation with consecutive practice trials and superior laryngeal visualization. Copyright © 2017 Elsevier B.V. All rights
Alonso Quintela, P; Oulego Erroz, I; Mora Matilla, M; Rodríguez Blanco, S; Mata Zubillaga, D; Regueras Santos, L
The aim of this study was to assess the usefulness of bedside ultrasound compared to capnography and X-ray for endotracheal intubation in children and newborns. Hemodynamically stable children intubated in pedriatric and neonatal intensive care unit were included. Endotracheal tube insertion was checked after every intubation attempt by tracheal ultrasound and capnography simultaneously. The endotracheal tube insertion depth was then checked by assesment of lung sliding by thoracic ultrasound. Thereafter, Chest X-ray was performed and interpreted as usual. Time to perform each technique was recorded. The study included 31 intubations in 26 patients (15 in PICU and 16 in NICU). There were no statistically significant differences between tracheal ultrasound and capnography or between thoracic ultrasound and x-ray in identifying the correct endotracheal intubation and assessment of endotracheal tube insertion depth, respectively. Sensibility and specificity of ultrasound compared to capnography was 92% and 100%, and 100% and 75% compared to X-ray. Ultrasound was significantly slower compared to capnography [12 (4-16) vs 6 (3-12) seconds; P<.001] and significantly quicker compared to X-ray [0.22 (0.17-0.40) vs. 20 (17-25) minutes, P<.001]. Ultrasound appears to be as effective as capnography, although slower, for identifying endotracheal intubation. Ultrasound may be useful in clinical situations, such as cardiopulmonary resuscitation where capnography is less reliable. Ultrasound is as effective and quicker than X-ray for assessment of endotracheal tube insertion depth, and it may contribute to decrease the routine use of X-ray after tracheal intubation. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.
Bhat, Rahul; Goyal, Munish; Graf, Shannon; Bhooshan, Anu; Teferra, Eshetu; Dubin, Jeffrey; Frohna, Bill
Emergency physicians frequently perform endotracheal intubation and mechanical ventilation. The impact of instituting early post-intubation interventions on patients boarding in the emergency department (ED) is not well studied. We sought to determine the impact of post-intubation interventions (arterial blood gas sampling, obtaining a chest x-ray (CXR), gastric decompression, early sedation, appropriate initial tidal volume, and quantitative capnography) on outcomes of mortality, ventilator-associated pneumonia (VAP), ventilator days, and intensive care unit (ICU) length-of-stay (LOS). This was an observational, retrospective study of patients intubated in the ED at a large tertiary-care teaching hospital and included patients in the ED for greater than two hours post-intubation. We excluded them if they had incomplete data, were designated "do not resuscitate," were managed primarily by the trauma team, or had surgery within six hours after intubation. Of 169 patients meeting criteria, 15 died and 10 developed VAP. The mortality odds ratio (OR) in patients receiving CXR was 0.10 (95% CI 0.01 to 0.98), and 0.11 (95% CI 0.03 to 0.46) in patients receiving early sedation. The mortality OR for patients with 3 or fewer interventions was 4.25 (95% CI 1.15 to 15.75) when compared to patients with 5 or more interventions. There was no significant relationship between VAP rate, ventilator days, or ICU LOS and any of the intervention groups. The performance of a CXR and early sedation as well as performing five or more vs. three or fewer post-intubation interventions in boarding adult ED patients was associated with decreased mortality.
Introduction Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy. Methods In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC®). Results A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001). Conclusion Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur. PMID:22695007
Joni E. Rabiner
Full Text Available Objective. To compare novice clinicians’ performance using GlideScope videolaryngoscopy (GVL to direct laryngoscopy (DL. Methods. This was a prospective, randomized crossover study. Incoming pediatric interns intubated pediatric simulators in four normal and difficult airway scenarios with GVL and DL. Primary outcomes included time to intubation and rate of successful intubation. Interns rated their satisfaction of the devices and chose the preferred device. Results. Twenty-five interns were included. In the normal airway scenario, there were no differences in mean time for intubation with GVL or DL (61.4 versus 67.4 seconds, or number of successful intubations (19 versus 18, . In the difficult airway scenario, interns took longer to intubate with GVL than DL (87.7 versus 61.3 seconds, , but there were no differences in successful intubations (14 versus 15, . There was a trend towards higher satisfaction for GVL than DL (7.3 versus 6.4, , and GVL was chosen as the preferred device by a majority of interns (17/25, 68%. Conclusions. For novice clinicians, GVL does not improve time to intubation or intubation success rates in a pediatric simulator model of normal and difficult airway scenarios. Still, these novice clinicians overall preferred GVL.
Full Text Available Introduction & Objective: In some medical situations administration of muscle relaxants after intravenous anesthetics for tracheal intubation may be unnecessary or sometimes could be hazardous. In such situations, replacing an alternative drug for the facilitation of tracheal intubation is obvious. Remifentanil is a short acting opioid drug which may be useful in solving this problem. The aim of this study was to compare the effects of propofol or thiopental in combination with remifentanil in the absence of muscle relaxants on larengoscopy and intubation conditions in general anesthesia. Materials & Methods: This is a randomized double-blind clinical trial which was performed in 1386 in Be’sat hospital of Sanandaj. Forty two ASA 1 and 2 patients recruited to receive propofol, 2 Mg/Kg, or thiopental, 5Mg/K. All patients received lidocaine, 1.5 Mg/Kg, and remifentanil, 2.5 µg/Kg, 30 seconds before anesthetics administration. larengoscopy and tracheal intubation were done 90 seconds after induction of anesthesia. On the basis of mask ventilation, jaw relaxation, vocal cords position and patient's response to intubations and endotracheal tube cuff inflation the intubation conditions were assessed and recorded as excellent, good ,acceptable or poor. The mean arterial pressure and heart rate were measured before and after anesthetics administration and also 45 seconds and two and five minutes after intubations. Data were analyzed by X2, fisher exact test ant student T-test using SPSS software. Results: Excellent or good larengoscopy and intubation conditions were observed in 9 (%42.9 of thiopental patients and 20 (%95.2 of propofol patients (p<0.05. Mean arterial pressure and heart rate decreased more significantly in propofol group in comparison with the thiopental group (p<0.05. Conclusion: Combination of remifentanil and propofol or thiopental could facilitate ventilation via face mask in all patients. Although combination of propofol and
Cabrini, Luca; Landoni, Giovanni; Baiardo Radaelli, Martina; Saleh, Omar; Votta, Carmine D; Fominskiy, Evgeny; Putzu, Alessandro; Snak de Souza, Cézar Daniel; Antonelli, Massimo; Bellomo, Rinaldo; Pelosi, Paolo; Zangrillo, Alberto
We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool. We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation , while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials. The limited available
Full Text Available Aim. To compare the surgical outcomes of surgery with and without bicanalicular silicon tube intubation for the treatment of patients who have primary uncomplicated nasolacrimal duct obstruction. Methods. This retrospective study is comprised of 113 patients with uncomplicated primary nasolacrimal duct obstruction. There were 2 groups in the study: Group 1 (n=58 patients underwent transcanalicular diode laser dacryocystorhinostomy surgery with bicanalicular silicon tube intubation and Group 2 (n=55 patients underwent transcanalicular diode laser dacryocystorhinostomy surgery without bicanalicular silicon tube intubation. The follow-up period was 18.42±2.8 months for Group 1 and 18.8±2.1 months for Group 2. Results. Success was defined by irrigation of the lacrimal system without regurgitation and by the absence of epiphora. Success rates were 84.4% for Group 1 and 63.6% for Group 2 (P=0.011. Statistically a significant difference was found between the two groups. Conclusion. The results of the study showed that transcanalicular diode laser dacryocystorhinostomy surgery with bicanalicular silicon tube intubation was more successful than the other method of surgery. Consequently, the application of silicone tube intubation in transcanalicular diode laser dacryocystorhinostomy surgery is recommended.
Golisch, W; Hönig, J F; Lange, H; Braun, U
Variations in anatomy of the bony and soft-tissue structures of the neck and facial cranium due to trauma, disease, or dysmorphic syndromes may lead to severe intubation problems. These patients are admitted for mandibulofacial and otolaryngologic surgery. It is important to inspect the patient's outer and inner pharyngeal structures carefully during preoperative assessment, as suggested by Mallampati. The observer estimates the facility of intubation by inspection of the faucial pillars, soft palate, and uvula. Unfortunately, even careful examination does not predict every case of difficult intubation, so that unexpected problems may occur. There may also be difficulties in ventilating these patients with a face mask. Safe intubation is possible in these cases using the laryngeal mask airway (LMA), laryngoscopy with a rigid optical aid, and the fibreoptic bronchoscope. Case report. We report a 14-month-old girl with Goldenhar's syndrome (oculo-auricular dysplasia) who presented for soft-palate surgery. This syndrome belongs to the group of cranio-mandibular-facial malformations; the main symptoms are congenital unilateral malformations in the area of the 1st and 2nd branchial arches. The patient's jaw was hypoplastic with aplasia of the temporo-mandibular joint, which led to asymmetry of the lower face and an extremely short mandible. Additionally, we observed a large tongue in relation to the small jaw. Macrostomia is part of the syndrome, and may lead to underestimation of intubation problems.(ABSTRACT TRUNCATED AT 250 WORDS)
Stadler, H.W.; Roedl, W.
Besides the demonstration of parenchymatous organs CT can be used also in the diagnosis of hollow organs of the gastrointestinal tract, e.g. the esophagus, stomach, duodenum, and the small and large bowels, since the development of fast scanners with higher resolution. Conventional X-ray and endoscopy have to be primary diagnostics. CT, on the other hand, is capable of assessing of extraluminal and intramural tumor extension. In inflammatory diseases of the gastrointestinal tract, CT can show the environmental reaction. In penetrating ulcers of the esophagus, stomach, and duodenum, the extension and direction of penetration can be figured by CT well. Extraenteral masses with secondary displacement, impression or infiltration of the gastrointestinal tract are often verified by CT only. One of the CT domains is the local relapse of rectum carcinoma following rectum amputation especially in differentiation from local scar formation. The importance of CT in radiotherapy treatment planning is not subject of this paper. (orig.) [de
Abbas, Hassan; Chang, Bryan; Chen, Zhe Jay
The presence of tumor and organ motions complicates the planning and delivery of radiotherapy for gastrointestinal cancers. Without proper accounting of the movements, target volume could be under-dosed and the nearby normal critical organs could be over-dosed. This situation is further exacerbated by the close proximity of abdominal tumors to many normal organs at risk (OARs). A number of strategies have been developed to deal with tumor and organ motions in radiotherapy. This article presents a review of the techniques used in the evaluation, quantification, and management of tumor and organ motions for radiotherapy of gastrointestinal cancers.
Wang, Henry E; Seitz, Samuel R; Hostler, David; Yealy, Donald M
Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited. To evaluate the effects of cumulative live ETI experience, elapsed duration of training, and clinical setting on PS ETI proficiency. The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), and other hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success and the PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, and the interaction (cumulative ETIs x elapsed days). Predicted probability plots were constructed depicting the "learning curve" overall and for each clinical setting. Results. Between one and 74 ETIs (median 7; IQR 4-12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and 903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044-1.091). ETI learning curves were steepest for the ICU and prehospital settings but lower than for other clinical settings. Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical
Ramesh T Timanaykar
Full Text Available Background: The Truview EVO2 TM laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade. Materials and Methods: In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20-50 years, presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated. Results: Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05. The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds was more with Truview than with Macintosh blade (P < 0.01. The Percentage of Glottic Opening (POGO score was significantly higher (97.26±8 in Truview as that observed with Macintosh blade (83.70±21.5. Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05 in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted. Conclusion: Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview.
Ching, Yiu-Hei; Karlnoski, Rachel A; Chen, Henian; Camporesi, Enrico M; Shah, Vimal V; Padhya, Tapan A; Mangar, Devanand
Flexible fiber-optic bronchoscope-guided orotracheal intubation is a valuable technique with demonstrated benefits in the management of difficult airways. Despite its popularity with anesthesia providers, the technique is not fail-safe and airway-related complications secondary to failed intubation attempts remain an important problem. We sought to determine the effect of incorporating lingual traction on the success rate of fiber-optic bronchoscope-guided intubation in patients with anticipated difficult airways. In this prospective, randomized, cohort study, we enrolled 91 adult patients with anticipated difficult airways scheduled for elective surgery to undergo fiber-optic bronchoscope-guided orotracheal intubation alone or with lingual traction by an individual anesthesiologist after induction of general anesthesia and neuromuscular blockade. A total of 78 patients were randomized: 39 patients to the fiber-optic bronchoscope-guided intubation with lingual traction group and 39 patients to the fiber-optic bronchoscope-guided intubation alone group. The primary endpoint was the rate of successful first attempt intubations. The secondary outcome was sore throat grade on post-operative day 1. Fiber-optic intubation with lingual traction compared to fiber-optic intubation alone resulted in a higher success rate (92.3 vs. 74.4 %, χ (2) = 4.523, p = 0.033) and greater odds for successful first attempt intubation (OR 4.138, 95 % CI 1.041-16.444, p = 0.044). Sore throat severity on post-operative day 1 was not significantly different but trended towards worsening grades with lingual traction. In this study, lingual traction was shown to be a valuable maneuver for facilitating fiber-optic bronchoscope-guided intubation in the management of patients with anticipated difficult airways.
Dante Ranieri Jr.
Full Text Available Purpose: this study investigated the influence of anatomical predictors on difficult laryngoscopy and orotracheal intubation in obese patients by comparing Macintosh and Airtraq(tm laryngoscopes. Methods: from 132 bariatric surgery patients (body mass index = 35 kg m-1, cervical perimeter, sternomental distance, interincisor distance, and Mallampati score were recorded. The patients were randomized into two groups according to whether a Macintosh (n = 64 or an Airtraq(tm (n = 68 laryngoscope was used for tracheal intubation. Time required for intubation was the first outcome. Cormack-Lehane score, number of intubation attempts, the Macintosh blade used, any need for external tracheal compression or the use of gum elastic bougie were recorded. Intubation failure and strategies adopted were also registered. Results: intubation failed in two patients in the Macintosh laryngoscope group, and these patients were included as worst cases scenario. The intubation times were 36.9 + 22.8 s and 13.7 + 3.1 s for the Macintosh and Airtraq(tm laryngoscope groups (p < 0.01, respectively. Cormack-Lehane scores were also lower for the Airtraq(tm group. One patient in the Macintosh group with intubation failure was quickly intubated with the Airtraq(tm. Cervical circumference (p < 0.01 and interincisor distance (p < 0.05 influenced the time required for intubation in the Macintosh group but not in the Airtraq(tm group. Conclusion: in obese patients despite increased neck circumference and limited mouth opening, the Airtraq(tm laryngoscope affords faster tracheal intubation than the Macintosh laryngoscope, and it may serve as an alternative when conventional laryngoscopy fails.
Park, Jae Hong
The safety and effectiveness of colonoscopy in the investigation of lower gastrointestinal tract pathology in children has been established for more than 2 decades in Korea. Skill and experience have since advanced to the point that both diagnostic and therapeutic colonoscopy are now routinely performed by most pediatric gastroenterologists. Pediatric colonoscopy differs significantly from its adult parallels in nearly every aspect including patient and parent management and preparation, selection criteria for sedation and general anesthetic, bowel preparation, expected diagnoses, instrument selection, imperative for terminal ileal intubation, and requirement for biopsies from macroscopically normal mucosa. Investigation of inflammatory bowel disease, whether for diagnosis or follow-up evaluation, and suspected colonic polyps are the most common indication for pediatric colonoscopy. The child who presents with signs and symptoms of lower gastrointestinal disorder should undergo colonoscopy with biopsy to make the diagnosis, as well as to help determine the appropriate therapy. This review introduces practical information on pediatric colonoscopy, the author's experiences, and the role of colonoscopic examination in the diagnosis and treatment of pediatric lower gastrointestinal disorders.
Sahu, Sandeep; Kishore, Kamal; Sachan, Vertika; Chatterjee, Arnidam
Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate.
Afreen, Mahrukh; Ansari, Murtaza Ahsan
Endotracheal intubation plays a key role in the management of upper airway obstruction in emergency situations. It is non-invasive and easily learned technique by medical professionals as compared to other more skilled, surgical procedures, e.g., tracheostomy and cricothyrotomies etc. But prolonged intubation may result in numerous complications, most notorious being tracheoesophageal fistula and narrowing of subglottic area. We report a profile of a patient who had been diagnosed as case of Guillian-Barre Syndrome, had difficulty in breathing due to paralysis of respiratory muscles. The patient was admitted in Medical Intensive Care Unit (MICU) for 40 days and was kept on artificial breathing through endotracheal intubation, which remained in place for 19 days. Later tracheostomy was performed. Patient ultimately developed severe subglottic stenosis and became dependent on tracheostomy tube.
Marrugo Pardo, Gilberto Eduardo
Full Text Available Infants with complications during labor, prematurity, or birth defects may be at risk when they require orotracheal intubation. We report the case of a full-term female infant with a dysmorphic syndrome, seen at a second level hospital in Bogotá, who required orotracheal intubation due to episodes of apnea and cyanosis 5 hours after birth, while she was in bed with her mother. After multiple attempts at orotracheal intubation, there was bleeding from a difficult-to-identify source. Finally, the anesthesiologist secured the airway with a laryngeal mask. She was referred to our institution where a panendoscopy revealed a penetrating lesion, three centimeters in depth, at the right vallecular. We present the assessment, the treatment, its alternatives and the evolution of the patient.
Mirmoghtadaee, P.; Mood, N.E.; Sabzghabaee, A.M.; Yaraghi, A.
Objectives: Patients poisoned with opioids sometimes need endotracheal intubation with or without the use of mechanical ventilation. This study was done to determine the prognostic risk factors for of the need for endotracheal intubation and mechanical ventilation. Methodology: In this cross-sectional study which was performed in Isfahan (Iran), one hundred (n=100) opioid poisoned patients whom their overdoses were diagnosed by their full and reliable history, physical examination and positive response to naloxone; vital signs at the hospital admission, blood biochemistry, ABG details and also the type and estimated dosage of opioid, route of consumption, and their need to mechanical ventilation were evaluated. Results: Patients were mostly aged between 20-40 years old. Seventy nine patients were male and 26 cases (21 men) required endotracheal intubation and 15 cases (14 men) needed both intubation and mechanical ventilation. The most consumed opiates among the poisoned patients were opium (35%), heroin (16%), Tramadol (15%), Methadone (9%), crack (6%), Diphenoxylate (4%) and others (15%). There was a significant difference between the mean heart rates and respiratory rate of the patients who were connected to the ventilator and others (99.8 +- 21.8 and 87.3 +- 16.3; p=0.01). The lower level of consciousness [OR: 2.2 95% Confidence Interval (CI): 1.2-4.2], and lower admission level of hemoglobin (OR: 3.6; CI:1.2-10.8) were among the factors for predicting the need for intubation and ventilation. Conclusion: Determining the risk factors with prognostic value for the need to intubation or ventilation seems to be necessary for improving the standard of therapy in opioids poisoned patients. (author)
Alter, Scott M; Haim, Eithan D; Sullivan, Alex H; Clayton, Lisa M
Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades. Design: retrospective chart review. hospital-based suburban ALS service with 20,000 annual calls. prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated. 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7). Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success. Copyright © 2018 Elsevier Inc. All rights reserved.
Prakash, Smita; Kumar, Amitabh; Bhandari, Shyam; Mullick, Parul; Singh, Rajvir; Gogia, Anoop Raj
Background and Aim: Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population. Methods: In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4) was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy. Results: The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC) 3 and 4 in sitting and supine positions, inter-incisor distance (IID) ≤3.5 cm, thyromental (TMD) and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring. Conclusions: We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5%) of minor difficulty in intubation. PMID:24403616
Full Text Available Background and Aim: Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population. Methods: In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4 was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy. Results: The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC 3 and 4 in sitting and supine positions, inter-incisor distance (IID ≤3.5 cm, thyromental (TMD and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring. Conclusions: We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5% of minor difficulty in intubation.
Farmer, A D; Coen, S J; Kano, M; Worthen, S F; Rossiter, H E; Navqi, H; Scott, S M; Furlong, P L; Aziz, Q
Esophageal intubation is a widely utilized technique for a diverse array of physiological studies, activating a complex physiological response mediated, in part, by the autonomic nervous system (ANS). In order to determine the optimal time period after intubation when physiological observations should be recorded, it is important to know the duration of, and factors that influence, this ANS response, in both health and disease. Fifty healthy subjects (27 males, median age 31.9 years, range 20-53 years) and 20 patients with Rome III defined functional chest pain (nine male, median age of 38.7 years, range 28-59 years) had personality traits and anxiety measured. Subjects had heart rate (HR), blood pressure (BP), sympathetic (cardiac sympathetic index, CSI), and parasympathetic nervous system (cardiac vagal tone, CVT) parameters measured at baseline and in response to per nasum intubation with an esophageal catheter. CSI/CVT recovery was measured following esophageal intubation. In all subjects, esophageal intubation caused an elevation in HR, BP, CSI, and skin conductance response (SCR; all p < 0.0001) but concomitant CVT and cardiac sensitivity to the baroreflex (CSB) withdrawal (all p < 0.04). Multiple linear regression analysis demonstrated that longer CVT recovery times were independently associated with higher neuroticism (p < 0.001). Patients had prolonged CSI and CVT recovery times in comparison to healthy subjects (112.5 s vs 46.5 s, p = 0.0001 and 549 s vs 223.5 s, p = 0.0001, respectively). Esophageal intubation activates a flight/flight ANS response. Future studies should allow for at least 10 min of recovery time. Consideration should be given to psychological traits and disease status as these can influence recovery. © 2013 John Wiley & Sons Ltd.
Full Text Available Abstract Purpose: Endotracheal intubation is a frequently utilized and highly invasive component of anesthesia that is often accompanied by potentially harmful hemodynamic pressor responses. The purpose of this study was to investigate the efficiency of a single pre-induction 1 mg/kg bolus injection of esmolol for attenuating these hemodynamic responses to endotracheal intubation in normotensive patients. Material and methods: The study was composed of 100 randomly selected male and female patients between the ages of 18 and 60 that were scheduled for elective surgery and belonged to ASA grade I or II. Two minutes prior to intubation the control group received 10 mL of saline (n=50 and the experimental group received an injection of esmolol 1 mg/kg diluted to 10 mL (n=50. Heart rate (HR, systolic blood pressure (SBP, diastolic blood pressure (DBP, mean arterial pressure (MAP, and rate pressure product (RPP were compared to basal values before receiving medication (T-0, during pre-induction (T-1, induction (T-2, intubation (T-3, and post-intubation at 1 (T-4, 3 (T-6, 5 (T-8, and 10 (T-13 minutes. Results: Esmolol significantly attenuated the hemodynamic responses to endotracheal intubation at the majority of measured points. Attenuation of HR (10.8%, SBP (7.04%, DBP (3.99%, MAP (5%, and RPP (16.9% was observed in the esmolol group when compared to the control group values. Conclusions: A single pre-induction 1 mg/kg bolus injection of esmolol successfully attenuated the hemodynamic pressor response in normotensive patients. A significant attenuation of heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure was observed at the majority of measured time points in the esmolol administered group compared to the control group. [J Contemp Med 2012; 2(2.000: 69-76
Valori, Roland M; Damery, Sarah; Gavin, Daniel R; Anderson, John T; Donnelly, Mark T; Williams, J Graham; Swarbrick, Edwin T
Cecal intubation rate (CIR) is an established performance indicator of colonoscopy. In some patients, cecal intubation with acceptable tolerance is only achieved with additional sedation. This study proposes a composite Performance Indicator of Colonic Intubation (PICI), which combines CIR, comfort, and sedation. METHODS : Data from 20 085 colonoscopies reported in the 2011 UK national audit were analyzed. PICI was defined as the percentage of procedures achieving cecal intubation with median dose (2 mg) of midazolam or less, and nurse-assessed comfort score of 1 - 3/5. Multivariate logistic regression analysis evaluated possible associations between PICI and patient, unit, colonoscopist, and diagnostic factors. RESULTS : PICI was achieved in 54.1 % of procedures. PICI identified factors affecting performance more frequently than single measures such as CIR and polyp detection, or CIR + comfort alone. Older age, male sex, adequate bowel preparation, and a positive fecal occult blood test as indication were associated with a higher PICI. Unit accreditation, the presence of magnetic imagers in the unit, greater annual volume, fewer years' experience, and higher training/trainer status were associated with higher PICI rates. Procedures in which PICI was achieved were associated with significantly higher polyp detection rates than when PICI was not achieved. CONCLUSIONS : PICI provides a simpler picture of performance of colonoscopic intubation than separate measures of CIR, comfort, and sedation. It is associated with more factors that are amenable to change that might improve performance and with higher likelihood of polyp detection. It is proposed that PICI becomes the key performance indicator for intubation of the colon in colonoscopy quality improvement initiatives. © Georg Thieme Verlag KG Stuttgart · New York.
Upper gastrointestinal haemorrhage has a variety of causes (Table 1) and is the commonest complication of peptic ulceration and portal hypertension. Peptic ulceration in the duodenum or stomach and oesophageal varices are the conditions most often responsible for patients who have the potential to present.
Mearin, Fermín; Rey, Enrique; Balboa, Agustín
This article discusses the studies on functional and motor gastrointestinal disorders presented at the 2014 Digestive Diseases Week conference that are of greatest interest to us. New data have been provided on the clinical importance of functional gastrointestinal disorders, with recent prevalence data for irritable bowel syndrome and fecal incontinence. We know more about the pathophysiological mechanisms of the various functional disorders, especially irritable bowel syndrome, which has had the largest number of studies. Thus, we have gained new data on microinflammation, genetics, microbiota, psychological aspects, etc. Symptoms such as abdominal distension have gained interest in the scientific community, both in terms of patients with irritable bowel syndrome and those with constipation. From the diagnostic point of view, the search continues for a biomarker for functional gastrointestinal disorders, especially for irritable bowel syndrome. In the therapeutic area, the importance of diet for these patients (FODMAP, fructans, etc.) is once again confirmed, and data is provided that backs the efficacy of already marketed drugs such as linaclotide, which rule out the use of other drugs such as mesalazine for patients with irritable bowel syndrome. This year, new forms of drug administration have been presented, including metoclopramide nasal sprays and granisetron transdermal patches for patients with gastroparesis. Lastly, a curiosity that caught our attention was the use of a vibrating capsule to stimulate gastrointestinal transit in patients with constipation. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
Varum, Felipe J O; McConnell, Emma L; Sousa, Joao J S; Veiga, Francisco; Basit, Abdul W
The concept of mucoadhesion is one that has the potential to improve the highly variable residence times experienced by drugs and dosage forms at various sites in the gastrointestinal tract, and consequently, to reduce variability and improve efficacy. Intimate contact with the mucosa should enhance absorption or improve topical therapy. A variety of approaches have been investigated for mucoadhesion in the gastrointestinal tract, particularly for the stomach and small intestine. Despite interesting results in these sites, mucoadhesive approaches have not yet shown success in humans. The potential of the lower gut for these applications has been largely neglected, although the large intestine in particular may benefit, and the colon has several factors that suggest mucoadhesion could be successful there, including lower motility and the possibility of a lower mucus turnover and thicker mucus layer. In vitro studies on colonic mucoadhesion show promise, and rectal administration has shown some positive results in vivo. This review considers the background to mucoadhesion with respect to the physiological conditions of the gastrointestinal tract as well as the principles that underlie this concept. Mucoadhesive approaches to gastrointestinal drug delivery will be examined, with particular attention given to the lower gut.
The nutritional management of a patient with gastrointestinal cancer fi rst begins with an appropriate nutritional assessment, seeing that several factors could affect the patient's nutritional status. The most signifi cant dietary advice for cancer patients in general, is to consume a signifi cant amount of energy daily to maintain ...
Sharma, Rashi; Lipi, Lipika; Gajendra, Smeeta; Mohapatra, Ishani; Goel, Ruchika K; Duggal, Rajan; Mishra, Smruti Ranjan; Gautam, Dheeraj
Histoplasmosis is an invasive mycosis caused by inhalation of the spores of dimorphic fungi Histoplasma capsulatum. The disease manifests in the lung as acute or chronic pulmonary histoplasmosis and in severe cases gets disseminated in multiple organs like skin, adrenal gland, central nervous system, lymph node, liver, spleen, bone marrow, and gastrointestinal tract. It occurs most commonly in immunodeficient patients like HIV-positive patients and transplant recipients, while immunocompetent hosts are affected rarely. In cases of gastrointestinal histoplasmosis, the samples are collected for culture and biopsy should be sent for histopathological examination for definitive diagnosis. We conducted a retrospective study of colonic biopsies performed in the department of gastroenterology in a tertiary care hospital of north India from January 2014 to December 2015. Five cases of colonic histoplasmosis were diagnosed on histopathology out of which 4 patients were from north India while 1 patient was from Myanmar. The patients presented with various complaints, including loose stools, diarrhea, altered bowel habits, and gastrointestinal bleeding. The prognosis is very good after early and aggressive treatment while the disease is fatal if it remains untreated. In our study, 2 patients died within few days of diagnosis due to delay in the diagnosis, dissemination, and associated complications. Other patients were started on amphotericin B deoxycholate and are under follow-up. An early diagnosis of gastrointestinal histoplasmosis is important as appropriate treatment leads to long-term survival while untreated cases are almost fatal.
One hundred and fourteen (114) and one hundred and ninety nine (199) were infested fish samples from gills and gastrointestinal tract respectively. Parasites recovered during the survey include two species from gills identified as. Ergasilus sarsi ((24.60%) a crustacean (copepod), and one protozoan (myxosporean) named.
20, No.2 (May) 2017. Oloyede, Odedara Omenu disorders (GIT) which are very common. Traditionally, diagnoses of the different types of gastrointestinal diseases are sometimes ... bacteria genera and species in the human body, regardless of body sites .... vitamin C causes the purple indicator solution to lose its colour.
Upper gastrointestinal haemorrhage has a variety of causes (Table 1) and is the commonest complication of peptic ulceration and portal hypertension. Peptic ulceration in the duo- denum or stomach and oesophageal varices are the conditions most often responsible for patients who have the potential to present.
Svetlana G. Makarova
Full Text Available In recent years, there has been a significant increase in the prevalence of food allergies. Pathological conditions associated with a food intolerance are becoming an increasingly urgent problem of pediatrics. According to different researchers, allergic lesions of the gastrointestinal tract occurs in 25–50% of patients with such common pathology as an allergy to cow's milk proteins. The severity of diseases associated with food allergies and their prognosis depend largely on early diagnosis and adequate treatment. Difficulties and errors in the diagnosis of gastrointestinal food allergies are associated with both subjective and objective reasons, primarily due to the fact that gastrointestinal reactions to food are often delayed and non-IgE-mediated. The article describes clinical forms of gastrointestinal food allergy according to the existing classification. Diagnostic algorithms and modern approaches to differential diagnosis of disease based on evidence-based medicine and corresponding to international consensus papers are given.
Kobayashi, Naoya; Ando, Kokichi; Saito, Kazutomo; Toyama, Hiroaki; Fudeta, Hiroto; Yamauchi, Masanori
We report a case of an oral penetrating injury caused by a toothbrush in a 4-year-old 17-kg boy. The toothbrush was lodged in the right cervical region through the oral cavity, and emergency surgery for removal was planned under general anesthesia. Although mask ventilation was not possible because of the protruding toothbrush handle, awake nasotracheal intubation was successfully performed with a fiber-scope and intravenous fentanyl 25 μg. We conclude that appropriate analgesics could facilitate awake intubation in pediatric patients.
Javed, H; Nair, M P; Koul, R L; Chacko, A; Fazalullah, M
No definite criteria exists in Guillian-Barre syndrome in children regarding prolonged ventilation through an endo-tracheal tube without tracheostomy and successful weaning using a T-piece. Here we report two such cases of Guillian-Barre syndrome requiring prolonged intubation for 56 days and ventilation for 30 days and ultimately successfully weaning them using the T-piece. Both the children eventually made a complete recovery, highlighting the point that in children prolonged intubation and ventilation using the portex tube is equally good, if not, better than tracheostomy with its attendant risks.
Ellis, Daniel Y; Harris, Tim; Zideman, David
Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.
Hermansen, Thomas; Lillebaek, Troels; Hansen, Ann-Brit E
BACKGROUND: Little is known about the QuantiFERON-TB Gold In-Tube Test (QFT) in extreme age groups. The test performance has been reported to be impaired in children and elderly, but reports are diverging. The aim of this study was to evaluate QFT performance in patients with and without Tubercul......BACKGROUND: Little is known about the QuantiFERON-TB Gold In-Tube Test (QFT) in extreme age groups. The test performance has been reported to be impaired in children and elderly, but reports are diverging. The aim of this study was to evaluate QFT performance in patients with and without...
van der Lee, Lisa; Hill, Anne-Marie; Patman, Shane
The objective of the review is to map evidence on the efficacy of a respiratory physiotherapy intervention for intubated and mechanically ventilated adults with community acquired pneumonia (CAP). Specifically, the review seeks to investigate if respiratory physiotherapy interventions can achieve the following for intubated and mechanically ventilated adults with CAP.
Evans, Christopher Charles Douglas; Brison, Robert J; Howes, Daniel; Stiell, Ian G; Pickett, William
Prehospital airway management for adult trauma patients remains controversial. We sought to review the frequency that paramedic non-drug assisted intubation or attempted intubation is performed for trauma patients in Ontario, Canada, and determine its association with mortality. We conducted a retrospective cohort study using the Ontario Trauma Registry's Comprehensive Data Set for 2002-2009. Eligible patients were greater than 16 years of age, had an initial Glasgow Coma Score of less than 9 and were cared for by ground-based non-critical care paramedics. The primary outcome was mortality. Outcomes were compared between patients undergoing prehospital intubation versus basic airway management. Logistic regression analyses were used to quantify the association between prehospital intubation and mortality. Of the 2229 patients included in the analysis, 671 (30.1%) underwent prehospital intubation. Annual rates of prehospital intubation declined from 33.7% to 14.0% (ptrendtrauma is being performed less frequently in Ontario, Canada. Within our study population, paramedic non-drug assisted intubation or attempted intubation was associated with a heightened risk of mortality.
Full Text Available Background: This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation. Methods: In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests. Results: Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation (P : 0.004; however, other demographic characteristics didn′t have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity (96.46% and modified Mallampati of highest sensitivity (98.40%. In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together. Conclusions: Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together.
Vaishali Chandrashekhar; Jaideep; Medha K; Sandhya P; Manish
BACKGROUND : This study was carried out to evaluate usefulness of preoperative Mallampati & Wilson’s score grading as a predictor for difficult laryngoscopy & intubation . AIMS : To determine the accuracy of the modified Mallampati test and Wilson score for predicting difficult tracheal intubation and correlation with Cormack Lehane grading . METHODS : This prospective randomized cross sectional Study carried out in 200 patients , poste...
Khandelwal, Nita; Khorsand, Sarah; Mitchell, Steven H; Joffe, Aaron M
Based on the data from elective surgical patients, positioning patients in a back-up head-elevated position for preoxygenation and tracheal intubation can improve patient safety. However, data specific to the emergent setting are lacking. We hypothesized that back-up head-elevated positioning would be associated with a decrease in complications related to tracheal intubation in the emergency room environment. This retrospective study was approved by the University of Washington Human Subjects Division (Seattle, WA). Eligible patients included all adults undergoing emergent tracheal intubation outside of the operating room by the anesthesiology-based airway service at 2 university-affiliated teaching hospitals. All intubations were through direct laryngoscopy for an indication other than full cardiopulmonary arrest. Patient characteristics and details of the intubation procedure were derived from the medical record. The primary study endpoint was the occurrence of a composite of any intubation-related complication: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. Multivariable logistic regression was used to estimate the odds of the primary endpoint in the supine versus back-up head-elevated positions with adjustment for a priori-defined potential confounders (body mass index and a difficult intubation prediction score [Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score]). Five hundred twenty-eight patients were analyzed. Overall, at least 1 intubation-related complication occurred in 76 of 336 (22.6%) patients managed in the supine position compared with 18 of 192 (9.3%) patients managed in the back-up head-elevated position. After adjusting for body mass index and the Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score, the odds of encountering the
on perfonnance and me value of cardiovascular training in improving performance in aerobic sports is well recognised. The role of me gastro-intestinal tracr, bom as a limiting and sustaining facror in aerobic exercises, is less well appreciared. Gastro-intestinal symptoms. The spectrum of gastro-intestinal effecrs of exercise ...
Background/Aim: Upper gastrointestinal (GI) endoscopy now assumes a prominent role in the diagnosis and therapy of upper GI diseases. Some indications for upper gastrointestinal endoscopy include dyspepsia, dysphagia, peptic ulcer disease (PUD) and upper gastrointestinal bleeding. This study aimed to review the ...
Larsen, P B; Hansen, E G; Jacobsen, L S
Background and objective: Previous studies mainly conducted on elective patients recommend doses of 0.9-1.2 mg kg[-1] rocuronium to obtain comparable intubation conditions with succinylcholine 1.0 mg kg[-1] after 60 s during a rapid-sequence induction. We decided to compare the overall intubating...... the intubation 60 s after injection of the neuromuscular blocker. Intubating conditions were evaluated according to an established guideline. Tracheal intubation not completed within 30 s was recorded as failed. Results: 222 patients were randomized. Three patients had their operation cancelled and 10 did...... conditions of standard doses of rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] during a strict rapid-sequence induction regimen including propofol and alfentanil. Methods: Male and female patients (ASA I-III) older than 17 yr scheduled for emergency abdominal or gynaecological surgery...
Manzano-Nunez, Ramiro; Herrera-Escobar, Juan Pablo; DuBose, Joseph; Hörer, Tal; Galvagno, Samuel; Orlas, Claudia Patricia; Parra, Michael W; Coccolini, Federico; Sartelli, Massimo; Falla-Martinez, Juan Camilo; García, Alberto Federico; Chica, Julian; Naranjo, Maria Paula; Sanchez, Alvaro Ignacio; Salazar, Camilo Jose; Calderón-Tapia, Luis Eduardo; Lopez-Castilla, Valeria; Ferrada, Paula; Moore, Ernest E; Ordonez, Carlos A
Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.
Driver, Brian E; McGill, John W
Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution. We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort. We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated. In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Roblot, C; Ferrandière, M; Bierlaire, D; Fusciardi, J; Mercier, C; Laffon, M
To evaluate the impact of Cormack and Lehane grade on the Intubating Laryngeal Mask Airway (LMA-Fastrach) using in women. Open prospective study. The study included 115 scheduled gynaecologic surgery women. An LMA-Fastrach was systematically performed in patients with a Cormack's grade > or =3 or when Arne's score was > or =7 whatever the Cormack. After induction of anaesthesia and neuromuscular blockade, Cormack's grade was assessed and LMA-Fastrach was inserted. Proper insertion was confirmed by the easiness of assisted ventilation and the normal aspect of the capnographic curve. Intubation through the LMA-Fastrach was carried out with the specific kit's endotracheal tube. More than two attempts were considered as a failure of the technique and an alternative method was performed. The following parameters were noted: age, weight, height, clinical predictors for difficult intubation (Arne et al.'s score), number of LMA-Fastrach insertion, ventilation efficiency through LMA-Fastrach, successful intubation with LMA-Fastrach and oesophageal intubation. Ventilation through the LMA-Fastrach was efficient in 97%. The success rate of intubation was 94.8% (86% on the first attempt). The success rate of ventilation and intubation were not statistically different according to the different Cormack's grades. The obesity (BMI>30) did not change the success rate of ventilation and intubation through the LMA-Fastrach. In women with either predicted or unpredicted difficult intubation, the success rates of ventilation and intubation through the LMA-Fastrach don't seem to be influenced by Cormack grade and obesity.
Turner, Joseph S; Ellender, Timothy J; Okonkwo, Enola R; Stepsis, Tyler M; Stevens, Andrew C; Sembroski, Erik G; Eddy, Christopher S; Perkins, Anthony J; Cooper, Dylan D
Endotracheal intubation is most commonly taught and performed in the supine position. Recent literature suggests that elevating the patient's head to a more upright position may decrease peri-intubation complications. However, there is little data on the feasibility of upright intubation in the emergency department. The goal of this study was to measure the success rate of emergency medicine residents performing intubation in supine and non-supine, including upright positions. This was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed. The number of attempts required for successful intubation was recorded by faculty and espiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0-10° (supine), 11-44° (inclined), and ≥45° (upright); first past success was also analyzed in 5 degree angle increments. A total of 231 intubations performed by 58 residents were analyzed. First pass success was 65.8% for the supine group, 77.9% for the inclined group, and 85.6% for the upright group (p=0.024). For every 5 degree increase in angle, there was increased likelihood of first pass success (AOR=1.11; 95% CI=1.01-1.22, p=0.043). In our study emergency medicine residents had a high rate of success intubating in the upright position. While this does not demonstrate causation, it correlates with recent literature challenging the traditional supine approach to intubation and indicates that further investigation into optimal positioning during emergency department intubations is warranted. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available Advances in the identification of gastrointestinal stromal tumors, its molecular and immunohiostochemical basis, and its management have been a watershed in the treatment of gastrointestinal tumors. This paradigm shift occurred over the last two decades and gastrointestinal stromal tumors have now come to be understood as rare gastrointestinal tract tumors with predictable behavior and outcome, replacing the older terminologies like leiomyoma, schwannoma or leiomyosarcoma. This report presents a case of gastric gastrointestinal stromal tumor operated recently in a 47-year-old female patient and the outcome, as well as literature review of the pathological identification, sites of origin, and factors predicting its behavior, prognosis and treatment.
Full Text Available Background. There is no consensus on the optimum management of failed tracheal intubation in emergency cesarean delivery performed for fetal compromise. The decision making process on whether to wake the patient or continue anesthesia with a supraglottic airway device is an underexplored area. This survey explores perceptions and experiences of obstetric anesthetists managing failed intubation. Methods. Anesthetists attending the Group of Obstetric Anaesthetists London (GOAL Meeting in April 2014 were surveyed. Results. Ninety-three percent of anesthetists surveyed would not always wake the patient in the event of failed intubation for emergency cesarean delivery performed for fetal compromise. The median (interquartile range of perceived acceptability of continuing anesthesia with a well-fitting supraglottic airway device, assessed using a visual analogue scale (0–100; 0 completely unacceptable; 100 completely acceptable, was 90 [22.5]. Preoperative patient consent regarding the use of a supraglottic airway device for surgery in the event of failed intubation would affect the decision making of 40% of anaesthetists surveyed. Conclusion. These results demonstrate that a significant body of anesthetists with a subspecialty interest in obstetric anesthesia in the UK would not always wake up the patient and would continue with anesthesia and surgery with a supraglottic airway device in this setting.
Full Text Available Background: The effects of pretreatment with magnesium on cardiovascular responses associated with intubation have been studied previously. In this study we wanted to find optimal dose of magnesium that causes decreased cardiovascular responses after laryngoscopy & endotracheal intubation. Methods: In a double-blind , randomized, clinical trial ,120 ASA-1 patients with ages between 15-50 years old , who were candidates for elective surgery, were selected and classified in 6 groups (20 patients in each . The pulse rate and arterial blood pressure were measured and recorded at 5 minutes before taking any drug then, according to different groups, patients took magnesium sulfate (10, 20, 30, 40, 50mg/kg and lidocaine (1.5 mg/kg. The induction of anesthesia was same in all groups and the pulse rate and arterial blood pressure were measured and recorded just before intubation and also at 1, 3 , and 5 minutes after intubation (before surgical incision . Statistical analysis was performed by use of ANOVA, Post Hoc test (Duncan, Pearson correlation, and Chi square test. Results: there were no statistically significant differences in blood pressure, pulse rate, Train Of Four (TOF, and complications between groups who received magnesium but the significant differences in these parameters were seen between magnesium and lidocaine groups. Conclusion: We concluded that pretreatment with different doses of magnesium sulfate have a safe decreasing effect on cardiovascular responses that is more effective than pretreatment with lidocaine. Keywords: magnesium sulfate, cardiovascular responses, lidocaine.
Pfeiffer, P; Bache, Stefan Holst; Isbye, D L
Ultrasound (US) may have an emerging role as an adjunct in verification of endotracheal intubation. Obtaining optimal US images in obese patients is generally regarded more difficult than for other patients. This study compared the time consumption of bilateral lung US with auscultation and capno...
Olvera, David J; Stuhlmiller, David F E; Wolfe, Allen; Swearingen, Charles F; Pennington, Troy; Davis, Daniel P
Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance. The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success. The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation. A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p improving RSI intubation performance in a large air medical company.
Results: The modified Mallampati had the highest sensitivity of 70% which was statistically significant with a P = 0.001. Conclusion: From this study we conclude that the modified Mallampati test was a better predictor of difficult intubation than the upper lip bite test and Thyromental Distance.
Granell Gil, M; Solís Albamonte, P; Córdova Hernández, C; Cobo, I; Guijarro, R; de Andrés Ibañez, J A
Lung isolation in thoracic surgery is a challenge, this is even more complex in the presence of unknown tracheal stenosis (TS). We report two cases of unknown TS and its airway management. TS appears most frequently after long term intubation close to the endotracheal tube cuff or in the stoma of tracheostomy that appears as a consequence of the granulation tissue after the surgical opening of the trachea. Clinical history, physical examination, difficult intubating predictors and imaging tests (CT scans) are crucial, however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction. In our cases, the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms. There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery. In the first case, a Univent ® tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred. In the second case, after intubation with VivaSight SL ® in an awake patient, the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy. Copyright © 2018 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Bannister, C M; Kashab, M; Dagestani, H; Placzek, M
After a difficult nasal intubation a premature infant leaked cerebrospinal fluid (CSF) from one nostril. After developing bacterial meningitis, the baby was referred for neurosurgical management of the CSF fistula. Transaxial computed tomograms demonstrated a nasal encephalocele, but coronal scans were needed to show the defect in the cribriform plate. Images PMID:8346963
Van de Leur, JP; Zwaveling, JH; Loef, BG; Van der Schans, CP
Study objective: Endotracheal suctioning in intubated patients is routinely applied in most ICUs but may have negative side effects. We hypothesised that on-demand minimally invasive suctioning would have fewer side effects than routine deep endotracheal suctioning, and would be comparable in
Kaufman, Gretchen E; Seymour, Rosemarie E; Bonner, Barbara B; Court, Michael H; Karas, Alicia Z
To determine whether rocuronium, a reversible neuromuscular blocking agent, would provide safe, short-term immobilization to facilitate endotracheal intubation in turtles. Prospective study. 30 healthy adult Gulf Coast box turtles. Turtles were given rocuronium, and responses were recorded every 3 minutes. Times to onset of effects, intubation, and recovery were recorded and analyzed for associations with dose and patient characteristics to determine an optimal dose range. Neostigmine and glycopyrrolate were given to augment recovery from neuromuscular blockade. Rocuronium administered at a dose of 0.25 to 0.5 mg/kg (0.11 to 0.23 mg/lb), IM, permitted intubation; lower doses were not effective. Mean +/- SD time to loss of the palpebral reflex was 6.4 +/- 4.0 minutes, and mean time to intubation was 9.2 +/- 6.4 minutes. Mean time to return of the palpebral reflex was 44 +/- 13.2 minutes, and mean time to walking was 55 +/- 16.6 minutes. Time to onset of effects was not associated with dose, but recovery times were prolonged with higher doses of rocuronium. Cardiac arrhythmias were observed in 13 (43%) turtles. Administration of rocuronium at a dose of 0.25 to 0.5 mg/kg is a safe and effective adjunct to general anesthesia in Gulf Coast box turtles. Because rocuronium does not provide any analgesic or sedative effects, the duration of neuromuscular blockade without anesthesia should be minimized to avoid undue distress.
Facial trauma significantly increases the difficulty in airway management in the emergency department or during the provision of anesthesia for surgery. We present airway management in a patient with severe facial trauma that necessitated awake nasotracheal fiber-optic intubation for safe induction of anesthesia.
using a flexible fiber-optic choledochoscope (1) The technique is indicated in patients with difficult airways in whom losing the airway following induction of anes- thesia is deemed dangerous or fatal. Successful awake fiber-optic intubation requires con-. Introduction. Trauma to the face presents considerable challenges to.
The main thrust of the technique is that cuff inflation of the endotracheal tube is used to lift the endotracheal tube off the posterior pharyngeal wall and thus direct it towards the glottis. The technique was used successfully in 5 consecutive patients needing nasotracheal intubation. Indeed a couple of these patients might have ...
L.J. Hoeve (Hans)
textabstractThe failure to extubate a preterm infant after prolonged intubation is often caused by laryngotracheal injury. This condition is treated by tracheotomy, anterior cricoid split, or often, by reintubation and subsequent extubation attempts in a later stage. To assess the value of
Bhargava, Rishi; Brown, Lance
The objective of this study was to describe our experience removing esophageal coins from children in a tertiary care pediatric emergency department over a 4-year period. We retrospectively reviewed a continuous quality improvement data set spanning October 1, 2004, through September 30, 2008. In 96 of 101 cases (95%), emergency physicians successfully retrieved the coin. The median age of the children was 19 months (interquartile range [IQR] 13-43 months; range 4 months-12.8 years). The median time to removal of coin from initiation of intubation was 8 minutes (IQR 4-14 minutes; range 1-60 minutes). Coins were extracted using forceps only in 56 cases, whereas forceps and a Foley catheter were used in the remainder. Succinylcholine and etomidate were used in almost all cases for rapid sequence intubation prior to coin removal. Complications were identified in 46 cases: minor bleeding (13), lip laceration (7), multiple attempts (5), hypoxia (3), accidental extubation (3), dental injuries (3), bradycardia (2), coin advanced (1), right main-stem bronchus intubation (1), and other (8). Emergency physicians successfully removed esophageal coins following rapid sequence intubation in most cases. Our approach may be considered for the management of pediatric esophageal coins, particularly in an academic pediatric emergency department.
H. L. Yang
Full Text Available Background. Postoperative sore throat is one of the major complaints of general anesthesia in the postanesthesia care unit. This prospective study investigated the preventive effect of ketorolac tromethamine spray in postendotracheal-intubation-induced sore throat after general anesthesia. Methods. Surgical patients undergoing general anesthesia with endotracheal intubation were recruited from a medical center. Patients were randomly assigned to group K (treated with 5% ketorolac tromethamine spray or group D (treated with distilled water spray. Before intubation, each endotracheal tube was sprayed with the appropriate solution by physicians over the 20 cm length of the cuff. Each group comprised 95 patients fitting the inclusion and exclusion criteria for whom complete data sets were collected. The intensity of the sore throat was measured at 1, 3, 6, and 24 h after surgery, and data were compared. Results. The two groups had similar characteristics. Postoperative sore throat was significantly less frequent in group K than in group D (p<0.001 and the pain intensity was significantly lower in group K than in group D at each time point (all p<0.001. Conclusions. This study demonstrated that preanesthesia 5% ketorolac tromethamine spray could effectively decrease postendotracheal-intubation-induced sore throat in patients undergoing general anesthesia.
Weiss, M; Mauch, J; Becke, K; Schmidt, J; Jöhr, M
Fibre optic-assisted tracheal intubation through the laryngeal mask airway is a simple and safe procedure for securing the airway in the paediatric patient with unexpected and known difficult tracheal intubation. Therefore, fibre optic-assisted tracheal intubation through the laryngeal mask airway represents a standard airway technique and must be part of clinical education and also regular training. However, the removal of the laryngeal mask airway over the tracheal tube is impaired by the short length of the tracheal tube, easily resulting in tube dislocation from the trachea. Among several techniques to overcome this problem, the Cook airway exchange catheter offers a reliable method not only for safe removal of the laryngeal mask over the tracheal tube but also for insertion of an adequate tracheal tube, particularly in paediatric patients. This is particularly important for cuffed tubes as the pilot balloon of the cuffed tube is too large to pass through laryngeal mask airway tubes size 2.5 and smaller. This presentation demonstrates fibre optic-assisted tracheal intubation through the laryngeal mask airway in children step-by-step and discusses its clinical implications. A list with compatible sizes of laryngeal mask airways, tracheal tubes and airway exchange catheters is also provided.
Keller, Christian; Brimacombe, Joseph; Lirk, Philipp; Pühringer, Fritz
The ProSeal laryngeal mask airway (ProSeal LMA) provides a better seal and probably better airway protection than the classic laryngeal mask airway (classic LMA). We report the use of the ProSeal LMA in a 26-yr-old female with HELLP syndrome for failed obstetric intubation and postoperative
Conclusions: We concluded that the NTG lingual spray in dose of 0.4 mg (1 spray or 0.8 mg (2 sprays was effective in attenuation of intubation induced hemodynamic response, in terms of preventing significant rise in SBP, DBP and MAP compared to control group.
Full Text Available Introduction. Intraoperative stress responses and postoperative pain can be monitored using photoplethysmography (PPG. PPG signal has two components, AC and DC. Effects of noxious stimuli-induced stress responses have not been studied on the DC component of PPG. The aim of this study was to investigate the effect of a known noxious stimulus (endotracheal intubation on both the AC and DC components of PPG. Methods. 15 surgical patients having general anesthesia were enrolled into this clinical study. PPG was recorded electronically from a pulse oximeter. Maximum changes in the AC and DC components of the PPG and pulse rate were determined in response to endotracheal intubation from high frequency (62.5 Hz PPG recordings. Results. Endotracheal intubation-induced autonomic stress response resulted in a significant decrease in the AC component of the PPG and an increase in pulse rate in every subject (p<0.05 for all. The decrease in the AC component of the PPG was 50±12% (p<0.05 and the increase in pulse rate was 26±10 bpm (p<0.05. The response of the DC component was variable (p = NS. Conclusion. Endotracheal intubation-induced stress response resulted in a significant and consistent change in the AC, but not the DC component of the PPG. This trial is registered with ClinicalTrials.gov Identifier NCT03032939.
Full Text Available This is a report of anterior osteophytes on the cervical vertebra resulting in distortion of the airway and leading to difficulty during intubation. The osteophytes associated with the syndrome of diffuse idiopathic skeletal hyperostosis were at the C2-3 and C6-7, T1 level and resulted in anterior displacement of the pharynx and the trachea respectively.
Buis, Maria L; Maissan, Iscander M; Hoeks, Sanne E; Klimek, Markus; Stolker, Robert J
More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated with severe complications and death. The aim of this review was to determine the number of ETIs a health care provider in training needs to perform to achieve proficiency within two attempts. A systematic search of the literature was conducted covering the time frame of January 1990 through July 2014. We identified 13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts need to be performed to reach a success rate of at least 90%. However, the evidence is heterogeneous, and the incidence of difficult airways in non-elective settings is up to 20 times higher compared to elective settings. Taking this factor into account, training should include a variety of exposures and should probably exceed 50 ETIs to successfully serve the most vulnerable patients. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Full Text Available Objectives. To study the effect of prehospital intubation (PHI on survival of patients with isolated severe traumatic brain injury (ISTBI. Method. Retrospective analyses of all intubated patients with ISTBI between 2008 and 2011 were studied. Comparison was made between those who were intubated in the PHI versus in the trauma resuscitation unit (TRU. Results. Among 1665 TBI patients, 160 met the inclusion criteria (105 underwent PHI, and 55 patients were intubated in TRU. PHI group was younger in age and had lower median scene motor GCS (P=0.001. Ventilator days and hospital length of stay (P=0.01 and 0.006, resp. were higher in TRUI group. Mean ISS, length of stay, initial blood pressure, pneumonia, and ARDS were comparable among the two groups. Mortality rate was higher in the PHI group (54% versus 31%, P=0.005. On multivariate regression analysis, scene motor GCS (OR 0.55; 95% CI 0.41–0.73 was an independent predictor for mortality. Conclusion. PHI did not offer survival benefit in our group of patients with ISTBI based on the head AIS and the scene motor GCS. However, more studies are warranted to prove this finding and identify patients who may benefit from this intervention.
Rehfeld, Jens F.
Gastrointestinal hormones are peptides released from endocrine cells and neurons in the digestive tract. More than 30 hormone genes are currently known to be expressed in the gastrointestinal tract, which makes the gut the largest hormone producing organ in the body. Modern biology makes...... it feasible to conceive the hormones under five headings: The structural homology groups a majority of the hormones into nine families, each of which is assumed to originate from one ancestral gene. The individual hormone gene often has multiple phenotypes due to alternative splicing, tandem organization......, or differentiated maturation of the prohormone. By a combination of these mechanisms, more than 100 different hormonally active peptides are released from the gut. Gut hormone genes are also widely expressed in cells outside the gut, some only in extraintestinal endocrine cells and neurons but others also in other...
Ma, Irene T.; Madura, James A.
Bariatric surgery is increasingly being performed in the medically complicated obese population as convincing data continue to mount, documenting the success of surgery not only in achieving meaningful weight loss but also in correcting obesity-related illnesses. Several surgical procedures with varying degrees of success and complications are currently being performed. This article discusses the short- and long-term gastrointestinal complications for the 4 most common bariatric surgical proc...
Montero Leon, Jorge Felipe; Silveira Pablos, Juan Mario; Figueroa, Alejandro Joan; Fuente Pelaez, Alexis
The tumors of the gastrointestinal stroma, known in English language as GIST (gastrointestinal stromal tumors) are mesenchymal tumors appearing in any place throughout the intestinal tract. The objective of present paper is to present the case of a female patient aged 60 came to Gynecology consultation of the National Institute of Oncology and Radiobiology due pain in epigastrium irradiating to right flank with increase of volume in the right iliac fossa and by ultrasonography it is a tumor of right ovary projecting to epigastrium and the right hypochondrium. The surgical intervention is described as well as the findings noted in macro- and microscopic studies, as well ass in latter studies by immunohistochemistry of lesion. We conclude with a diagnosis of tumor of gastrointestinal stroma and the results of performed surgical and drugs interventions. It is recommended to assess the significance of a close relationship among general surgeons and gynecologists in face of unexpected diseases due to its difficult preoperative diagnosis leading to a appropriate surgical treatment due to its complexity it is necessary the competence of both surgical specialties
Prescher, Hannes; Grover, Emily; Mosier, Jarrod; Stolz, Uwe; Biffar, David E; Hamilton, Allan J; Sakles, John C
Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.
Ul Haq, Muhammad Irfan; Ullah, Hameed
Background: Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT) with lower jaw protrusion (LJP) maneuver in predicting difficult laryngoscopy and intubation. Materials and Methods: Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated for both these tests with 95% confidence interval (CI) using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant. Results: LJP maneuver had higher sensitivity (95.9% vs. 27.1%), NPV (98.7% vs. 82.0%), and accuracy (90.1% vs. 80.3%) when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT. Conclusion: The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway. PMID:24106353
Muhammad Irfan Ul Haq
Full Text Available Background: Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT with lower jaw protrusion (LJP maneuver in predicting difficult laryngoscopy and intubation. Materials and Methods: Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV and negative predictive value (NPV were calculated for both these tests with 95% confidence interval (CI using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant. Results: LJP maneuver had higher sensitivity (95.9% vs. 27.1%, NPV (98.7% vs. 82.0%, and accuracy (90.1% vs. 80.3% when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT. Conclusion: The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway.
Gupta, Anjeleena K; Sharma, Bimla; Kumar, Arvind; Sood, Jayashree
To use laparoscope as an easily available and easy to use alternative option to videolaryngoscope. The aim of the study was to assess the improvement in the glottic view using a conventional direct laryngoscope (DL) assisted by a laparoscope with its endovision system along with the time taken for tracheal intubation. A prospective, double blind, randomized, controlled study was conducted in a tertiary care centre. Sixty patients with American Society of Anesthesiologists (ASA) physical status I and II requiring general anaesthesia and tracheal intubation for elective surgery were included in the study. The patients were anaesthetized, paralysed, DL was performed and Cormack and Lehane grade (C and L) noted, followed by the introduction of the laparoscope alongside the flange of the Macintosh laryngoscope and a further C and L grading done as seen on monitor. Demographic data, ASA physical status, airway assessment, mouth opening, modified Mallampatti class, jaw protrusion, thyromental and sternomental distances, optimal external laryngeal manipulation, time taken for intubation, pulse oximetry, blood on; tracheal tube, lip, dentition or mucosal trauma, sore throat, hoarseness of voice, excessive secretions and regurgitation were recorded. Statistical analysis was done using statistics package for social sciences software (17.0 version). A P-value less than 0.05 was considered statistically significant. Eighty-three percent of the patients showed improvement in glottic view after laparoscopic assistance. Eighty-one and 85% of the patients with C and L grade II and III respectively on DL had an improved glottic view with this technique. The mean time to intubate was 37 seconds. Laparoscopic assistance provided a better glottic view than DL in most patients (83%). It has a potential advantage over standard DL in difficult intubation.
Del Buono, Romualdo; Sabatino, Lorenzo; Greco, Federico
Direct laryngoscopy is the gold standard of the airway management in patients without predicted difficulties. If unpredicted difficulties are encountered instead, different algorithms to follow have been developed. To date, no single predictor is sufficiently valid. In clinical practice, it is used a combination of them to enhance the estimate, and despite the variety of parameters used, not all the difficult intubations are predicted. The aim of this work is to retrospectively analyze neck computed tomography scans of 37 patients who have had tracheal intubation and search for anatomic neck fat compartments that correlate with the intubation difficulty, and eventually find a suitable, clinical parameter that can potentially enhance the prediction of a difficult airway when used in combination of the preexisting scores. the patients are divided by direct laryngoscopy view into two groups: Group A ( n = 31): Normal airway, with a Cormack Lehane, Score I or II; Group B ( n = 6): Difficult airway, with a Cormack Lehane Score III or IV. In the zone of interest, it was measured the neck volume parameter and other subparameters. Despite a positive trend is shown for anterior fat volume (AFV) ( P = 0.23) and fat volume (FV) ( P = 0.28), statistically significant differences ( P < 0.05) were not found between Group A and B in any of the measurements acquired. According to the literature, our results confirmed that there is still no single element that can predict a difficult intubation. Although no statistical significance was found, the AFV and FV have shown to have a potential predictive role for difficult intubation. Further studies with bigger samples are advisable to confirm this encouraging result.
Locks, Giovani de Figueiredo; Almeida, Maria Cristina Simões de
The priming principle consists of administering a low neuromuscular blocker dose, minutes before the total dose for tracheal intubation, to shorten non-depolarizing blockers onset. There is, however, the risk for muscle fade and bronchoaspiration. Laryngeal muscles are of especial interest for tracheal intubation maneuvers and airway protection. Since their direct monitoring imposes technical difficulties, it has been reported that orbicularis oculi correlates with laryngeal muscles in terms of sensitivity to neuromuscular blocks. This study aimed at evaluating the presence of orbicularis oculi muscle fade after priming atracurium dose and at comparing clinical tracheal intubation conditions after two priming dose intervals. Participated in this study 35 adult patients, physical status ASA I or II, without risk factors for bronchoaspiration and submitted to elective surgeries. General anesthesia was induced with alfentanil and propofol and patients were manually ventilated under mask. Surface electrodes were then positioned on the temporal branch of the facial nerve, and the acceleration transducer was placed on the orbicularis oculi. Priming atracurium dose (0.02 mg.kg-1) was administered and T4/T1 ratio was evaluated every minute during 5 minutes in 20 cases (G1) and during 7 minutes in 13 cases (G2). After this interval, complementary atracurium dose (0.5 mg.kg-1) was administered and tracheal intubation was performed one minute later. Fade was defined as T4/T1 ratio below 0.9. There has been no fade in any patient during the monitoring interval. In 80% and 69% of G1 or G2 patients, respectively, tracheal intubation was classified as clinically acceptable (p > 0.05). Priming atracurium dose (0.02 mg.kg-1) does not determine orbicularis oculi fade and there is no difference between 5 or 7 minutes priming intervals.
Full Text Available BACKGROUND Laryngoscopic manipulation and endotracheal intubation are very painful stimuli capable of producing tachycardia, arrhythmia and hypertension. The aim of the study was to evaluate the efficacy of single premedication dose of I. V dexmedetomidine in attenuating pressor response to laryngoscopy & endotracheal intubation. MATERIALS AND METHODS This study was carried out at S.V. Medical College, Tirupati for one year period. The study was undertaken after obtaining ethical committee clearance as well as written informed consent from all patients. 60 patients in the age group 20-40 yrs. of either sex, belonging to ASA grade I and II scheduled for elective surgical procedures under General anaesthesia were included. 60 patients aged between 20 to 40 years belonging to ASA grade I & II were randomly divided into 2 groups, each group consists of 30 patients Group I (Saline group 100 ml normal saline infused, Group II (Dexmedetomidine group 1 mcg/kg in 100 ml normal saline infused over 15 min. The hemodynamic parameters were monitored from baseline upto 10 min after intubation. RESULTS Demographic data were analysed by student’s t test. Analysis of variance for repeated measures (ANOVA was used to analyse changes over time. The statistical software SPSS version 16.0 was used for the analysis of the data and Microsoft Word and Excel have been used to generate graphs, tables etc. There was statistically significant difference (p<0.05 between dexmedetomidine and normal saline in heart rate, systolic, diastolic, mean arterial pressure at all time points after tracheal intubation with dexmedetomidine. CONCLUSION Dexmedetomidine in the dose of 1 μg/kg as IV infusion, given 15 minutes before induction can be used safely to attenuate the pressor response to laryngoscopy and intubation without significant side effects.
Varni, James W; Shulman, Robert J; Self, Mariella M; Saeed, Shehzad A; Patel, Ashish S; Nurko, Samuel; Neigut, Deborah A; Saps, Miguel; Zacur, George M; Dark, Chelsea V; Bendo, Cristiane B; Pohl, John F
To investigate the effects of patient health communication regarding their inflammatory bowel disease (IBD) to their health care providers and significant others in their daily life as a mediator in the relationship between gastrointestinal symptoms and gastrointestinal worry in pediatric patients. The Pediatric Quality of Life Inventory Gastrointestinal Symptoms, Gastrointestinal Worry, and Communication Scales, and Pediatric Quality of Life Inventory 4.0 Generic Core Scales were completed in a 9-site study by 252 pediatric patients with IBD. Gastrointestinal Symptoms Scales measuring stomach pain, constipation, or diarrhea and patient communication were tested for bivariate and multivariate linear associations with Gastrointestinal Worry Scales specific to patient worry about stomach pain or bowel movements. Mediational analyses were conducted to test the hypothesized mediating effects of patient health communication as an intervening variable in the relationship between gastrointestinal symptoms and gastrointestinal worry. The predictive effects of gastrointestinal symptoms on gastrointestinal worry were mediated in part by patient health communication with health care providers/significant others in their daily life. In predictive models using multiple regression analyses, the full conceptual model of demographic variables, gastrointestinal symptoms (stomach pain, constipation, or diarrhea), and patient communication significantly accounted for 46, 43, and 54 percent of the variance in gastrointestinal worry (all Ps health communication explains in part the effects of gastrointestinal symptoms on gastrointestinal worry in pediatric patients with IBD. Supporting patient disease-specific communication to their health care providers and significant others may improve health-related quality of life for pediatric patients with IBD.
Sarkılar, Gamze; Sargın, Mehmet; Sarıtaş, Tuba Berra; Borazan, Hale; Gök, Funda; Kılıçaslan, Alper; Otelcioğlu, Şeref
This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses.
Paul, A M; Young, N H; Price, G C
Non-medicine-assisted tracheal intubation in prehospital trauma is associated with a dismal prognosis. We wished to study the outcome of medical patients who underwent non-medicine-assisted tracheal intubation. This retrospective study of patients attending our university hospital emergency department was conducted over seven years. The tracheal intubation database was analysed to identify medical patients not in cardiac arrest undergoing tracheal intubation without medicines. Intensive care unit, hospital, 12-month mortality and patients' residence at 12 months were recorded. Eighty patients were identified who met inclusion criteria. The most common reason for intubation was definite airway compromise due to decreased conscious level (62.5%), then respiratory failure (26.3%) and finally potentially compromised airway due to a decreased conscious level (11.2%). Eighty-eight percent of patients with a definitely compromised airway were successfully intubated at first attempt compared with 66.7% of patients with a potentially compromised airway or respiratory failure (P= 0.03). Of 75 patients with complete data, 30 (40%) were survivors at 12 months, with all but two (6.7%) living at home. Non-medicine-assisted laryngoscopy leads to an increased first time tracheal intubation failure rate in patients with intact airway reflexes and, therefore, cannot be recommended as best practice.
Full Text Available The aim of this study was to compare the effects of fentanyl or dexmedetomidine when used in combination with propofol and lidocaine for tracheal intubation without using muscle relaxants. Sixty patients with American Society of Anesthesiologists stage I risk were randomized to receive 1 mg/kg dexmedetomidine (Group D, n = 30 or 2 mg/kg fentanyl (Group F, n = 30, both in combination with 1.5 mg/kg lidocaine and 3 mg/kg propofol. The requirement for intubation was determined based on mask ventilation capability, jaw motility, position of the vocal cords and the patient's response to intubation and inflation of the endotracheal tube cuff. Systolic arterial pressure, mean arterial pressure, heart rate and peripheral oxygen saturation values were also recorded. Rate pressure products were calculated. Jaw relaxation, position of the vocal cords and patient's response to intubation and inflation of the endotracheal tube cuff were significantly better in Group D than in Group F (p < 0.05. The intubation conditions were significantly more satisfactory in Group D than in Group F (p = 0.01. Heart rate was significantly lower in Group D than in Group F after the administration of the study drugs and intubation (p < 0.05. Mean arterial pressure was significantly lower in Group F than in Group D after propofol injection and at 3 and 5 minutes after intubation (p < 0.05. After intubation, the rate pressure product values were significantly lower in Group D than in Group F (p < 0.05. We conclude that endotracheal intubation was better with the dexmedetomidine–lidocaine–propofol combination than with the fentanyl–lidocaine–propofol combination. However, side effects such as bradycardia should be considered when using dexmedetomidine.
Full Text Available BACKGROUND AND OBJECTIVES: This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. METHODS: Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 μg kg-1 remifentanil (Group 1, n = 25 or a combination of 2 μg kg-1 remifentanil and 1 mg kg-1 lidocaine (Group 2, n = 25. To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2 were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. RESULTS: Acceptable intubation parameters were achieved in 24 patients in Group 1 (96% and in 23 patients in Group 2 (92%. In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p = 0.000 CONCLUSION: By the addition of 2 μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1 mg/kg lidocaine to 2 μg/kg remifentanil does not provide any additional improvement in the intubation parameters.
Chambers, Neil A; Hullett, Bruce
Some techniques used to achieve intubation in children predicted to have a difficult airway do not involve direct laryngoscopy or assessment of the laryngeal grade. Direct laryngoscopy may therefore be performed immediately after intubation to provide a record for future anesthetics. It is unknown whether this postintubation grade accurately reflects the standard laryngeal grade in this group. The aim of the study was to identify those children who were predicted to be a difficult intubation and to perform direct laryngoscopy before and after intubation. We set out to ascertain if direct laryngoscopy performed after intubation could accurately predict the standard un-intubated laryngeal grade in this group. All children presenting for general anesthesia who were clinically predicted to be a difficult intubation were considered for this study and prospectively recruited. After induction of anesthesia, one study anesthetist performed direct laryngoscopy before and another study anesthetist then performed direct laryngoscopy after intubation. These laryngeal grades were then compared. A total of 21 children were successfully recruited and studied, and all patients were successfully intubated. Overall, the postintubation grade did not reliably reflect the standard grade, but did not differ by more than one grade in any patient. In one-third of subjects, the postintubation grade was equal to the standard grade, in one-third it was a grade 'easier' and in one-third a grade 'harder'. Assessment and documentation of a postintubation laryngeal grade does not appear to provide reliable information for future anesthetics and may even have the potential to be misleading. Any such documentation should always refer to the presence of an endotracheal tube and be interpreted with caution. © 2013 John Wiley & Sons Ltd.
Xu, Mao; Li, Xiao-Xi; Guo, Xiang-Yang; Wang, Jun
Airway management is critical in patients with cervical spondylosis, a population with a high incidence of difficult airway. Intubation with Shikani Optical Stylet (SOS) has become increasingly popular in difficult airway. We compared the effects of intubation with SOS versus Macintosh laryngoscope (MLS) in patients undergoing surgery for cervical spondylosis. A total of 270 patients scheduled for elective surgery for cervical spondylosis of spinal cord and nerve root type from August 2012 to January 2016 were enrolled and randomly allocated to the MLS or SOS group by random numbers. Patients were evaluated for difficult airway preoperatively, and Cormack-Lehane laryngoscopy classification was determined during anesthesia induction. Difficult airway was defined as Cormack-Lehane Grades III-IV. Patients were intubated with the randomly assigned intubation device. The success rate, intubation time, required assistance, immediate complications, and postoperative complaints were recorded. Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by independent samples t-test or rank sum test. The success rate of intubation among normal airways was 100% in both groups. In patients with difficult airway, the success rates in the MLS and SOS groups were 84.2% and 94.1%, respectively (P = 0.605). Intubation with SOS took longer compared with MLS (normal airway: 25.1 ± 5.8 s vs. 24.5 ± 5.7 s, P = 0.426; difficult airway: 38.5 ± 8.5 s vs. 36.1 ± 8.2 s, P = 0.389). Intubation with SOS required less assistance in patients with difficult airway (5.9% vs. 100%, Pspondylosis. Compared with MLS, SOS appears clinically beneficial for intubation, especially in patients with difficult airway. Chinese Clinical Trial Registry, ChiCTR-IOR-16007821; http://www.chictr.org.cn/showproj.aspx?proj=13203.
Jepsen, Cecilie H; Gätke, Mona R; Thøgersen, Bente
BACKGROUND: Flexible fibreoptic endoscopic (FFE) intubation is considered the 'gold-standard' when difficult airway management is anticipated. Several videolaryngoscopes have been developed to facilitate intubation by laryngoscopy. OBJECTIVE: The aim of the study was to compare the performance......Grath videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema. MAIN OUTCOME MEASURES...
Eeshwar Rao Madishetti
Full Text Available AIMS This study aims to compare endotracheal intubation using the Airtraq with bougie vs. the Airtraq without bougie with respect to: Time for intubation, Ease of intubation, Maneuvers employed to facilitate intubation, Number of attempts. MATERIALS AND METHODS This randomised prospective study was done with Seventy five patients undergoing elective surgery under general anaesthesia. 37 patients in group Airtraq (A and 38 patients in group AB were studied. RESULTS All the demographic details of the patients ASA Physical status and airway parameter are insignificant in both groups, i.e. they are similar. There is no significant differences in the mean inter-incisor distance and the mean Thyro-Mental Distance between the study groups. The distribution of patients according to Modified Mallampati Class in the two groups were similar. When the two groups were compared with respect to the number of patients in each group requiring particular maneuvers to optimise glottic view and facilitate intubation, no statistical difference was observed. However, there was a statistically and clinically significant difference when the two groups were compared with respect to the number of patients requiring various maneuvers to optimise the glottic view to facilitate intubation. Four of seven patients in group Airtraq (A who had trauma had also required additional maneuvers to facilitate intubation. One of these four had a grade 3 Cormack-Lehane view despite maneuvers and a second attempt was needed in two patients. In our study, trauma was observed more frequently in Airtraq (A group. Its greater frequency in group Airtraq (A as compared to Airtraq with bougie (AB was both statistically and clinically significant. Majority of the patients in group AirtraqTM with bougie (AB were intubated easily, but proportion did not reach statistical significance when compared with group Airtraq. TM CONCLUSION The Gum Elastic Bougie aids intubation with the Airtraq avoiding
Knaak, Jan; McVey, Mark; Bazerbachi, Fateh; Goldaracena, Nicolás; Spetzler, Vinzent; Selzner, Nazia; Cattral, Mark; Greig, Paul; Lilly, Les; McGilvray, Ian; Levy, Gary; Ghanekar, Anand; Renner, Eberhard; Grant, David; Hawryluck, Laura; Selzner, Markus
Data regarding transplantation outcomes in ventilated intensive care unit (ICU)-dependent patients with end-stage liver disease (ESLD) are conflicting. This single-center cohort study investigated the outcomes of patients with ESLD who were intubated with mechanical support before liver transplantation (LT). The ICU plus intubation group consisted of 42 patients with decompensated cirrhosis and mechanical ventilation before transplantation. LT was considered for intubated ICU patients if the fraction of inspired oxygen was ≤40% with a positive end-expiratory pressure ≤ 10, low pressor requirements, and the absence of an active infection. Intubated ICU patients were compared to 80 patients requiring ICU admission before transplantation without intubation and to 126 matched non-ICU-bound patients. Patients requiring ICU care with intubation and ICU care alone had more severe postoperative complications than non-ICU-bound patients. Intubation before transplantation was associated with more postoperative pneumonias (15% in intubated ICU transplant candidates, 5% in ICU-bound but not intubated patients, and 3% in control group patients; P = 0.02). Parameters of reperfusion injury and renal function on postoperative day (POD) 2 and POD 7 were similar in all groups. Bilirubin levels were higher in the ICU plus intubation group at POD 2 and POD 7 after transplantation but were normalized in all groups within 3 months. The ICU plus intubation group versus the ICU-only group and the non-ICU group had decreased 1-, 3-, and 5-year graft survival (81% versus 84% versus 92%, 76% versus 78% versus 87%, and 71% versus 77% versus 84%, respectively; P = 0.19), but statistical significance was not reached. A Glasgow coma scale score of 7 before transplantation was associated with high postoperative mortality in ICU-bound patients requiring intubation (38% versus 23%; P = 0.01). In conclusion, ICU admission and mechanical ventilation should not be considered
Jin, Huijun; Patil, Pavan Manohar
No consensus exists to date regarding the best method of controlling the airway for oral or craniomaxillofacial surgery when orotracheal and nasotracheal intubations are unsuccessful or contraindicated. The most commonly used method of tracheostomy has been associated with a high degree of morbidity. Therefore, the present study was conducted to determine the indications, safety, efficacy, time required, drawbacks, complications, and costs of the midline submental intubation (SMI) approach in elective oral and craniomaxillofacial surgical procedures. A retrospective case series study was used to evaluate the surgical, financial, and photographic records of all patients who had undergone oral or craniomaxillofacial operations at Sharda University School of Dental Sciences, Greater Noida, from April 2006 to March 2014. The indications, drawbacks, time required for the procedure, ability to provide a secure airway, intra- and postoperative complications, and additional costs associated with SMI were analyzed. Of the 2,823 patients treated, the present study included 120 patients (97 men and 23 women, aged 19 to 60 years). The average time required for SMI was 10 ± 2 minutes. No episode of intraoperative oxygen desaturation was noted. One intraoperative complication, an injury to the ventral surface of the tongue, was encountered. Two patients developed infection at the skin incision site. No significant additional cost was incurred with the use of SMI. SMI has been successfully used in elective oral and craniomaxillofacial surgical procedures for which oral and nasal intubations were either not indicated or not possible. The advantages include a quick procedure, insignificant complications, the ability to provide a stable airway, and no added costs, making SMI a quick, safe, efficient, and cost-effective alternative in such cases. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Badiger, S; John, M; Fearnley, R A; Ahmad, I
Awake fibre-optic intubation is a widely practised technique for anticipated difficult airway management. Despite the administration of supplemental oxygen during the procedure, patients are still at risk of hypoxia because of the effects of sedation, local anaesthesia, procedural complications, and the presence of co-morbidities. Traditionally used oxygen-delivery devices are low flow, and most do not have a sufficient reservoir or allow adequate fresh gas flow to meet the patient's peak inspiratory flow rate, nor provide an adequate fractional inspired oxygen concentration to prevent desaturation should complications arise. A prospective observational study was conducted using a high-flow humidified transnasal oxygen-delivery system during awake fibre-optic intubation in 50 patients with anticipated difficult airways. There were no episodes of desaturation or hypercapnia using the high-flow system, and in all patients the oxygen saturation improved above baseline values, despite one instance of apnoea resulting from over-sedation. All patients reported a comfortable experience using the device. The high-flow nasal oxygen-delivery system improves oxygenation saturation, decreases the risk of desaturation during the procedure, and potentially, optimizes conditions for awake fibre-optic intubation. The soft nasal cannulae uniquely allow continuous oxygenation and simultaneous passage of the fibrescope and tracheal tube. The safety of the procedure may be increased, because any obstruction, hypoventilation, or periods of apnoea that may arise may be tolerated for longer, allowing more time to achieve ventilation in an optimally oxygenated patient. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Full Text Available BACKGROUND: In the 2003 Toronto SARS outbreak, SARS-CoV was transmitted in hospitals despite adherence to infection control procedures. Considerable controversy resulted regarding which procedures and behaviours were associated with the greatest risk of SARS-CoV transmission. METHODS: A retrospective cohort study was conducted to identify risk factors for transmission of SARS-CoV during intubation from laboratory confirmed SARS patients to HCWs involved in their care. All SARS patients requiring intubation during the Toronto outbreak were identified. All HCWs who provided care to intubated SARS patients during treatment or transportation and who entered a patient room or had direct patient contact from 24 hours before to 4 hours after intubation were eligible for this study. Data was collected on patients by chart review and on HCWs by interviewer-administered questionnaire. Generalized estimating equation (GEE logistic regression models and classification and regression trees (CART were used to identify risk factors for SARS transmission. RESULTS: 45 laboratory-confirmed intubated SARS patients were identified. Of the 697 HCWs involved in their care, 624 (90% participated in the study. SARS-CoV was transmitted to 26 HCWs from 7 patients; 21 HCWs were infected by 3 patients. In multivariate GEE logistic regression models, presence in the room during fiberoptic intubation (OR = 2.79, p = .004 or ECG (OR = 3.52, p = .002, unprotected eye contact with secretions (OR = 7.34, p = .001, patient APACHE II score > or = 20 (OR = 17.05, p = .009 and patient Pa0(2/Fi0(2 ratio < or = 59 (OR = 8.65, p = .001 were associated with increased risk of transmission of SARS-CoV. In CART analyses, the four covariates which explained the greatest amount of variation in SARS-CoV transmission were covariates representing individual patients. CONCLUSION: Close contact with the airway of severely ill patients and failure of infection control practices to prevent exposure
Suppan, L.; Tramèr, M. R.; Niquille, M.; Grosgurin, O.; Marti, C.
Background. Immobilization of the cervical spine worsens tracheal intubation conditions. Various intubation devices have been tested in this setting. Their relative usefulness remains unclear. Methods. We searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials comparing any intubation device with the Macintosh laryngoscope in human subjects with cervical spine immobilization. The primary outcome was the risk of tracheal intubation failure at the first attempt. Secondary outcomes were quality of glottis visualization, time until successful intubation, and risk of oropharyngeal complications. Results. Twenty-four trials (1866 patients) met inclusion criteria. With alternative intubation devices, the risk of intubation failure was lower compared with Macintosh laryngoscopy [risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35–0.80]. Meta-analyses could be performed for five intubation devices (Airtraq, Airwayscope, C-Mac, Glidescope, and McGrath). The Airtraq was associated with a statistically significant reduction of the risk of intubation failure at the first attempt (RR 0.14; 95% CI 0.06–0.33), a higher rate of Cormack–Lehane grade 1 (RR 2.98; 95% CI 1.94–4.56), a reduction of time until successful intubation (weighted mean difference −10.1 s; 95% CI −3.2 to −17.0), and a reduction of oropharyngeal complications (RR 0.24; 95% CI 0.06–0.93). Other devices were associated with improved glottis visualization but no statistically significant differences in intubation failure or time to intubation compared with conventional laryngoscopy. Conclusions. In situations where the spine is immobilized, the Airtraq device reduces the risk of intubation failure. There is a lack of evidence for the usefulness of other intubation devices. PMID:26133898
S G Rewatkar
Full Text Available Survey of gastrointestinal helminth parasites in camel migrated from U.P., M.P., and Rajasthan at Nagpur region was carried out in early summer, 2008. Total 28 samples (12 males and 16 females were collected from different places of Nagpur region. They revealed parasites as Trichuris sp.(50%, Strongyloides sp.(32.14%, Trichostrongylus sp.(10.71%, Nematodirus sp.(10.71%, Haemonchus sp.(14.28%, Eurytrema sp.(21.42% ,Eimeria sp.(25%, Entamoeba sp.(17.85% and Balantidium sp.(7.14%.All were found positive for mixed helminthic infection. [Vet World 2009; 2(7.000: 258-258
As early as several days after the publication of the information concerning Roentgen's discovery the first radiological examinations were performed in Poland. The new method was immediately introduced into medical practice, including gastroenterology. In that pioneer period the most important works were those by Walery Jaworski who was the first man in the world to perform an X-ray of gall stones as well as the stomach with the use of a contrast medium. In its more-than-a-hundred-year history Polish gastrointestinal radiology has attempted not only to catch up with the world science, but it also has made a considerable contribution to its development.
Gillis, Lynette A; Sokol, Ronald J
Although non-specific gastrointestinal and hepatic symptoms are commonly found in most mitochondrial disorders, they are among the cardinal manifestations of several primary mitochondrial diseases, such as: mitochondrial neurogastrointestinal encephalomyopathy; mitochondrial DNA depletion syndrome; Alpers syndrome; and Pearson syndrome. Management of these heterogeneous disorders includes the empiric supplementation with various "mitochondrial cocktails," supportive therapies, and avoidance of drugs and conditions known to have a detrimental effect on the respiratory chain. There is a great need for improved methods of treatment and controlled clinical trials of existing therapies. Liver transplantation is successful in acquired cases; however neuromuscular involvement in primary mitochondrial disorders should be a contraindication for liver transplantation.
Ma, Irene T; Madura, James A
Bariatric surgery is increasingly being performed in the medically complicated obese population as convincing data continue to mount, documenting the success of surgery not only in achieving meaningful weight loss but also in correcting obesity-related illnesses. Several surgical procedures with varying degrees of success and complications are currently being performed. This article discusses the short- and long-term gastrointestinal complications for the 4 most common bariatric surgical procedures: laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.
Peris Bondia, Francisco
La microbiota gastrointestinal humana es una de las comunidades microbianas más diversa y compleja que se puede encontrar en la naturaleza. Las nuevas tecnologías de secuenciación permiten obtener una amplia visión de la diversidad microbiana, lo que ha revelado una gran cantidad de bacterias no cultivables. A pesar del potencial de estas tecnologías de alto rendimiento la metagenómica no muestra la imagen completa. La citometría de flujo es una metodología que permite describir y/o separa...
This article explores changes in the ageing gastrointestinal tract, including: » Diminished sense of taste and smell. » Shrinking of the maxillary and mandibular bones in the jaw. » Slowing of oesophageal peristalsis giving a feeling that something is 'stuck in the throat'. » Relaxation of the lower sphincter leading to gastro-oesophageal reflux. » Reduction in gastric bicarbonate and prostaglandin in mucus increasing susceptibility to stomach ulcers. » Changes in villi in the small intestine reducing the area for absorption. » Overpopulation of bacteria in the small intestine leading to decreased absorption of folic acid and minerals.
Ma, Irene T.
Bariatric surgery is increasingly being performed in the medically complicated obese population as convincing data continue to mount, documenting the success of surgery not only in achieving meaningful weight loss but also in correcting obesity-related illnesses. Several surgical procedures with varying degrees of success and complications are currently being performed. This article discusses the short- and long-term gastrointestinal complications for the 4 most common bariatric surgical procedures: laparoscopic adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. PMID:27118949
Sahn, Benjamin; Bitton, Samuel
This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients. Copyright © 2016 Elsevier Inc. All rights reserved.
Taiwo, Olanrewaju Abdurrazaq; Ibikunle, Adebayo Aremu; Braimah, Ramat Oyebunmi; Suleiman, Musa Kallamu
Several oral and maxillofacial surgery procedures require the simultaneous use of the oropharyngeal space by both the surgeons and the anaesthetists. This poses a lot of challenges especially in optimally securing the airway. Nasotracheal intubation or tracheostomy with their significant morbidity might even be contraindicated in these scenarios owing to several factors elucidated in the literature. Submental endotracheal intubation might be the last resort in adequately protecting the airway without interfering with the surgery. It also permits concurrent access to the dental occlusion and nasal pyramid without the risk associated with nasal intubation and morbidity of tracheostomy. Contraindications include patients who require long periods of assisted ventilation and a severe traumatic wound on the floor of the mouth. Complications include localised infection and sepsis, poor wound healing or scarring, and post-operative salivary fistula. The rationale for this study is to describe the indications, contraindications and the technique of submental endotracheal intubation as performed in our hospital. PMID:26712300
Nashwa Nabil Mohamed
Conclusion: The optimum use of fiberoptic bronchoscope with avoidance of jaw thrust maneuver attenuates the hemodynamic response to intubation which is beneficial in diabetic patients with ischemic heart disease. Stress response hormones showed no statistically significant difference between groups.
Full Text Available The usage frequency and scope of supraglottic airway devices in anesthesia has expanded since the original laryngeal mask airway (LMA prototype was invented by Dr Archie Brain in the early 1980s. Today, anesthesiologists are spoilt-for-choice with more than thirty options. The LMA Classic Excel™ was introduced to anesthesia practice in 2009; designed with an epiglottic elevating bar and a removable airway connector to facilitate tracheal intubation using the LMA as a conduit. We present a case report of a women diagnosed with papillary carcinoma of thyroid, who underwent bronchoscopic assessment of the trachea and subsequent intubation for an en-bloc dissection and removal of thyroid gland through the LMA Classic Excel™.
Stoica, Radu; Negru, Irina; Matache, Radu; MirunaTodor
Granulomatosis with polyangiitis (GPA or Wegener) is a systemic autoimmune disease with inflammation of small- and medium-size vessels. It can affect practically any organ or system, but renal, respiratory andjoint systems are most frequently damaged. Positive pANCA antibodies can raise the suspicion of diagnosis. Subglottic stenosis is relatively frequent, in a quarter of patients, especially in the third decade women. The case presented is of an 80-year-old woman, recently diagnosed with pulmonary, renal and systemic manifestations of GPA and with a subglottic stenosis rapidly evolving towards endotracheal intubation, tracheostomy with mechanical ventilation and renal failure. Further evolution has been favorable under corticoid therapy. After weaning from the mechanical ventilation and30 days after the suppression of the tracheostomy, the patient developed a tracheal stenosis with mixed etiology, secondary to vasculitis and prolonged intubation with tracheostomy. Tracheal resection with termino-terminal anastomosis was performed in emergency with simple post-operative evolution and without late complications.
Kononikhin, A S; Starodubtseva, N L; Chagovets, V V; Ryndin, A Y; Burov, A A; Popov, I A; Bugrova, A E; Dautov, R A; Tokareva, A O; Podurovskaya, Y L; Ionov, O V; Frankevich, V E; Nikolaev, E N; Sukhikh, G T
Invasiveness of examination and therapy methods is a serious problem for intensive care and nursing of premature infants. Exhaled breath condensate (EBC) is the most attractive biofluid for non-invasive methods development in neonatology for monitoring the status of intubated infants. The aim of the study was to propose an approach for EBC sampling and analysis from mechanically ventilated neonates. EBC collection system with good reproducibility of sampling was demonstrated. Discovery-based proteomic and metabolomic studies were performed using nano-HPLC coupled to high resolution MS. Label-free semi-quantitative data were compared for intubated neonates with congenital pneumonia (12 infants) and left-sided congenital diaphragmatic hernia (12 infants) in order to define disease-specific features. Totally 119 proteins and 164 metabolites were found. A number of proteins and metabolites that can act as potential biomarkers of respiratory diseases were proposed and require further validation. Copyright © 2016 Elsevier B.V. All rights reserved.
Kristensen, M S; Fried, E; Biro, P
BACKGROUND: Tracheal intubation with a flexible scope is a cornerstone technique in patients with severely difficult airways, but may fail. We report on a technique, Infrared Red Intubation System (IRRIS), that seems to facilitate the identification of the glottis. METHODS: The IRRIS is placed over...... transillumination, showing the pathway to the trachea. We have introduced this as an adjunct when managing our patients with difficult airways. We describe the technique and retrospectively report on the first ten patients where it was used. RESULTS: All ten patients had significant pathology in the airway...... the patient's cricothyroid membrane and emits blinking infrared light through the patient's skin into the subglottic space. When a flexible videoscope (one that does not filter infrared light) is introduced into the airway, it will display this as a blinking white light emerging from the glottis, retrograde...
Mearin, Fermín; Rey, Enrique; Balboa, Agustín
This article discusses the most interesting presentations at Digestive Disease Week, held in San Diego, in the field of functional and motor gastrointestinal disorders. One of the most important contributions was undoubtedly the presentation of the new Rome IV diagnostic criteria for functional gastrointestinal disorders. We therefore devote some space in this article to explaining these new criteria in the most common functional disorders. In fact, there has already been discussion of data comparing Rome IV and Rome III criteria in the diagnosis of irritable bowel syndrome, confirming that the new criteria are somewhat more restrictive. From the physiopathological point of view, several studies have shown that the aggregation of physiopathological alterations increases symptom severity in distinct functional disorders. From the therapeutic point of view, more data were presented on the efficacy of acotiamide and its mechanisms of action in functional dyspepsia, the safety and efficacy of domperidone in patients with gastroparesis, and the efficacy of linaclotide both in irritable bowel syndrome and constipation. In irritable bowel syndrome, more data have come to light on the favourable results of a low FODMAP diet, with emphasis on its role in modifying the microbiota. Finally, long-term efficacy data were presented on the distinct treatment options in achalasia. Copyright Â© 2016 Elsevier España, S.L.U. All rights reserved.
Lee, Yunna; Jo, Jeongbin; Chung, Hae Young; Pothoulakis, Charalabos; Im, Eunok
The endocannabinoid system mainly consists of endogenously produced cannabinoids (endocannabinoids) and two G protein-coupled receptors (GPCRs), cannabinoid receptors 1 and 2 (CB 1 and CB 2 ). This system also includes enzymes responsible for the synthesis and degradation of endocannabinoids and molecules required for the uptake and transport of endocannabinoids. In addition, endocannabinoid-related lipid mediators and other putative endocannabinoid receptors, such as transient receptor potential channels and other GPCRs, have been identified. Accumulating evidence indicates that the endocannabinoid system is a key modulator of gastrointestinal physiology, influencing satiety, emesis, immune function, mucosal integrity, motility, secretion, and visceral sensation. In light of therapeutic benefits of herbal and synthetic cannabinoids, the vast potential of the endocannabinoid system for the treatment of gastrointestinal diseases has been demonstrated. This review focuses on the role of the endocannabinoid system in gut homeostasis and in the pathogenesis of intestinal disorders associated with intestinal motility, inflammation, and cancer. Finally, links between gut microorganisms and the endocannabinoid system are briefly discussed. Copyright © 2016 the American Physiological Society.
Craig, L E; Hardam, E E; Hertzke, D M; Flatland, B; Rohrbach, B W; Moore, R R
A retrospective study of cases of a unique intramural inflammatory mass within the feline gastrointestinal tract was performed in order to describe and characterize the lesion. Twenty-five cases were identified from archival surgical and postmortem tissues. The lesion most often occurred as an ulcerated intramural mass at the pyloric sphincter (n = 12) or the ileocecocolic junction or colon (n = 9); the remaining cases were in the small intestine. Seven cases also had lymph node involvement. The lesions were characterized by eosinophilic inflammation, large reactive fibroblasts, and trabeculae of dense collagen. Intralesional bacteria were identified in 56% of the cases overall and all of the ileocecocolic junction and colon lesions. Fifty-eight percent of cats tested had peripheral eosinophilia. Cats treated with prednisone had a significantly longer survival time than those receiving other treatments. We propose that this is a unique fibroblastic response of the feline gastrointestinal tract to eosinophilic inflammation that in some cases is associated with bacteria. The lesion is often grossly and sometimes histologically mistaken for neoplasia.
Zhu, Chang-Zhen; Liu, Dong; Kang, Wei-Ming; Yu, Jian-Chun; Ma, Zhi-Qiang; Ye, Xin; Li, Kang
Ghrelin, as a kind of multifunctional protein polypeptide, is mainly produced in the fundus of the stomach and can promote occurrence and development of many tumors, including gastrointestinal tumors, which has been proved by the relevant researches. Most gastrointestinal stromal tumors (GISTs, about 80%), as the most common mesenchymal tumor, also develop in the fundus. Scientific research has confirmed that ghrelin, its receptors and mRNA respectively can be found in GISTs, which demonstrated the existence of a ghrelin autocrine/paracrine loop in GIST tissues. However, no reports to date have specified the mechanism whether ghrelin can promote the occurrence and development of GISTs. Studies of pulmonary artery endothelial cells in a low-oxygen environment and cardiac muscle cells in an ischemic environment have shown that ghrelin can activate the phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin (PI3K/AKT/mTOR) signaling pathway. Moreover, some studies of GISTs have confirmed that activation of the PI3K/AKT/mTOR pathway can indeed promote the growth and progression of GISTs. Whether ghrelin is involved in the development or progression of GISTs through certain pathways remains unknown. Can we find a new target for the treatment of GISTs? This review explores and summaries the relationship among ghrelin, the PI3K/AKT/mTOR pathway and the development of GISTs.
Full Text Available INTRODUCTION Many pharmacological agents have been evaluated in regards to their efficacy of blunting the adverse cardiovascular response to laryngoscopy and tracheal intubation. The aim of this study was to evaluate the efficacy of dexmedetomidine compared to fentanyl in blunting the haemodynamic response to laryngoscopy and intubation. METHOD Sixty patients were randomly allocated into two groups (30 patients in each group. The group D received intravenously 1 µgm/kg dexmedetomidine infusion and group F received 2µgm/kg fentanyl infusion. The study drugs were prepared in an identical looking container and were infused fifteen minutes prior to induction of anaesthesia. The study drugs were infused over a period of ten minutes and all the patients underwent a similar anaesthetics technique. Heart rate (HR and blood pressure (systolic, diastolic and mean blood pressure were noted at baseline, at the end of infusion of the study drugs, after induction of anaesthesia, immediately after laryngoscopy and intubation and at 1, 3, 5, 7 and 10 minutes after laryngoscopy and intubation. RESULTS HR significantly decreased in the group D when compared to group F immediately after study drug infusion and there was statistically significant reduction in heart rate for up to 5 min after intubation in both the groups. Although HR increased after intubation in both the groups, the magnitude was lower in the group D. In both the groups, laryngoscopy and intubation led to an increase in systolic, diastolic and mean arterial pressure; the magnitude was lower in the group D. CONCLUSION Dexmeditomidine (1µ/kg attenuates these untoward responses of laryngoscopy and intubation more effectively than fentanyl (2 µ/kg when administered as bolus dose in the pre-induction period of general anaesthesia.
Amour, Julien; Marmion, Frédéric; Birenbaum, Aurélie; Nicolas-Robin, Armelle; Coriat, Pierre; Riou, Bruno; Langeron, Olivier
Plastic single-use laryngoscope blades are inexpensive and carry a lower risk of infection compared with metal reusable blades, but their efficiency during rapid sequence induction remains a matter of debate. The authors therefore compared plastic and metal blades during rapid sequence induction in a prospective randomized trial. Two hundred eighty-four adult patients undergoing general anesthesia requiring rapid sequence induction were randomly assigned on a weekly basis to either plastic single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using metal blade. The primary endpoint of the study was the rate of failed intubations, and the secondary endpoint was the incidence of complications (oxygen desaturation, lung aspiration, and oropharynx trauma). Both groups were similar in their main characteristics, including risk factors for difficult intubation. On the first attempt, the rate of failed intubation was significantly increased in plastic blade group (17 vs. 3%; P < 0.01). In metal blade group, 50% of failed intubations were still difficult after the second attempt. In plastic blade group, all initial failed intubations were successfully intubated using metal blade, with an improvement in Cormack and Lehane grade. There was a significant increase in the complication rate in plastic group (15 vs. 6%; P < 0.05). In rapid sequence induction of anesthesia, the plastic laryngoscope blade is less efficient than a metal blade and thus should not be recommended for use in this clinical setting.
Sahdev, S; Motwane, S
A variety of methods and materials have been used for the treatment of the problems relating to the canalicular system. An insight into the rail roading technique for intubation of the canaliculi with sutupak in cases of common canalicular duct obstruction is presented here. About 30 patients with block at the common canalicular duct, which was detected by dacryocystography were operated for dacryocystorhinostomy with intubation of both the canaliculi with sutupak No. 0 by rail roading technique with good results.
Full Text Available A variety of methods and materials have been used for the treatment of the problems relating to the canalicular system. An insight into the rail roading technique for intubation of the canaliculi with sutupak in cases of common canalicular duct obstruction is presented here. About 30 patients with block at the common canalicular duct, which was detected by dacryocystography were operated for dacryocystorhinostomy with intubation of both the canaliculi with sutupak No. 0 by rail roading technique with good results.
Full Text Available PURPOSE: Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication. METHODS: Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included, measure the heart rate over time and finally the estimate the numbers of lost beats. RESULTS: 333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%. Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0-1]. When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15-83]. During intubation the median number of lost beats was 8 - when atropine was not used compared to 0 [0-0] when atropine was used (p50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.
Acer, Niyazi; Akkaya, Akcan; Tuğay, Baki Umut; Öztürk, Ahmet
Objective: Various prediction tests were formulated to forecast difficult intubation. The Mallampati test, Wilson score, Cormack-Lehane test and thyromental distance are the most commonly used tests pre-operatively to assess the airway. The objective of the present study was to investigate whether a combination of the Mallampati and Cormack-Lehane's classification to predict difficult intubation compared with sternomental and thyromental distances, mandibular length, width and nec...
Yumul, Roya; Elvir-Lazo, Ofelia L; White, Paul F; Durra, Omar; Ternian, Alen; Tamman, Richard; Naruse, Robert; Ebba, Hailu; Yusufali, Taizoon; Wong, Robert; Hernandez Conte, Antonio; Farnad, Shahbaz; Pham, Christine; Wender, Ronald H
To compare the C-MAC video laryngoscope to the standard flexible fiberoptic scope (FFS) with an eye piece (but without a camera or a video screen) for intubation of patients undergoing cervical spine surgery with manual inline stabilization. The primary end point was the time to achieve successful tracheal intubation. Secondary end points included glottic view at intubation and number of intubation attempts. Prospective, randomized, single-blinded study. Cedars Sinai Medical Center in Los Angeles, CA. One hundred forty patients (American Society of Anaesthesiologists physical status I-III), aged 18 to 80years undergoing elective cervical spine surgery. Patients were prospectively randomized to undergo tracheal intubation using either an FFS (n=70) or the C-MAC video laryngoscope (n=70). After performing a preoperative airway evaluation, patients underwent a standardized induction sequence. The glottic view was assessed at the time of tracheal tube placement using the Cormack-Lehane and percentage of glottic opening scoring systems. In addition, the time required for successful insertion of the tracheal tube, number of intubation attempts to secure the airway, the need for adjuvant airway devices, hemodynamic changes, adverse events, and any airway-related trauma were recorded. The glottic view at the time of intubation did not differ significantly with the 2 devices; however, the C-MAC facilitated more rapid tracheal intubation compared with the FFS (P=.001). The peak heart rate response following insertion of the tracheal tube was also reduced (P=.004) in the C-MAC (vs FFS) group. The C-MAC may offer an advantage over the FFS with respect to the time required to obtain glottic view and successful placement of the tracheal tube in patients requiring cervical spine immobilization. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.
Kok, Tracy; George, Ronald B; McKeen, Dolores; Vakharia, Narendra; Pink, Aaron
Studies show that the Levitan FPS (first pass success) Scope™ (LFS) is analogous to a bougie in simulated difficult airways with comparable tracheal intubation success rates. In this study, the efficacy and safety of tracheal intubation with the LFS was compared with that of the Macintosh laryngoscope utilizing manual in-line stabilization (MILS) to simulate difficult airways. Ninety-four subjects successfully completed the trial. Manual in-line stabilization of the cervical spine was applied and the initial laryngoscopy was performed using either the Macintosh or the LFS in conjunction with the Macintosh. Following the initial grading, a second laryngoscopy was repeated using the second randomized technique. Cormack-Lehane grades, percentage of glottic opening (POGO) scores, time to intubate, number of intubation attempts, and the use of alternate techniques were recorded. The anesthesiologist rated the subjective difficulty in using each technique with a numeric rating scale and a visual rating scale. There was no significant difference in the primary outcome "good laryngoscopic views" (Cormack-Lehane grade 1 and 2) compared with "poor laryngoscopic views" (Cormack-Lehane grade 3 and 4) between the LFS and the Macintosh. There were higher POGO scores with the LFS compared with the Macintosh (80% vs 20%, respectively; P < 0.0001), but this did not translate to easier intubations, as documented by the need for an alternate intubation technique or time to intubate (< 30 and < 60 sec, respectively). The incidence of mucosal trauma, sore throat, and hemodynamic responses did not differ significantly between the two techniques. The LFS in conjunction with the Macintosh laryngoscope does not improve the efficacy or safety of tracheal intubation in a simulated difficult airway.
Niyazi Acer; Akcan Akkaya; Baki Umut Tuğay; Ahmet Öztürk
Objective: Various prediction tests were formulated to forecast difficult intubation. The Mallampati test, Wilson score, Cormack-Lehane test and thyromental distance are the most commonly used tests pre-operatively to assess the airway. The objective of the present study was to investigate whether a combination of the Mallampati and Cormack-Lehane’s classification to predict difficult intubation compared with sternomental and thyromental distances, mandibular length, width and neck length and...
Acer, Niyazi; Akkaya, Akcan; Tuğay, Baki Umut; Öztürk, Ahmet
Objective: Various prediction tests were formulated to forecast difficult intubation. The Mallampati test, Wilson score, Cormack-Lehane test and thyromental distance are the most commonly used tests pre-operatively to assess the airway. The objective of the present study was to investigate whether a combination of the Mallampati and Cormack-Lehane's classification to predict difficult intubation compared with sternomental and thyromental distances, mandibular length, width and...
Minami, Daisuke; Takigawa, Nagio; Kano, Hirohisa; Ninomiya, Takashi; Kubo, Toshio; Ichihara, Eiki; Ohashi, Kadoaki; Sato, Akiko; Hotta, Katsuyuki; Tabata, Masahiro; Tanimoto, Mitsune; Kiura, Katsuyuki
Although endobronchial intubation during a bronchoscopic examination is useful for invasive procedures, it is not routine practice in Japan. The present study evaluated discomfort due to endobronchial intubation using fentanyl and midazolam sedation during bronchoscopy. Thirty-nine patients were enrolled prospectively from November 2014 to September 2015 at Okayama University Hospital. Fentanyl (20 µg) was administered to the patients just before endobronchial intubation, and fentanyl (10 µg) and midazolam (1 mg) were added as needed during the procedure. A questionnaire survey was administered 2 h after the examination. In the questionnaire, patient satisfaction was scored using a visual analog scale as follows: excellent (1 point), good (2 points), normal (3 points), uncomfortable (4 points) and very uncomfortable (5 points). An additional question ('Do you remember the bronchoscopic examination?') was also asked. Predefined parameters (blood pressure, heart rate, oxygen saturation and complications) were recorded. The enrolled patients included 22 males and 17 females; their median age was 70 (range: 28-88) years. The patients received a mean dose of 47.9 µg of fentanyl (range: 30-90 µg) and 2.79 mg of midazolam (range: 1-7 mg). In total, 28 patients (71.7%) agreed to undergo a second bronchoscopic examination; the mean levels of discomfort and for the re-examination were 2.07 points each. About 41% of the patients remembered the bronchoscopic examination. No severe complications were reported. Endobronchial intubation using fentanyl and midazolam sedation during an invasive bronchoscopic procedure might be recommended. UMIN000015578 in the UMIN Clinical Trials Registry. © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: email@example.com
Storm, Benjamin; Dybwik, Knut; Nielsen, Erik Waage
In large international studies, upper airway-related stenosis, granulomas, malacias, and laryngeal nerve palsies following percutaneous tracheostomy have an estimated incidence of 6% to 31%. The incidence following prolonged oral intubation is estimated to be 10% to 22%. The purpose of this study was to assess the incidence of late complications in our unit. Retrospective search of a single-unit intensive care patient population. Patient records for a defined period were searched using a predefined search string, identifying those who received invasive mechanical ventilation and split in subgroups by orotracheal tube or tracheostomy tube. This search was cross-linked with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes associated with recognized complications (J38.0, J38.3,J38.6, J38.7, J39.8, J39.9, J95.0, J95.5, J95.8, J95.9, J99, R04.8,S27.5). During the period January 1, 1997 to December 31, 2013, 32,852 patients were admitted to the intensive care unit. Of these, 1,620 patients received invasive mechanical ventilation. Out of this group, 519 had a tracheostomy and 1,109 were orally intubated. Four tracheostomized and zero orotracheally intubated patients had ICD-10 codes related to complications. From the patient records it became clear that three of four patients with tracheostomy had airway symptoms before being tracheostomized, and the fourth patient had her tracheostomy following a postintubation airway stenosis. Spanning a 17-year period, our study did not show any long-term symptomatic upper airway complications following tracheostomy and only one following orotracheal intubation. This contrasts the internationally estimated incidence. 4 Laryngoscope, 126:1077-1082, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.
Holm, Anna; Dreyer, Pia
There is a change in paradigm in intensive care units with trends towards lighter sedation. Light or no sedation protocols are, however, a radical change for clinical practice and can cause challenges for the patients. Undergoing mechanical ventilation when conscious can be a distressing experience for the patients. Receiving a tracheostomy increases patient comfort, but some patients still undergo prolonged endotracheal intubation during mechanical ventilation. The experience of being conscious during endotracheal intubation and mechanical ventilation in the intensive care unit has not previously been described. The aim of the study was to explore adult intensive care unit patients' experience of being conscious during endotracheal intubation and mechanical ventilation. Data collection was performed through semi-structured interviews and four patients were enrolled. Data were collected at two multidisciplinary intensive care units in Denmark. Data were analysed using Ricoeur's theory of interpretation, using the method described by Dreyer and Pedersen. The scientific tradition was phenomenological-hermeneutic. During the analysis, three themes emerged: (1) The tube in the throat. (2) To be conscious but feeling doped. (3) When passing of time is dragging on. The findings shed a light over the experience of being conscious during endotracheal intubation and mechanical ventilation in the intensive care unit. A no-sedation protocol may cause problems for the patients both of a physical and an existential character, but despite this, patients seem positive towards being conscious. The study suggests that clinical nursing practice may have to be further developed to accommodate the patients' needs, e.g. communicating and participating as well as optimizing nursing interventions towards thirst, pain and tube management. Furthermore, the intensive care unit setting may need revision, providing space for the patient and sensory meaningful inputs in the technologically
Pedro Neves Tavares
Full Text Available For many years endotracheal intubation and mechanical ventilation have been the standard of care for very low birth weight infants but, in the last decade, nasal continuous positive airway pressure (nCPAP has been described in many studies as an option for the treatment of preterm infants with respiratory distress syndrome. In fact, recent studies have shown that early nCPAP is not associated with higher rates of morbidity and mortality and does not imply more days of ventilation support when compared to traditional ventilation techniques. The authors conducted a study to compare the outcomes (in terms of mortality, morbidity and need for medical support of very low birth weight infants treated with nCPAP or endotracheal intubation and mechanical ventilation. One hundred and four newborns were enrolled in this study, 44 (42.3% were treated with nCPAP and 60 (57.7% with endotracheal intubation followed by mechanical ventilation. A subgroup analysis of newborns with gestational age between 28 and 31 weeks was also performed. It included 57 newborns with similar demographic characteristics, 29 (50.9% treated with nCPAP and 28 (49.1% with endotracheal intubation followed by mechanical ventilation. No statistically significant differences were found in the frequency of death or bronchopulmonary dysplasia. Statistically significant differences were found in the prevalence of hyaline membrane disease (p = 0.033 and surfactant administration (p = 0.021 with lower rates in the nCPAP group. No other differences were found in the prevalence of other morbidities or in the need for medical support after birth. These results suggests that nCPAP might be chosen as primary ventilatory support choice in very low birth weight preterm, when there are no contraindications to its use.
Pedersen, Carsten M; Rosendahl-Nielsen, Mette; Hjermind, Jeanette
bleeding, infection, atelectasis, hypoxemia, cardiovascular instability, elevated intracranial pressure, and may also cause lesions in the tracheal mucosa. The aim of this article was to review the available literature regarding endotracheal suctioning of adult intubated intensive care patients......s, performing continuous rather than intermittent suctioning, avoiding saline lavage, providing hyperoxygenation before and after the suction procedure, providing hyperinflation combined with hyperoxygenation on a non-routine basis, always using aseptic technique, and using either closed or open...
Schmid, E.U.; Greeff, F.; Alberts, A.S.; Shiels, R.A.; Friediger, D.; Terblanche, A.P.S.; Schoeman, L.; Burger, W.; Falkson, G.; Van der Hoven, A.
After intubation for advanced, inoperable squamous carcinoma of the oesophagus, a prospectively controlled randomized trial was done to investigate the effect of radiotherapy (41 patients) or mono-chemotherapy (40 patients) or no further treatment (46 patients). Treatment had no significant effect on either palliation or survival (p≤0.7) and did not alter the natural history of the disease. (author). 8 refs., 1 tab., 1 fig
Yu, Dong; Li, Genchi; Feng, Yunhao; Yang, Yonghuan; Hao, Xiali
It is difficult to measure the circular arc radius for central angle less than 30 degrees. The existing measuring methods are of low efficiency and big error. Through designing the machine vision system and studying the image detecting method for measurement, It is obtained good results by using the new measurement for tracheal intubation's circular arc radius, Realized a rapid and accurate measurement of the circular arc radius, and expanded the application in the field of machine vision.
Johansen, Karina; Holm-Knudsen, Rolf J; Charabi, Birgitte
An unanticipated difficult airway is very uncommon in infants. The recommendations for managing the cannot ventilate-cannot intubate (CVCI) situation in infants and small children are based on difficult airway algorithms for adults. These algorithms usually recommend placement of a transtracheal...... cannula or performing a surgical tracheotomy as a last resort. In this study, we compared the success rate and time used for inserting a transtracheal cannula vs performing a modified surgical tracheotomy in a piglet model....
Swanton, B J
BACKGROUND AND OBJECTIVE: Respiratory burst is an essential component of the neutrophil\\'s biocidal function. In vitro, sodium thiopental, isoflurane and lidocaine each inhibit neutrophil respiratory burst. The objectives of this study were (a) to determine the effect of a standard clinical induction\\/tracheal intubation sequence on neutrophil respiratory burst and (b) to determine the effect of intravenous lidocaine administration during induction of anaesthesia on neutrophil respiratory burst. METHODS: Twenty ASA I and II patients, aged 18-60 years, undergoing elective surgery were studied. After induction of anaesthesia [fentanyl (2 microg kg-1), thiopental (4-6 mg kg-1), isoflurane (end-tidal concentration 0.5-1.5%) in nitrous oxide (66%) and oxygen], patients randomly received either lidocaine 1.5 mg kg-1 (group L) or 0.9% saline (group S) prior to tracheal intubation. Neutrophil respiratory burst was measured immediately prior to induction of anaesthesia, immediately before and 1 and 5 min after lidocaine\\/saline. RESULTS: Neutrophil respiratory burst decreased significantly after induction of anaesthesia in both groups [87.4 +\\/- 8.2% (group L) and 88.5 +\\/- 13.4% (group S) of preinduction level (P < 0.01 both groups)]. After intravenous lidocaine (but not saline) administration, neutrophil respiratory burst returned towards preinduction levels, both before (97.1 +\\/- 23.6%) and after (94.4 +\\/- 16.6%) tracheal intubation. CONCLUSION: Induction of anaesthesia and tracheal intubation using thiopentone and isoflurane, inhibit neutrophil respiratory burst. This effect may be diminished by the administration of lidocaine.
Ramos-Navarro, Cristina; Sanchez-Luna, Manuel; Sanz-L?pez, Ester; Maderuelo-Rodriguez, Elena; Zamora-Flores, Elena
Background?Noninvasive ventilation is being increasingly used on preterm infants to reduce ventilator lung injury and bronchopulmonary dysplasia. The aim of this study was to evaluate the effectiveness of synchronized nasal intermittent positive pressure ventilation (SNIPPV) to prevent intubation in premature infants. Methods?Prospective observational study of SNIPPV use on preterm infants of less than 32 weeks' gestation. All patients were managed using a prospective protocol intended to red...
Andreatta, Pamela B; Dooley-Hash, Suzanne L; Klotz, Jessica J; Hauptman, Joe G; Biddinger, Bea; House, Joseph B
We evaluated the retention of pediatric and neonatal intubation performance abilities of clinicians trained on a simulated or live tissue model at 3 intervals after initial training to assess competency degradation related to either training modality or retention interval. We implemented a quasi-experimental design with purposive sampling to assess performance differences between 171 subjects randomly assigned to 1 of 3 intervals after initial training: 6 weeks, 18 weeks, or 52 weeks. Training followed the American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using 1 of 2 models (live feline or simulated feline). Assessment data were captured using validated instruments and analyzed using analysis of variance with repeated measures (statistical significance set at P < 0.05). Cognitive retention scores decreased significantly (P = 0.000) from posttraining cognitive scores. There were no significant differences between posttraining and retention scores for pediatric and neonatal performances. Both affect and self-efficacy retention scores decreased significantly (P = 0.000) from posttraining scores at 18 and 52 weeks, but remained constant at 6 weeks. Retention scores for all dimensions showed a significant difference between subjects with varying amounts of experience performing pediatric and neonatal intubation, such that those with more experience scored higher those with less (P < 0.003). Retention performance outcomes decreased sufficiently from posttraining scores to suggest that training refreshment could serve to maintain posttraining competency in the ability to perform pediatric and neonatal intubation. Retraining intervals may be best aligned with provider experience levels. Future research focusing on the effect of variable interval refresher training on retention in pediatric and neonatal intubation is merited.
van Houte, J; Donker, D W; Wagenaar, L J; Slootweg, A P; Kirkels, J H; van Dijk, D
We report on the use of percutaneous femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a fully awake, non-intubated and spontaneously breathing patient suffering from acute, severe and refractory cardiogenic shock due to a (sub)acute anterior myocardial infarction. Intensified heart failure therapy was closely monitored with a pulmonary artery catheter and allowed gradual weaning off the ECMO support without additional invasive measures, notably without mechanical ventila...
This paper discusses airway management in the post anaesthetic care unit (PACU). Many patients will be extubated on arrival to the PACU, however a small number will need further support with tracheal intubation. Patient assessment is a key role for the PACU staff and using the ABCDE approach will provide a systematic method for assessing the patient and determining suitability for extubation. Care of the patient following extubation is also described.
Mehmet Turan Inal
Full Text Available Background: The difficulties with airway management is the main reason for pediatric anesthesia-related morbidity and mortality. Objective: To assess the value of modified Mallampati test, Upper-Lip-Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients. Design: Prospective analysis. Measurements and results: Data were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The Cormack and Lehane classification was used to evaluate difficult laryngoscopy. Sensitivity, specificity, positive predictive value and AUC values for each test were measured. Results: The sensitivity and specificity of modified Mallampati test were 76.92% and 95.54%, while those for ULBT were 69.23% and 97.32%. The optimal cutoff point for the ratio of height to thyromental distance and thyromental distance for predicting difficult laryngoscopy was 23.5 (sensitivity, 57.69%; specificity, 86.61% and 5.5 cm (sensitivity, 61.54%; specificity, 99.11%. The modified Mallampati was the most sensitive of the tests. The ratio of height to thyromental distance was the least sensitive test. Conclusion: These results suggested that the modified Mallampati and Upper-Lip-Bite tests may be useful in pediatric patients for predicting difficult intubation.
Feng, Juanjuan; Wang, Xiuqin; Tian, Yu; Bu, Yanan; Luo, Chuannan; Sun, Min
Carbon fibers (CFs) were functionalized with graphene oxide (GO) by an electrophoretic deposition (EPD) method for in-tube solid-phase microextraction (SPME). GO-CFs were filled into a poly(ether ether ketone) (PEEK) tube to obtain a fibers-in-tube SPME device, which was connected with high performance liquid chromatography (HPLC) equipment to build online SPME-HPLC system. Compared with CFs, GO-CFs presented obviously better extraction performance, due to excellent adsorption property and large surface area of GO. Using ten polycyclic aromatic hydrocarbons (PAHs) as model analytes, the important extraction conditions were optimized, such as sample flow rate, extraction time, organic solvent content and desorption time. An online analysis method was established with wide linear range (0.01-50μgL -1 ) and low detection limits (0.001-0.004μgL -1 ). Good sensitivity resulted from high enrichment factors (1133-3840) of GO-CFs in-tube device towards PAHs. The analysis method was used to online determination of PAHs in wastewater samples. Some target analytes were detected and relative recoveries were in the range of 90.2-112%. It is obvious that the proposed GO-CFs in-tube device was an efficient extraction device, and EPD could be used to develop nanomaterials functionalized sorbents for sample preparation. Copyright © 2017 Elsevier B.V. All rights reserved.
Ali, Mohamed Shaaban; Bakri, Mohamed Hassan; Mohamed, Hesham Ali; Shehab, Hany; Al Taher, Waleed
External laryngeal manipulation (ELM) is used to get better laryngeal view during direct laryngoscopy. This study was designed to test the hypothesis that ELM done by the intubating anesthetist (laryngoscopist) offers the best laryngeal view for tracheal intubation. A total of 160 patients underwent different surgical procedures were included in this study. Percentage of glottic opening (POGO) score and Cormack and Lehane scale were used as outcome measures for comparison between different laryngoscopic views. Four views were described; basic laryngoscopic view and then views after ELM done by the assistant, by the laryngoscopist and finally by the assistant after the guidance from the laryngoscopist respectively. The last three views compared with the basic laryngoscopic view. ELM done by the laryngoscopist or by the assistant after guidance from the laryngoscopist showed significant improvement of Cormack grades and POGO scores compared with basic laryngoscopic view. Number of patients with Cormack grade1 increased from 39 after direct laryngoscopy to 97 and 96 patients (P < 0.001 by Fisher's exact test), after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. Furthermore, the number of patients with POGO scores of 100% increased from 39 after direct laryngoscopy to 78 and 61 (P < 0.01) patients after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. It appeared from this study that ELM done by the anesthetist makes the best laryngeal view for tracheal intubation.
Andreatta, Pamela B; Klotz, Jessica J; Dooley-Hash, Suzanne L; Hauptman, Joe G; Biddinger, Bea; House, Joseph B
The purpose of this article was to establish psychometric validity evidence for competency assessment instruments and to evaluate the impact of 2 forms of training on the abilities of clinicians to perform neonatal intubation. To inform the development of assessment instruments, we conducted comprehensive task analyses including each performance domain associated with neonatal intubation. Expert review confirmed content validity. Construct validity was established using the instruments to differentiate between the intubation performance abilities of practitioners (N = 294) with variable experience (novice through expert). Training outcomes were evaluated using a quasi-experimental design to evaluate performance differences between 294 subjects randomly assigned to 1 of 2 training groups. The training intervention followed American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using either (1) live feline or (2) simulated feline models. Performance assessment data were captured before and directly following the training. All data were analyzed using analysis of variance with repeated measures and statistical significance set at P programs could be tailored to the level of provider experience to make efficient use of time and educational resources. Future research focusing on the uses of assessment in the applied clinical environment, as well as identification of optimal training cycles for performance retention, is merited.
Schneider, Thomas-Michael; Bence, Tibor; Brettner, Franz
Near-fatal asthma attacks are life threatening events that often require mechanical ventilation. Extracorporeal carbon dioxide removal (ECCO 2 R) is, beside extracorporeal membrane oxygenation (ECMO), a well-established rescue option whenever ventilation gets to its limits. But there seems to be very rare experience with those techniques in avoiding mechanical ventilation in severe asthma attacks. A 67-year-old man with a near-fatal asthma attack deteriorated under non-invasive ventilation conditions. Beside pharmacological treatment, the intensivists decided to use an extracorporeal carbon dioxide removal system (ECCO 2 R) to avoid sedation and intubation. Within only a few hours, there was a breakthrough and the patient's status improved continuously. One and a half days later, weaning from ECCO 2 R was already completed. The discussion deals with several advantages of extracorporeal lung support in acute asthma, the potential of avoiding intubation and sedation, as well as the benefits of a conscious and spontaneously breathing patient. Extracorporeal membrane oxygenation (ECMO) in general and ECCO 2 R in particular is a highly effective method for the treatment of an acute near-fatal asthma attack. Pathophysiological aspects favor the "awake" approach, without sedation, intubation, and mechanical ventilation. Therefore, experienced clinicians might consider "awake" ECCO 2 R in similar cases.
Kohlhaas, M; Wiegmann, L; Gaszczyk, M; Walter, A; Schaudig, U; Richard, G
Treating injuries of the lacrimal system with a silicon intubation is an approved method to prevent post-traumatic epiphora. Between 1990 and 1999, operations were carried out on 44 patients with injuries of the canaliculi with silicon ring intubations. Interesting for us were the age distribution, causes of injuries, localisation and mid- to long-term postoperative complications. The age of the patients was between 1.75 and 74 years, 48% of the injuries were caused by household accidents, 23% by violence, 20% by traffic accidents and 9% by job-related accidents. The canaliculus inferior was injured in 68% of all patients. We found 10 postoperative complications, e.g. ectropia, a too long silicon ring or granuloma. We found a positive anatomical readapted lacrimal system in 88% and 12% of our patients complained of distinct to severe epiphora. The treatment of lacrimal laceration with a silicon intubation is an excellent method but special care should be taken with correct positioning of the lid margin.
Mizuno, Ju; Morita, Shigeho; Suzuki, Maya; Arita, Hideko; Hanaoka, Kazuo
In tracheal intubation assisted by tube-guiding devices passing through the tube, such as fiberoptic scopes, bougies, tracheal tube exchange catheters, and light wands, passage of the tube-guiding device, by itself, is often easy. But advancing a tracheal tube with a conventional distal tip over these tube-guiding devices is frequently difficult or impossible, because its rigid, side-beveled tip frequently catches on anatomical features of the airway. A novel tracheal tube, the Parker Flex-Tip tube (Parker Medical, Colorado, USA) has a centered, curved, tapered and flexible distal tip that passes through the airway faster and easier than conventional tracheal tubes. As it is advanced along a tube-guiding device, the tip of the Parker tube travels along the midline of the airway, without the gap that usually exists between the distal edge of a conventional tracheal tube and the tube-guiding device. The gapless, midline travel of the Parker tube leads to a greater incidence of first-attempt intubation success with tube-guiding devices, because there is less risk of tube tip hang-ups on the arytenoids and the vocal cords. Clinically, use of the Parker tube is helpful for oral and nasal intubations, especially in patients with difficult airways.
Shannon M. Fernando
Full Text Available Salicylates are common substances for deliberate self-harm. Acute salicylate toxicity is classically associated with an initial respiratory alkalosis, followed by an anion gap metabolic acidosis. The respiratory alkalosis is achieved through hyperventilation, driven by direct stimulation on the respiratory centers in the medulla and considered as a compensatory mechanism to avoid acidemia. However, in later stages of severe salicylate toxicity, patients become increasingly obtunded, with subsequent loss of airway reflexes, and therefore intubation may be necessary. Mechanical ventilation has been recommended against in acute salicylate poisoning, as it is believed to take away the compensatory hyperpnea and tachypnea. Despite the intuitive physiological basis for this recommendation, there is a paucity of evidence to support it. We describe a case of a 59-year-old male presenting with decreased level of consciousness and no known history of ingestion. He was intubated and experienced profound hypercarbia and acidemia despite mechanical ventilation with high minute ventilation and tidal volumes. This case illustrates the deleterious effects of intubation in severe salicylate toxicity.
Lee, A R; Yang, S; Shin, Y H; Kim, J A; Chung, I S; Cho, H S; Lee, J J
We evaluated the effects of three airway manipulation manoeuvres: (a) conventional (single-handed chin lift); (b) backward, upward and right-sided pressure (BURP) manoeuvre; and (c) modified jaw thrust manoeuvre (two-handed aided by an assistant) on laryngeal view and intubation time using the Clarus Video System in 215 patients undergoing general anaesthesia with orotracheal intubation. In the first part of this study, the laryngeal view was recorded as a modified Cormack-Lehane grade with each manoeuvre. In the second part, intubation was performed using the assigned airway manipulation. The primary outcome was the time to intubation, and the secondary outcomes were the modified Cormack-Lehane grade, the number of attempts and the overall success rate. There were significant differences in modified Cormack-Lehane grade between the three airway manipulations (p < 0.0001). Post-hoc analysis indicated that the modified jaw thrust improved the laryngeal view compared with the conventional (p < 0.0001) and the BURP manoeuvres (p < 0.0001). The BURP worsened the laryngeal view compared with the conventional manoeuvre (p = 0.0132). The time to intubation in the modified jaw thrust group was shorter than with the conventional manoeuvre (p = 0.0004) and the BURP group (p < 0.0001). We conclude that the modified jaw thrust is the most effective manoeuvre at improving the laryngeal view and shortening intubation time with the Clarus Video System. © 2013 The Association of Anaesthetists of Great Britain and Ireland.
Maharaj, C H
The Airtraq laryngoscope is a novel single use tracheal intubation device. We compared the Airtraq with the Macintosh laryngoscope in patients deemed at low risk for difficult intubation in a randomised, controlled clinical trial. Sixty consenting patients presenting for surgery requiring tracheal intubation were randomly allocated to undergo intubation using a Macintosh (n = 30) or Airtraq (n = 30) laryngoscope. All patients were intubated by one of four anaesthetists experienced in the use of both laryngoscopes. No significant differences in demographic or airway variables were observed between the groups. All but one patient, in the Macintosh group, was successfully intubated on the first attempt. There was no difference between groups in the duration of intubation attempts. In comparison to the Macintosh laryngoscope, the Airtraq resulted in modest improvements in the intubation difficulty score, and in ease of use. Tracheal intubation with the Airtraq resulted in less alterations in heart rate. These findings demonstrate the utility of the Airtraq laryngoscope for tracheal intubation in low risk patients.
Tremblay, Marie-Hélène; Williams, Stephan; Robitaille, Arnaud; Drolet, Pierre
The GlideScope videolaryngoscope allows equal or superior glottic visualization compared with direct laryngoscopy, but predictive features for difficult GlideScope intubation have not been identified. We undertook this prospective study to identify patient characteristics associated with difficult GlideScope intubation. Demographic and morphometric factors were recorded preoperatively for 400 patients undergoing anesthesia with endotracheal intubation. After induction, direct laryngoscopy was performed in all patients to assess the Cormack and Lehane grade of glottic visualization followed by GlideScope intubation. The number of attempts and time needed for intubation were recorded. Univariate and multivariate analyses were performed to identify the characteristics associated with difficult GlideScope intubation. Intubation required 1, 2, and 3 attempts in 342, 48, and 9 participants, respectively, with one failure. Mean time for intubation was 21 +/- 14 s. After univariate analysis, the following characteristics were significantly correlated (P Cormack and Lehane grade during direct laryngoscopy. However, after introducing these variables in nominal logistic and proportional hazard multiple regression models, only high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, and short sternothyroid distance were significantly associated with multiple attempts or lengthier intubations. Despite a high success rate, intubation with the GlideScope is likely to be more challenging in patients with high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, or short sternothyroid distance.
A Comparison of Macintosh and Airtraq Laryngoscopes for Endotracheal Intubation in Adult Patients With Cervical Spine Immobilization Using Manual In Line Axial Stabilization: A Prospective Randomized Study.
Vijayakumar, Vinodhadevi; Rao, Shwethapriya; Shetty, Nanda
During cervical spine immobilization using Manual In Line Axial Stabilization (MILS), it is difficult to visualize the larynx by aligning the oropharyngeolaryngeal axes using Macintosh laryngoscope. Theoretically, Airtraq an anatomically shaped blade with endotracheal tube guide channel offers advantage over Macintosh. We hypothesized that intubation would be easier and faster with Airtraq compared with Macintosh laryngoscope. Ninety anesthetized adult patients with normal airways were intubated by experienced anesthesiologists after cervical immobilization with MILS either with Macintosh or Airtraq. Primary outcomes compared were successful intubation, and degree of difficulty of intubation as assessed by Intubation Difficulty Scale (IDS) score. Secondary outcomes compared were duration of laryngoscopy and intubation, degree of difficulty of intubation as assessed by Numerical Rating Scale score, soft tissue, and dental trauma. All 90 patients were successfully intubated in the first attempt. Intubation as assessed by IDS score was easier in Airtraq (84.44%) in contrast to slight difficulty in the Macintosh (77.78%) group; Numerical Rating Scale score was easy in both the groups (Airtraq-91.12%; Macintosh-93.34%). The median (interquartile range [IQR]) time for laryngoscopy, (12 s [IQR, 8 to 17.5) vs. 8 s [IQR, 6 to 12]); total duration for intubation (25 s [IQR, 20-33] vs. 22 s [IQR, 18-27.5]) were prolonged in Airtraq group in comparison to Macintosh group. In anesthetized adult patients with MILS compared with Macintosh, Airtraq provides equal success rate of intubation, statistically significant (although clinically insignificant) longer duration for laryngoscopy and intubation. Intubation with Airtraq was significantly easier than Macintosh as assessed by the IDS score.
Rehfeld, Jens F.
Gastrointestinal hormones are peptides released from endocrine cells and neurons in the digestive tract. More than 30 hormone genes are currently known to be expressed in the gastrointestinal tract, which makes the gut the largest hormone-producing organ in the body. Modern biology makes it feasi...
Here, we studied the gastrointestinal parasites of nonhuman mammalian hosts living in 10 rainforest patches of the Anamalai Tiger Reserve, India. We examined 349 faecal samples of 17 mammalian species and successfully identified 24 gastroin-testinal parasite taxa including 1 protozoan, 2 trematode, 3 cestode and 18 ...
Laheij, R.J.F.; Verlaan, M.; Oijen, M.G.H. van; Doelder, M.S. de; Jong, C.A.J. de; Jansen, J.B.M.J.
Excessive alcohol intake frequently results in gastrointestinal discomfort. It is an empirical fact that the severity of gastrointestinal discomfort induced by alcohol abuse is subject to interindividual variation. The aim of this study was to determine whether genetic polymorphism in alcohol
Laheij, R. J. E.; Verlaan, M.; van Oijen, M. G. H.; de Doelder, M. S.; Dejong, C. A. J.; Jansen, J. B. M. J.
Excessive alcohol intake frequently results in gastrointestinal discomfort. It is an empirical fact that the severity of gastrointestinal discomfort induced by alcohol abuse is subject to interindividual variation. The aim of this study was to determine whether genetic polymorphism in alcohol
Background: Uncomplicated dyspepsia has a low predictive value in diagnosing upper gastrointestinal organic disease making early endoscopy essential. Objective: To assess the reliability of clinical information in the diagnosis of organic disease in patients referred for upper gastrointestinal endoscopy. Methods: Patients ...
Background: To determine the incidence of oxygen desaturation and whether routine oxygen monitoring is necessary during unsedated diagnostic flexible upper gastrointestinal endoscopy. Methods: A prospective study involving 54 consecutive in and out patients who had diagnostic upper gastrointestinal endoscopy at ...
Full Text Available Stress has major role in functional gastrointestinal system disorders. The most typical example of this situation is Irritable bowel syndrome. Gastrointestinal system’s response to acute or short-term of stress is delay of gastric emptying and stimulation of colonic transition. While CRF2 receptors are mediate the upper section inhibition, CRF1 is responsible for the lower part colonic and anxiogenic response. Visceral hypersensitivity is managed by the emotional motor system, the amygdala plays a significant role and mucosal mast cells arise. But in people with symptoms of functional gastrointestinal, how is differ motility response in healthy individuals, this situation is due to lack of autonomous nervous system or an increased sensitivity of stress is not adequately understood. The brain-gastrointestinal axis frequency and severity of symptoms associated with negative emotions. American Gastroenterology Association is closely associated with the quality of life and is very difficult to treat the symptoms of gastrointestinal disorders, re-interpreted under the heading of 'Gastrointestinal Distress'. This review is defined as gastrointestinal distresses, physical, emotional, and behavioral components as a disorder in which, almost like an anxiety disorder are discussed. Physical component is pain, gas, and defecation problems, cognitive component is external foci control, catastrophization and anticipatory anxiety, the emotional component is somatic anxiety, hypervigilance, and avoidance of gastrointestinal stimuli as defined. [Archives Medical Review Journal 2012; 21(2.000: 122-133
Nutman, J; Steinherz, R; Sivan, Y; Goodman, R M
We describe a patient with possible Waardenburg syndrome associated with anal atresia and oesophageal atresia with tracheooesophageal fistula. Three other published cases with atretic gastrointestinal anomalies associated with the Waardenburg syndrome are reviewed. We conclude that the association between atretic lesions of the gastrointestinal tract and the Waardenburg syndrome may be a significant one.
Nutman, J; Steinherz, R; Sivan, Y; Goodman, R M
We describe a patient with possible Waardenburg syndrome associated with anal atresia and oesophageal atresia with tracheooesophageal fistula. Three other published cases with atretic gastrointestinal anomalies associated with the Waardenburg syndrome are reviewed. We conclude that the association between atretic lesions of the gastrointestinal tract and the Waardenburg syndrome may be a significant one. Images PMID:3712396
Prolla, J C; Diehl, A S; Bemvenuti, G A; Loguercio, S V; Magalhães, D S; Silveira, T R
Upper gastrointestinal fiberendoscopy in pediatric patients is done safely and under local anesthesia in most instances. This study of 47 children confirmed the value of fiberendoscopy in establishing the etiology of upper gastrointestinal hemorrhage and the presence of esophageal varices. It also contributed significantly to the management of patients with disphagia, pyrosis, epigastric pain, and ingestion of foreign bodies. No significant morbidity was caused.
Madsen, Jan Lysgård; Graff, Jesper
BACKGROUND: Existing data on the effect of ageing on gastrointestinal motility are few. In this study, we assessed the propulsive effect of all main segments of the gastrointestinal tract in a group of healthy older people. METHODS: 16 healthy volunteers (eight women, eight men) of mean age 81 ye...
Bjelakovic, G.; Nikolova, D.; Simonetti, R.G.
BACKGROUND: Oxidative stress may cause gastrointestinal cancers. The evidence on whether antioxidant supplements are effective in preventing gastrointestinal cancers is contradictory. OBJECTIVES: To assess the beneficial and harmful effects of antioxidant supplements in preventing gastrointestinal...... Database from inception to October 2007. We scanned reference lists and contacted pharmaceutical companies. SELECTION CRITERIA: Randomised trials comparing antioxidant supplements to placebo/no intervention examining occurrence of gastrointestinal cancers. DATA COLLECTION AND ANALYSIS: Two authors (GB...... and DN) independently selected trials for inclusion and extracted data. Outcome measures were gastrointestinal cancers, overall mortality, and adverse effects. Outcomes were reported as relative risks (RR) with 95% confidence interval (CI) based on random-effects and fixed-effect model meta...
... News Physician Resources Professions Site Index A-Z X-ray (Radiography) - Upper GI Tract Upper gastrointestinal tract radiography or ... X-ray? What is Upper Gastrointestinal (GI) Tract Radiography? Upper gastrointestinal tract radiography, also called an upper ...
Schurink, B.; Tielemans, M.M.; Aaldering, B.R.; Eikendal, T.; Jaspers Focks, J.; Laheij, R.J.F.; Jansen, J.B.M.J.; Rossum, L.G.M. van; Oijen, M.G.H. van
BACKGROUND: Gastrointestinal symptoms are frequently reported adverse effects of antidepressants, but antidepressants are also a treatment modality in functional gastrointestinal disorders. We aimed to assess the association between antidepressant use and gastrointestinal symptoms in the general
Makepeace, A.R.; Fermont, D.C.; Bennett, M.H.
Seventy-two patients with gastrointestinal non-Hodgkin's lymphoma treated between 1952 and 1980 are reviewed. The small intestine was involved in 49% of cases and the stomach in 29%. Surgical resection of the tumour was performed whenever feasible. Radiotherapy was used either adjuvantly or for incompletely excised tumours and chemotherapy was more often reserved for advanced, unresected disease. The overall 5 year survival was 36% and the 5 year relapse free survival was 22%. Forty-one (57%) patients relapsed of whom 33 (80%) subsequently died of non-Hodgkin's lymphoma. The histology in each case was reviewed using the British National Lymphoma Investigation criteria and 94% of cases were reclassified as Grade 2 non-Hodgkin's lymphoma. (author)
Korman, U.; Ersavasti, G.; Kurugoglu, S.; Akman, C. [Department of Diagnostic Radiology, Cerrahpasa Medical School, University of Istanbul, TR-34 300 Istanbul (Turkey); Uygun, N.T. [Department of Pathology, Cerrahpasa Medical School, University of Istanbul, TR-34 300 Istanbul (Turkey)
A 68-year-old woman who had previously undergone small intestinal resection because of leiomyosarcoma was referred to our clinic with epigastric pain. A double-contrast barium study and the subsequent abdominopelvic CT and abdominal MRI examinations demonstrated multiple extraluminal growing tumors arising from the walls of stomach, small bowell, and colon. A CT-guided aspiration biopsy revealed malignant mesenchymal tumor. The presence of disseminated intra-abdominal masses without concomitant ascites and invasion of tissue planes on CT in a patient operated on prior because of a leiomyosarcoma led to the diagnosis of gastrointestinal leiomyosarcomatosis. In this report we discuss the radiological approach to this rare entity. (orig.). With 4 figs.
Full Text Available BACKGROUND : This study was carried out to evaluate usefulness of preoperative Mallampati & Wilson’s score grading as a predictor for difficult laryngoscopy & intubation . AIMS : To determine the accuracy of the modified Mallampati test and Wilson score for predicting difficult tracheal intubation and correlation with Cormack Lehane grading . METHODS : This prospective randomized cross sectional Study carried out in 200 patients , posted for surgical procedure under GA with ETT intubation. Preoperative airway assessment using Mallampati grading (MPG & Wilson score done. Conventional anesthesia t echnique followed. Cormack Lehane grading done at laryngoscopy & correlated with previous scores for each patient. RESULTS : A MPG of I/II was found in 140 patients (70% , while 60 patients (30% were class III/IV. 138 patients (69% had a Wilson score of 0 /1 , while 60(30% had a score of 2/3 and 2 patients (1% scored ≥4. One hundred & eighty patients (90% were classified as Cormack - Lehane grade I/II , while 20 patients (10% were considered grade III/IV. Of the 60 patients with a Wilson score of 2/3 , 6 cas es (10% two attempts were required and in 2 cases (3.3% in spite of more than two attempts intubation proved impossible with the conventional laryngoscope , articulated McCoy blade was used. Two patients with a Wilson score ≥4 were intubated with gum elas tic bougie , using articulated McCoy blade. Overall , out of 200 , in 6 patients (3% two attempts of intubation was required and 4 patients (2% intubation required the use of some kind of gadget other than conventional laryngoscope and more than 2 attempts. The correlation between the Cormack - Lehane classification and the number of endotracheal intubation attempts showed that of the 180 patients with I / II grade , 4 patients (1.3% two attempts were required. Of the 20 patients classified as Cormack - Lehane III/IV , 4 cases (20% intubation proved impossible with conventional technique. This
Full Text Available CONTEXT Previous studies suggest glottic view is better achieved with straight blades while tracheal intubation is easier with curved blades and videolaryngoscope is better than conventional laryngoscope. AIMS Comparison of conventional laryngoscope (Macintosh blade and Miller blade with channelled videolaryngoscope (King Vision TM with respect to laryngeal visualisation and difficulty in endotracheal intubation. SETTINGS AND DESIGN This prospective randomised comparative study was conducted at a tertiary care hospital (in ASA I and ASA II patients after approval from the Institutional Ethics Committee. METHODS We compared Macintosh, Miller, and the King VisionTM videolaryngoscope for glottic visualisation and ease of tracheal intubation. Patients undergoing elective surgeries under general anaesthesia requiring endotracheal intubation were randomly divided into three groups (N=180. After induction of anaesthesia, laryngoscopy was performed and trachea intubated. We recorded visualisation of glottis (Cormack-Lehane grade-CL, ease of intubation, number of attempts, need to change blade, and need for external laryngeal manipulation. STATISTICAL ANALYSIS Demographic data, Mandibular length, Mallampati classification were compared using ANOVA, Chi-square test, Kruskal-Wallis Test, where P value <0.005 is statically significant. RESULTS CL grade 1 was most often observed in King Vision -TM VL group (90% which is followed by Miller (28.33%, and Macintosh group (15%. We found intubation was to be easier (grade 1 with King Vision -TM VL group (73.33%, followed by Macintosh (38.33%, and Miller group (1.67%. External manipulation (BURP was needed more frequently in patients in Miller group (71.67%, followed by Macintosh (28.33% and in King Vision -TM VL group (6.67%. All (100% patients were intubated in the 1 st attempt with King Vision -TM VL group, followed by Macintosh group (90% and Miller group (58.33%. CONCLUSIONS In patients with normal airway
Chiang, Wen-Chu; Hsieh, Ming-Ju; Chu, Hsin-Lan; Chen, Albert Y; Wen, Shin-Yi; Yang, Wen-Shuo; Chien, Yu-Chun; Wang, Yao-Cheng; Lee, Bin-Chou; Wang, Huei-Chih; Huang, Edward Pei-Chuan; Yang, Chih-Wei; Sun, Jen-Tang; Chong, Kah-Meng; Lin, Hao-Yang; Hsu, Shu-Hsien; Chen, Shey-Ying; Ma, Matthew Huei-Ming
The effect of out-of-hospital intubation in patients with out-of-hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out-of-hospital intubation among Asian areas. This study evaluates the association between successful intubation and out-of-hospital cardiac arrest survival in Taipei. We analyzed 6 years of Utstein-based registry data from nontrauma adult patients with out-of-hospital cardiac arrest who underwent out-of-hospital airway management including intubation, laryngeal mask airway, or bag-valve-mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support-serviced districts was also performed. A total of 10,853 cases from 2008 to 2013 were analyzed. Among out-of-hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag-valve-mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag-valve-mask device use, successful out-of-hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses. In nontrauma adult out-of-hospital cardiac arrest in Taipei, successful out-of-hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome. Copyright © 2017 American College of Emergency Physicians. Published by
Nikolić, M; Hanževački, M; Jurčić, P; Budimir, I; Ljubičić, N
In the developed Western countries, despite the accumulation of knowledge about the causes and treatment of gastrointestinal bleeding, as well as the experience of gastroenterologists-endoscopists using sophisticated endoscopic devices, the number of hospitalizations and mortality rates has not declined as expected. The most likely explanations are the following: aging population, increased prevalence of alcoholic liver cirrhosis, gastroesophageal reflux disease and obesity, Helicobacter pylori antibiotic resistance, using dual anti-aggregation therapy, anticoagulants, and excessive use of nonsteroidal anti-inflammatory drugs. The aim of this paper is to show the incidence and the most common signs and symptoms of gastrointestinal bleeding. The aim is also to present initial clinical evaluation, diagnostic methods, the main causes of gastrointestinal bleeding, endoscopic hemostatic modalities and treatment of bleeding from the upper and lower gastrointestinal tract. Using the MEDLINE and Ovid databases, we searched the meta-analyses and systematic reviews published in English during the 2005-2015 period. Meta-analyses included results of randomized, double-blind studies on adults treated for gastrointestinal bleeding. Included were guidelines of the European and American Society of Gastroenterological Endoscopy, as well as recent expert work. In this review, we bring the state-of-the-art on gastrointestinal bleeding, new classification of gastrointestinal bleeding from the upper, mid and lower gut, controversy of nasogastric tube placement, use of prokinetic agents and inhibitor proton pumps in acute gastrointestinal bleeding from the upper tract, restrictive transfusion strategy, useful clinical stratification of the severity of bleeding, indications for hospitalization and outcome of using the clinical bleeding score, proper use of gastroprotection in patients at a high risk of peptic ulcer, the need of initial endoscopy, variceal assessment in newly diagnosed
Full Text Available This study was designed to study the efficacy of intravenous dexmedetomidine for attenuation of cardiovascular responses to laryngoscopy and endotracheal intubation in patients with coronary artery disease. Sixty adult patients scheduled for elective off-pump coronary artery bypass surgery were randomly allocated to receive dexmedetomidine (0.5 mcg/kg or normal saline 15 min before intubation. Patients were compared for hemodynamic changes (heart rate, arterial blood pressure and pulmonary artery pressure at baseline, 5 min after drug infusion, before intubation and 1, 3 and 5 min after intubation. The dexmedetomidine group had a better control of hemodynamics during laryngoscopy and endotracheal intubation. Dexmedetomidine at a dose of 0.5 mcg/kg as 10-min infusion was administered prior to induction of general anesthesia attenuates the sympathetic response to laryngoscopy and intubation in patients undergoing myocardial revascularization. The authors suggest its administration even in patients receiving beta blockers.
Sakles, John C; Mosier, Jarrod; Chiu, Stephen; Cosentino, Mari; Kalin, Leah
We determine the proportion of successful intubations with the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in emergency department (ED) intubations. This was a retrospective analysis of prospectively collected data entered into a continuous quality improvement database during a 28-month period in an academic ED. After each intubation, the operator completed a standardized data form evaluating multiple aspects of the intubation, including patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. Intubation was considered ultimately successful if the endotracheal tube was correctly inserted into the trachea with the initial device. An attempt was defined as insertion of the device into the mouth regardless of whether there was an attempt to pass the tube. The primary outcome measure was ultimate success. Secondary outcome measures were first-attempt success, Cormack-Lehane view, and esophageal intubation. Multivariate logistic regression analyses, with the inclusion of a propensity score, were performed for the outcome variables ultimate success and first-attempt success. During the 28-month study period, 750 intubations were performed with either the C-MAC with a size 3 or 4 blade or a direct laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed with the C-MAC as the initial device and 495 with a Macintosh direct laryngoscope as the initial device. The C-MAC resulted in successful intubation in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95% CI 81.0% to 87.5%). In the multivariate regression model, with a propensity score included, the C-MAC was positively predictive of ultimate success (odds ratio 12.7; 95% CI 4.1 to 38.8) and first-attempt success (odds ratio 2.2; 95% CI 1.2 to 3.8). When
Bretthauer, Michael; Aabakken, Lars; Dekker, Evelien; Kaminski, Michal F.; Rösch, Thomas; Hultcrantz, Rolf; Suchanek, Stepan; Jover, Rodrigo; Kuipers, Ernst J.; Bisschops, Raf; Spada, Cristiano; Valori, Roland; Domagk, Dirk; Rees, Colin; Rutter, Matthew D.
To develop standards for high quality of gastrointestinal endoscopy, the European Society of Gastrointestinal Endoscopy (ESGE) has established the ESGE Quality Improvement Committee. A prerequisite for quality assurance and improvement for all gastrointestinal endoscopy procedures is
Nishisaki, Akira; Donoghue, Aaron J; Colborn, Shawn; Watson, Christine; Meyer, Andrew; Brown, Calvin A; Helfaer, Mark A; Walls, Ron M; Nadkarni, Vinay M
Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during intensive care unit rotations. The authors hypothesized that "just-in-time" simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs. For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non-refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared. Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non-refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The resident's first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28-3.87, P = 0.005). Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the resident
Polo-Garvín, A; García-Sánchez, M J; Perán, F; Almazán, A
To compare the effects of thiopental and propofol on hemodynamic and metabolic endocrine response to laryngoscopy and intubation. We selected two homogeneous groups of 14 healthy patients premedicated with midazolam i.m. (0.07 mg/kg). Induction was with diazepam (0.1 mg/kg), fentanyl (2 micrograms/kg), atropine 0.5 mg and thiopental or propofol (4-6.5 mg/kg and 1.5-2.5 mg/kg, respectively). Parameters recorded were direct arterial pressure, baseline heart rate, and heart rate after induction and at 2 and 5 minutes after intubation. We measured adrenaline (A), noradrenaline (NA), dopamine (Da), glucagon, beta-endorphines, ACTH, cortisol, glucose and amino acids in the baseline and post-intubation blood samples. We observed a significant increase (p < 0.05) in systolic and diastolic arterial pressure after intubation (10% and 22% respectively) in the thiopental group as compared with the propofol group. With both induction agents, heart rate was higher than baseline values at the three times (p < 0.001). In the thiopental group heart rate was higher after intubation than after induction (p < 0.05). Cortisol fell after intubation in the propofol group (p < 0.05); no other hormonal differences were observed. Hyperglycemia (p < 0.0001) was similar for both groups, while in the propofol group there were significant decreases in several amino acids. Propofol has a greater mitigating effect on the hyperdynamic response to intubation in healthy patients. For the two induction agents we measured no significant differences in stress hormone levels, apart from the drop in cortisol with propofol. We observed a change in energy-producing metabolites.
Full Text Available The aim of the study was to assess and compare laryngoscopic view of Truview evo2 laryngoscope with that of Macintosh laryngoscope in patients with one or more predictors of difficult intubation (PDI. Moreover ease of intubation with Truview evo2 in terms of absolute time requirement was also aimed at. Patients for elective surgery requiring endotracheal intubation were initially assessed for three PDI parameters - modified Mallampati test, thyro-mental distance& Atlanto-occipital (AO joint extension. Patients with cumulative PDI scores of 2 to 5 (in a scale of 0 to 8 were evaluated for Cormack& Lehane (CL grading by Macintosh blade after standard induction. Cases with CL grade of two or more were further evaluated by Truview evo2 laryngoscope and corresponding CL grades were assigned. Intubation attempted under Truview evo2 vision and time required for each successful tracheal intubation (i.e. tracheal intubation completed within one minute was noted. Total fifty cases were studied. The CL grades assigned by Macintosh blade correlated well with the cumulative PDI scores assigned preoperatively, confirming there predictability. Truview evo2 improved laryngeal view in 92 % cases by one or more CL grade. Intubation with Truview evo2 was possible in 88% cases within stipulated time of one minute and mean time of 28.6 seconds with SD of 11.23 was reasonably quick. No significant complication like oro- pharyngeal trauma or extreme pressor response to laryngoscopy was noticed. To conclude, Truview evo2 proved to be a better tool than conventional laryngoscope in anticipated difficult situations.
Kandemir, Tünay; Şavlı, Serpil; Ünver, Süheyla; Kandemir, Erbin
Objective The aim of this study was to determine the combinations of the Mallampati test and anthropometric measurements with the highest selectivity value. In addition, we aim to identify a possible correlation between head circumference measurement, the presence of malignancy and difficult intubation. Methods Patients who were scheduled to undergo elective surgery under general anaesthesia, who fell into Group 1–2 according to ASA criteria and were between the ages of 18–70 years were included in the study. Patients with Cormack-Lehane scores of 3–4 were considered to be difficult intubations. Thyromental distance, sternomental distance, mandibular distance, neck length, neck circumference and head circumference were measured during the anthropometric measurements. Results According to the ROC analysis, there was a significant difference in the thyromental distance, sternomental distance, neck length, neck circumference and head circumference between the easy and difficult intubation groups (p<0.05). The incidence of difficult intubation was 8.3% in patients with non-head-neck malignancies, whereas the incidence was 7.1% in patients without any malignancies. The difference between these groups was not statistically significant (χ2=0.101; p=0.751). Conclusion To predict the incidence of difficult intubation, the test with the highest selectivity and highest positive predictive values was the combination of Mallampati-thyromental distance. We believe that the head circumference and neck length measurement, in addition to the current anthropometric measurements, may be crucial to predict the incidence of difficult intubations. In addition, we believe that the anticipation of difficult intubations in patients with non-head-neck malignancies is not different from the normal population. PMID:27366457
Tseng, Chih-Wei; Koo, Malcolm; Hsieh, Yu-Hsi
The water exchange (WE) method can decrease the discomfort of the patients undergoing colonoscopy. It also provides salvage cleansing and improves adenoma detection, but a longer intubation time is required. Cap-assisted colonoscopy leads to a significant reduction in cecal intubation time compared with traditional colonoscopy with air insufflation. The aim of this study was to investigate whether combined cap-assisted colonoscopy and water exchange (CWE) could decrease the cecal intubation time compared with WE. A total of 120 patients undergoing fully sedated colonoscopy at a regional hospital in southern Taiwan were randomized to colonoscopy with either CWE (n=59) or WE (n=61). The primary endpoint was cecal intubation time. The mean cecal intubation time was significantly shorter in CWE (12.0 min) compared with WE (14.8 min) (P=0.004). The volume of infused water during insertion was lower in CWE (840 ml) compared with WE (1044 ml) (P=0.003). The adenoma detection rate was 50.8 and 47.5% for CWE and WE, respectively (P=0.472). The Boston Bowel Preparation Scale scores were comparable in the two groups. Results from the multiple linear regression analysis indicated that WE with a cap, a higher degree of endoscopist's experience, a higher Boston Bowel Preparation Scale score, and a lower volume of water infused during insertion, without abdominal compression, without change of position, and without chronic laxative use, were significantly associated with a shorter cecal intubation time. In comparison with WE, CWE could shorten the cecal intubation time and required lower volume of water infusion during insertion without compromising the cleansing effect of WE.
Yu, J H; Wang, Y
Objective: To observe the clinical feasibility and security of SMT-Ⅱ video laryngoscope in difficult airway intubation in emergency department. Methods: This study took 90 adults with difficult airway who were admitted to the rescue room of Jingxi court of Beijing Chao-Yang Hospital, Capital Medical University from January 2015 to December 2016.The patients were randomly divided into 2 groups(SMT-Ⅱ video laryngoscope group: n =45, Macintosh direct laryngoscope group: n =45), which were treated with endotracheal intubation and ventilator assisted ventilation.The evaluation of difficult mask ventilation(DMV) independent risk factor score, Wlison score, Cormack-Lehane grade, mouth opening, thyromental distance, visualization of the glottis, time for laryngoscopy, time for tracheal intubation, first-pass success rate of intubation, complications, mean arterial pressure(MAP) and heart rate(HR) before induction, after laryngoscopy, after induction, after intubation 5 minutes, 10 minutes were recorded.ANOVA, t -test, Chi-square test was used to analyze differences data, respectively. Results: There was no significant difference between the two groups in terms of gender, age, height, weight and other general data, mouth opening, DMV independent risk factor score, Wlison score, and thyromental distance(χ(2)=0.045, t =-0.367, t =0.684, t =0.511, t =0.330, t =-0.724, t =1.219, t =1.034, all P >0.05). A Cormack-Lehane grade Ⅰ or Ⅱ view were 44 cases in SMT-Ⅱ video laryngoscope group and 14 cases in Macintosh direct laryngoscope group. It significantly improved with the use of SMT- Ⅱ video laryngoscope, compared with Macintosh direct laryngoscope(χ(2)=52.096, P <0.01). The time to best view was shorter in SMT-Ⅱ video laryngoscope group compared to that in Macintosh direct laryngoscope group with (15.0±1.0) seconds vs . (24.2±3.4) seconds( t =-26.319, P <0.05). The tube passage time was shorter with SMT-Ⅱ video laryngoscope (31.6±4.3) seconds vs . (12.7±0
Shen, She-Liang; Xie, Yi-hong; Wang, Wen-Yuan; Hu, Shuang-Fei; Zhang, Yun-Long
Fibreoptic intubation is a valuable technique for difficult airway management in which conscious sedation is paramount. To investigate the efficacy and safety of dexmedetomidine (DEX) and sufentanil (SUF) for conscious sedation during awake nasotracheal intubation under vision by a fibreoptic bronchoscope. Forty patients with anticipated difficult airways of American Society of Anesthesiologists I-II scheduled for awake fibreoptic nasotracheal intubation were randomised into two groups each containing 20 subjects. DEX group received DEX at a dose of 1.0 μg/kg over 10 min followed by a continuous infusion of 0.5 μg/kg per hour, while SUF group received SUF target controlled infusion in which the target plasma concentration was 0.3 ng/mL. The nasotracheal intubation conditions and the tolerance to nasotracheal intubation were observed; the occurrence of adverse events including hypertension, bradycardia and respiratory depression during nasotracheal intubation and post-surgical throat pain and hoarseness, and post-surgical memory score were recorded. Better nasotracheal intubation conditions and higher tolerance to intubation were observed in DEX group than those in SUF group (P memory score for sedation during awake fibreoptic nasotracheal intubation. © 2013 John Wiley & Sons Ltd.
Linke, R.; Tatsch, K.
Prior to surgery of gastrointestinal tumors exact information about tumor localization, extent and possible infiltration in adjacent structures are important. The task for radiological and scintigraphic methods is predominantly the preoperative tumor staging. The upper (esophagus, stomach, duodenum) and the lower (colon, rectum) gastrointestinal tract should be routinely investigated by endoscopy and endosonography. CT or MRI imaging may add information about tumor extent, infiltration in adjacent structures and pathologically enlarged lymph nodes. The latter may be detected with similar or higher sensitivity by PET as well. Furthermore, with PET it is possible to differentiate a tumor recurrence from postoperative scar tissue earlier than with conventional morphological imaging techniques, for example in colorectal cancer. Liver tumors should primarily be inspected sonographically followed by an MRI scan if dignity is uncertain. The receptor scintigraphy with radioactive ligands allows to further characterize a detected tumor. Benigne liver lesions can be distinguished from malignant tumors (metastasis, hepatocellular carcinoma [HCC]) by the neogalactoalbumin-(NGA-)scintigraphy, because NGA binds exclusively to the liver galactose receptors of normally functioning hepatocytes. For the differentiation between liver metastasis and HCC insulin scintigraphy can be used, since insulin binds significantly in HCC due to an overexpression of insulin receptors in these tumors. If a malignant process is suspected, additionally CT-arterioportography may be recommended, because this newer radiological technique is capable to visualize lesions smaller than 1 cm. In such cases PET is sensitive as well and due to increased glucose metabolism even small foci can be detected with comparably high sepcificity. The method of choice for the detection of a pancreatic tumor is endoscopic sonography. In most cases the dignity of the tumor can be verified by ERCP, but sometimes it is very
Background Premedication before neonatal intubation is heterogeneous and contentious. The combination of a short acting, rapid onset opioid with a muscle relaxant is considered suitable by many experts. The purpose of this study was to describe the tolerance and conditions of intubation following anaesthesia with atropine, sufentanil and atracurium in very premature infants. Methods Monocentric, prospective observational study in premature infants born before 32 weeks of gestational age, hospitalised in the NICU and requiring semi-urgent or elective intubation. Intubation conditions, heart rate, pulse oxymetry (SpO2), arterial blood pressure and transcutaneous PCO2 (TcPCO2) were collected in real time during 30 minutes following the first drug injection. Repeated physiological measurements were analysed using mixed linear models. Results Thirty five intubations were performed in 24 infants with a median post conceptional age of 27.6 weeks and a median weight of 850 g at the time of intubation. The first attempt was successful in 74% and was similar for junior (75%) and senior (74%) operators. The operator rated conditions as “excellent” or “good” in 94% of intubations. A persistent increase in TcPCO2 as compared to baseline was observed whereas other vital parameters showed no significant variations 5, 10, 15 and 30 minutes after the first drug injection. Eighteen (51%) desaturations (SpO2 less than or equal to 80% for more than 60 seconds) and 2 (6%) bradycardia (heart rate less than100 bpm for more than 60 seconds) were observed. Conclusion This drug combination offers satisfactory success rate for first attempt and intubation conditions for the operator without any significant change in heart rate and blood pressure for the patient. However it is associated with frequent desaturations and a possible persistent hypercapnia. SpO2 and PCO2 can be significantly modified during neonatal intubation and should be cautiously followed in this high
Full Text Available BACKGROUND Airway management is of prime importance to the anaesthesiologists. Unanticipated difficult laryngoscopy and endotracheal intubation remains a primary concern for the anaesthesiologists. The reported incidence of a difficult laryngoscopy or endotracheal intubation varies from 1.5% to 13% in patients undergoing surgery. Failure to intubate is detected in 0.05-0.35% of the patients. Thus, preoperative airway assessment is of pivotal importance for the anaesthesiologist to predict difficult intubation. The aim of the study is to study the usefulness of two different airway assessment predictors, a clinical and radiological tool to predict difficult intubation. MATERIALS AND METHODS Two hundred and eight patients in the age group of 15-75 years of either sex were included in the study. We assessed the clinical variable: modified Mallampati classification and radiological variable: the atlanto-occipital distance, in all the patients. Patients with tumours or malformations of head and neck and oral cavity, edentulous patients, pregnant patients and those requiring emergency surgeries were excluded. A Cormack-Lehane grade of I and II were considered as easy intubation and III and IV were considered as difficult intubation. RESULTS Thirty eight patients had difficult intubation. The sensitivity and specificity of the clinical model were found to be 97.2% and 95.3%, respectively. The sensitivity and specificity of the combined clinical and radiological model were found to be 100% and 95.3%, respectively. The area below the ROC curves measures the probability of the correct prediction of the clinical and the combined models. It was found to be 0.992 and 0.993, respectively. This means that the clinical and combined models correctly predicted the outcome with a probability of 99.2% and 99.3%, respectively. CONCLUSION From this study, we found that- 1. Clinical models- Modified Mallampati classification is an important predictor of difficult
Castejón de la Encina, M ª Elena; Sanjuán Quiles, Ángela; Del Moral Vicente-Mazariegos, Ignacio; García Aracil, Noelia; José Alcaide, Lourdes; Richart Martínez, Miguel
To compare the efficacy and safety of endotracheal intubation (ETI) in a simulated clinical environment in motion vs a motionless one. Clinical simulation trial of ETI with 3 endotracheal tubes (Airtraq, Fast-trach, Macintosh laryngoscope) in mannequins with realistic physiological responses (MetiMan) in 2 scenarios: an environment in motion vs a motionless one. Thirty-six physicians expert in prehospital ETI participated. Outcome variables were successful intubation, effective intubation, number of attempts, maximum apnea time, and total maneuver time. The safety variables were the presence of bradycardia, tachycardia, or high or low systolic blood pressures (ie, 20% variation from baseline); hypoxemia (decrease in oxygen saturation to <90% or 10% below baseline), tube placement in the esophagus or main bronchus, and dental trauma. No statistically significant differences between the 2 scenarios were found in the numbers of successful ETI (motionless, 71 [65.7%]; in motion, 67 [62.0%]; P=.277) or effective ETI (motionless, 104 [96.3%]; in motion, 105 [97.2%]; P=.108). Likewise, the number of attempts were similar (motionless, 91 [84.2%]; in motion, 90 [83.3%]; P=.305). Nor did we see differences in the mean (SD) maximum apnea times (motionless, 14.0 [5.6] seconds; in motion, 14.9 [8.1] seconds; P=.570) or mean total maneuver times (motionless, 236.7 [73.4] seconds; in motion, 210.3 [77.9] seconds; P=.164). The prevalences of bradycardia, tachycardia, high or low systolic blood pressure, hypoxemia, placements in the esophagus or bronchus, and dental trauma also did not differ significantly between the 2 scenarios. Neither efficacy nor safety variables differed significantly when ETI was performed in mannequins in a motionless environment vs one simulating ambulances in motion.
Kim, Samuel S; Khalpey, Zain; Hsu, Charles; Little, Alex G
This study sought to identify the changing characteristic patterns and locations of stenosis after tracheostomy or intubation and to assess the risk factors associated with perioperative complication and restenosis after primary resection and reconstruction. A retrospective review was performed (January /2012 to March 2015) on patients treated at the University of Arizona Medical Center (Tucson, Arizona) who had symptomatic tracheal stenosis secondary to prolonged intubation or tracheostomy. Data on demographics, surgical approach, and outcome were obtained. Analysis was performed using the χ 2 test, Kaplan-Meier estimate of survival, Cox proportional hazards survival analysis, and univariate and multivariate logistic regression. Forty-eight patients were referred for surgical resection, and 36 patients underwent primary resection and reconstruction; 72% of patients had previous endobronchial treatments for stenosis. Fourteen patients had postintubation tracheal stenosis, and 22 had tracheostomy-related stenosis (16 percutaneous, 6 open tracheostomy). Among all patients, 52.8% had stenosis proximal to or involving the cricoid; 72.7% of patients with tracheostomy-related stenosis had stenosis at or proximal to the cricoid, whereas only 21.4% of the patients with intubation-related stenosis had a similar location. Nineteen patients underwent laryngotracheal resection, and 17 patients had tracheal resection. The mean length of resection was 3.6 cm. A body mass index greater than 35 was associated with increased perioperative complications (p = 0.012). In multivariate analysis, patients younger than 30 years of age at operation had an increased relative risk of recurrence. Recent advances in percutaneous tracheostomy have increased the numbers of patients presenting with proximal tracheal stenosis, thus necessitating more complex subglottic resection and reconstruction. The anastomotic and overall complication rate remains low despite these more complex operations
Kavakli, Ali Sait; Kavrut Ozturk, Nilgun; Karaveli, Arzu; Onuk, Asuman Arslan; Ozyurek, Lutfi; Inanoglu, Kerem
Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Makkar, Rohit; Lopez, Rocio; Shen, Bo
The aims of this study were to investigate the frequency and factors involved in the terminal ileum intubation of patients with chronic, non-bloody diarrhea and to compare diagnostic yields of colonoscopy and ileocolonoscopy. The medical records of 945 patients undergoing colonoscopy for chronic, non-bloody diarrhea were reviewed. Findings of microscopic colitis, Clostridium difficile colitis, celiac disease, inflammatory bowel disease or tropical sprue were considered as definitive causes of diarrhea. A total of 689 patients met the diagnosis of chronic, non-bloody diarrhea, in which 370 (53.7%) underwent ileocolonoscopy. Specific histological diagnosis could explain the patient's symptoms in 107 (15.5%) patients. The diagnostic yield were 15.0% in the colonoscopy-only group, 16.9% in the ileocolonoscopy without biopsy group, and 15.5% in the ileocolonoscopy with biopsy group. Of the 19 patients with an abnormal terminal ileal biopsy, six (31.6%) had an otherwise normal colonic appearance which would have been diagnosed as normal if the ileum had not been reached and biopsied. In those with Crohn's disease (n = 7), five had ileocolitis and two had colitis only. A multivariate analysis showed that age of the patients and otherwise normal gross endoscopic results to be the only factors associated with a lower likelihood of ileal intubation by endoscopists. The ileal intubation rate was 53.7% in our patients with chronic, non-bloody diarrhea. Diagnostic yield of ileocolonoscopy with biopsy in US patients with chronic, non-bloody diarrhea appeared to be low, if the colon side was normal on endoscopy. But this may provide supportive evidence in patients diagnosed with ileocolonic Crohn's disease. © 2013 Wiley Publishing Asia Pty Ltd and Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine.
Full Text Available Background: The placement of a tube into a patient′s trachea "the intubation" as we call is not as simple as it looks. It is a very tricky and tedious maneuver that entails skills to assess and perform. Nevertheless, often this is left to the chores of inefficient hands due to a paucity of the availability of experts. They seldom are able to complete the task and often wind up calling the attention of the unit. The present review is an attempt to describe the need to undertake intubation, the procedures and techniques, the complications, including morbidity and mortality and airway management. This overview includes explicit descriptions of the difficult airway which represents multifaceted interface amid patient factors, clinical setting, and skills of the practitioner. Materials and Methods: To accomplish the target, peer-reviewed English language articles published during third millennium up to 2013 were selected from Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo. Review of Literature: The review constituted a systematic search of literature on the requirements that necessitate the practice of intubation, different techniques that facilitate easy conduct of procedure, the complications, including, morbidity and mortality, and the airway management. Conclusion: Recording every single detail has been beyond the scope of this review, however; some aspects have been wrapped up in nutshell. Some areas of the review are too basic which the medics are well aware of and knowledgeable. Nevertheless, these are difficult to be dispensed with in consideration of their source to the awareness of a common man and a great majority of the patients.
Full Text Available Purpose: The aim of this study is to compare the laryngeal view in Airtraq and Macintosh laryngoscopes. Methods: This descriptive observational study was conducted on hospitalized patients at Shohadaye Ashayer Hospital who were candidate for elective surgery with general anesthesia. One anesthesiologist evaluated and recorded glottis view with Macintosh laryngoscopy based on cormack lehane score and another anesthesiologist who was unaware of the observations of the previous anesthesiologist evaluated and recorded glottis view with Airtraq laryngoscope. Results: The mean age of patients was 30.6 ± 8.89 years old. Mean BMI 22.10 ± 3.25 kg/m2 and duration of intubation was 28.3±6.92 seconds. The Airtraq laryngoscope significantly decreased the Cormack-Lehane score (P = 0.043. Cormack lehane score With the Macintosh laryngoscope was I in 187 patients (69%, II in 56 patients (21.3%, III in 20 patients (7.8% and IV in 5 patients (1.9% and with laryngoscope Airtraq was I in 248 cases (93.6%, II in 16 patients (5.2% and III in 3 patients (1.1%. Improvement in view of larynx was observed in 194 cases (73.0% with Airtraq laryngoscope and lack of improvement was seen in 73 (27.0% cases. Conclusion: Considering the high rate of improvement in observation of view of larynx with an Airtraq laryngoscope, decreasing the Cormack-Lehane score, and facilitating the tracheal intubation, Airtraq laryngoscope is a safe and useful for tracheal intubation in elective surgery with general anesthesia.
Mohamed Shaaban Ali
Full Text Available Purpose: External laryngeal manipulation (ELM is used to get better laryngeal view during direct laryngoscopy. This study was designed to test the hypothesis that ELM done by the intubating anesthetist (laryngoscopist offers the best laryngeal view for tracheal intubation. Materials and method: A total of 160 patients underwent different surgical procedures were included in this study. Percentage of glottic opening (POGO score and Cormack and Lehane scale were used as outcome measures for comparison between different laryngoscopic views. Four views were described; basic laryngoscopic view and then views after ELM done by the assistant, by the laryngoscopist and finally by the assistant after the guidance from the laryngoscopist respectively. The last three views compared with the basic laryngoscopic view. Results: ELM done by the laryngoscopist or by the assistant after guidance from the laryngoscopist showed significant improvement of Cormack grades and POGO scores compared with basic laryngoscopic view. Number of patients with Cormack grade1 increased from 39 after direct laryngoscopy to 97 and 96 patients (P < 0.001 by Fisher′s exact test, after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. Furthermore, the number of patients with POGO scores of 100% increased from 39 after direct laryngoscopy to 78 and 61 (P < 0.01 patients after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. Conclusion: It appeared from this study that ELM done by the anesthetist makes the best laryngeal view for tracheal intubation.
McPherson, Duncan; Vaughan, Ralph S; Wilkes, Antony R; Mapleson, William W; Hodzovic, Iljaz
Unexpected difficulty in tracheal intubation is an intermittent and often terrifying problem for all practising anaesthetists. There are many preoperative assessment tests to predict a difficult laryngeal view or a difficult intubation, but we found no published evidence of how frequently these predictive tests are used or how useful they are perceived to be by anaesthetists. We decided to ask UK and non-UK anaesthetists attending the Annual Scientific Meeting of the European Society of Anaesthesiology about their practice in predicting difficult intubation. The study was conceived as a survey. The airway tests were compiled into a questionnaire, hand distributed among anaesthetists at Euroanaesthesia - the European group (after excluding UK attendees) - and posted to randomly selected anaesthetists in the UK - the UK group. Overall, 888 of 1230 (72%) questionnaires were completed. The response rate from the UK group of anaesthetists was 69% (481 of 700) and from the European group was 77% (407 of 530). On a scale 1 (never) to 5 (always), the mean score for frequency of use was similar for both groups of anaesthetists and ranged from about 4 for mouth opening to about 1 for Nodding Donkey. The mean score for usefulness (1 = useless, 5 = extremely useful) ranged from about 3.7 to 2 for the same two tests. The UK group found most tests slightly less useful than did the European group. With regard to the frequency of assessing the airway, 9% of the European group, but 16% of the UK group, failed always (score 5) or regularly (score 4) to assess the airway before general anaesthesia. Furthermore, 21 and 36% of the UK and European groups, respectively, failed to do so before regional anaesthesia. These results are a cause for concern with regard to both airway management training and patient safety.
Aydogmus, Meltem Turkay; Turk, Hacer Sebnem Yeltepe; Oba, Sibel; Unsal, Oya; Sinikoglu, Sitki Nadir
In laparoscopic surgical procedures, experts recommend tracheal intubation for airway management. Laryngeal mask airway (LMA) can be a good alternative to intubation. In this case series, we aimed to examine the use of the Supreme™ LMA (SLMA) in laparoscopic surgical practice. We planned the study for sixty patients between the ages of 18 and 60, who would undergo laparoscopic surgery. We recorded one, 15, 30, 45, and 60-minute peripheral O2 saturation (SpO2) and end-tidal carbon dioxide (EtCO2) values, heart rate and mean arterial blood pressure (MAP). We observed the duration of SLMA insertion, the rate of gastric tube applicability, whether nausea, vomiting, and coughing developed, and whether there was postoperative 1-hour sore throat. The initial EtCO2 mean was lower than the EtCO2 means of 15, 30, 45, and 60 minutes (p < 0.0001) and the 15-minute EtCO2 mean was lower than other measured EtCO2 means. We observed the initial heart rate mean to be higher than the ones following the SLMA insertion, prior to the SLMA removal, and after the SLMA removal. The heart rate mean after the SLMA insertion was remarkably lower than the heart rate mean prior to the SLMA removal (p=0.013). The MAP after the SLMA insertion was lower than the initial MAP means, as well as the MAP averages prior to after the removal of SLMA (p=0.0001). SLMA can be a suitable alternative to intubation in laparoscopic surgical procedures in a group of selected patients. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Poorahong, Sujittra; Thammakhet, Chongdee; Thavarungkul, Panote; Kanatharana, Proespichaya
A simple and high extraction efficiency online in-tube microextractor (ITME) was developed for bisphenol A (BPA) detection in water samples. The ITME was fabricated by a stepwise electrodeposition of polyaniline, polyethylene glycol and polydimethylsiloxane composite (CPANI) inside a silico-steel tube. The obtained ITME coupled with UV-Vis detection at 278 nm was investigated. By this method, the extraction and pre-concentration of BPA in water were carried out in a single step. Under optimum conditions, the system provided a linear dynamic range of 0.1 to 100 μM with a limit of detection of 20 nM (S/N ≥3). A single in-tube microextractor had a good stability of more than 60 consecutive injections for 10.0 μM BPA with a relative standard deviation of less than 4%. Moreover, a good tube-to-tube reproducibility and precision were obtained. The system was applied to detect BPA in water samples from six brands of baby bottles and the results showed good agreement with those obtained from the conventional GC-MS method. Acceptable percentage recoveries from the spiked water samples were obtained, ranging from 83-102% for this new method compared with 73-107% for the GC-MS standard method. This new in-tube CPANI microextractor provided an excellent extraction efficiency and a good reproducibility. In addition, it can also be easily applied for the analysis of other polar organic compounds contaminated in water sample.
Sheila Nainan Myatra
Full Text Available Tracheal intubation (TI is a routine procedure in the Intensive Care Unit (ICU and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.
patients. In this study, we proposed that I-gel combined with tracheal intubation could reduce the stress response of posterior fossa surgery patients. Methods. Sixty-six posterior fossa surgery patients were randomly allocated to receive either tracheal tube intubation (Group TT or I-gel facilitated endotracheal tube intubation (Group TI. Hemodynamic and respiratory variables, stress and inflammatory response, oxidative stress, anesthesia recovery parameters, and adverse events during emergence were compared. Results. Mean arterial pressure and heart rate were lower in Group TI during intubation and extubation (P<0.05 versus Group TT. Respiratory variables including peak airway pressure and end-tidal carbon dioxide tension were similar intraoperative, while plasma β-endorphin, cortisol, interleukin-6, tumor necrosis factor-alpha, malondialdehyde concentrations, and blood glucose were significantly lower in Group TI during emergence relative to Group TT. Postoperative bucking and serious hypertensions were seen in Group TT but not in Group TI. Conclusion. Utilization of I-gel combined with endotracheal tube in posterior fossa surgery patients is safe which can yield more stable hemodynamic profile during intubation and emergence and lower inflammatory and oxidative response, leading to uneventful recovery.
Full Text Available Nasal route of intubation is commonly used for surgical procedures involving Head and Neck, Patients with intra - oral pathology, structural abnormalities, trismus, cervical spine instability, cervical spine disease and OSA. The intubation may be aided by direct laryngoscopy, flexible fibreoptic laryngoscopy or by blind technique. The classical tec hnique of blind nasal intubation requires a spontaneously breathing patient and uses breath sounds to guide placement. Most common complication associated with this technique is epistaxis. Other rare complications include - Inferior turbinate avulsion, mid dle turbinate/nasal polyp/tumour avulsion, Bacteraemia, Retropharyngeal mucosa dissection/laceration. Here we present to you a case of fracture mandible posted for ORIF for which blind nasal intubation was planned. While attempting the intubation the endot racheal tube coursed behind the retropharyngeal mucosa for a short distance before entering the trachea. Post - operatively the patient was put on Ryle’s tube feeding for 3 days followed by orals. The track healed spontaneously and the recovery was uneventfu l.
Cemalovic, Nail; Scoccimarro, Anthony; Arslan, Albert; Fraser, Robert; Kanter, Marc; Caputo, Nicholas
The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physician's perception of desaturation events. A timed, observation prospective cohort study was conducted. A post-intubation survey was administered to the intubating physician. Each step of the procedure was timed by an observer in order to determine actual TTI. The number of desaturation events was also recorded. One hundred individual intubations were included. The provider perceived TTI was significantly different and underestimated when compared with the actual TTI (23 s, 95% confidence interval (CI) 20.4-25.49 vs 45.5 s, 95% CI 40.2-50.7, P time to desaturation was 65.1 s. Our findings have shown that provider's perception of TTI occurs sooner than actually observed. Also, the providers were less aware of desaturation during the procedure. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
Patel, Akash R; Oheb, Daniel; Zaslow, Tracy L
Because sports participation at all levels often requires international travel, coaches, athletic trainers, and team physicians must effectively protect athletes from gastrointestinal infections. Traveler's diarrhea is the most common travel-related illness and can significantly interfere with training and performance. A review of relevant publications was completed using PubMed and Google Scholar. Clinical review. Level 5 Results: Enterotoxigenic and enteroaggregative Escherichia coli are the most common bacterial causes of traveler's diarrhea. Traveler's diarrhea generally occurs within 4 days of arrival, and symptoms tend to resolve within 5 days of onset. There are several prophylactic agents that physicians can recommend to athletes, including antibiotics, bismuth subsalicylate, and probiotics; however, each has its own unique limitations. Decision-making should be based on the athlete's destination, length of stay, and intent of travel. Prophylaxis with antibiotics is highly effective; however, physicians should be hesitant to prescribe medication due to the side effects and risks for creating antibiotic-resistant bacterial strains. Antibiotics may be indicated for high-risk groups, such as those with a baseline disease or travelers who have little flexible time. Since most cases of traveler's diarrhea are caused by food and/or water contamination, all athletes should be educated on the appropriate food and water consumption safety measures prior to travel.
Han, Jaeyong; Lee, Seung Hun; Giebisch, Gerhard; Wang, Tong
Potassium channels and transporters maintain potassium homeostasis and play significant roles in several different biological actions via potassium ion regulation. In previous decades, the key revelations that potassium channels and transporters are involved in the production of gastric acid and the regulation of secretion in the stomach have been recognized. Drugs used to treat peptic ulceration are often potassium transporter inhibitors. It has also been reported that potassium channels are involved in ulcerative colitis. Direct toxicity to the intestines from nonsteroidal anti-inflammatory drugs has been associated with altered potassium channel activities. Several reports have indicated that the long-term use of the antianginal drug Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, increases the chances of ulceration and perforation from the oral to anal regions throughout the gastrointestinal (GI) tract. Several of these drug features provide further insights into the role of potassium channels in the occurrence of ulceration in the GI tract. The purpose of this review is to investigate whether potassium channelopathies are involved in the mechanisms responsible for ulceration that occurs throughout the GI tract.
Kluger, Nicolas; Jokinen, Martta; Krohn, Kai; Ranki, Annamari
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) (or autoimmune polyendocrine syndrome type 1) is a rare autosomal recessive disorder caused by mutations in the autoimmune regulator gene. It causes a loss in central immune tolerance, failure to eliminate autoreactive T cells in the thymus, and their escape to the periphery. APECED patients are susceptible to mucocutaneous candidiasis and multiple endocrine and nonendocrine autoimmune diseases. Although it depends on the series, approximately 25% of APECED patients are affected by gastrointestinal (GI) manifestations, mainly autoimmune-related disorders like autoimmune hepatitis, atrophic gastritis with or without pernicious anemia (Biermer disease), intestinal infections, and malabsorption. In contrast to the major organ-specific autoimmune symptoms of APECED, the GI symptoms and their underlying pathogenesis are poorly understood. Yet isolated case reports and small series depict severe intestinal involvement in children, leading to malabsorption, multiple deficiencies, growth impairment, and possible death. Moreover, very few systematic studies of GI function with intestinal biopsies have been performed. GI symptoms may be the first manifestation of APECED, yet they may have various causes; effective treatment will therefore vary. We provide here an updated review of GI manifestations in APECED, including principles of diagnosis and therapy.
Mearin, Fermín; Rey, Enrique; Balboa, Agustín
This article discusses the most interesting studies on functional and motor gastrointestinal disorders presented at Digestive Diseases Week (DDW), 2015. Researchers are still seeking biomarkers for irritable bowel syndrome and have presented new data. One study confirmed that the use of low-dose antidepressants has an antinociceptive effect without altering the psychological features of patients with functional dyspepsia. A contribution that could have immediate application is the use of transcutaneous electroacupuncture, which has demonstrated effectiveness in controlling nausea in patients with gastroparesis. New data have come to light on the importance of diet in irritable bowel syndrome, although the effectiveness of a low-FODMAP diet seems to be losing momentum with time. Multiple data were presented on the long-term efficacy of rifaximin therapy in patients with irritable bowel syndrome and diarrhoea. In addition, among other contributions, and more as a curiosity, a study evaluated the effect of histamine in the diet of patients with irritable bowel syndrome. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Desh D. Singh
Full Text Available Intestinal microbiota play an important role in maintaining normal gastrointestinal (GI function and ensuring that changes in the composition of the intestinal microbiota can promote GI function. The digestive tract is full of bacteria and many of these, including probiotics, are necessary for optimal digestive function. During bacterial gastroenteritis, harmful bacteria invade the digestive tract causing unpleasant symptoms and upsetting the balance between good and bad bacteria. Supplemental probiotics can help restore this balance. Studies have demonstrated that probiotics can often help reduce the severity of symptoms such as diarrhea and may help accelerate recovery. Probiotics are therapeutic preparations of live microorganisms administered in sufficient dosage to be beneficial to health. The therapeutic effects of these microorganisms appear to be strain specific. Primal Defense®, a unique, probiotic, bacterial compound, contains probiotics that support gut flora balance, promote consistent bowel function, control stomach acid levels to quickly eliminate burning sensation in the stomach and maintain immune system response. The probiotics in Primal Defense® maximize the benefits of a healthy diet by supporting normal absorption and assimilation of nutrients in the gut. Nearly 75% of our immune defenses are located in the digestive tract, so maintaining a favorable bacterial balance in the intestines (ideally 80% good or neutral bacteria to 20% bad or harmful bacteria is crucial to achieving and maintaining optimum health.
Menciassi, Arianna; Quirini, Marco; Dario, Paolo
The impulse given by robotic technologies and imaging techniques to the development of a new way to conceive and perform surgery is clearly visible. Nowadays, minimally invasive surgical (MIS) procedures are often performed with the assistance of robots, such as the Da Vinci master-slave system, the AESOP robot with voice control, etc. In addition, mechatronic technologies are becoming the elective technologies for designing advanced hand-held surgical tools. The introduction of robotic technologies in endoscopy has been slower than in MIS, since the development of miniaturized robotic components for entering the small orifices of the human body is difficult. On the other hand, the large contribution that robotic technologies could bring to endoluminal techniques has been evident since the first development of instrumented catheters. In the 1990s, there was an increasing activity in the application of robotic technologies to improve endoscopic procedures in the gastrointestinal tract. The objective of robotic colonoscopy and gastroscopy was to obtain more effective diagnoses in terms of reduced pain for the patients, and to make uniform the diagnostic procedures, which too often depended on the manual abilities of the endoscopist. Currently, the availability of more reliable robotic technologies for miniaturization of size and integration of functions has allowed to conceive and develop robotic pills for the early screening of the digestive tract, with dramatic potential advantages for patients, endoscopists, and healthcare system.
Gottlieb, Michael; Nakitende, Damali; Sundaram, Tina; Serici, Anthony; Shah, Shital; Bailitz, John
In the emergency department setting, it is essential to rapidly and accurately confirm correct endotracheal tube (ETT) placement. Ultrasound is an increasingly studied modality for identifying ETT location. However, there has been significant variation in techniques between studies, with some using the dynamic technique, while others use a static approach. This study compared the static and dynamic techniques to determine which was more accurate for ETT identification. We performed this study in a cadaver lab using three different cadavers to represent variations in neck circumference. Cadavers were randomized to either tracheal or esophageal intubation in equal proportions. Blinded sonographers then assessed the location of the ETT using either static or dynamic sonography. We assessed accuracy of sonographer identification of ETT location, time to identification, and operator confidence. A total of 120 intubations were performed: 62 tracheal intubations and 58 esophageal intubations. The static technique was 93.6% (95% confidence interval [CI] [84.3% to 98.2%]) sensitive and 98.3% specific (95% CI [90.8% to 99.9%]). The dynamic technique was 92.1% (95% CI [82.4% to 97.4%]) sensitive and 91.2% specific (95% CI [80.7% to 97.1%]). The mean time to identification was 6.72 seconds (95% CI [5.53 to 7.9] seconds) in the static technique and 6.4 seconds (95% CI [5.65 to 7.16] seconds) in the dynamic technique. Operator confidence was 4.9/5.0 (95% CI [4.83 to 4.97]) in the static technique and 4.86/5.0 (95% CI [4.78 to 4.94]) in the dynamic technique. There was no statistically significant difference between groups for any of the outcomes. This study demonstrated that both the static and dynamic sonography approaches were rapid and accurate for confirming ETT location with no statistically significant difference between modalities. Further studies are recommended to compare these techniques in ED patients and with more novice sonographers.
Full Text Available Introduction Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS transportation. Measurement of endotracheal tube (ETT cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. Methods We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. Results We analyzed data for 55 patients. There was a mean age of 57 years (range 18–90. The mean ETT cuff pressure was 70 (95% CI= [61–80] cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p120 cmH2O, the maximum pressure on the analog gauge. Conclusion Patients presenting to HEMS after intubation by the referral agency (EMS or hospital have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.
Fabricius-Bjerre, Andreas; Overgaard, Anders; Winther-Olesen, Marie
Brain activation reduces balance between cerebral consumption of oxygen versus carbohydrate as expressed by the so-called cerebral oxygen-carbohydrate-index (OCI). We evaluated whether preparation for surgery, anaesthesia including tracheal intubation and surgery affect OCI. In patients undergoing...... aortic surgery, arterial to internal jugular venous (a-v) concentration differences for oxygen versus lactate and glucose were determined from before anaesthesia to when the patient left the recovery room. Intravenous anaesthesia was supplemented with thoracic epidural anaesthesia for open aortic surgery...
Honardar, Marzieh R; Posner, Karen L; Domino, Karen B
This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%-64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%).
Yıldırım, İlker; İnal, Mehmet Turan; Memiş, Dilek; Turan, F Nesrin
Pregnancy-induced anatomical and physiological changes in the airway make airway management difficult in obstetric patients; thus, preoperative evaluation of the airway is important for obstetric patients. To determine the effectiveness of the modified Mallampati test; the interincisor, sternomental and thyromental distances and the upper limb bite test. The second aim was to assess the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. Cross-sectional study. Pregnant women (n=250) scheduled for caesarean section were analysed. The patients' ages, heights and weights were collected. Preoperative airway evaluation was done by using a modified version of the Mallampati test. The interincisor, sternomental and thyromental distances were measured, and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by using Cormack-Lehane classification. No statistically significant differences were found between groups in age, height or weight (p>0.05). The modified Mallampati test and interincisor, sternomental and thyromental distances revealed a lower number of easy intubations than that determined by the Cormack-Lehane classification and a higher number of difficult intubations than the actual number of cases (p<0.05). The sensitivity and specificity of the modified Mallampati test, the upper limb bite test, the interincisor distance test and the sternomental and thyromental distance tests were found to be 73.08, 57.69, 84.62, 80.77 and 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05, respectively. When the combinations were examined, the sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test were found to be 57.69 and 100, respectively. When the upper limb bite test was combined with the interincisor distance, the sensitivity and specificity were 46.15 and 100, respectively. We found a sensitivity and specificity of 93.75 and 95
Full Text Available Background: Pregnancy-induced anatomical and physiological changes in the airway make airway management difficult in obstetric patients; thus, preoperative evaluation of the airway is important for obstetric patients. Aims: To determine the effectiveness of the modified Mallampati test; the interincisor, sternomental and thyromental distances and the upper limb bite test. The second aim was to assess the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. Study Design: Cross-sectional study. Methods: Pregnant women (n=250 scheduled for caesarean section were analysed. The patients" ages, heights and weights were collected. Preoperative airway evaluation was done by using a modified version of the Mallampati test. The interincisor, sternomental and thyromental distances were measured, and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by using Cormack-Lehane classification. Results: No statistically significant differences were found between groups in age, height or weight (p>0.05. The modified Mallampati test and interincisor, sternomental and thyromental distances revealed a lower number of easy intubations than that determined by the Cormack-Lehane classification and a higher number of difficult intubations than the actual number of cases (p<0.05. The sensitivity and specificity of the modified Mallampati test, the upper limb bite test, the interincisor distance test and the sternomental and thyromental distance tests were found to be 73.08, 57.69, 84.62, 80.77 and 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05, respectively. When the combinations were examined, the sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test were found to be 57.69 and 100, respectively. When the upper limb bite test was combined with the interincisor distance, the sensitivity and specificity were 46.15 and 100, respectively
Murray, H W; Roberts, R B
Twenty-six adults with Streptococcus bovis endocarditis and ten with bacteremia alone were studied to determine possible portals of entry. Of 36 patients (17 with endocarditis, eight with bacteremia alone), 25 had gastrointestinal lesions or manipulation. In 22, the gastrointestinal tract appeared to be the source of S bovis bacteremia. Four patients had either carcinoma of the colon (two) or potentially malignant villous adenomas (two) when first seen because of S bovis bacteremia. None of these, nor two other patients with benign colonic polyps, had bowel-related symptoms or signs prior to admission. Since S bovis is a normal intestinal tract inhabitant, bacteremia may frequently be associated with bowel lesions. Streptococcus bovis bacteremia may provide an early clue to the presence of serious and clinically unexpected gastrointestinal disease. Gastrointestinal tract evaluation should be part of S bovis bacteremia patient management, with or without endocarditis.
Gouma, D. J.; de Wit, L. T.; Nieveen van Dijkum, E.; van Delden, O.; Bemelman, W. A.; Rauws, E. A.; van Lanschot, J. J.; Obertop, H.
BACKGROUND: Diagnostic laparoscopy has been used frequently as a preoperative staging procedure for different gastrointestinal malignancies. The assessment of solid abdominal organs and retroperitoneal ingrowth or detection of lymph-node metastasis is limited, however. A recent development,
This page lists cancer drugs approved by the Food and Drug Administration (FDA) for gastrointestinal stromal tumors (GIST). The list includes generic names and brand names. The drug names link to NCI's Cancer Drug Information summaries.
Hahn, Soojung; Yoo, Jongman
An organoid is a cellular structure three-dimensionally (3D) cultured from self-organizing stem cells in vitro, which has a cell population, architectures, and organ specific functions like the originating organs. Recent advances in the 3D culture of isolated intestinal crypts or gastric glands have enabled the generation of human gastrointestinal epithelial organoids. Gastrointestinal organoids recapitulate the human in vivo physiology because of all the intestinal epithelial cell types that differentiated and proliferated from tissue resident stem cells. Thus far, gastrointestinal organoids have been extensively used for generating gastrointestinal disease models. This protocol describes the method of isolating a gland or crypt using stomach or colon tissue after surgery and establishing them into gastroids or colonoids.
Nijhawan, S; Rai, R R; Agarwal, S; Vijayvergiya, R
We report management of unusual foreign bodies of upper gastrointestinal tract, namely beer bottle cap, raisins and pistachu, mango peel, betelnut and plum seed at a university hospital in Northern India.
Zhao, Jingbo; Liao, Donghua; Yang, Jian
Gastrointestinal tract sensory-motor abnormalities are common in patients with diabetes mellitus with symptoms arising from the whole GI tract. Common complaints include dysphasia, early satiety, reflux, constipation, abdominal pain, nausea, vomiting, and diarrhea. The pathogenesis of GI symptoms...
Ayman E. Eskander
CONCLUSION: Ketamine sedation found to be safe for paediatric gastrointestinal endoscopy in Egyptian children without co-morbidities. Transient Hypoxia (13% may occur but easily reversed by nasal oxygen therapy.
Samarasena, Jason B; Hu, Ke-Qin
Hepatobiliary manifestations of gastrointestinal and nutritional disorders can occur as part of the clinical spectrum of the underlying disease or as a consequence of the treatment of the disease. This article reviews aspects of pathogenesis, diagnosis, and management of hepatobiliary manifestations associated with a selection of gastrointestinal and nutritional disorders including inflammatory bowel disease, celiac disease, Whipple's disease, and parenteral nutrition associated disorders. Copyright © 2011 Elsevier Inc. All rights reserved.
Silverman, J M; Hamlin, J A
It is well known that malignant melanoma can metastasize widely. Although these metastases in the gastrointestinal tract usually appear as small 'bull's-eye' or 'target' lesions, there are a few reports of relatively large melanoma metastases. We report five cases of large melanoma lesions metastatic to the alimentary canal. We also emphasise the consideration of a thorough gastrointestinal tract evaluation in patients with malignant melanoma especially if they are symptomatic.
Rehfeld, Jens F
Gastrointestinal hormones are peptides released from neuroendocrine cells in the digestive tract. More than 30 hormone genes are currently known to be expressed in the gut, which makes it the largest hormone-producing organ in the body. Modern biology makes it feasible to conceive the hormones un......, but also constitute regulatory systems operating in the whole organism. This overview of gut hormone biology is supplemented with an annotation on some Scandinavian contributions to gastrointestinal hormone research....
Sedation practices for gastrointestinal endoscopic (GIE) procedures vary widely in different countries depending on health system regulations and local circumstances. The goal of procedural sedation is the safe and effective control of pain and anxiety, as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation-related complications in gastrointestinal endoscopy, once occurred, can lead to significant morbidity and occasional mortality in patients. The risk fa...
This article summarizes the main studies in the field of non-variceal gastrointestinal bleeding reported in the last American Congress of Gastroenterology (Digestive Disease Week) in 2013. Some of these studies have provided new knowledge and expertise in areas of uncertainty. In this context and among other findings, it has been reported that the administration of a proton pump inhibitor (PPI) prior to endoscopy or the early performance of endoscopy-within 6 hours of admission in patients with upper gastrointestinal bleeding (UGIB) (or colonoscopy within 24 hours in patients with lower gastrointestinal bleeding)-does not improve the prognosis of the event. It has also been reported that oral administration of a PPI after endoscopic hemostasis may produce a similar outcome to that of intravenously administered PPI in patients with upper gastrointestinal bleeding (UGIB). In the field of endoscopic therapy, the use of radiofrequency ablation for antral vascular ectasia is of interest. Regarding UGIB and nonsteroidal antiinflammatory drugs (NSAIDs), new data confirm the risk of cardiovascular events by stopping treatment with acetylsalicylic acid (ASA) after an episode of UGIB, the increased risk of UGIB when associating gastrotoxic drugs, and the need to identify both the gastrointestinal and cardiovascular risks of each NSAID and coxib when prescribing these agents. Finally, there is evidence that both environmental and genetic factors are involved in individual susceptibility to gastrointestinal bleeding. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Orlando, Antonella; Russo, Francesco
Cancers of the gastrointestinal tract account for 25 % of all cancers and for 9 % of all causes of cancer death in the world, so gastrointestinal cancers represent a major health problem. In the past decades, an emerging role has been attributed to the interactions between the gastrointestinal content and the onset of neoplasia. Thus, exogenous microbial administration of peculiar bacterial strains (probiotics) has been suggested as having a profound influence on multiple processes associated with a change in cancer risk. Probiotics are mono or mixed cultures of live microorganisms that might beneficially affect the host by improving the characteristics of indigenous microflora. Although the effects of probiotic administration has been intensively investigated in vitro, in animal models, in healthy volunteers, and in some human gastrointestinal diseases, very little is still known about the possible cross-interactions among probiotic administration, changes of intestinal flora, and the neoplastic transformation of gastrointestinal mucosa. Theoretically, probiotics are able to reduce cancer risk by a number of mechanisms: (a) binding and degradation of potential carcinogens; (b) quantitative, qualitative and metabolic alterations of the intestinal microflora; (c) production of anti-tumorigenic or anti-mutagenic compounds; (d) competitive action towards pathogenic bacteria; (e) enhancement of the host's immune response; (f) direct effects on cell proliferation. This review will attempt to highlight the literature on the most widely recognized effects of probiotics against neoplastic transformation of gastrointestinal mucosa and in particular on their effects on cell proliferation.
Glassman, Laura W; Grocott, Olivia R; Kunz, Portia A; Larson, Anna M; Zella, Garrett; Ganguli, Kriston; Thibert, Ronald L
Angelman syndrome (AS) is a neurogenetic disorder characterized by intellectual disability, expressive speech impairment, movement disorder, epilepsy, and a happy demeanor. Children with AS are frequently reported to be poor feeders during infancy and as having gastrointestinal issues such as constipation, reflux, and abnormal food related behaviors throughout their lifetime. To assess the prevalence of gastrointestinal disorders in individuals with AS, we retrospectively analyzed medical records of 120 individuals seen at the Angelman Syndrome Clinic at Massachusetts General Hospital and 43 individuals seen at the University of North Carolina Comprehensive Angelman Clinic. The majority of patients' medical records indicated at least one symptom of gastrointestinal dysfunction, with constipation and gastroesophageal reflux disease (GERD) the most common. Other gastrointestinal issues reported were cyclic vomiting episodes, difficulty swallowing, excessive swallowing, and eosinophilic esophagitis. Upper gastrointestinal symptoms such as GERD, swallowing difficulties, cyclic vomiting, and eosinophilic esophagitis were more common in those with deletions and uniparental disomy, likely related to the involvement of multiple genes and subsequent hypotonia. The frequency of constipation is consistent among all genetic subtypes while early feeding issues appear to mainly affect those with deletions. Caregivers and healthcare providers should be aware of the high prevalence of these issues, as proper treatment may improve not only gastrointestinal dysfunction but also sleep and behavioral issues. © 2017 Wiley Periodicals, Inc.
Sulser, Simon; Ubmann, Dirk; Schlaepfer, Martin; Brueesch, Martin; Goliasch, Georg; Seifert, Burkhardt; Spahn, Donat R; Ruetzler, Kurt
Airway management in the emergency room can be challenging when patients suffer from life-threatening conditions. Mental stress, ignorance of the patient's medical history, potential cervical injury or immobilisation and the presence of vomit and/or blood may also contribute to a difficult airway. Videolaryngoscopes have been introduced into clinical practice to visualise the airway and ultimately increase the success rate of airway management. The aim of this study was to test the hypothesis that the C-MAC videolaryngoscope improves first-attempt intubation success rate compared with direct laryngoscopy in patients undergoing emergency rapid sequence intubation in the emergency room setting. A randomised clinical trial. Emergency Department of the University Hospital, Zurich, Switzerland. With approval of the local ethics committee, we prospectively enrolled 150 patients between 18 and 99 years of age requiring emergency rapid sequence intubation in the emergency room of the University Hospital Zurich. Patients were randomised (1 : 1) to undergo tracheal intubation using the C-MAC videolaryngoscope or by direct laryngoscopy. Owing to ethical considerations, patients who had sustained maxillo-facial trauma, immobilised cervical spine, known difficult airway or ongoing cardiopulmonary resuscitation were excluded from our study. All intubations were performed by one of three very experienced anaesthesia consultants. First-attempt success rate served as our primary outcome parameter. Secondary outcome parameters were time to intubation; total number of intubation attempts; Cormack and Lehane score; inadvertent oesophageal intubation; ease of intubation; complications including violations of the teeth, injury/bleeding of the larynx/pharynx and aspiration/regurgitation of gastric contents; necessity of using further alternative airway devices for successful intubation; maximum decrease of oxygen saturation and technical problems with the device. A total of 150
Smereka, Jacek; Ladny, Jerzy R; Naylor, Amanda; Ruetzler, Kurt; Szarpak, Lukasz
The aim of this study was to compare C-MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Scenario A: Nearly all participants performed successful intubations with both MAC and C-MAC on the first attempt (95.7% MAC vs. 100% C-MAC), with similar intubation times (16.5s MAC vs. 18s C-MAC). Scenario B: The results with C-MAC were significantly better than those with MAC (pimmobilization. Copyright © 2017 Elsevier Inc. All rights reserved.
Larsen, P B; Hansen, E G; Jacobsen, L S
conditions of standard doses of rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] during a strict rapid-sequence induction regimen including propofol and alfentanil. Methods: Male and female patients (ASA I-III) older than 17 yr scheduled for emergency abdominal or gynaecological surgery...... 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] provide clinically acceptable intubation conditions in 60 s in patients scheduled for emergency surgery. Under the conditions of this rapid-sequence induction regimen rocuronium may be a substitute for succinylcholine.......Background and objective: Previous studies mainly conducted on elective patients recommend doses of 0.9-1.2 mg kg[-1] rocuronium to obtain comparable intubation conditions with succinylcholine 1.0 mg kg[-1] after 60 s during a rapid-sequence induction. We decided to compare the overall intubating...
Hye Seung Lee
Full Text Available With recent advances in molecular diagnostic methods and targeted cancer therapies, several molecular tests have been recommended for gastric cancer (GC and colorectal cancer (CRC. Microsatellite instability analysis of gastrointestinal cancers is performed to screen for Lynch syndrome, predict favorable prognosis, and screen patients for immunotherapy. The epidermal growth factor receptor (EGFR tyrosine kinase inhibitor has been approved in metastatic CRCs with wildtype RAS (KRAS and NRAS exon 2–4. A BRAF mutation is required for predicting poor prognosis. Additionally, amplification of human epidermal growth factor receptor 2 (HER2 and MET is also associated with resistance to EGFR inhibitor in metastatic CRC patients. The BRAF V600E mutation is found in sporadic microsatellite unstable CRCs, and thus is helpful for ruling out Lynch syndrome. In addition, the KRAS mutation is a prognostic biomarker and the PIK3CA mutation is a molecular biomarker predicting response to phosphoinositide 3-kinase/AKT/mammalian target of rapamycin inhibitors and response to aspirin therapy in CRC patients. Additionally, HER2 testing should be performed in all recurrent or metastatic GCs. If the results of HER2 immunohistochemistry are equivocal, HER2 silver or fluorescence in situ hybridization testing are essential for confirmative determination of HER2 status. Epstein-Barr virus–positive GCs have distinct characteristics, including heavy lymphoid stroma, hypermethylation phenotype, and high expression of immune modulators. Recent advances in next-generation sequencing technologies enable us to examine various genetic alterations using a single test. Pathologists play a crucial role in ensuring reliable molecular testing and they should also take an integral role between molecular laboratories and clinicians.
Patel, Vivek; Armstrong, David; Ganguli, Malika; Roopra, Sandeep; Kantipudi, Neha; Albashir, Siwar; Kamath, Markad V
Gastrointestinal (GI) endoscopy is used to inspect the lumen or interior of the GI tract for several purposes, including, (1) making a clinical diagnosis, in real time, based on the visual appearances; (2) taking targeted tissue samples for subsequent histopathological examination; and (3) in some cases, performing therapeutic interventions targeted at specific lesions. GI endoscopy is therefore predicated on the assumption that the operator-the endoscopist-is able to identify and characterize abnormalities or lesions accurately and reproducibly. However, as in other areas of clinical medicine, such as histopathology and radiology, many studies have documented marked interobserver and intraobserver variability in lesion recognition. Thus, there is a clear need and opportunity for techniques or methodologies that will enhance the quality of lesion recognition and diagnosis and improve the outcomes of GI endoscopy. Deep learning models provide a basis to make better clinical decisions in medical image analysis. Biomedical image segmentation, classification, and registration can be improved with deep learning. Recent evidence suggests that the application of deep learning methods to medical image analysis can contribute significantly to computer-aided diagnosis. Deep learning models are usually considered to be more flexible and provide reliable solutions for image analysis problems compared to conventional computer vision models. The use of fast computers offers the possibility of real-time support that is important for endoscopic diagnosis, which has to be made in real time. Advanced graphics processing units and cloud computing have also favored the use of machine learning, and more particularly, deep learning for patient care. This paper reviews the rapidly evolving literature on the feasibility of applying deep learning algorithms to endoscopic imaging.
Gupta, Nancy; Haq, Khwaja F.; Mahajan, Sugandhi; Nagpal, Prashant; Doshi, Bijal
Patient: Female, 66 Final Diagnosis: Calciphylaxis Symptoms: Gastrointesinal haemorrhage Medication: None Clinical Procedure: Hemodialysis • blood transfusions Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Calciphylaxis is associated with a high mortality that approaches 80%. The diagnosis is usually made when obvious skin lesions (painful violaceous mottling of the skin) are present. However, visceral involvement is rare. We present a case of calciphylaxis leading to lower gastrointestinal (GI) bleeding and rectal ulceration of the GI mucosa. Case Report: A 66-year-old woman with past medical history of diabetes mellitus, hypertension, end-stage renal disease (ESRD), recently diagnosed ovarian cancer, and on hemodialysis (HD) presented with painful black necrotic eschar on both legs. The radiograph of the legs demonstrated extensive calcification of the lower extremity arteries. The hospital course was complicated with lower GI bleeding. A CT scan of the abdomen revealed severe circumferential calcification of the abdominal aorta, celiac artery, and superior and inferior mesenteric arteries and their branches. Colonoscopy revealed severe rectal necrosis. She was deemed to be a poor surgical candidate due to comorbidities and presence of extensive vascular calcifications. Recurrent episodes of profuse GI bleeding were managed conservatively with blood transfusion as needed. Following her diagnosis of calciphylaxis, supplementation with vitamin D and calcium containing phosphate binders was stopped. She was started on daily hemodialysis with low calcium dialysate bath as well as intravenous sodium thiosulphate. The clinical condition of the patient deteriorated. The patient died secondary to multiorgan failure. Conclusions: Calciphylaxis leading to intestinal ischemia/perforation should be considered in the differential diagnosis in ESRD on HD presenting with abdominal pain or GI bleeding. PMID:26572938
Abu Lais Mustaque
Full Text Available INTRODUCTION Laryngoscopy and intubation is an integral part for providing general anaesthesia to patients undergoing various types of surgery. It also plays an important role in critical care units viz. for providing mechanical ventilation. It is a very essential tool in the hands of anaesthesiologist in maintaining airway. The present study is undertaken to determine and compare the efficacy of single bolus dose of IV esmolol 1 mg/kg and IV fentanyl 2 mcg/kg in attenuating the haemodynamic responses to laryngoscopy and tracheal intubation and to ascertain the effectiveness of esmolol hydrochloride and fentanyl citrate in suppressing sympathetic responses. MATERIAL & METHODS The study was conducted under the Department of Anaesthesiology and Critical Care, Assam Medical College and Hospital, Dibrugarh, during the period July 2013 to June 2014. For this purpose, 150 patients of either sex between 20-50 years of ASA I & II physical status were selected after obtaining informed and written consent and were divided into two groups namely, Group E receiving IV esmolol (1 mg/kg and Group F receiving IV fentanyl (2 mcg/kg. RESULTS Inj. fentanyl 2 mcg/kg IV administered 5 minutes before laryngoscopy and intubation was able to prevent adverse haemodynamic changes better than Inj. esmolol 1 mg/kg IV administered 3 minutes prior to laryngoscopy and intubation during elective surgeries under general anaesthesia. CONCLUSION Hence, from the findings of this study we can conclude that IV bolus dose of fentanyl 2 mcg/kg administered 5 minutes before laryngoscopy and intubation can attenuate the sympathetic response to laryngoscopy and intubation without any side effects of the drug in healthy patients undergoing elective surgeries under general anaesthesia.
van der Lee, Lisa; Hill, Anne-Marie; Patman, Shane
Community acquired pneumonia (CAP) is a common reason for admission to an intensive care unit for intubation and mechanical ventilation, and results in high morbidity and mortality. The primary aim of the study was to investigate availability and provision of respiratory physiotherapy, outside of normal business hours, for intubated and mechanically ventilated adults with CAP in Australian hospitals. A cross-sectional, mixed methods online survey was conducted. Participants were senior intensive care unit physiotherapists from 88 public and private hospitals. Main outcome measures included presence and nature of an after-hours physiotherapy service and factors perceived to influence the need for after-hours respiratory physiotherapy intervention, when the service was available, for intubated adult patients with CAP. Data were also collected regarding respiratory intervention provided after-hours by other ICU professionals. Response rate was 72% (n=75). An after-hours physiotherapy service was provided by n=31 (46%) hospitals and onsite after-hours physiotherapy presence was limited (22%), with a combination of onsite and on-call service reported by 19%. Treatment response (83%) was the most frequent factor for referring patients with CAP for after-hours physiotherapy intervention by the treating day-time physiotherapist. Nurses performing respiratory intervention (77%) was significantly associated with no available after-hours physiotherapy service (p=0.04). Physiotherapy after-hours service in Australia is limited, therefore it is common for intubated patients with CAP not to receive any respiratory physiotherapy intervention outside of normal business hours. In the absence of an after-hours physiotherapist, nurses were most likely to perform after-hours respiratory intervention to intubated patients with CAP. Further research is required to determine whether the frequency of respiratory physiotherapy intervention, including after-hours provision of treatment
Trbolova, Alexandra; Ghaffari, Masoud Selk; Capik, Igor
Gabapentin is an antiepileptic drug widely approved as an add-on therapy for epilepsy treatment in human and dogs. There is a clinical impression that gabapentin is a suitable drug which attenuates the IOP elevation associated with tracheal intubation in humans. The present study performed to determine the effects of oral gabapentin on intraocular pressure (IOP) changes following tracheal intubation in dogs. Twenty adult healthy dogs were randomly assigned to treatment (n = 10) and control (n = 10) groups. Dogs in the treatment group received oral gabapentin (50 mg/kg) 2 h before induction of anesthesia and dogs in the control group received oral gelatin capsule placebo at the same time. The dogs were anesthetized with propofol 6 mg/kg, and anesthesia was maintained with a constant infusion of 0.2 mg/kg/min of propofol for 20 min. IOP were measured immediately before induction and then repeated immediately after induction, as well as 5 min, 10 min and 15 min following tracheal intubation in both groups. IOP was significantly higher immediately after induction, and 5 min after tracheal intubation when compared with IOP reading before induction in the control group. There was no statistically significant change in IOPs immediately after induction, and 5 min after tracheal intubation in comparison to the values before induction in the treatment group. Based on the findings of this study, preanesthetic oral administration of gabapentin significantly prevents an increase in the IOP associated with tracheal intubation in dogs anesthetized with propofol.
Manzar, Shabih; Nair, Arun K; Pai, Mangalore G; Paul, Jose; Manikoth, Prakash; Georage, Mariam; Al-Khusaiby, Saleh M
Nasal intermittent positive pressure ventilation (NIPPV) has widely been used in neonates to prevent extubation failure and apnea. This pilot study was carried out to look at the early use of NIPPV to avoid intubation. The study was carried out over a period of 3 months from August 2003 to October 2003 at the Royal Hospital, Muscat, Sultanate of Oman. The neonates with clinical signs of moderate to severe respiratory distress were given a trial of early NIPPV based on the avoid-intubation protocol. Inclusion, exclusion and failure criteria with general procedure were made clear to all medical and nursing staff and the protocol was posted in the unit for further time to time referral. A total of 16 neonates met the inclusion criteria for early NIPPV trial. Out of these, 13 (81%) had a successful NIPPV. The mean age of entry was 0.95 hours; however, the mean duration of NIPPV was 23 hours. No NIPPV related complications were noted in the study group. We concluded that NIPPV is an appropriate mode of ventilation in neonates requiring respiratory support. The major advantage of NIPPV is the non-invasive mechanics. It is also less expensive and less labor intensive. Further randomized controlled trials with larger sample size are warranted to confirm our findings.
Negm, Hesham; Mosleh, Mohamed; Fathy, Hesham
The objective of this study is to evaluate the results of circumferential tracheal and cricotracheal resection with primary anastomosis for the treatment of post-intubation tracheal and cricotracheal stenosis. This is a retrospective analytical study. A total number of 24 patients were included in this study. The relevant preoperative, operative and postoperative records were collected and analyzed. Twenty patients were finally symptom-free reflecting an anastomosis success rate of 83.3 %. Variable grades of anastomotic restenosis occurred in 11 (45.8 %) patients, three patients were symptom-free and eight had airway obstructive symptoms. Four out of the eight patients with symptomatic restenosis were symptom-free with endoscopic dilatation while the remaining four patients required a permanent airway appliance (T-tube, tracheostomy) for the relief of airway obstruction and this group was considered as anastomotic failure. Cricoid involvement, associated cricoid resection and the type of anastomosis were the variables that had statistical impact on the occurrence of restenosis (P = 0.017, 0.017, 0.05; respectively). Tracheal resection with primary anastomosis is a safe effective treatment method for post-intubation tracheal stenosis in carefully selected patients. Restenosis does not always mean failure of the procedure since it may be successfully managed with endoscopic dilatation.
Rocha Ana C
Full Text Available Abstract Background Carinal hooks increases difficulty at endotracheal intubation. Amputation of the carinal hook during passage and malpositioning of the tube to the hook are some of the potential problems related with left-sided Carlens double lumen tube (DLT. This article reports an amputation of the hook during a difficult selective intubation and aimed at calling the attention to complications associated with DLTs and the importance of fiberoptic bronchoscopy. Case presentation A 68 year-old woman was scheduled for right-sided thoracotomy in whom blind DLT insertion was performed. Narrowed trachea causes difficulty in rotating the DLT 90° counter-clockwise. After carinal hook was noticed upon visual inspection of the DLT, fiberoptic bronchoscopy was used to remove the missing part (with the use of forceps from the right mainstem bronchus. Conclusion Insertion of DLTs with carinal hook is associated with technical problems and potentially life-threatening hazards have discouraged their use. Fiberoptic evaluation and repositioning solves most of the problems. Although amputation of the carinal hook has not been previously reported, clinicians should be alert. This case report emphasizes the utility of the fiberoptic bronchoscopy in the operating theatre for placement, positioning and inspection of the carinal hook DLT.
Budde, Arne O; Desciak, Matthew; Reddy, Venugopal; Falcucci, Octavio A; Vaida, Sonia J; Pott, Leonard M
The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.
Buitrago, Ricardo; Serna, Adriana; González-Rivas, Diego; Beltrán, Rafael; Palacio, Carlos Mario; Parades, Pablo; Beltrán, Julian
The first video-assisted thoracic lobectomy in non-intubated patient in America was performed on 27 th of September 2014 in Bogotá Colombia, The National Cancer Institute in Bogotá received Dr. Diego González-Rivas to make possible this kind of procedure in a 53-year-old man, with a history of papillary thyroid cancer treated with surgery and Iodine therapy, in whom two pulmonary nodules were found in the monitoring tomography. We resected the nodule located at the right upper lobe previously marked by scintigraphy, the other one required a lobectomy because it was a deep nodule with malignant radiologic appearance inside of the middle lobe. The procedure discoursed in a non-intubated patient without technical difficulties or complications, very short recovery time, minimum pain and a quiet and usual postoperative evolution. This procedure, the first reported in America was replicated after others with similar results in several countries thanks to the collaboration between surgeons, anesthesiologists, radiologists, nurses and therapists, because especially in such interventions teamwork is essential. We believe that given the benefits in terms of recovery for the patient and anesthetic time, we could go on replicating the experience in selected patients.
Sippl, Philipp; Ganslandt, Thomas; Prokosch, Hans-Ulrich; Muenster, Tino; Toddenroth, Dennis
Fine-meshed perioperative measurements are offering enormous potential for automatically investigating clinical complications during general anesthesia. In this study, we employed multiple machine learning methods to model perioperative hypoxia and compare their respective capabilities. After exporting and visualizing 620 series of perioperative vital signs, we had ten anesthesiologists annotate the subjective presence and severity of temporary post-intubation oxygen desaturation. We then applied specific clustering and prediction methods on the acquired annotations, and evaluated their performance in comparison to the inter-rater agreement between experts. When reproducing the expert annotations, the sensitivity and specificity of multi-layer neural networks substantially outperformed clustering and simpler threshold-based methods. The achieved performance of our best automated hypoxia models thereby approximately equaled the observed agreement between different medical experts. Furthermore, we deployed our classification methods for processing unlabeled inputs to estimate the incidence of hypoxic episodes in another sizeable patient cohort, which attests to the feasibility of using the approach on a larger scale. We interpret that our machine learning models could be instrumental for computerized observational studies of the clinical determinants of post-intubation oxygen deficiency. Future research might also investigate potential benefits of more advanced preprocessing approaches such as automated feature learning.
Full Text Available Jonathan D Litten1, JungHun Choi2, David Drozek31Department of Mechanical Engineering; 2Department of Mechanical Engineering and Biomedical Engineering Program; 3College of Osteopathic Medicine, Department of Specialty Medicine, Ohio University, Athens, OH, USAAbstract: A colonoscopy add-on device has been developed to reduce intubation time without modification of the current colonoscope and peripheral devices. One of the main purposes of the system is to minimize trauma caused by the distal tip of the colonoscope. The detachable sensory fixture at the end of the distal tip measures the distance between the distal tip and the colon wall in three directions, and the actuation system attached at the base of the colonoscope controls the distal tip by rotating two dial knobs. The device controls the distal tip to minimize contact between the distal tip and the colon wall, and the distal tip ideally points out the next possible lumen. A compatibility test of the infrared sensory system was carried out, and the design of the actuation system was accomplished. The system is integrated and controlled by a microprocessor. The device was tested in a silicon colon and porcine intestine. The results showed that a colonoscopist successfully reached the cecum with the aid of the colonoscopy add-on device without significant contact between the colon wall and the distal tip. The colonoscopy aid device was very helpful for the novice colonoscopist.Keywords: colonoscope, infrared sensors, intubation, trauma, colonoscopy training model
Full Text Available Amyotrophic Lateral Sclerosis is a rapidly progressive disease from the fi fth to sixth decades of life causing degeneration and death of the upper and lower motor neurons and no effective treatment. The diagnosis isdependent on the clinical presentation and consistent electrodiagnostic studies. Progressive denervation affects the muscles, causing muscular weakness and atrophy, when the ventilation muscles are affected deathdue to respiratory failure occurs within a few years. We present the case of a 54 years old, 180 cm height and 94 kg weight male patient with amyotrophic lateral sclerosis who underwent surgical treatment of thyroidcancer. Fiberoptic intubation was orally performed providing spontaneus breathing. Propofol was applied after passing vocal cords. Anesthesia was maintained with sevofl orane (%2 and a mixture of oxygen and airunder volume controlled ventilation. Rocuronium was used 20 mg at the beginning of the surgery. At the end of surgery, he wasn’t extubated and transferred to anesthesia intensive care unit. He was extubated after tenhours and he was awaked perfectly. The patient was discharged from intensive care unit after 24 hours and from hospital after ten days. We reported that amyotrophic lateral sclerosis patient with limited mouth opening who underwent thyroid surgery, using awake intubation.
Full Text Available Nikolaos Trakos, Emmanouil Mavrikakis, Kostas G Boboridis, Marselos Ralidis, George Dimitriadis, Ioannis MavrikakisOculoplastic Service, Metropolitan Hospital, Athens, GreecePurpose: To describe a modification of the retrograde intubation dacryocystorhinostomy (DCR in patients with proximal canalicular obstruction.Materials and methods: Interventional case report of a 43-year-old female with a nine-month history of left epiphora following a road traffic accident involving the proximal lower canaliculus. An external DCR approach was performed. Following the creation of a lower canalicular pseudopunctum, the O’Donoghue silicone stent was introduced through the common ostium, out through the pseudopunctum of the lower canaliculus, and returned through the punctum of the normal upper canaliculus down through the common ostium into the nose.Results: The patient experienced complete resolution of symptoms and on her last follow-up, two years later, her lower canaliculus was patent to syringing.Conclusion: This modification of the retrograde intubation DCR is an effective technique which decreases the intraoperative time needed to insert the tubes and minimises further trauma to the newly created punctal area.Keywords: retrograde dacryocystorhinostomy, proximal canalicular obstruction, midcanalicular obstruction, conjuctivodacryocystorhinostomy
Sakugawa, Yoko; Kamizato, Kota; Miyata, Yuji; Kakinohana, Manabu; Sugahara, Kazuhiro
We experienced management of general anesthesia in a patients with Coffin-Siris syndrome (CS syndrome) which is an autosomal dominant disorder characterized by mental retardation, growth failure, hypoplasia of the fifth finger's distal phalanx and limb, and syndrome-specific facial appearance. Anesthesia was induced by sevoflurane by mask. After obtaining muscle relaxation by rocuronium, laryngoscopy by Machintosh #2 failed to reveal the vocal cord. However, the vocal cord was revealed by AirwayScope (AWS) for the pediatrics and then tracheal intubation was successful. Surgical procedures and anes-thetic management were performed uneventfully. This case demonstrates usefulness of AWS in pediatric patients with difficult intubation.
Full Text Available BACKGROUND Endotracheal intubation was first described by Rowbotham and Magill in 1921. 1 In 1940 Reid and Brace first described hemodynamic response to Laryngoscopy and Intubation due to Noxious stimuli. 2 The circulatory responses to laryngeal and tracheal stimulation are due to sympathoadrenal stimulation. 3 Laryngoscopy and Tracheal Intubation induces changes in circulating Catecholamine levels significantly. Norepinephrine, Epinephrine and Dopamine levels rise, but the raise in Norepinephrine levels is consistently associated with elevation of Blood pressure and Heart rate. 4 Even though the elevation in Blood pressure and Heart rate due to Laryngoscopy and Intubation are brief, they may have detrimental effects in high risk patients including Myocardial Infarction, Cardiac failure, Intracranial haemorrhage and increases in Intracranial pressure. 5 Many strategies have been advocated to minimize these hemodynamic adverse responses and aimed at different levels of the reflex arc. 6 Block of the peripheral sensory receptors and afferent input is by topical application and infiltration of Local Anaesthetic to Superior laryngeal nerve. Block of central mechanism of integration and sensory input by drugs like Fentanyl, Morphine etc. Block of efferent pathway and effector sites IV Lignocaine, Beta blockers, Calcium channel blockers, Hydralazine etc. No single drug or technique is satisfactory. The aim of this study is to evaluate the efficacy of Gabapentin in attenuating hemodynamic response to laryngoscopy and intubation in a placebo controlled double blind study. MATERIALS AND METHODS A clinical comparative study of attenuation of sympathetic response to laryngoscopy and intubation was done in 150 patients posted for elective surgery divided into two groups and were randomly allocated Group 1 – placebo capsules with sugar and Group 2 – Gabapentin 300 mg capsules. Heart rate, systolic, diastolic blood pressure, mean arterial pressure were
Bhaskar, Nutan; Shweihat, Yousef R; Bartter, Thaddeus
Ultrasound-guided transbronchial needle aspiration using the bronchoscope with a dedicated curvilinear probe has emerged as a primary tool for the investigation of mediastinal pathology. Recently, the utility of this scope has been expanded to include access via the esophagus. In this case series, we describe a role for esophageal ultrasound using the endobronchial ultrasound bronchoscope in the diagnostic evaluation of critically ill/intubated patients with mediastinal disease. Esophageal access with the ultrasound bronchoscope allows the pulmonologist to diagnose mediastinal disease in the intubated patient with minimal risk.
Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq and Truview laryngoscopes may reduce this risk.
Maharaj, C H
The Airtraq Laryngoscope is a novel intubation device which allows visualisation of the vocal cords without alignment of the oral, pharyngeal and tracheal axes. We compared the Airtraq with the Macintosh laryngoscope in simulated easy and difficult laryngoscopy. Twenty-five anaesthetists were allowed up to three attempts to intubate the trachea in each of three laryngoscopy scenarios using a Laerdal Intubation Trainer followed by five scenarios using a Laerdal SimMan Manikin. Each anaesthetist then performed tracheal intubation of the normal airway a second time to characterise the learning curve. In the simulated easy laryngoscopy scenarios, there was no difference between the Airtraq and the Macintosh in success of tracheal intubation. The time taken to intubate at the end of the protocol was significantly lower using the Airtraq (9.5 (6.7) vs. 14.2 (7.4) s), demonstrating a rapid acquisition of skills. In the simulated difficult laryngoscopy scenarios, the Airtraq was more successful in achieving tracheal intubation, required less time to intubate successfully, caused less dental trauma, and was considered by the anaesthetists to be easier to use.
Yi, Jie; Gong, Yahong; Quan, Xiang; Huang, Yuguang
The Airtraq laryngoscope and the GlideScope are commonly used in many airway scenarios. However, their features have not been fully described for double-lumen tube intubation. A prospective randomized study was designed to compare their intubation performances in thoracic surgery patients. Seventy ASA physical status I and II patients with predicted normal airway were scheduled for thoracic surgeries with double-lumen tube intubation. They were randomly assigned to one of two groups and intubated with either the Airtraq laryngoscope (group A, n = 35) or the GlideScope (group G, n = 35). Airway assessments were performed prior to anesthesia, and all patients were induced with a standard anesthetic regimen. The Cormack-Lehane grades were initially evaluated with a Macintosh laryngoscope and subsequently with the group-specific laryngoscope before intubation. Intubation time was recorded as the primary outcome. The Cormack-Lehane grade, the success of the first intubation attempt, the intubation difficulty scales and ease of tube advancement were noted. Hemodynamic variables during intubation and incidence of post-operative sore throat were documented as well. The intubation time of group A was shorter than that of group G (36.6 ± 20.2 s vs. 54.6 ± 25.7 s, p = 0.002). The Cormack-Lehane grade (I/II/III/IV) was significantly better in group A (33/2/0/0 vs. 28/7/0/0, p = 0.042). The mean arterial pressure and heart rate rose to higher levels during intubation with the GlideScope than with the Airtraq laryngoscope. The success of the first intubation attempt and the intubation difficulty scales were comparable between the two groups. The numbers of patients who experienced postoperative sore throat were similar (6 vs. 8) in the two groups. Compared with the GlideScope, the specially designed Airtraq laryngoscope might be more suitable for double-lumen tube intubations in patients with predicted normal airway. www.chictr.org Identifier: Chi
Full Text Available Abstract Background Iron deficiency anaemia (IDA due to occult gastrointestinal (GI blood loss usually remains unnoticed until patient become symptomatic. There is sparse data in IDA patients without gastrointestinal symptoms. This study was designed to find out the frequency and predictors of endoscopic lesions in IDA without gastrointestinal symptoms. Cross-sectional study performed on a convenience sample of consecutive subjects. Methods Ninety five consecutive patients with laboratory based diagnosis of IDA having no gastrointestinal symptoms were interviewed and their clinical and biochemical variables were recorded. All the study patients underwent esophago-gastroduodenoscopy (EGD and colonoscopy. Endoscopic findings were documented as presence/absence of bleeding related lesion and presence/absence of cause of IDA. Multiple logistic regressions were performed to identify variables significantly related to outcome variables. Results Possible cause of anaemia was found in 71% and bleeding related lesions were found in 53% of patients. Upper gastrointestinal tract lesions were found in 41% of patients with bleeding related lesions. On multivariable logistic regression; advancing age, low mean corpuscular volume (MCV ≤ 60 fl, and positive fecal occult blood test were predictive factors for bleeding related GI lesions and cause of IDA Conclusion Clinical and Biochemical markers can predict gastrointestinal lesions on endoscopy in IDA patients without gastrointestinal symptoms. High proportion of upper gastrointestinal involvement warrants EGD as initial endoscopic procedure however, this needs validation by further studies.
Full Text Available The source of most cases of gastrointestinal bleeding is the upper gastrointestinal tract. Since bleeding from the small intestine is very rare and difficult to diagnose, time is required to identify the source. Among small intestine bleeds, vascular abnormalities account for 70–80%, followed by small intestine tumors that account for 5–10%. The reported peak age of the onset of small intestinal tumors is about 50 years. Furthermore, rare small bowel tumors account for only 1–2% of all gastrointestinal tumors. We describe a 29-year-old man who presented with obscure anemia due to gastrointestinal bleeding and underwent laparotomy. Surgical findings revealed a well-circumscribed lesion measuring 45 × 40 mm in the jejunum that initially appeared similar to diverticulosis with an abscess. However, the postoperative pathological diagnosis was a gastrointestinal stromal tumor with extramural growth.
Crewdson, K; Lockey, D J; Røislien, J; Lossius, H M; Rehn, M
Pre-hospital basic airway interventions can be ineffective at providing adequate oxygenation and ventilation in some severely ill or injured patients, and advanced airway interventions are then required. Controversy exists regarding the level of provider required to perform successful pre-hospital intubation. A previous meta-analysis reported pre-hospital intubation success rates of 0.849 for non-physicians versus 0.991 for physicians. The evidence base on the topic has expanded significantly in the last 10 years. This study systematically reviewed recent literature and presents comprehensive data on intubation success rates. A systematic search of MEDLINE and EMBASE was performed using PRISMA methodology to identify articles on pre-hospital tracheal intubation published between 2006 and 2016. Overall success rates were estimated using random effects meta-analysis. The relationship between intubation success rate and provider type was assessed in weighted linear regression analysis. Of the 1838 identified studies, 38 met the study inclusion criteria. Intubation was performed by non-physicians in half of the studies and by physicians in the other half. The crude median (range) reported overall success rate was 0.969 (0.616-1.000). In random effects meta-analysis, the estimated overall intubation success rate was 0.953 (0.938-0.965). The crude median (range) reported intubation success rates for non-physicians were 0.917 (0.616-1.000) and, for physicians, were 0.988 (0.781-1.000) (p = 0.003). The reported overall success rate of pre-hospital intubation has improved, yet there is still a significant difference between non-physician and physician providers. The finding that less-experienced personnel perform less well is not unexpected, but since there is considerable evidence that poorly performed intubation carries a significant risk of morbidity and mortality careful consideration should be given to the training and experience required to deliver this
Full Text Available Background: Cervical spine immobilization results in a poor laryngeal view on direct laryngoscopy leading to difficulty in intubation. This randomized prospective study was designed to compare the laryngeal view and ease of intubation with the Macintosh, McCoy, and TruView laryngoscopes in patients with immobilized cervical spine. Materials and Methods: 60 adult patients of ASA grade I-II with immobilized cervical spine undergoing elective cervical spine surgery were enrolled. Anesthesia was induced with propofol, fentanyl, and vecuronium and maintained with isoflurane and nitrous oxide in oxygen. The patients were randomly allocated into three groups to achieve tracheal intubation with Macintosh, McCoy, or TruView laryngoscopes. When the best possible view of the glottis was obtained, the Cormack-Lehane laryngoscopy grade and the percentage of glottic opening (POGO score were assessed. Other measurements included the intubation time, the intubation difficulty score, and the intubation success rate. Hemodynamic parameters and any airway complications were also recorded. Results: TruView reduced the intubation difficulty score, improved the Cormack and Lehane glottic view, and the POGO score compared with the McCoy and Macintosh laryngoscopes. The first attempt intubation success rate was also high in the TruView laryngoscope group. However, there were no differences in the time required for successful intubation and the overall success rates between the devices tested. No dental injury or hypoxia occurred with either device. Conclusion: The use of a TruView laryngoscope resulted in better glottis visualization, easier tracheal intubation, and higher first attempt success rate as compared to Macintosh and McCoy laryngoscopes in immobilized cervical spine patients.
Szarpak, Łukasz; Karczewska, Katarzyna; Czyżewski, Łukasz; Truszewski, Zenon; Kurowski, Andrzej
We hypothesized that the Airtraq laryngoscope (Airtraq LLC, Bonita Springs, Fla) is beneficial for intubation of pediatric manikins while performing cardiopulmonary resuscitation (CPR). In the present study, we evaluated the effectiveness of the Macintosh (MAC) laryngoscope (HEINE Optotechnik, Munich, Germany) and Airtraq in 3 simulated CPR scenarios. A randomized crossover simulation trial was designed. Eighty-three nurses intubated the trachea of a PediaSIM CPR training manikin (FCAE HealthCare, Sarasota, Fla) using the MAC and Airtraq in a normal airway scenario, normal airway with chest compression scenario, and difficult airway with chest compression scenario. The participants were directed to perform a maximum of 3 attempts in each scenario. The success rate, time to intubation, Cormack & Lehane grade, dental compression, and the ease of intubation were measured. All participants performed successful intubation with the Airtraq in all 3 scenarios. In all scenarios, the success rate was significantly higher and the time to intubation was significantly shorter with the Airtraq than with the MAC. Glottic visualization using the Cormack-Lehane scale was also better when using Airtraq in all scenarios. In this manikin study, we found that the Airtraq can be used successfully for the intubation of pediatric manikins with normal and difficult airways by medical staff without previous experience in pediatric intubation. Moreover, intubation can be achieved without interrupting chest compression. The use of the Airtraq compared with the MAC led to faster time to intubation. Nevertheless, we recommend that the performance of the Airtraq and the MAC during CPR should be further evaluated in a clinical setting.
Semler, Matthew W; Janz, David R; Russell, Derek W; Casey, Jonathan D; Lentz, Robert J; Zouk, Aline N; deBoisblanc, Bennett P; Santanilla, Jairo I; Khan, Yasin A; Joffe, Aaron M; Stigler, William S; Rice, Todd W
Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. Multicenter, randomized trial comparing the ramped position (head of the bed elevated to 25°) with the sniffing position (torso supine, neck flexed, and head extended) among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four ICUs between July 22, 2015, and July 19, 2016. The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after intubation. Secondary outcomes included Cormack-Lehane grade of glottic view, difficulty of intubation, and number of laryngoscopy attempts. The median lowest arterial oxygen saturation was 93% (interquartile range [IQR], 84%-99%) with the ramped position vs 92% (IQR, 79%-98%) with the sniffing position (P = .27). The ramped position appeared to increase the incidence of grade III or IV view (25.4% vs 11.5%, P = .01), increase the incidence of difficult intubation (12.3% vs 4.6%, P = .04), and decrease the rate of intubation on the first attempt (76.2% vs 85.4%, P = .02), respectively. In this multicenter trial, the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position. The ramped position may worsen glottic view and increase the number of laryngoscopy attempts required for successful intubation. ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
The studies presented at the recent American Congress of Gastroenterology in the field of non-variceal upper gastrointestinal bleeding (associated or not to NSAIDs or ASA use) have not been numerous but interesting. The key findings are: a) rabeprazole, the only PPI that had few studies in this field, is effective in the prevention of gastric ulcers; b) famotidine could also be effective in the prevention of complications by AAS; c) the new competitive inhibitors of the acid potassium pump are effective (as much as PPIs) on the recurrence of peptic ulcers by ASA; d) early endoscop (<8 h) in non-variceal upper gastrointestinal bleeding seems to offer no better results than those made in the first 24 h; e) endoscopic therapy in Forrest 1a ulcers does not obliterate the bleeding artery in 30% of cases and is the cause of bleeding recurrence; f) alternative therapies with glue or clotting products are being increasingly used in endoscopic therapy of gastrointestinal bleeding; g) liberal administration of blood in the GI bleeding is associated with poor prognosis; h) lesions of the small intestine are frequent cause of gastrointestinal bleeding when upper endoscopy shows no positive stigmata; and i) capsule endoscopy studies have high performance in gastrointestinal bleeding of obscure origin, if performed early in the first two days after the beginning of the bleeding episode. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
Reddy, Thanmaya G; Knight, John; Holmes, Ross P; Harvey, Lisa M; Mitchem, April L E; Wilcox, Charles M; Monkemuller, Klaus E; Assimos, Dean G
Urinary oxalate excretion is a risk factor for nephrolithiasis and is a result of endogenous metabolism and gastrointestinal processes. Gastrointestinal absorption of oxalate has been well demonstrated but to our knowledge evidence for secretion of oxalate is absent in humans. The objective of this study was to measure the amount and conformation of oxalate in the stomach and small intestine of adult subjects undergoing gastrointestinal endoscopy. Eleven adults participated in this study. Gastrointestinal fluid was collected from the stomach and small intestine during endoscopy. A determination of the soluble and insoluble components of oxalate was made by centrifugation of the sample and subsequent acidification of the resultant pellet and supernatant. Samples were processed and the amount of oxalate was measured by ion chromatography, the limit of which is 1.6 μM. The majority of small intestinal samples contained some degree of oxalate. This is in contrast to the stomach where minimal oxalate was detected. There was a wide range of oxalate concentrations and a greater degree of insoluble oxalate in small intestinal samples. Our results suggest that some degree of oxalate secretion in the small intestine may occur in the fasted state while this is less likely in the stomach. Further studies are warranted to provide definitive evidence of gastrointestinal secretion of oxalate.
Williams, Christina D
Gastrointestinal cancers account for 20% of all incident cancers in the United States. Much work has been done to understand the role dietary factors play in the prevention of gastrointestinal cancers, yet evidence regarding the potential preventive effect of antioxidants is conflicting. This review highlights the recent studies investigating the associations between dietary antioxidants and cancers of the gastrointestinal tract. In-vitro and in-vivo studies in animals continue to support the hypothesis that antioxidants reduce the risk of gastrointestinal cancers. Results in human populations are not as supportive. Antioxidant nutrients and fruits and vegetables do not seem to confer protection against colorectal cancer, and certain antioxidants were found to increase the risk of distal colon cancer. Individual antioxidants also do not help prevent pancreatic cancer. Total antioxidant intake and plant-based foods seem promising for stomach cancer prevention, while vitamin C lowers the risk of esophageal cancer. Preventive effects for stomach and esophageal cancers were often limited to or stronger in smokers. Evidence is scarce regarding antioxidants and liver cancer. Antioxidants do not aid in the prevention of gastrointestinal cancers in the general population; however, they may act as chemopreventive agents for stomach and esophageal cancers, especially in high-risk populations.
Carabotti, Marilia; Lahner, Edith; Esposito, Gianluca; Sacchi, Maria Carlotta; Severi, Carola; Annibale, Bruno
Abstract Autoimmune gastritis is often suspected for its hematologic findings, and rarely the diagnosis is made for the presence of gastrointestinal symptoms. Aims of this cross-sectional study were to assess in a large cohort of patients affected by autoimmune gastritis the occurrence and the pattern of gastrointestinal symptoms and to evaluate whether symptomatic patients are characterized by specific clinical features. Gastrointestinal symptoms of 379 consecutive autoimmune gastritis patients were systematically assessed and classified following Rome III Criteria. Association between symptoms and anemia pattern, positivity to gastric autoantibodies, Helicobacter pylori infection, and concomitant autoimmune disease were evaluated. In total, 70.2% of patients were female, median age 55 years (range 17–83). Pernicious anemia (53.6%), iron deficiency anemia (34.8%), gastric autoantibodies (68.8%), and autoimmune disorders (41.7%) were present. However, 56.7% of patients complained of gastrointestinal symptoms, 69.8% of them had exclusively upper symptoms, 15.8% only lower and 14.4% concomitant upper and lower symptoms. Dyspepsia, subtype postprandial distress syndrome was the most represented, being present in 60.2% of symptomatic patients. Univariate and multivariate analyses showed that age gastritis is assoc