Ultrasound-guided sphenopalatine ganglion block for effective analgesia during awake fiberoptic nasotracheal intubation: A case report

BACKGROUND Awake fiberoptic nasotracheal intubation(AFNI)is the preferred airway ma-nagement strategy for patients with difficult airways.However,this procedure can cause significant physical and psychological distress.This case report explores the application of a sphenopalatine ganglion(SPG)block as an alternative anal-gesic modality to mitigate the discomfort associated with AFNI.CASE SUMMARY A 63-year-old female with a history of right maxillary osteosarcoma underwent craniotomy for a suspected malignant brain lesion.The patient’s medical history included prior surgery,chemotherapy,and radiation therapy,resulting in signi-ficant jaw impairment and limited neck mobility.Considering the anticipated air-way challenges,AFNI was planned.A SPG block was performed under real-time ultrasound guidance,providing effective analgesia during nasotracheal intuba-tion.CONCLUSION The SPG block represents a promising analgesic approach in AFNI,offering po-tential benefits in alleviating pain involving the nasal and nasopharyngeal regions as well as improving patient cooperation.

Assessing the Impact of General Anesthesia and Bronchial Intubation in Conjunction with Thoracic Paravertebral Nerve Block on Cellular Immunity and Surgical Management in Tuberculous Pyothorax Patients

Objective:This study aims to investigate the impact of combining general anesthesia with bronchial intubation and thoracic paravertebral nerve block during surgery for patients with tuberculous pyothorax.Methods:Eighty patients diagnosed with tuberculous pyothorax,admitted to the hospital between January 2023 and September 2023,were randomly selected for this study.The patients were divided into control and study groups using a numerical table method.The control group underwent general anesthesia with bronchial intubation,while the study group received general anesthesia with bronchial intubation in conjunction with thoracic paravertebral nerve block.Subsequently,the patients were monitored to assess mean arterial pressure,heart rate variations,and adverse reactions to anesthesia.Results:The study group exhibited significantly lower mean arterial pressure and heart rate levels during the post-surgical incision,immediate end of surgery,and immediate extubation periods compared to the control group(P<0.05).Furthermore,the Ricker and Ramsay scores in the study group were significantly lower than those in the control group(P<0.05).Conclusion:The combined use of general anesthesia via bronchial intubation and thoracic paravertebral nerve block has been found to stabilize mean arterial pressure and heart rate while providing effective sedation for surgical treatment in patients with tuberculous septic thorax.

Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy

BACKGROUND:It is controversial whether prophylactic endotracheal intubation(PEI)protects the airway before endoscopy in critically ill patients with upper gastrointestinal bleeding(UGIB).The study aimed to explore the predictive value of PEI for cardiopulmonary outcomes and identify high-risk patients with UGIB undergoing endoscopy.METHODS:Patients undergoing endoscopy for UGIB were retrospectively enrolled in the eICU Collaborative Research Database(eICU-CRD).The composite cardiopulmonary outcomes included aspiration,pneumonia,pulmonary edema,shock or hypotension,cardiac arrest,myocardial infarction,and arrhythmia.The incidence of cardiopulmonary outcomes within 48 h after endoscopy was compared between the PEI and non-PEI groups.Logistic regression analyses and propensity score matching analyses were performed to estimate effects of PEI on cardiopulmonary outcomes.Moreover,restricted cubic spline plots were used to assess for any threshold effects in the association between baseline variables and risk of cardiopulmonary outcomes(yes/no)in the PEI group.RESULTS:A total of 946 patients were divided into the PEI group(108/946,11.4%)and the non-PEI group(838/946,88.6%).After propensity score matching,the PEI group(n=50)had a higher incidence of cardiopulmonary outcomes(58.0%vs.30.3%,P=0.001).PEI was a risk factor for cardiopulmonary outcomes after adjusting for confounders(odds ratio[OR]3.176,95%confidence interval[95%CI]1.567-6.438,P=0.001).The subgroup analysis indicated the similar results.A shock index>0.77 was a predictor for cardiopulmonary outcomes in patients undergoing PEI(P=0.015).The probability of cardiopulmonary outcomes in the PEI group depended on the Charlson Comorbidity Index(OR 1.465,95%CI 1.079-1.989,P=0.014)and shock index>0.77(compared with shock index≤0.77[OR 2.981,95%CI 1.186-7.492,P=0.020,AUC=0.764]).CONCLUSION:PEI may be associated with cardiopulmonary outcomes in elderly and critically ill patients with UGIB undergoing endoscopy.Furthermore,a shock index greater than 0.77 could be used as a predictor of a worse prognosis in patients undergoing PEI.

Percutaneous transhepatic cholangial drainage-guided methylene blue for fistulotomy using dual-knife for bile duct intubation: A case report

BACKGROUND Difficult bile duct intubation is a big challenge for endoscopists during endoscopic retrograde cholangiopancreatography(ERCP)procedure.We report a case of percutaneous transhepatic cholangial drainage(PTCD)-guided methylene blue for fistulotomy using dual-knife for bile duct intubation.CASE SUMMARY A 50-year-old male patient had developed obstructive jaundice,and ERCP procedure need to be performed to treat the obstructive jaundice.But intubation cannot be performed if the duodenal papilla cannot be identified because of previous surgery for a perforated descending duodenal diverticulum.We used PTCD-guided methylene blue to identify the intramural common bile duct before dual-knife fistulotomy,and bile duct intubation was successfully completed.CONCLUSION The method that combing methylene blue and dual-knife fistulotomy to achieve bile duct intubation during difficult ERCP is safe and effective.

General anesthesia with endotracheal intubation ensures the quick removal of magnetic foreign bodies:A case report

BACKGROUND The incidence of ingestion of magnetic foreign bodies in the gastrointestinal tract has been increasing year by year.Due to their strong magnetic attraction,if multiple gastrointestinal foreign bodies enter the small intestine,it can lead to serious complications such as intestinal perforation,necrosis,torsion,and bleeding.Severe cases require surgical intervention.CASE SUMMARY We report a 6-year-old child who accidentally swallowed multiple magnetic balls.Under timely and safe anesthesia,the magnetic balls were quickly removed through gastroscopy before entering the small intestine.CONCLUSION General anesthesia with endotracheal intubation can ensure full anesthesia under the condition of fasting for less than 6 h.In order to prevent magnetic foreign bodies from entering the small intestine,timely and effective measures must be taken to remove the foreign bodies.

The ED_(50)of Remazolam Toluenesulfonate Combined with a Subthreshold Dose of Esketamine for Inhibiting Cardiovascular Response to Tracheal Intubation in Elderly Patients

Objective:To explore the half-effective dose(ED_(50))of remazolam toluenesulfonate combined with subthreshold amounts of esketamine for inhibiting cardiovascular response to tracheal intubation in elderly patients.Method:We included 42 patients,aged 65-75,who required general anesthesia and single-lumen endotracheal intubation for elective surgery.The first patient was administered remazolam toluenesulfonate at a dose of 0.20 mg/kg.Once the patient lost consciousness,their alertness/sedation score(OAA/S score)was≤1,and their BIS score was≤60,and a subthreshold dose(0.3 mg/kg)of esketamine was given.The subsequent doses were adjusted using a sequential approach based on the cardiovascular response to tracheal intubation observed in the previous patient.The dose was modified in increments or decrements of 0.01 mg/kg.The ED_(50)and 95%CI of remazolam toluenesulfonate were calculated using the Dixon and Massey sequential distribution test method.Result:The inhibition of endotracheal intubation response was positively correlated with the dose of remazolam toluenesulfonate,and the depth of sedation could not be achieved when the amount was≤0.22 mg/kg.The ED_(50)of remazolam toluenesulfonate combined with a subthreshold dose of esketamine in inhibiting cardiovascular response to tracheal intubation in elderly patients was 0.30(0.28,0.33)mg/kg.There was no statistically significant difference in blood pressure between the induction of anesthesia and before the operation.Conclusion:When compounded with 0.3 mg/kg esketamine,the ED_(50)of Remazolam toluenesulfonate in inhibiting cardiovascular response to endotracheal intubation in elderly patients was 0.30 mg/kg(95%CI0.28-0.33 mg/kg).

Digital Intubation without Stylet: Myth or Reality? Case Report

Digital intubation was discovered as one of the first methods to face a difficult airway without direct laryngoscopy. From the very beginning, this technique has been surrounded by much controversy, mainly because it required to be performed by an expert. Nowadays, it remains a useful technique when treating patients with difficult airways, so it is of utmost importance all personnel involved with airway management must know and perfect this technique when scenarios where conventional laryngoscopy or rescue devices for difficult airway are not available or contraindicated. The present work’s main objective is to suggest digital intubation as a safe and effective technique for the management of patients with difficult airways when there are no other devices available. The authors present a successful case of digital intubation on a patient with a difficult airway, demonstrating this technique is useful when performed by expert practitioners and when there is no other equipment available.

Clinical Application of Modified Anyang Type 2 Esophageal Intubation Instrument──A New Esophageal Intubation Method

The preliminary experience in the clinical use of Anyang Type 2 esophageal intubation instrument, designed by ourselves, in 11 patients with severe esophageal obstruction due to advanced carcinoma of the esophageal was reported. The diagnosis of all 11 cases was confirmed by bariummeal roentgenography. After intubation, all the patients could take liquid or soft diet by mouth.There was no operative mortality and the patients survived 2 to 14 months (mean5.7 months). All of them could take food by mouth before death. The clinical application proved that the intubation has been a safe and suitable management.

Comparison of Cardiac Output and Hemodynamic Responses of Intubation among Different Videolaryngoscopies in Normotensive and Hypertensive Patients

Tracheal intubation with Macintosh laryngoscope（MAC） might result in severe cardiovascular complications. The results of conducted studies investigating the effects of videolaryngoscopies on hemodynamic response of tracheal intubation are conflicting. We know little about the effects of videolaryngoscopies on cardiac output changes during tracheal intubation. We compared cardiac output（COP） and hemodynamic responses in normal blood pressure（n=60） and hypertensive patients（n=60） among 3 intubation devices： the MAC, the UE videolaryngoscopy ？（UE）, and the UE video intubation stylet ？（VS）. Cardiac index（CI）, stroke volume index（SVI）, heart rate（HR）, systolic blood pressure（SBP） and diastolic blood pressure（DBP） were recorded using Lidco Rapid V2？ preinduction, preintubation, and every minute for the first 5 min after intubation. We assessed oropharyngeal and laryngeal structures injury as well. Intubation time was significantly shorter than MAC groups（P〈0.001） only in UE group of normotensive and hypertensive patients. In normotensive patients, there were no significant differences in any of COP variables or hemodynamic variables among the three devices. In hypertensive patients, SBP and DBP in the MAC group were significantly higher（P〈0.05 or 〈0.01） than the UE and VS groups at 1, 2 and 3 min after intubation, but there were no significant differences in CI, SVI and HR among the three devices. There was no significant difference in oropharyngeal and laryngeal structures injury among all groups. It was concluded that both the UE and VS attenuate only the hemodynamic response to intubation as compared with the MAC in hypertensive patients, but not in normotensive patients.

Evaluation of Risk Factors for Arytenoid Dislocation after Endotracheal Intubation: a Retrospective Case-control Study

Objective To investigate the risk factors for postoperative arytenoid dislocation. Methods From September 2003 to August 2013, the records of 16 patients with a history of postoperative arytenoid dislocation were reviewed. Patients matched in terms of date and type of procedures were chosen as the controls(n=16). Recorded data for all patients were demographics, smoking status, alcoholic status, preoperative physical status, airway evaluation, intubation procedures, preoperative laboratory test results, anesthetic consumption and intensive care unit stay. For arytenoid dislocation cases, we further analyzed the incidences of the left and right arytenoid dislocation, and the outcomes of surgical repair and conservative treatment. Categorical variables were presented as frequencies and percentages, and were compared using the chi-squared test. Continuous variables were expressed as means±SD and compared using the Student's unpaired t-test. To determine the predictors of arytenoid dislocation, a logistic regression model was used for multivariate analysis. Results Sixteen patients with postoperative arytenoid dislocation were enrolled, with a median age of 52 years. Most postoperative arytenoid dislocation patients(15/16, 93.75%) received surgical repair, except one patient who recovered after conservative treatment. None of the postoperative arytenoid dislocation patients were smokers. Red blood cell(P=0.044) and hemoglobin(P=0.031) levels were significantly lower among arytenoid dislocation cases compared with the controls. Conclusions Non-smoking and anemic patients may be susceptible to postoperative arytenoid dislocation. However, neither of them was independent risk factor for postoperative arytenoid dislocation.

A comparison between monocanalicular and pushed monocanalicular silicone intubation in the treatment of congenital nasolacrimal duct obstruction

AIM: To compare the success rate of monocanalicular versus pushed monocanalicular silicone intubation(PMCI)of the nasolacrimal duct for congenital nasolacrimal duct obstruction(CNLDO).METHODS: In a prospective randomized clinical trial 53 eyes of 49 patients with CNLDO underwent either monocanalicular silicone intubation(MCI)(n =28 eyes) or PMCI(n =25 eyes). All procedures were performed by 1oculoplastic surgeon. Treatment success was defined as the complete resolution of epiphora at 3mo after tube removal.RESULTS: The surgical outcome was assessed in 20 eyes with MCI and 20 eyes with PMCI. The mean age of treatment was 26.25 ±10.08mo(range, 13-49mo) for MCI and 26.85±12.25mo(range, 16-68mo) for PMCI. Treatment success was achieved in 18 of 20 eyes(90.0%) in the MCI group compared with 10 of 20 eyes(50%) in the PMCI group(P =0.01). In the PMCI group, the tube loss(30%)was greater than the MCI group(5%), however the differences between the 2 groups proved to be not significant(P =0.91).CONCLUSION: Our results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in this small series of patients.

One-stitch anastomosis through the skin with bicanalicular intubation:a modified approach for repair of bicanalicular laceration

AIM:To evaluate the efficacy and safety of one-stitch anastomosis through the skin with bicanalicular silicone tube intubation in repairing of bicanalicular laceration.METHODS:The clinical data of 15 consecutive patients with both superior and inferior canalicular laceration in one eye who underwent surgical repair using one-stitch anastomosis through the skin and bicanalicular stent were retrospective studied.All the operations were performed under surgical microscope,5-0 silk sutures were used and were with bicanalicular silicone tube(diameter was 8mm) intubation,for one lacerated canaliculi one-stitch anastomosis through the skin.The stents were left in place for 3 months postoperatively and then removed.The follow-up period was 3-36 months(average 14 months). RESULTS:In 15 patients,13 patients were cured entirely,1 patient was meliorated,1 patient with no effects.All patients had got good recovery of eyelid laceration with no traumatic deformity in eyelid and canthus.Complication was seen in one case,for not followed the doctor’s guidance to come back to hospital to had the suture removed on the 7thday after operation,when he came at the 15thday,the inferior canalicular wall and eyelid skin were corroded by the suture caused 2mm wound,and the inside silicone tube was exposed,a promptly repair with 10-0 nylon suture was done,the wound healed in a week.There were no early tube protrusions and punctal slits in the patients.CONCLUSION:One-stitch anastomosis through the skin with bicanalicular silicone tube intubation is a good method in repair of bicanalicular laceration in one eye,the cut ends can be anastomosed directly,and with excellent cosmetic results,it is acceptable for the patients.For there is no suture remained in the wound permanently,so there is no suture-related granuloma which may cause obstruction or stenosis of canaliculi.It is simple,economical,effective and safe.

Bicanalicular versus monocanalicular intubation after failed probing in congenital nasolacrimal duct obstruction

AIM：To investigate the clinical outcomes of different intubation techniques in the cases of failed primary probing.METHODS： This retrospective study was performed on338 patients with the diagnosis of congenital nasolacrimal duct obstruction with age 1-4y that had failed primary probing.Intubation was performed under light sedation in operating room and the stent was left 3mo in place.Clinical outcome was investigated 3mo after tube removal.RESULTS： Bicanalicular intubation method had higher complete and relative success rates compared to monocanalicular intubation（P =0.00）.In addition,Monoka intubation had better outcomes compared to Masterka technique（P =0.046）.No difference was found between genders but the higher the age,the better the outcomes with bicanalicular technique rather than monocanalicular.CONCLUSION： Overall success rate of bicanalicular intubation is superior to monocanalicular technique especially in older ages.Also,based upon our clinical outcomes,Masterka intubation is not recommended in cases of failed probing.

The incidence of oxygen desaturation during rapid sequence induction and intubation

BACKGROUND: Rapid sequence induction and intubation(RSII) is an emergency airway management technique for patients with a risk of pulmonary aspiration. It involves preoxygenation, administration of predetermined doses of induction and paralytic drugs, avoidance of mask ventilation, and laryngoscopy followed by tracheal intubation and keeping cricoid pressure applied till endotracheal tube cuff be inflated. Oxygen desaturation has been seen during RSII. We assessed the incidence of oxygen desaturation during RSII.METHODS: An institution-based observational study was conducted from March 3 to May 4, 2014 in our hospital. All patients who were operated upon under general anesthesia with RSII during the study period were included. A checklist was prepared for data collection.RESULTS: A total of 153 patients were included in this study with a response rate of 91.6%. Appropriate drugs for RSII, equipments for RSII, equipments for diffi cult intubation, suction machine with a catheter, a monitor and an oxygen backup such as ambu bag were not prepared for 41(26.8%), 50(32.7%), 51(33.3%), 38(24.8%) and 25(16.3%) patients respectively. Cricoid pressure was not applied at all for 17(11.1%) patients and 53(34.6%) patients were ventilated after induction of anesthesia but before intubation and endotracheal cuff inflation. A total of 55(35.9%) patients desaturated during RSII(SPO2<95%). The minimum, maximum and mean oxygen desaturations were 26%, 94% and 70.9% respectively. The oxygen desaturation was in the range of <50%, 50%–64%, 65%–74%, 75%–84%, 85%–89 % and 90%–94% for 6(3.9%), 7(4.6%), 5(3.3%), 10(6.5%), 13(8.5%) and 14(9.2%) patients respectively.CONCLUSION: The incidence of oxygen desaturation during RSII was high in our hospital. Preoperative patient optimization and training about the techniques of RSII should be emphasized.

Video versus direct laryngoscopy on successful firstpass endotracheal intubation in ICU patients

BACKGROUND: Airway management in intensive care unit(ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy(DL) and that by using the video laryngoscopy(VL).METHODS: A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success. RESULTS: A total of 163 ICU patients underwent intubation during the study period(81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group(67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications(all P>0.05). CONCLUSION: Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.

Expert Recommendations for Tracheal Intubation in Critically Ill Patients with Noval Coronavirus Disease 2019

Coronavirus Disease 2019(COVID-19),caused by a novel coronavirus(SARS-Co V-2),is a highly contagious disease.It firstly appeared in Wuhan,Hubei province of China in December 2019.During the next two months,it moved rapidly throughout China.Most of the infected patients have mild symptoms including fever,fatigue and cough,but in severe cases,patients can progress rapidly and develop into acute respiratory distress syndrome,septic shock,metabolic acidosis and coagulopathy.The new coronavirus was reported to spread via droplets,contact and natural aerosols from human to human.Therefore,aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections.In fact,SARSCo V-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan.The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation,by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians.During the airway management,enhanced droplet/airborne personal protective equitment(PPE)should be applied to the health care providers.A good airway assessment before airway intervention is of vital importance.For patients with normal airway,awake intubation should be avoided,and modified rapid sequence induction is strongly recommended.Sufficient muscle relaxant should be assured before intubation.For patients with difficult airway,good preparation of airway devices and detailed intubation plans should be made.

Relationship between intubation rate and continuous positive airway pressure therapy in the prehospital setting

BACKGROUND: To determine whether the prehospital use of continuous positive airway pressure(CPAP) therapy is associated with a reduced rate of endotracheal intubation in patients with an acute respiratory disorder brought to the emergency department(ED).METHODS: We reviewed medical records of patients with acute respiratory distress who had been treated with CPAP in the Mobile Intensive Care Unit(MICU) from January 2010 to December 2011. These records were compared with those of patients who received standardized care without CPAP in the MICU from January 2004 to December 2004. Categorical variables were summarized as frequencies and compared between groups using Fisher's exact test or the Chi-square test. Continuous variables were summarized as medians(interquartile range), and comparison between the groups was made using Wilcoxon's rank-sum test. The relationship between CPAP and intubation rate was determined using multivariable logistic regression analysis of propensity scores. The results were presented as odds ratio(OR), 95% confidence interval(CI), and P value for test effect. The adequacy of the model was calibrated using Hosmer and Lemeshow's goodness-of-fit test. P<0.05 was considered statistically significant.RESULTS: The records of 785 patients were reviewed. Of the 215 patients treated with CPAP in the MICU, 13% were intubated after admission. In contrast, of the 570 patients who did not receive CPAP, 28% were intubated after ED admission. Unadjusted logistic regression analysis showed that patients who had been treated with CPAP were less likely to be intubated than those without CPAP treatment(OR=0.37, 95% CI, 0.24–0.57, P<0.0001). With propensity scores adjusted, multivariate logistic regression analysis showed that CPAP treatment was associated with a 62% reduction of intubation(OR=0.384, 95%CI, 0.25–0.60, P≤0.0001).CONCLUSIONS: In patients with acute respiratory disorder, there was a relationship between CPAP therapy and the decreased intubation rate. CPAP therapy was feasible in prehospital management of patients with respiratory distress.

A comparison of lightwand and laryngoscopic intubation techniques in patients undergoing laparoscopic cholecystectomy

Objective：To assess the effects of lightwand and laryngoscopic intubation techniques in patients undergoing laparoscopic cholecystectomy （LC）. Methods： 300 ASA physical status Ⅰ and Ⅱ patients, undergoing LC, were randomly assigned to two groups, with 150 cases in each group. Patients in the LS group underwent endotracheal intubation using a standard direct-suspension laryngoscopic technique. Patients in the LW group were intubated by using transilhimination with a lightwand. Mean arterial pressure and heart rate were recorded before induction, and at 1, 3 and 5 rain after intubation. The incidence and of sore throat, hoarseness, and dysphagia was assessed twenty-four hours after surgery. Results： This study demonstrated no clinically significant difference in cardiovascular variables between the two techniques. Patients had a significantly lower incidence of sore throat, hoarseness, and dysphagia when the lightwand was used for intubation. Conclusion： This study suggests that lightwand intubation may decrease the incidence of postoperative sore throat, hoarseness, and dysphagia, thereby potentially increasing satisfaction in surgical patients. Therefore, more frequent use of the lightwand is recommended for endotracheal intubation.

Difficult Intubation in a Patient with Dysphagia after Posterior Occipitocervical Fusion: A Case Report

The authors encountered a case involving difficult intubation during anesthesia for revision of cervical fixation angle in a 62-year-old woman, with a history of chronic rheumatoid arthritis, who experienced dysphagia after initial posterior occipitocervical fusion to correct atlantoaxial subluxation. Two days after initial surgery, she developed trismus with neck flexion and dysphagia, and underwent revision surgery. General anesthesia was planned;however, tracheal intubation using the McGrath laryngoscope and bronchofiberscope was difficult, which prolonged anesthesia induction. Narrowing of the oral and pharyngeal cavities associated with overcorrection of the cervical spine was believed to be the reason for difficulty in manipulating the tracheal intubation devices. In posterior occipitocervical fusion, intraoperative evaluation of the occipito-second cervical vertebra (O-C2) angle is reported to be useful in preventing postoperative dyspnea and/or dysphagia, and avoids the need for revision of fixation angle. However, when revision surgery is needed, selection of airway management methods and tracheal intubation devices are important considerations because patients are likely to have restricted mobility in the cervical spine and narrowing of the oral and pharyngeal cavities.

Comparison of Hemodynamic Responses Associated with Tracheal Intubation Under Various Induction Doses of Remifentanil and Propofol

.Background: The optimal dose of propofol and remifentanil induction to minimize the cardiovascular response associated with tracheal intubation may exist. We investigated the cardiovascular response associated with tracheal intubation when various continuous induction doses of remifentanil in combination with propofol were used. Methods: Seventy- five patients were randomly allocated into 1 of 3 groups: the R-0.4 P-1 group (remifentanil 0.4 μg/kg/min and propofol 1 mg/kg);the R-0.5 P-1 group (remifentanil 0.5 μg/kg/min and propofol 1 mg/kg);and the R-0.4 P-2 group (remifentanil 0.4 μg/kg/min and propofol 2 mg/kg). One minute after remifentanil infusion commenced, a bolus of propofol was injected. Rocuronium 1 mg/kg was administered 1 min after propofol injection following loss of consciousness. Controlled ventilation was then performed for 2 min, and the trachea was intubated 4 min after the start of the remifentanil infusion. The infusion rate of remifentanil was decreased to 0.1 μg/kg/min after intubation. Blood pressure (BP) and heart rate (HR) were measured during this period until 5 min after tracheal intubation. Results: The changes in BP response due to tracheal intubation in the R-0.4 P-1 group were greater than those in the other 2 groups, whereas the HR responses to tracheal intubation were similar among the 3 groups. Conclusion: The combination of remifentanil 0.4 μg/kg/min and propofol 1 mg/kg led to an exaggerated cardiovascular response to tracheal intubation compared with the other combination groups.