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).

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department:an exploratory analysis

Cardiac arrest poses a significant global public health challenge,manifesting in approximately 550,000 cases annually within the United States.[1]In-hospital cardiac arrest(IHCA)is commonly attributed to airways and respiratory issues.[2]Recommendations emphasize the expertise of responders in airway management.[3]Various options exist,such as chest compression-only cardiopulmonary resuscitation(CPR),bag-mask ventilation(BMV),and advanced airways.The BMV and advanced airways are not deemed equivalent or superior based on previous evidence.[4]Achieving consistency in choosing and timing the optimal airway approach during IHCA is crucial.The current American Heart Association guidelines suggest an advanced airway strategy when endotracheal intubation(ETI)success rates are high,but the optimal time for advanced airway management remains unclear.[5]Wong et al[6]revealed that survival improved by less than 5 min with advanced airway management.According to a subgroup analysis of IHCA patients in emergency departments(EDs),early intubation was associated with a 1.5-fold greater rate of return of spontaneous circulation(ROSC)than in other locations.[7]ED patients’constant monitoring and immediate management,with readily available intubation equipment,enhance early intubation and survival rates.[6]Nonetheless,IHCA patients intubated within the first 15 min had a lower ROSC rate.

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.

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.

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.

Prophylactic tracheal intubation for upper GI bleeding: A meta-analysis

AIM: To evaluate usefulness of prophylactically intubating upper gastrointestinal bleeding(UGIB) patients. METHODS: UGIB results in a significant number of hospital admissions annually with endoscopy being the key intervention. In these patients, risks are associated with the bleeding and the procedure, including pulmonary aspiration. However, very little literature is available assessing the use of prophylactic endotracheal intubation on aspiration in these patients. A comprehensive search was performed in May 2014 in Scopus, CINAHL, Cochrane databases, Pub Med/Medline, Embase, and published abstracts from national gastroenterology meetings in the United States(2004-2014). Included studies examined UGIB patients and compared prophylactic intubation to no intubation before endoscopy. Meta-analysis was conducted using Rev Man 5.2 by Mantel-Haenszel and Der Simonian and Laird models with results presented as odds ratio for aspiration, pneumonia(within 48 h), and mortality. Funnel plots were utilized for publication bias and I2 measure of inconsistency for heterogeneity assessments. RESULTS: Initial search identified 571 articles. Of these articles, 10 relevant peer-reviewed articles in English and two relevant abstracts were selected to review by two independent authors(Almashhrawi AA and Bechtold ML). Of these studies, eight were excluded: Five did not have a control arm, one was a letter the editor, one was a survey study, and one was focused on prevention of UGIB. Therefore, four studies(N = 367) were included. Of the UGIB patients prophylactically intubated before endoscopy, pneumonia(within 48 h) was identified in 20 of 134(14.9%) patients as compared to 5 of 95(5.3%) patients that were not intubated prophylactically(P = 0.02). Despite observed trends, no significantdifferences were found for mortality(P = 0.18) or aspiration(P = 0.11).CONCLUSION: Pneumonia within 48 h is more likely in UGIB patients who received prophylactic endotracheal intubation prior to endoscopy.

Effect of Magnesium Sulfate Nebulization on Stress Response Induced Tracheal Intubation;Prospective, Randomized Study

Background and Aims: Multiple, nonpharmacological and pharmacological measures have been used for attenuating stress response of intubation with variable results. N-methyl-D-aspartate (NMDA) receptors have a role in nociception and inflammation. NMDA receptors are located in peripheral and the central nervous system. Magnesium is also a NMDA receptor blocker. Aim of the Study: To evaluate the effect of nebulized magnesium sulfate on reduce the stress response induced tracheal intubation Material and Methods: Following institutional ethical committee approval and written informed consent, a prospective randomized double-blinded study was conducted in 100 cases divided into two equal groups. Patients included in the study were of either gender belonging to American Society of Anesthesiologists (ASA) status 1 or 2 undergoing elective surgery requiring tracheal intubation. Patients will be recruited in the study divided into two equal groups;Patients in Group A: will receive nebulized magnesium sulfate in 3 ml (240 mg) over 15 min. While group B: will receive nebulized normal saline in 3 ml over 15 min, ending 5 min before the induction of anesthesia. SBP, DBP, HR, and blood glucose level will be measured at the following intervals;Baseline (before induction), after premedication (sedation), after induction, after ETT intubation, 3 min later, 6 min later. Results: Preoperative magnesium sulfate nebulization has a significant effect (p value < 0.001) on attenuating the stress response (SBP, DBP, HR, and SBG) to tracheal intubation at the following intervals;post ETT intubation, 3 min later, and 6 min later. Conclusion: Magnesium sulfate significantly reduces the stress response of intubation.

Use of Platelet Rich Plasma (PRP) in the Treatment of Acute Post Intubation Tracheal Rupture: Report of Two Cases

The use of PRP involves a complex network of molecular events which accelerate tissue regenera-tion due to its richness in growth factors plus a variety of biologic mediators. Several communica-tions tell us about its usefulness on the dental implantology field, plastic surgery, orthopedics and peripheral nerve regeneration after trauma. We have presented our successful experience of its use in pneumology when treating severe hemoptysis, respiratory fistulae, spontaneous pneumothorax and one tracheal rupture. In this article we present two cases of post intubation tracheal rupture successfully treated with the local instillation of PRP on one of them and with the injection of PRP along the lips of the tracheal wound on the other. Tracheal rupture is a rare but life threatening complication of emergency intubation requiring an effective response in order to avoid the risk of patient death due to secondary mediastinitis and sepsis. Up to now there is no general consensus in the treatment of this condition and alternatives in use are not universally accepted. The use of local autologous PRP in our experience has demonstrated a favorable performance in such cases, turning it in a highly promising tool for the treatment of conditions such as this, in which a rapidly effective and minimally invasive handling is required.

Outcomes in Seriously Head-Injured Patients Undergoing Pre-Hospital Tracheal Intubation vs. Emergency Department Tracheal Intubation

Background: The optimal treatment of major head injuries in the resuscitative phase of care post-injury has yet to be determined. This study measured the effect on mortality of pre-hospital intubation (PHI) vs. emergency department in tubation (EDI) of patients suffering serious head injury. Methods: In the single emergency medical services system for this Canadian province, we used a population-based trauma database, conventional logistic regression (with and without the use of a propensity score to control for selection effect bias) to evaluate the effect of PHI vs. EDI on in-hospital mortality. Inclusion criteria were age ≥ 16 years, serious head injury (Abbreviated Injury Score ≥ 3, non-penetrating trauma) and resuscitative intubation (PHI or EDI). Results: Over 5 years, 283 patients (2000-2005) met inclusion crite ria. Conventional unconditional logistic regression modelled on mortality with “PHI vs. EDI” as the intervention of interest showed an odds ratio of 2.015 (95% CI 1.062 3.825) for improved survival if these patients were intubated in the emergency department rather than in the pre-hospital phase of care. A propensity score adjustment demonstrated a similar but more conservative point estimate (OR 1.727, 95% CI: 0.993 3.004). Conclusions: This observational study demonstrated a survival advantage with EDI (versus PHI) in seriously head-injured patients in a mature, province-wide emergency medical services system.

Delayed diagnosis of arytenoid cartilage dislocation after tracheal intubation in the intensive care unit:A case report

BACKGROUND Arytenoid cartilage dislocation is a rare and often overlooked complication of tracheal intubation or blunt laryngeal trauma.The most common symptom is persistent hoarseness.Although cases of arytenoid dislocation due to tracheal intubation are reported more frequently in otolaryngology,reports on its occurrence in the intensive care unit(ICU)are lacking.We report a case of delayed diagnosis of arytenoid cartilage dislocation after tracheal intubation in the ICU.CASE SUMMARY A 20-year-old woman was referred to the ICU following a fall from a height.Her voice was normal;laryngeal computed tomography showed unremarkable findings on admission.However,due to deterioration of the patient’s condition,tracheal intubation,and emergency exploratory laparotomy followed by laparoscopic surgery two d later under general anesthesia were performed.After extubation,the patient was sedated and could not communicate effectively.On the 10th day after extubation,the patient complained of hoarseness and coughing with liquids,which was attributed to laryngeal edema and is common after tracheal intubation.Therefore,specific treatment was not administered.However,the patient’s symptoms did not improve.Five d later,an electronic laryngoscope examination revealed dislocation of the left arytenoid cartilage.The patient underwent arytenoid closed reduction under general anesthesia by an experienced otolaryngologist.Reported symptoms improved subsequently.The sixmonth follow up revealed that the hoarseness had resolved within four weeks of the reduction procedure.CONCLUSION Symptoms of arytenoid cartilage dislocation are difficult to identify in the ICU leading to missed or delayed diagnosis among patients.

Risk Analysis of Risk Factors for Pressure Injury Related to Tracheal Intubation in ICU Patients

Objective:This article mainly analyzes the risk factors of pressure injury related to tracheal intubation in ICU patients.Methods:This time,the investigation and research were mainly conducted on 110 patients with tracheal intubation received in the ICU of our hospital from June 2020 to June 2021,and the risk factors for related pressure injuries were analyzed.Results:According to statistics,the incidence rate of patients with tracheal intubation-related pressure injury was 23.63%,of which the lip had the highest incidence;the indwelling time of the tracheal tube,the wetness score,the movement force score,and the frictional shear score in the Braden score of the tracheal intubation These are all risk factors for pressure injury related to tracheal intubation(P<0.05).Conclusion:ICU patients have a higher incidence of related pressure injuries during tracheal intubation,so it is necessary to strengthen the care of risk factors and take reasonable and effective measures to prevent them.

EFFECTS OF ALFENTANIL AND ESMOLOL ON HEMODYNAMIC AND CATECHOLAMINE RESPONSE TO TRACHEAL INTUBATION

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Submental tracheal intubation for resection of recurrent giant pituitary tumor:a case report

在为巨大的垂体肿瘤的切除术收到 transmaxillary 途径的病人的航线管理介绍临床的挑战给麻醉学者。为气管的 intubation 的口头或鼻的线路能防碍外科的过程。这份报告描述 submental 为在经由 transmaxillary 经历了周期性的巨大的垂体肿瘤的切除术的一个病人的航线管理的气管的 intubation 途径。Submental 气管的 intubation 在操作期间是为航线管理的一种能适应、安全的其他的技术。

CLINICAL APPLICATION OF ACUPUNCTURE ON ALLEVIATION OF STRESS REACTION INDUCED BY TRACHEAL INTUBATION IN GENERAL ANESTHESIA

By summarizing the formation of stress reaction induced by tracheal intubation and method of medicinal control, the recognition of Chinese medicine in treatment of cardiac arrhythmia and hypertension with acupuncture and the clinical application of acupuncture on stress reaction induced by tracheal intubation, it is concluded that the side effects of tracheal intubation are inevitable, even though there are many methods presented for the prevention and treatment for it. In recent years, the functions of acupuncture in anesthesia, especially in regulation of circulatory properties have been developed gradually and have been applied by many physicians in controlling the stress reaction induced by tracheal intubation in general anesthesia. Being a kind of dual-directional and positive regulation and stimulation, acupuncture provides definite and safe effects on controlling the stress reaction induced by tracheal intubation.

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.

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.

Comment on: Effect of intubation in patients with functional epiphora after endoscopic dacryocystorhinostomy

Dear Editor,We read with interest the article by Han et al[1]in which they retrospectively assessed the effect of bicanalicular intubation for functional epiphora after a failed endoscopic dacryocystorhinostomy(DCR).They confirmed the post-DCR“functional obstruction”based on fluorescein dye disappearance(FDDT)and irrigation test[1].

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.

Rosmarinic acid improves tracheal smooth muscle responsiveness and lung pathological changes in ovalbumin-sensitized rats

Objective:To evaluate the effect of rosmarinic acid on tracheal smooth muscle responsiveness and lung pathological changes in ovalbumin-sensitized rats.Methods:Rats were randomly divided into six groups:the control group,the asthmatic group,and the asthmatic groups treated with dexamethasone(1 mg/kg;oral gavage)or three doses of rosmarinic acid(0.5,1,and 2 mg/kg;oral gavage).For induction of asthma,rats received intraperitoneal injections and inhalation of ovalbumin.After 21 days,bronchoalveolar lavage fluid and lung samples were collected for histopathological analyses.Moreover,total and differential white blood cell counts were determined.Results:The rosmarinic acid-treated group had significantly lower tracheal smooth muscle responses to methacholine than the asthmatic group.In addition,rosmarinic acid reduced white blood cell count and the percentages of eosinophils,monocytes,and neutrophils while increasing the percentage of lymphocytes.Ovalbumin-induced lung pathological changes were significantly improved by treatment with rosmarinic acid.Conclusions:Rosmarinic acid improves tracheal smooth muscle responsiveness and lung pathological changes in ovalbumin-sensitized rats.