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.

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.

Endotracheal intubation in patients with COVID-19 using an ultrathin flexible gastrointestinal endoscope

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 occasionally becomes severe and requires endotracheal intubation.Endotracheal intubation is usually performed using a laryngoscope;however,the operator needs to be in close proximity to the patient’s face during the procedure,which increases the risk of droplet exposure.Therefore,we simulated fiberoptic endotracheal intubation on a mannequin representing the patient,using an ultrathin flexible gastrointestinal endoscope as an alternative to the bronchoscope,in order to maintain distance from the patient during the procedure.We performed this procedure 10 times and measured the time required;the median procedure time was 6.4 s(interquartile range,5.7-8.1 s).The advantage of this method is the short procedure time and distance maintained from the patients.The flexible tip-steerable control and length of the gastrointestinal endoscope contributed to shortening the procedure time and maintaining distance from the patients.In addition,this method can handle difficult airways without risk of misplacement of the endotracheal tube.However,it is necessary to consider the risk of aerosol generation associated with this procedure.In the pandemic setting of coronavirus disease 2019,this approach may be useful when a gastrointestinal endoscopist is in charge of endotracheal intubation of patients with coronavirus disease 2019.

Clinical Criteria for Airway Assessment: Correlations with Laryngoscopy and Endotracheal Intubation Conditions

Difficult intubation, inadequate ventilation and esophageal intubation are the principal causes of death or brain damage related to airway manipulation. The objective of this cross-sectional study was to correlate a preanesthetic evaluation that may be capable of predicting a difficult intubation with the conditions encountered at laryngoscopy and endotracheal intubation. Eighty-one patients submitted to general anesthesia were evaluated at a preanesthetic consultation according to the modified Mallampati classification, the Wilson score and the American Society of Anesthesiologists (ASA) difficult airway algorithm. Findings were then correlated with the Cormack-Lehane classification and with the number of attempts at endotracheal intubation. No statistically significant correlations were found between the patients’ Mallampati classification and their Cormack-Lehane grade or between the Mallampati classification and the number of attempts required to achieve endotracheal intubation. Laryngoscopy proved difficult in four patients and in all of these cases the Wilson score had been indicative of a possibly difficult airway, highlighting its good predicting sensitivity. However, the specificity of this test was low, since another 24 patients had the same Wilson score but were classified as Cormack-Lehane I/II. Moreover, two patients who had a Wilson score ≥ 4 were also classified as Cormack-Lehane grade I/II. The study concluded that the Wilson score, although seldom used in clinical practice, is a highly sensitive predictor of a difficult airway;its specificity, however, is low.

Simulation and Acquisition of Endotracheal Intubation Skills by Medical Students—A Pilot Study

Introduction: Endotracheal intubation is a vital life-saving skill required by physicians in life-threatening situations in and out of the hospital. Medical students are exposed to these procedures mainly as they rotate through the department of Anaesthesia, in their subspecialty posting in Surgery. In this study, we sought to assess the ease of learning endotracheal intubation by medical students in the skills laboratory using an adult-sized (Laerdal Medical) manikin. Methods: This was a prospective descriptive study assessing the ability of medical students at endotracheal intubation during their 12-week rotation in the Anaesthesia Department during their subspecialty posting from August to October 2019 in the Skills Laboratory. An adult-sized manikin (Laerdal Medical) intubating head was used for the study. This was preceded by a detailed lecture and demonstration in the skills laboratory after successful passage of the endotracheal tube and connected to a self-inflating ventilation (Ambou) bag. Adequate chest movement meant proper placement, while the fullness of the stomach meant oesophageal intubation. Results: All the 500 level (45) students in the class were recruited for this prospective study. 30 (66%) had successful endotracheal intubation at the first attempt, 7 (14.4%) at the second attempt, 5 (11.1%) at the third attempt, 2 (4.4%) students at the fourth attempt and 1 (2.2%) had successful endotracheal intubation at the fifth attempt. Attempts were made to reinforce information on the practical procedure by a repeat performance by the instructor after each set of successful attempts was separated from the pack of unsuccessful candidates. In the end, however, we had 100% successful endotracheal intubation, but after 5 attempts by the last medical student. Conclusion: Endotracheal intubation skills can be learned with some level of ease when done after detailed information and training of medical students. More so when not under undue stress and life-threatening situations in the skills laboratory. By extension, this increases the confidence of medical students in the live patients in the Operating Theatre, after repeated attempts in the skills laboratory. This has the benefit of improving the chances of acquisition of endotracheal intubation in real-life situations.

Effects of dexmedetomidine + propofol intervention during general anesthesia induction on endotracheal intubation

Objective:To investigate the effects of dexmedetomidine + propofol intervention during general anesthesia induction on endotracheal intubation.Methods: A total of 218 patients receiving tracheal intubation general anesthesia in the hospital between January 2017 and December 2017 were divided into the control group (n=109) and the dexmedetomidine group (n=109) by random number table method. Control group underwent routine propofol anesthesia induction and dexmedetomidine group underwent dexmedetomidine anesthesia induction on the basis of propofol. The differences in the severity of inflammatory response and stress response were compared between the two groups of patients after general anesthesia induction (T0), 1 min after endotracheal intubation (T1), 5 min after endotracheal intubation (T2) and 10 min after endotracheal intubation (T3).Results:At T0, there was no statistically significant difference in serum levels of inflammatory factors and stress hormones between the two groups. At T1, T2 and T3, serum inflammatory factors CRP, IL-1, IL-6, IL-8 and TNF-α levels of dexmedetomidine group were lower than those of control group;serum stress hormones ACTH, Cor, NE, AngⅠ and AngⅡ levels were lower than those of control group. Conclusion: Dexmedetomidine + propofol general anesthesia induction can effectively reduce the inflammatory stress response caused by endotracheal intubation.

Endotracheal intubation sedation in the intensive care unit

Endotracheal intubation is one of the most common,yet most dangerous procedure performed in the intensive care unit(ICU).Complications of ICU intubations include severe hypotension,hypoxemia,and cardiac arrest.Multiple observational studies have evaluated risk factors associated with these complications.Among the risk factors identified,the choice of sedative agents administered,a modifiable risk factor,has been reported to affect these complications(hypotension).Propofol,etomidate,and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation.Propofol demonstrates rapid onset and offset,however,has drawbacks of profound vasodilation and associated cardiac depression.Etomidate is commonly used in the critically ill population.However,it is known to cause reversible inhibition of 11β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h.This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use.Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects.However,its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations.Moreover,unlike propofol or etomidate,ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill.Lately,a combination of ketamine and propofol,“Ketofol”,has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs.Furthermore,the doses of both drugs are reduced.In situations where a difficult airway is anticipated,awake intubation with the help of a fiberoptic scope or video laryngoscope is considered.Dexmedetomidine is a commonly used sedative agent for these procedures.

Study on Effect of Laryngeal Mask Anesthesia and Endotracheal Intubation Anesthesia on Elderly Patients Undergoing Laparoscopic Gallbladder Surgery

Objective:To analyze the effect of laryngeal mask anesthesia and endotracheal intubation anesthesia in elderly laparoscopic gallbladder surgery.Methods:100 subjects of the experiment came from elderly patients with gallbladder stones admitted from September 2016 to September 2019 in our hospital.There were group A and group B of 50 cases each,and were used tube anesthesia and laryngeal mask anesthesia,then comparing the anesthesia effect.Results:Statistical significance(P<0.05):Air pressure and end-respiratory carbon dioxide partial pressure index changes when immediately after insertion,immediately after removal,3 minutes after removal;heart rate,mean arterial pressure,airway pressure,and end-expiratory carbon dioxide index changes when 3 minutes after insertion and immediately before removal;blood glucose and cortisol changes when after insertion,immediately before removal and min after removal.No statistical significance(P>0.05):Changes in heart rate,mean arterial pressure,airway pressure,and endexpiratory carbon dioxide indexes before insertion;changes in blood glucose and cortisol indexes before insertion.Conclusion:It is more ideal for elderly patients with abdominal cavity and gallbladder surgery to have laryngeal mask anesthesia,which can effectively keep blood circulation stable and have promotion value.

Evaluation of Google Glass^(■) with Camera Adaptor and GoPro^(■) as Teaching Tools for Endotracheal Intubation in the Austere Medical Environment

Objective: Endotracheal intubation (ETI) is a life-saving emergency procedure, but it is a complex skill that is difficult to teach. Recent studies have shown that video laryngoscopy is effective in teaching ETI to learners at various levels of medical expertise;however, it has proven to be costly and provides images of inconsistent quality. In this educational proof of concept feasibility convenience sample pilot study, we aim to explore and compare the effectiveness of using modified Google Glass? (GG) and GoPro? (GP) technologies to visualize and teach ETI to critical care physicians in the austere medical environment of a low-income country. We propose, based on our findings, that this inexpensive technology could teach lifesaving ETI to pre-hospital providers in the austere medical environment, medical students, rural emergency physicians, critical care physicians in low-income countries, far forward military medical providers, and other learners. Methods: A case series of twenty-five patients, five in the United States (US) at Memorial Hospital in South Bend, IN and twenty at Saint Luc’s Hospital in Port Au Prince, Haiti, is presented. These patients were collected from November 1st 2015 through February 1st of 2016. The anesthesiologist and the emergency physicians in the United States utilized GG to intubate five patients in the US prior to the twenty patients intubated during two separate trips to Haiti. On the two separate trips to Haiti, the GG was trialed and modified to obtain better exposure. These adaptations resulted in the final collection of twenty patients studied with the adapted GG system and GP. Physicians graded airway visualization based on LEMON and Cormack-Lehane scores. Previously published parameters for the assessment of failed intubation risk and passage of the cords were used as data points for analysis using a Likert-Scale analysis for each parameter. The data were analyzed by averages of Likert-Scale scoring with their respective standard deviations. Results: The results show that the GP is superior to GG for assessing the LEMON scoring system until visualization of the oropharynx, while the GG is markedly superior for calculation of Cormack-Lehane score (cord visualization) and passing of the endotracheal tube. Conclusion: A review of the twenty-five cases demonstrates that while GP allows for better visualization for the parameters that require a wider view of the patient, the modified GG allows for superior visualization in the parameters that require a more focused view of the cords. GG can serve as an effective educational tool in the ICU for physicians and other providers in the austere medical environment who require effective ETI training. In addition, we propose that these techniques can serve as an inexpensive yet effective means of teaching hands on endotracheal intubation skills to learners of varying levels of clinical experience.

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).

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.

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.

Shikani Optical Stylet–guided Intubation via the Intubating Laryngeal Airway in Patients With Scar Contracture of the Face and Neck

Objective To evaluate the feasibility of the Shikani Optical Stylet(SOS)-guided intubation through a new Intubating Laryngeal Airway(ILA)in anticipated difficult airways caused by scar contracture of the face and neck.Methods Thirty-three adult patients with anticipated difficult airways undergoing selective faciocervical scar plastic surgery under general anesthesia were enrolled in this study.After anesthesia induction,a size 2.5,3.5 or 4.5 ILA was inserted.Following good lung ventilation being verified,the SOS preloaded with an endotracheal tube was inserted via the ILA.Once the clear vocal cords came into view under the SOS,the endotracheal tube was advanced through glottis into the trachea.Results The ILA provided an effective airway in all patients.Intubation was successful at the first attempt on 22/33(66.7%)occasions and at the second attempt on 6/33(18.2%).Intubation failed in 5(15.1%)patients who suffered from severe limitation of head extension due to scar contracture of the neck.These patients’tracheas were finally intubated using a fibreoptic bronchoscope via the ILA.Conclusions The SOS-guided intubating method via the ILA is a feasible technique in patients with scar contracture of the face and neck.However,in patients with severe limitation of head extension,the use of SOS cannot be recommended.The SOS can be used as an alternative apparatus when the fibreoptic bronchoscope is not available.

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.

Endotracheal Cuff Pressures Generated by Different Members of the Anaesthesia Services in a Ghanaian Teaching Hospital

Background: The main function of the endotracheal tube (ETT) cuff is to ensure a tight seal between the tracheal wall and the endotracheal tube to prevent stomach contents from entering the trachea during ventilation thus preventing aspiration. Whereas excessive inflation of the cuff is associated with complications as a result of impaired blood supply to the trachea mucosa, low inflation pressure puts the patient at risk of aspiration. This study sought to find the accuracy of correctly estimating the cuff pressure and whether experience has effect on the accuracy. Methods: After approval from the Ethics Committee, we observed 199 patients who had general anaesthesia and had been intubated at the Komfo Anokye Teaching Hospital,KumasiGhana. Anaesthesia practitioners were blinded to the study. The endotracheal cuff pressure was measured using a low pressure manometer. The experience of the Anaesthetist was also noted. Results: Only 26% of the cuff pressures measured were within the acceptable range of 20-30 cm H2O. 4.5% of the pressures measured were below the acceptable minimum value of20 cm H2O hence exposing the patient to the risk of aspiration. 68% of the cuff pressures measured were above the maximum pressure of30 cm H2O. Physician anaesthetists were likely to inflate the cuff correctly. They had average inflation pressures of24 cm H2O with minimum and maximum inflation pressures of15 cm H2O and32 cm H2O respectively. Resident physician anaesthetists inflate the endotracheal pressures moderately high, an average of41.64 cm H2O. Nurse anaesthetists and student nurse anaesthetists had a tendency to overinflate the endotracheal cuff above the recommended range of 20-30 cm H2O. Their mean inflating pressures were 64.7 and 68.54 respectively. Conclusion: ETT cuff pressures measured by the low pressure aneroid manometer in patients undergoing general anaesthesia in Komfo Anokye Teaching Hospital are routinely high and are significantly higher when inflated by nurse anaesthetists, student nurse anaesthetists and Anaesthesia residents.

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.

A Randomized Comparison of a Parker Endotracheal Tube and a Standard Tube Oriented 90°Counterclockwise

Purpose: During oral fiberoptic intubation, advancement of an endotracheal tube (ETT) into the trachea is occasionally impeded by laryngeal structures. The curved flex tip Parker ETT has been shown to improve the likelihood of successful advancement as opposed to a standard ETT that is advanced in neutral orientation. However, a Parker tube has not been compared to a standard ETT oriented 90° counterclockwise from the neutral position. We hypothesize that fiber-optically-guided advancement of an ETT into the trachea will be more successful when using a Parker tube than a 90° counterclockwise-oriented standard ETT. Methods: This unblinded, randomized controlled trial compares the rate of successful advancement of a fiberoptically-guided endotracheal tube into the trachea. Two groups of randomly assigned patients with non-difficult airways are compared: a Parker flex-tip tube (Parker Group;n = 57) versus a standard ETT oriented 90° counterclockwise (Standard Group;n = 58). Our primary outcome is the first pass success rate of advanceing the ETT into the trachea. Results: First pass success occurred in 48 of 57 (84%) patients in the Parker Group vs. 39 of 58 (67%) of patients in the Standard Group (p = 0.0497). Conclusion: When advancing an ETT over an oral fiberoptic scope and into the trachea, a Parker curved flex tip ETT is statistically more likely to be placed successfully on the first pass than is a standard ETT oriented 90° counterclockwise.

A Comparison of the Best Place to Fix Endotracheal Tubes for Men and Women When Men and Women Are in the Same Height

Background: Comparison of the tracheal tube depth over the same body height of men and women based upon intubation depth markings. Methods: Kashan University of Medical Sciences ethics committee approved the study and written informed consent was taken for each patient. Patients undergoing surgery requiring general anesthesia with oro-tracheal intubation were included in a prospective observational study. After induction of general anesthesia, the endotracheal tube was secured at the point at which the cuff was just below the vocal cord on laryngoscopy. Results: In a statistical study of 682 intubated patients which consisted of 499 women and 183 men, 28 cases of laryngoscopic view grade III and IV were excluded from the study. The measurement markings on the ETT at the level of right corner of the mouth were 20.65 ± 0.13 and 18.52 ± 0.08 for men and women respectively (CI 95%). Patient’s height has a meaningful correlation with the measurement of the fixation point of the ETT. Pearson correlation coefficient between the securing point of the tube and height was 0.2 and 0.357 for men and women respectively. In most cases of men and women of the same height, Mann-Whitney U test rejected the hypothesis that the tube can be fixed in the particular point. Conclusions: In general, men are taller than women. Comparing the fixation depth of the tube, even when man and woman have the same body height, the endotracheal tube might be placed in a deeper level for men rather than women.