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.

Oxidative Damage to Lung Tissue and Peripheral Blood in Endotracheal PM_(2.5)-treated Rats

Objective To investigate the oxidative damage to lung tissue and peripherial blood in PM2.5-treated rats. Methods PM2.5 samples were collected using an auto-sampling instrument in summer and winter. Treated samples were endotracheally instilled into rats. Activity of reduced glutathione peroxidase （GSH-Px） and concentration of malondialdehyde （MDA） were used as oxidative damage biomarkers of lung tissue and peripheral blood detected with the biochemical method. DNA migration length （μm） and rate of tail were used as DNA damage biomarkers of lung tissue and peripheral blood detected with the biochemical method. Results The activity of GSH-Px and the concentration of MDA in lung tissue significantly decreased after exposure to PM2.5 for 7-14 days. In peripheral blood, the concentration of MDA decreased, but the activity of GSH-Px increased 7 and 14 days after experiments. The two indicators had a dose-effect relation and similar changing tendency in lung tissue and peripheral blood. The DNA migration length （μm） and rate of tail in lung tissue and peripheral blood significantly increased 7 and 14 days after exposure to PM2.5. The two indicators had a dose-effect relation and similar changing tendency in lung tissue and peripheral blood. Conclusion PM2.5 has a definite oxidative effect on lung tissue and peripheral blood. The activity of GSH-Px and the concentration of MDA are valuable biomarkers of oxidative lung tissue damage induced by PM2.5. The DNA migration length （μm） and rate of tail are simple and valuable biomarkers of PM2 5-induced DNA damage in lung tissues and peripheral blood. The degree of DNA damage in peripheral blood can predict the degree of DNA damage in lung tissue.

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.

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.

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.

Novel Formula for Calculation of the Optimal Insertion Depth for Cuffed Endotracheal Tubes in Pediatric Major Surgery

Background: Accurate determination of the optimal insertion depth of a pediatric endotracheal tube (ETT) is quite important. The aim of this study was to create an easily available formula that can be used to determine the optimal insertion depth for a cuffed ETT even without depth marking with clear definitions of the upper and lower limits for the tip of ETT in the trachea in clinical practice. Methods: Eighty children under 12 years of age were enrolled. The depth marking of the cuffed ETT was placed at the vocal cords and both lungs were then auscultated using a stethoscope. The upper limit was radiographically defined as the position of the tip of the cuffed ETT being between the clavicles. The lower limit was defined as a distance of 5 mm above the carina. The relationship between the insertion depth and patient characteristics was analyzed to create a formula for optimal ETT insertion depth. Results: Sixty-nine ETTs were optimally placed in the trachea. There were good correlations between the optimal insertion depth of ETTs and patients characteristics (height (R = 0.92);BSA (R = 0.92);weight (R = 0.91);age (R = 0.88)). Using these patient characteristics, we created the following three formulas for calculation of the optimal insertion depth for pediatric cuffed ETTs: insertion depth (cm) = height (cm)/11 + 5.5, weight (kg)/3 + 9.5 or 11 + 3/4 × age (years). The rates of appropriate tube placement of both pediatric cuffed ETTs were 87.5% (Hi-Contour) and 85.0% (Microcuff). Conclusions: Our formula and graphs may be easy to determine the optimal insertion depth of cuffed ETT even without depth marking in clinical practice.

National Survey of Attitudes and Practices of Endotracheal Tube Management in Infants and Small Children in Japan

Background: Surveys of pediatric endotracheal tube (ETT) management previously reported that specialists in pediatric anesthesia and intensive care medicine preferred to use uncuffed ETTs for children younger than 8 to 10 years of age. The aim of this study was to reveal the most recent attitudes and clinical practices of pediatric ETT management in Japan. Methods: The attitudes and clinical practices of pediatric ETT management were investigated using the data sheets of each institution and each patient. The data sheets contained information on patient characteristics and type of hospital, surgical procedures, devices used for intubation, and ETT information including types, size, depth, intracuff pressure (ICP), interval of ICP measurement, laryngeal packing, ETT exchange, airway complications, and reintubations. Results: The response rate of this survey was 66.7%. More than half of children older than 2 years of age were intubated with cuffed ETTs;83.5% of cuffed ETTs were used with the cuffs inflated, and ICP was measured in 80.7% of cuffed ETTs. More than half of ICP measurements were only taken at the time of intubation. Post-extubation stridor was rarely observed in cuffed (0.4%) or uncuffed ETTs (1.2%). The pediatric ETT management questionnaire revealed age-based size selection, differences in pressure of air leakage between cuffed (15 - 20 cmH2O) and uncuffed ETTs (20 - 30 cmH2O) of different sizes, the depthmarking method of insertion length. Continuous measurement of ICP was not common. Conclusion: This study revealed widespread use of cuffed ETTs in children older than 2 years of age, rarely occurrence of post-extubation stridor, inflation of cuffs, and practice of ICP measurement.

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.

Estimation of Endotracheal Tube Cuff Pressure in a Large Teaching Hospital in Ghana

Background: Maintenance of optimal Endotracheal Tube cuff Pressure (ETTcP) in anaesthetic practice reduces cuff pressure complications. Aneroid manometers for measurement of ETTcP are not widely available in Ghana, hence anaesthesia providers estimate ETTcP according to their experience. The study assessed ETTcP obtained from estimation techniques between anaesthesia providers at Korle-Bu Teaching Hospital (KBTH). It also evaluated the Volume of Air Required (VAR) to obtain an acceptable cuff inflation pressure for sizes 7.0 and 8.0 mm adult endotracheal tubes used at the hospital, and the effect of patient’s age, weight and height on this volume. Methods: Eighty-one patients who underwent general anaesthesia were recruited. ETTcP was measured using an aneroid manometer via a three-way tap. After full cuff deflation, the cuff was refilled with air until an ETTcP of 20 cm H2O was obtained. Independent t-test was used to measure the statistical variations in the ETTcP using estimation techniques in relation to recommended levels as well as the significant difference of mean VAR to obtain a cuff pressure of 20 cm H2O. Grouped t-test was used to determine significant differences in ETTcP between anaesthesia providers using estimation techniques. Results: Mean ETTcP obtained from estimation techniques was (61.87, 73.79) cm H2O. The mean ETTcP measured for Physician and Nurse Anaesthetists were 65.36 cm H20 and 69.52 cm H2O respectively. The mean VAR to achieve an ETTcP of 20 cm H2O for endotracheal tube sizes 7.0 mm and 8.0 mm were 3.90 ± 1.13 mls and 4.55 ± 0.95 mls respectively. Age and weight significantly influenced the VAR to achieve a cuff pressure of 20 cm H2O, however, height did not. Conclusions: This study demonstrated that cuff pressures obtained by estimation techniques were generally higher than the recommended average with no significant difference between anaesthesia providers. However, in the absence of an aneroid manometer, ETTcP of tube sizes 7.0 mm and 8.0 mm can be safely approximated to the recommended levels with predetermined inflation volumes.

Evaluation and Management of Massive Endotracheal Hemorrhage in Pediatric Patients: A Case Report and Review of Literature

Massive hemoptysis is a frightening and life-threatening event in children. Prompt, aggressive evaluation and management are necessary. The most common cause of hemoptysis in a pediatric patient is infectious, but other various etiologies including tracheotomy related problems, cystic fibrosis, bronchiectasis, congenital anomalies of the cardiopulmonary vasculature and suction trauma must be considered as well. Presented is a report of a case of acute, massive endotracheal hemorrhage with multiple methods of management including balloon tamponade, highly selective embolization, and mainstem occlusion. This case is an addition to our previously reported case series of nine pediatric patients with massive pulmonary hemorrhage. Various diagnostic and management techniques of hemoptyis in pediatric patients are discussed with an extensive review of the literature.

Should We Pay More Attention to Endotracheal Tube Fixation during Anesthesia—Surveys from Chinese Anesthesiologists for Endotracheal Tube Fixation and Endotracheal Tube Displacement in 2014 and 2020

Background: Displacement of endotracheal tube (ETT) can result in endobronchial intubation and accidental extubation that severely threatens safety of surgical patients. However, few surveys have investigated intraoperative ETT displacement experienced by anesthesiologists. The objective of these surveys was to investigate ETT fixation method and ETT displacement during general anesthesia experienced by anesthesiologists in China in 2014 and 2020. Methods: A questionnaire was designed with twenty questions and randomly distributed to anesthesiologists in two survey methods. In 2014, we collected responses from anesthesiologists who participated in the 22nd annual meeting of the Chinese Society of Anesthesiology in a face-to-face setting;in 2020, anesthesiologists from twenty-eight provinces completed the questionnaire through an online questionnaire survey platform. Differences in the responses from the anesthesiologists in 2014 and 2020 were assessed with a chi-square test. Results: In total, 568 questionnaires were collected, of which 541 questionnaires were valid (valid response rate 95.2%). A majority of the respondents (65.6%) had experienced ETT displacement, and 4.3% of respondents had experienced serious complications due to ETT displacement. Three hundred and twenty-nine respondents (60.8%) fixed the ETT with adhesive tape in the shape of the letter X. A majority of respondents considered the influence of surgical site, body position (97.8% of all respondents), and age (77.1% of all respondents) on fixing the ETT. Adhesive tape was the most commonly used material to fix the ETT (90.4% of the respondents). Conclusion: During clinical anesthesia, a majority of anesthesiologists experienced ETT displacement that can result in serious consequences. Therefore, the management of ETT should be a priority during the operation.

Formation of granulation tissue on bilateral vocal cords after doublelumen endotracheal intubation:A case report

BACKGROUND Most case reports on laryngeal granuloma formation have described patients after tracheotomy and single-lumen endotracheal intubation.Few studies have investigated vocal cord granuloma formation after double-lumen endotracheal(DLT)intubation.CASE SUMMARY We report granulation tissue formation on the bilateral vocal cords after DLT intubation in a 45-year-old,153-cm-tall female patient.Previous imaging reports showed no formation of vocal cord granuloma before DLT intubation.Therefore,we inferred that DLT intubation may have been the main reason for the postoperative granulation tissue formation on her bilateral vocal cords,based on the patient’s history of DLT intubation,persistent hoarseness after thoracic surgery,and fibrolaryngoscopic and pathological reports during 12 mo follow-up.CONCLUSION Thirty-two Fr DLT tubes should be utilized for thoracic surgery on female patients who are shorter than 153 cm in height.

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.

A Comparison of Five Adhesive Tapes for Securing Endotracheal Tube in a Manikin

Background: Adhesive tape is the common method for endotracheal tube (ETT) secured to prevent tube displacement and unplanned extubation in an anesthesia setting. However, it is unclear which tape is superior for ETT fixation among the various tapes used in clinical practice. This study examines the force required to move 2 cm ETT and extubate ETT from an intubation manikin with five different adhesive tapes. Methods: We orally intubated an adult intubation manikin with an inner-diameter 7.5 mm ETT, inflated the cuff to 20 cm H2O. Then we secured ETT with five different adhesive tapes (Transpore tapeTM, Urgosyval tape®, TransporeTM White tape, Multipore tape, DuraporeTM tape) in a conventional fixation method. A digital force gauge was connected to the ETT and pulled in a direction erected to the oral cavity. We measured the force required to move 2 cm ETT and extubate ETT (defined as 5 cm ETT displacement) from the manikin. Data were analyzed with one-way analysis of variance, with P < 0.05. Results: DuraporeTM tape had the largest average force of 2 cm displacement (58.9 ± 5.7N) (P < 0.05). The extubation force of DuraporeTM tape (59.7 ± 4.9N) was larger than Urgosyval® tape (40.4 ± 2.9N) (P < 0.05), TransporeTM tape (48.7 ± 5.1N) (P < 0.05), Transpore WhiteTM tape (48.7 ± 5.1N) (P < 0.05). Conclusion: DuraporeTM tape was superior to the other four tapes (TransporeTM tape, Urgosyval® tape, TransporeTM white tape, Multipore tape) in holding the ETT in place in the manikin.

Endotracheal Tube Displacement during Cardiac Surgery in Infants: A Retrospective Cohort Study of Its Incidence and Predictors

Introduction: With the traction on the trachea and intrathoracic manipulation during cardiac surgery, the position of the endotracheal tube (ETT) might be changed as compared to before surgery. Migration of the ETT during pediatric cardiac surgery is particularly problematic in infants. Methods: In this retrospective cohort study, chest X-rays were taken in the operating room just before and after surgery. The position of the ETT among all infants under 1 year of age who underwent cardiac surgery between December 2017 to December 2019 was evaluated. The displacement of the ETT position was examined by measuring the position of the tube tip from the tracheal bifurcation on a chest X-ray, and the relationship between surgery-related factors (age, height, weight, sex, surgery time, cardiopulmonary bypass, tube size, use of tube cuff) was analyzed. Results: Eighty-eight of the 141 patients were enrolled. There was a significant proximal displacement of the ETT tip during cardiac surgery. The distance from the carina to the tube tip after surgery was long, on average 2.5 mm, compared to that before surgery (P = 0.013). Cephalad displacement of the ETT either ≥5 mm or ≥2.5 mm was found in 28 and in 38 out of 88 infants after surgery, respectively. After performing multivariate analysis, the use of un-cuffed ETT was the sole exploratory variable predictive of tube tip displacement (OR 0.34, 95% CI 0.10 - 0.93 if ≥5 mm;and OR 0.24, 95% CI 0.08 - 0.75 if ≥2.5 mm displacement;P = 0.04 and 0.01, respectively). Conclusion: Proximal displacement of the ETT during cardiac surgery occurs more frequently in infants with un-cuffed ETT.

Perianesthesia emergency repair of a cut endotracheal tube’s inflatable tube:A case report

BACKGROUND During the perianesthesia period,emergency situations threatening the life and safety of patients can occur at any time.When dealing with some emergencies,occasional confusion is inevitable.CASE SUMMARY This case report describes the rare situation wherein a surgeon inadvertently detached the inflatable tube of an endotracheal tube during a tonsillectomy,and positive pressure ventilation could not be provided.While reintubation may increase the risk of respiratory tract infection and aspiration,patients with a difficult airway might die due to apnea.The best treatment method is to optimize the damaged tracheal tube junction to avoid secondary intubation and ensure patient safety.An intravenous needle and cannula were used to repair the damaged gap in the current case.Following the repair,the anesthesia machine showed no indication of low tidal volume,and there was no deflation of the endotracheal tube cuff.Subsequently,the patient was transferred to the postanesthesia recovery room,and the tracheal tube was removed with satisfactory results.CONCLUSION Using an intravenous needle to repair a break in the inflatable tube surrounding an endotracheal tube is safe and reliable.

Inter-Professional-Compassionate pain management during endotracheal suctioning: a valuable lesson from a Chinese surgical intensive care unit

Objective:To compare the effects of a pain management program and routine suctioning methods on the level of pain presence and agitation in Chinese adults admitted to the intensive care unit.To disseminate the results from the implementation of the evidence-informed pain management interventions for reducing pain presence and agitation during endotracheal tube suctioning(ETS)and translate the key finding to clinical nursing practice.Methods:A quasi-experimental study of a two-group post-test design was conducted in adults admitted after surgery to a surgical intensive care unit(SICU)of the Second Affiliated Hospital of Kunming Medical University,Yunnan,China in 2018.Fifty-two adults who met the study eligibility were included after consent,26 in each group.Patients in the control group received usual care while patients in the intervention group received interventions to reduce agitation and pain-related ETS.The impacts of the intervention on the level of pain presence and agitation were measured at 5 measuring time points using the Chinese versions of Critical-Care Pain Observation Tool(CPOT)and Richmond Agitation Sedation Scale(RASS).Results:The level of pain presence in the intervention group statistically significantly decreased during,immediately after,and 5 min after suctioning.The level of agitation in the intervention group significantly decreased during and immediately after suctioning.Conclusions:The findings provide support for the positive pain-relieving effects of the evidence-informed pain-related ETS management interventions when compared with the usual ETS practice.The study interventions were sufficiently effective and safe to maintain patent airway clean and patent as standardized suctioning and helps pain relief.So,evidence-based pain-related ETS management intervention is worthy of recommending to utilize in SICU patients as well as other patients who required suctioning.It is worth noting that integrating pre-emptive analgesia prescription and administration with non-pharmacological intervention plays a critical role in achieving pain relief.

Difficult Endotracheal Intubation -Scales and Causes

The aim of the study is to assess the possibility of intubation in each patient, the lyche to be difficult intubation, to fred all the causes of the difficult intubation, to fred and apply appropriate scales for difficult intubation, to estimate the frequency of difficult intubation. Endotmcheal intubation is the basic reanimation procedure performed both in hospital and out-of-hospital settings. It is carded out whenever chest movements and spontaneous respiration are compromised. Respiratory arrest may occur for a variety of reasons （such as cardac arrest, coma of any origin, poisining） or direct damage to the airways, e.g. in various traumas （damages to the face, oropharynx, larynx, trachea, chest）. The basic endotracheal intubation kit contains： laryngoscope, endotracheal tubes, connectors （tube and Ambu bag connectors）, complete Ambu kit （face mask and bag）, 20 mL syringe for cuff inflating, suction apparatus, stylete, and Magill forceps. In order to assess the successfulness of endotracheal intubation, it is necessary first to identify patients who need to be intubated. With the aim of identifying such patients, numerous screening tests and scales have been created to predict difficult intubation. The best known and most commonly used are the Mallampati and Wilson classifications as well as the LEMON airway assessment method. Nevertheless, difficult intubation accounts for 1% of cases. It usually occurs when manipulation of the laryngoscope blade is not possible in obese patients and patients with short neck, in congenital restricted mouth opening, limited neck movement as well as limited temporomandibular joint mobility; in cases of edema, fibrosis and lesions of the tongue, pharynx and larynx; when there are anatomical variations and congenital malformations of the oral cavity, pharynx, larynx, head, neck and chest.