Background: Endotracheal intubation is known as the best and challenging procedure to airway control for patients in shock or with unprotected airways. Failed intubation can have serious consequences and lead to high morbidity and mortality of the patients. Videolaryngoscope is a new device that contains a miniaturized camera at the blade tip to visualize the glottis indirectly. Fewer failed intubations have occurred when a videolaryngoscope was used. Other types of videolaryngoscopes were then developed; all have been shown to improve the view of the vocal cords. It may be inferred that for the professional group, including emergency physicians, paramedics, or emergency nurses, video laryngoscopy may be a good alternative to direct laryngoscopy for intubation under difficult conditions. The incidence of complications was not significantly different between the C-MAC 20% versus direct laryngoscopy 13%. The main goal of this review was to compare the direct laryngoscopy with the (indirect) video laryngoscopy in terms of increased first success rate and good vision of the larynx to find a smooth induction of endotracheal intubation. Methods: Currently available evidence on MEDLINE, PubMed, Google scholar and Cochrane Evidence Based Medicine Reviews, in addition to the citation reviews by manual search of new anesthesia and surgical journals related to laryngoscopies and tracheal intubation. Results: This review of recent studies showed that the laryngoscopic device design would result in smooth approach of endotracheal intubation by means of good visualization of glottis and the best success rates in the hands of both the experienced and novice. Video laryngoscopes may improve safety by avoiding many unnecessary attempts when performing tracheal intubation with DL compared to VL as well as easy learning of both direct and indirect laryngoscopy. Conclusion: The comparative studies of different video laryngoscopes showed that DL compared with VL, reveal that video laryngoscopes reduced failed intubation in anticipated difficult airways, improve a good laryngeal view and found that there were fewer failed intubations using a videolaryngoscope when the intubator had equivalent experience with both devices, but not with DL alone. And therefore, knowledge about ETI and their skills, are crucial in increasing the rate of survival.
Background: Hyperalgesia is a major complication of continuous or intermittent opioid administration. The evidence suggests that concomitant administration of low-dose naloxone could prevent the development of acute opioid-induced hyperalgesia, with no effect on pain control. Objectives: The current study aimed to assess the effects of intraoperative low-dose naloxone, adding to remifentanil infusion on preventing acute postoperative hyperalgesia in patients undergoing general anesthesia for laparotomy. Methods: In this randomized clinical trial, patients undergoing general anesthesia for laparotomic hysterectomy in a tertiary referral teaching hospital from February to December 2019 were randomly assigned to one of three groups of remifentanil-naloxone (remifentanil 0.3 μg/ kg/min with low-dose naloxone 0.25μg/kg /h prepared in 50 mL of normal saline), remifentanil (0.3 μg/kg/min), and control (receiving 50 mL saline infusion), intraoperatively. Patients and researchers were blinded to the type of intervention. The severity of hyperalgesia, as the main outcome, was evaluated by the static Tactile test. The severity of pain was assessed by visual analogous scale 0.5, 2, 6, 12, and 24 hours after surgery. Results: In total, 75 patients were evaluated. The results showed no difference concerning the independent variables (age, body mass index, hypertension, surgery duration, anesthesia duration, and American Society of Anesthesiologists (ASA) class) between the three groups. Heart rate was significantly different in all study time points between the three groups (P < 0.001), but mean arterial pressure and systolic and diastolic blood pressure showed no significant difference (P > 0.05) throughout the study. Assessment of hyperalgesia using the tactile test revealed a higher incidence of hyperalgesia in the remifentanil group in 0.5, 2, 6, 12, and 24 hours after surgery compared to the other two groups, which was statistically significant between the groups at 0.5, 2, and 6 hours after surgery (P < 0.05). Shivering incidence, Morphine dose in 24 hours post-surgery, morphine dose in the recovery room, and VAS for pain were significantly different during the study between the three groups (P < 0.05). Conclusions: This study demonstrated the efficacy of intraoperative low-dose naloxone (0.25 μg/kg/h) added to remifentanil infusion on reducing the frequency and severity of acute postoperative hyperalgesia in patients undergoing general anesthesia for laparotomy hysterectomy.
Background and objective:: Because of fixed airway obstruction in patients with laryngeal
tumors, measurement of FEV1 can help in predicting the degree of airway obstruction and
deciding the safe plan for anesthesia. Materials and methods:: 154 patients, 40-80 years old, with ASA class II-III who were
scheduled for elective surgery enrolled in this study. Pulmonary function tests (PFT) was done
before surgery for all patients. They were divided into three groups based on the result of
PFT: Group 1: FEV1> 2.5 L which received standard anesthesia induction. Group 2:
FEV1=1.5-2.5 L, induction was performed by keeping spontaneous breathing and Group 3:
FEV1 < 1.5 L: which awake intubation was performed with topical anesthesia. Results:: there was significant difference in intubation time and attempts among 3 groups
(8.91.8, 10.71.7, 15.66.3 sec.p=.000; 1.20.5, 1.4 0.6, 1.70.8, p=.002 respectively).
Failed intubations were 3, 4, 9 in three groups respectively, which was not statistically different
(P=0.1). Conclusion:: Due to fixed airway obstruction in patients with laryngeal tumors, FEV1 can be
used as a predictor for classification and choosing a safe method for induction of anesthesia.
This study aims to define the incidence and risk factors of both emergence agitation and hypoactive emergence in adult patients and substance-dependent patients following general anesthesia to elaborate on the risk factors and precise management of them.The study recruited 1,136 adult patients who received elective surgeries under general anesthesia for this prospective observational study. Inadequate emergence was determined according to the Richmond Agitation-Sedation Scale (RASS). Emergence agitation was defined as a RASS ≥ +1 point, and hypoactive emergence was defined as a RASS ≤ -2 points. Subgroup analyses were then conducted on patients with substance dependence.Inadequate emergence in the post-anesthesia care unit (PACU) occurred in 20.3% of patients, including 13.9% with emergence agitation and 6.4% with hypoactive emergence. Ninety-five patients had a history of substance dependence. Compared to divorced patients, never-married and presently married patients, who underwent gynecological and thoracic surgeries, had a lower risk of agitation. Neurologic disorders, intraoperative blood loss, intraoperative morphine, and PACU analgesic drug administration were associated with increased agitation risk. Hypertension and psychological disorders, intraoperative opioids, and PACU Foley catheter fixation were associated with increased hypoactive emergence risk. Substance-dependent patients had higher risk for agitation (21.1%, P = 0.019) and hypoactive emergence (10.5%, P = 0.044).Inadequate emergence in PACU following general anesthesia is a significant problem correlated with several perioperative factors. Patients with a history of substance dependence appear to be more at risk of inadequate emergence than the general population.
Objective: This study compares the effects of infusion of Propofol - Remifentanil with Midazolam - Remifentanil in reducing bleeding in patients undergoing middle ear surgery. Methods: This study was conducted as a double blinded randomized clinical trial among 86 patients undergone elective surgery of the middle ear, they were divided in two 43 members group. All of the patients received Isoflurane and N2O as maintenance of general anesthesia. When entering the middle ear, in order to reduce bleeding and achieve surgeon’s satisfaction, either the combination of Midazolam - Remifentanil (M-R) or the combination of Propofol - Remifentanil (P-R) was adjuvant in each group. The (M-R) group received 0.5-1 μg/kg/min Midazolam with intravenous infusion and (P-R) group received 50-100 μg/kg/min Propofol with intravenous infusion; 1.0 μg/kg/min Remifentanil was administered in both groups. Vital signs of the patients were measured and recorded in 5 minutes intervals during the surgical procedure. The BIS scores was monitored and recorded in each group. Satisfaction of the surgeon from surgical setting and the amount of bleeding was recorded based on the score 0-10. Results: There was no significant difference in systolic and diastolic blood pressure, mean arterial pressure (MAP), heart rate and BIS scores between the two groups during the procedure (P>0.05). Surgeon satisfaction showed no significant difference between the two groups (P>0.05). The differences between surgical procedure duration and period of PACU staying were statistically of no important significance between the two groups (P>0.05). Conclusion: It seems that in the middle ear procedures the combination of Propofol - Remifentanil and Midazolam - Remifentanil have not statistically significant differences in hemodynamic control, surgeon’s satisfaction, duration of surgical procedure and discharge from PACU. Therefore, adjuvant drug selection might consider either of these two regimens in order to achieve better surgical condition. Further studies are recommended to confirm these findings.
Background: Our goal was to compare two common methods including auscultation and Fiber-Optic Bronchoscopy (FOB) in confirming the correct placement of Double-Lumen Tube (DLT).
Methods: Seventy six patients were enrolled. After DLT insertion, clinical verification was made by auscultation, then FOB was applied. At lateral decubitus, the position of DLT was rechecked by auscultation, and then by FOB. The incorrect position including malposition and misplacement were compared between two routine methods of auscultation and FOB.
Results: After blind intubation, 21.1% of DLTs were considered to be in an incorrect position. Meanwhile, FOB showed that 46.1% of DLTs were not placed correctly. Among all the patients, 53.9% of DLTs were in the optimal position. Misplacement was diagnosed in 35.5% and malposition in 10.5% of the patients. After positioning to the lateral decubitus, using auscultation, we found that 5.3% of tubes were dislocated, but according to FOB, it was 10.5%. The agreement coefficient between auscultation and FOB was 0.42 in the supine position and 0.64 in lateral position.
Conclusion: Our results showed that although FOB needs more time to check the position of DLT, it should be used to confirm the exact position of DLT.
Introduction:Retrograde laryngeal block is a new technique that blocks complete supraglottic and glottic area by introducing catheter retrograde from trachea to these regions. Methods and Materials:This is a clinical trial conducted on two groups each containing 15 patients, who were candidate for awake intubation.The first group (A) underwent conventional method of airway block, by multiple injections of local anesthetic.The second group (B) underwent retrograde laryngeal block as a new method of regional airway anesthesia.In this method the catheter is inserted from cricothyriod membrane through a flexible guide wire, and then local anesthetic drug will be administered by direct vision of tip of the catheter by employing glide scope.The catheter has three separate orifices; each will stay on distinct area of either supraglottic and glottis area which can be adjusted at any level through this area that is considered to be blocked.Result: Both groups had hemodynamic stability during performing block.In group A we had two incidences of laryngospasm due to pain of multiple needle insertion; in group B we had no incidence of laryngospasm (P=0.1).In group A we had 5 patients with partial airway block which needed further intervention during awake intubation but in group B all the cases had complete and perfect airway block (P=0.001).Patients comfort was better in group B with single injection than group A with multiple injections (P=0.005). Discusion:The advantage of this method is single injection and high quality of block performance in comparison with the other technique.It can be conducted for the patients with neck pathologies that make conventional airway block impossible.Conclussion: This method can be applied in patients with neck pathologies that make conventional block impossible.
Background: Deliberate hypotension is a strategy that reduces intraoperative bleeding and increases the speed of surgery in otolaryngology procedures. Magnesium (Mg) sulfate is a vasodilator agent that reduces intraoperative hypnotic requirements and in combination with analgesic agents, it reduces intraoperative and postoperative pain. In this study we evaluated the use of intravenous Mg sulfate for inducing deliberate hypotension in rhinoplasty. Methods: Sixty ASA I, II patients aged between 18 to 45, scheduled for rhinoplasty were recruited into a randomized clinical trial. Patients were randomly assigned into placebo (group P) and Mg sulfate (group M) groups. For patients in group M, 40m/kg Mg sulfate was administered before induction and continued with 15mg/kg/hr infusion during the operation. Patients of group P received normal saline as placebo. In each group mean arterial pressure (MAP), mean heart rate, amount of bleeding, anesthetic agents, opioid requirement and duration of surgery were recorded. The incidence of nausea, vomiting, shivering and the score of pain were recorded in post-operative period in both groups. Results: Patients in group M had lower MAP (P= 0.0001), less intraoperative bleeding (P=0.0001), lower anesthetic agents (P=0.0001) and opioid consumption (P=0.001), and shorter duration of procedure (P=0.0001). Mean heart rate was lower in group P (P=0.001). Moreover, surgeon`s satisfaction was more in group P (P=0.001).They also had less incidence of post-operative nausea and vomiting (P=0.008), shivering (P=0.001) and lower pain scores postoperatively (P=0.0001). Conclusion: Magnesium sulfate can be a useful drug to induce controlled hypotension in rhinoplasty surgery. By employing this agent patients have better anesthetic condition and recovery profile
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