The correlation among the Ramsay sedation scale, Richmond agitation sedation scale and Riker sedation agitation scale during midazolam-remifentanil sedation / Correlação entre a escala de sedação de Ramsay, escala de sedação-agitação de Richmond e escala de sedação-agitação de Riker durante sedação com midazolam-remifentanil

Abstract Background and objectives: Sedative and analgesic treatment administered to critically ill patients need to be regularly assessed to ensure that previously stated goals are well achieved as the risk of complications of oversedation is minimized. We revised and prospectively tested the Ramsay Sedation scale (RSS) for interrater reliability and compared it with the Sedation-Agitation Scale (SAS) and the Richmond Agitation Sedation Scale (RASS) to test construct validity during midazolam-remifentanil sedation. Methods: A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS, RSS, and RASS. Ninety-two ICU patients were examined a total of 276 times by evaluator pairs. Results: The mean patient age was 61.32 ± 18.68 years, 45,7% were female (n = 42), 54.3% male (n = 50). Their APACHE values varied between 3 and 39 with an average of 13.27 ± 7.86 and 75% of the cases were under mechanical ventilation. When classified by using RSS (2.70 ± 1.28), 10.9% were anxious or agitated (RSS1), 68.5% were calm (RSS 2-3), and 20.6% were sedated (RSS 4-6). When classified by using RASS (-0.64 ± 1.58), 20.7% were anxious or agitated (RASS+1 to +4), 63.0% were calm (RASS 0 to -2), and 16.3% were sedated (RASS -3 to -5). When classified by using SAS (2.63 ± 1.00), 12% were anxious or agitated (SAS 5-7), 57.6% were calm (SAS 4), and 30.4% were sedated (SAS 1-3). RSS was correlated with the SAS (r = -0.656, p < 0.001) and RASS was correlated with the SAS (r = 0.565, p < 0.001). RSS was highly correlated with the RASS (r = -0.664, p < 0.001). Conclusions: Ramsay is both reliable and valid (high correlation with the RASS and SAS scales) in assessing agitation and sedation in adult ICU patients.

Resumo Justificativa e objetivos: O tratamento de pacientes em estado crítico com sedativos e analgésicos deve ser regularmente avaliado para garantir que as metas pré-definidas sejam atingidas, bem como minimizar o risco de complicações resultantes de sedação em excesso. Conduzimos uma revisão e testamos prospectivamente a Escala de Sedação de Ramsay (Ramsay Sedation Scale [RSS]) para a confiabilidade interavaliador e a comparamos com a Escala de Sedação e Agitação de Riker (Riker Sedation-Agitation Scale [RRSAS]) e a Escala de Sedação e Agitação de Richmond (Richmond Agitation Sedation Scale [RASS]) para testar a validade de construto durante a sedação com midazolam-remifentanil. Métodos: Uma amostra de conveniência de pacientes de UTI foi simultânea e independentemente examinada por pares de avaliadores treinados com o uso das escalas revisadas RRSAS, RSS e RASS. Foram examinados 92 pacientes de UTI por pares de avaliadores em 276 momentos. Resultados: A média dos pacientes foi de 61,32 ± 18,68 anos; 45,7% eram do sexo feminino (n = 42) e 54,3% do masculino (n = 50). Seus escores APACHE variaram entre 3-39, com média de 13,27 ± 7,86, e 75% dos casos receberam ventilação mecânica. Quando RSS foi usada para a classificação (2,70 ± 1,28), 10,9% dos pacientes estavam ansiosos ou agitados (RSS1), 68,5% estavam calmos (RSS 2 a 3) e 20,6% estavam sedados (RSS 4 a 6). Quando RASS foi usada para a classificação (-0,64 ± 1,58), 20,7% dos pacientes estavam ansiosos ou agitados (RASS +1 a +4), 63,0% estavam calmos (RASS 0 a -2) e 16,3% estavam sedados (RASS -3 a -5). Quando RSAS foi usada para a classificação (2,63 ± 1,00), 12% dos pacientes estavam ansiosos ou agitados (RSAS 5 a 7), 57,6% estavam calmos (RSAS 4) e 30,4% estavam sedados (RSAS 1 a 3). Houve correlação de RSS com RSAS (r = -0,656, p < 0,001) e de RASS com RSAS (r = 0,565, p < 0,001). Houve forte correlação de RSS com RASS (r = -0,664, p < 0,001). Conclusões: A RSS é confiável e válida (forte correlação com RASS e RSAS) para avaliar a sedação e agitação em pacientes adultos internados em UTI.

accuracy of tests used to predict difficult airway and a comparison of macintosh laryngoscope to video laryngoscope for intubation

Objectives: To compare TruView EVO2 video laryngoscope [VL] and Macintosh laryngoscope [ML] as regards their success rates in difficult intubation, hemodynamic response and postoperative complications. Design: Prospective study Setting: Training and Research Hospital, Istanbul, Turkey

Subjects and Methods: A total of 60 cases were enrolled to the study. Group ML [N = 30] were intubated using ML and Group VL [N = 30] were intubated using TruView EVO2[TM] VL. Main Outcomes Measures: Cormack-Lehane score was used to evaluate the visualization vocal cords and intubation difficulty. The time required for visualization of vocal cords, total intubation time, difficulty in intubation were also recorded

Results: For all cases, having BMI > 30, Mallampati grade > 3, Cormack-Lehane score > 3, short neck, not being able to touch chin to chest, no mandibular protrusion, distance between incisor teeth < 3 cm and, thyromental distance < 7 cm corresponded to the difficult intubation cases of 46.15%. The time period of visualization of vocal cords was significantly longer in Group VL. Cormack- Lehane > 3 and difficult intubation rate was significantly higher in Group ML. The ratio of ones having Mallampati scores of III - IV and Cormack-Lehane scores of I - II was found 17% in Group ML, while the ratio was 30% for Group VL. In all cases, regarding patients having difficult intubation, the success rate of intubation was found as 79.3%

Conclusion: High success rates of intubation were seen with both TruView EVO2[TM] VL and ML. Either ML or VL can be used in case of difficult intubations

Comparison of the applicability and safety of the cobra perilaryngeal airway and the laryngeal mask airway classic in anesthetized and paralyzed patients

To compare two supraglottic airway devices [SAD], laryngeal mask airway classic [LMA- Classic] and cobra perilaryngeal airway [Cobra-PLA], in terms of insetion characteristics, sealing pressure, hemodynamic effects and post-operative complications. Prospective study. Okmeydani Teaching and Research Hospital, Istanbul, Turkey. A total of sixty patients were included in our study. Patients were randomly divided into two groups as Group Cobra-PLA and Group LMA-Classic.upon successful insertion, the cuff was inflated with air to a pressure of 60 cm H[2]O by using manometer. A maximum of two attempts were made to insert the SAD. In case of failure, orotracheal intubation was the SAD devices, the duration of insertion, the number of attempts, the insertion complications, ventilation parameters, hemodynamic parameters and postoperative adverse effects were recorded for each group. In Group Cobra-PLA and Group LMA-Classic, the SAD were successfully inserted respectively in 26 [86.7%] and 28 [93.3%] patients. The duration of insertion was shorter in group LMA-Classic [p < 0.05]. The seal pressure was significantly higher in group Cobra-PLA [p < 0.001]. Bleeding was less frequently observed in patients with LMA-Classic group [p < 0.05]. Both SAD can safely be used as an alternative to endotracheal intubation. According to the results of our study, LAM-Classic seems to be a more practical device regarding the insertion characteristics and the postoperative complications; however, it should be noted that sealing pressure is higher in Cobra-PLA

Comparison of percutaneous dilatational tracheostomy with surgical tracheostomy

Tracheostomy is done mostly in critically ill patients, many of whom may not survive. We still do not know the long term complications of tracheostomy itself; tracheal and subglottic stenosis, and tracheomalacia. To compare the complications of surgical tracheostomy [ST] versus percutaneous dilatational tracheostomy [PDT] by means of MRI control up to 1 month after closed tracheostomy. There was no death related to tracheostomy. In both groups there were two preoperative complications: one minor hemorrhage and one subcutaneous empysema in the ST group, and one minor bleeding and one puncture of endotracheal tube cuff in the PDT group. When the early and the late postoperative complications of the two groups were compared, it was observed that in the ST group, five early [one minor bleeding, three stomal infections and one accidental decannulation], and two late [one peristomal granuloma and one persistent stoma] postoperative complications had occurred. In the PDT group, four early [minor bleeding] and two late postoperative complications [two minor bleeding] were observed. MRI of two patients in the PDT group demonstrated tracheal stenosis. PDT is as safe and as effective as ST. Although the early and late postoperative complication rates were not significant in the PDT group, we believe that further investigations with larger groups are necessary to find long-term outcome following PDT. MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen