Cytokines and Defensins in Tissue Biopsies Obtained by Bronchoscopy from Patients with Post-Intubation Tracheal Stenosis.

Aims: The objective of our study was to perform the routine analysis of bronchoscopically obtained tracheal samples to determine the appearance and relative distribution of cytokines and antimicrobial proteins in patients with post-intubation tracheal stenosis (PITS). Study Design: Retrospective. Place and Duration of Study: Rīga Stradiņš University, Institute of Anatomy and Anthropology, Pauls Stradiņš Clinical University Hospital, between May 2014 and May 2015. Methodology: Five patients with PITS were involved in this study. Tissue samples were obtained by bronchoscopy from the upper part of trachea, then proceeded for routine histological staining with hematoxylin and eosin. Interleukine-1 (IL-1), interleukine-10 (IL-10) and tumor necrosis factor alpha (TNFα), as well as beta defensin-2 (β def-2) were detected by use of immunohistochemistry (IMH) method. The number of immunoreactive (positive) structures was graded semi-quantitatively. Results: Squamous metaplasia, inflammatory cell infiltration and formation of granulation tissue were observed in all cases. Significant expression of IL-10 and β def-2 was seen as various number of immunoreactive structures in tracheal tissue. Only few scattered IL-1 and TNFα positive macrophages were found in part of cases. Conclusions: The leading role in pathogenesis of post-intubation tracheal stenosis is assumed to be the chronic inflammation, fibrous scarring, as well as the remodeling of tracheal wall due to the ischemia. Compensatory expression of antimicrobial peptide β def-2 and anti-inflammatory cytokine IL-10 indicates the intense local tissue defense reactions. TNFα and IL-1 are not among the most significant factors in pathogenesis of PITS.

Prognostic Factors for Endotracheal Silicone Stenting in the Management of Inoperable Post-Intubation Tracheal Stenosis

PURPOSE: Stenting has been developed to deal with airway stenosis and is applicable in patients with post-intubation tracheal stenosis (PITS) in whom surgery would not be indicated. The purpose of this study was to investigate the prognostic factors in inoperable patients in whom a silicone stent was inserted due to PITS. MATERIALS AND METHODS: We retrospectively evaluated 55 PITS patients undergoing silicone stenting between January 2001 and December 2009. RESULTS: Silicone stent was inserted to narrowed trachea after the combination of pre-dilatation including laser cauterization, mechanical bougienation and ballooning. Following airway stabilization, the stent could be removed successfully in 40% (22/55) of the patients after median 12 months of stenting. However, in 60% (33/55) of patients, the stent could not be removed successfully and surgical management was needed after initial stabilization. Multivariate analysis revealed that the stent could be successfully removed more frequently in those who do not have cardiovascular disease [odds ratio (OR)=12.195; p=0.036] and the intervention was performed within 6 months after intubation (OR=13.029; p=0.031). CONCLUSION: Among those patients undergoing silicone stenting due to PITS, the stent could be successfully removed when patients do not have cardiovascular disease and stented within 6 months after intubation.

Efficacy of esmolol administration at different time intervals in attenuating hemodynamic response to tracheal intubation.

Background: Laryngoscopy and endotracheal intubation are known to cause increase in both arterial blood pressure and heart rate. Several strategies have been evolved to blunt the haemodynamic response to tracheal intubation but each method has its own advantages and disadvantages. Esmolol, a cardio selective Beta -1 blocking drug, can alleviate some of these problems. Esmolol, when administered parenterally, exhibits rapid onset and a short duration of action due to its rapid clearance by red blood cell esterases. Hence we conducted the present study to evaluate the efficacy and optimum time of single bolus esmolol administration in attenuating hypertensive- tachycardiac response to laryngoscopy and tracheal intubation. Materials and Methods: The randomized double blind prospective study was conducted in 60 patients, in the age group of 20-40 years, of both sexes, belonging to American Society of Anaesthesiologists (ASA) physical status class I or II and scheduled for elective surgery requiring endotracheal intubation and general anaesthesia. The efficacy and optimum time of single bolus esmolol administration in attenuating hypertensive - tachycardiac response to laryngoscopy and tracheal intubation was evaluated. Patients in group I (n=20) received bolus administration of injection esmolol 1.5 mg/kg intravenously (iv) 90 seconds before intubation; in group II (n=20) three minutes before intubation and in group III (n=20) six minutes before intubation. Results: There was no clinical and statistically significant variation in heart rate in group I and II at different time intervals of the study period but in group III heart rate increased significantly one minute after tracheal intubation. (P<0.05) One minute after intubation, the increase in systolic, diastolic and mean blood pressure and rate pressure product was statistically significant in group I (P<0.01) and group III. (P<0.05) However, in group II increase in systolic blood pressure and rate pressure product was statistically not significant. (P>0.05) Conclusion: To conclude, single intravenous bolus dose of esmolol (1.5 mg/kg) is safe and more effective in attenuating haemodynamic response to laryngoscopy and tracheal intubation when administered three minutes prior to intubation.

Prophylactic effect of dexamethasone in reducing postoperative sore throat / 대한마취과학회지

BACKGROUND: This study was performed to compare the effectiveness of prophylactic dexamethasone and postintubation dexamethasone in reducing the incidence and severity of postoperative sore throat (POST). METHODS: This was a prospective, randomized, double-blind clinical trial. The study population consisted of 70 patients between 20 and 60 years old who were classified as American Society of Anesthesiologists I-II and were scheduled for elective laparoscopic cholecystectomy. The patients were divided randomly into two groups. Patients in the prophylactic and postintubation groups received intravenous injection of 10 mg of dexamethasone 30 min before or after tracheal intubation, respectively. The patients were interviewed 1, 6, and 24 h after the operation. The incidence and severity of POST were recorded. RESULTS: The severity scores of POST at 1 and 6 h after the operation were significantly lower in the prophylactic group than in the postintubation group. There were no significant differences in the incidence of POST during the 24 h after the operation between the two groups (22/32 in the prophylactic group vs. 27/34 in the postintubation group, P = 0.403). CONCLUSIONS: Intravenous injection of 10 mg of dexamethasone was more effective in reducing the severity of POST when administered before tracheal intubation compared with after tracheal intubation.

Intubação nasotraqueal guiada por rinoscópio em criança de um ano de idade portadora de Osteogenesis imperfecta: relato de caso / Intubación nasotraqueal guiada por rinoscopio en niño de un año de edad portador de Osteogenesis imperfecta: relato de caso / Rhinoscope-guided nasotracheal intubation in a one-year old child with Osteogenesis imperfecta: case report

JUSTIFICATIVA E OBJETIVOS: A Osteogênesis Imperfecta (OI) é uma rara doença genética de herança autossômica dominante. A anestesia para o paciente portador da OI inclui diversos desafios, entre eles o manuseio da via aérea e a escolha da técnica anestésica. O objetivo do presente artigo foi descrever caso de criança portadora desta doença associada à hidrocefalia, submetida à anestesia venosa total e intubação nasotraqueal guiada por rinoscópio para realização de derivação ventrículo-peritoneal. RELATO DO CASO: Paciente do sexo masculino, um ano e três meses de idade, com diagnósticos de OI (tipo III) e hidrocefalia submetido à derivação ventrículo-peritoneal. Após a administração de midazolam (1 mg.kg-1) por via oral 30 minutos antes do procedimento, a criança foi monitorizada, seguindo-se a venóclise com cateter 24G. Após oxigenação, procedeu-se à indução anestésica com remifentanil, propofol e cisatracúrio. A intubação nasotraqueal foi guiada por rinolaringoscópio (Olimpus® ENF P3) e cânula de 4,5 mm com balonete foi inserida sem intercorrências. A anestesia foi mantida com infusão de remifentanil e propofol. A operação teve duração de 120 minutos, sem intercorrências. CONCLUSÕES: O presente relato descreveu alternativa de aces-so à via aérea em crianças submetidas à anestesia geral e que por algum motivo não podem ser ventiladas através da máscara laríngea. O rinolaringoscópio, por apresentar diâmetro reduzido, permite a inserção de cânulas traqueais que não poderiam ser utilizadas com o emprego do fibroscópio convencional.

BACKGROUND AND OBJECTIVES: Osteogenesis imperfecta (OI) is a rare, autosomal dominant disease. Anesthesia for patients with OI has several challenges; among them, management of the airways and the choice of anesthetic technique should be mentioned. The objective of this report was to describe the case of a child with this disorder associated with hydrocephalus who underwent total intravenous anesthesia and rhinoscope-guided nasotracheal intubation for a ventriculoperitoneal shunt. CASE REPORT: This is a 15-month old male with OI (type III) and hydrocephalus who underwent placement of a ventriculoperitoneal shunt. After the oral administration of midazolam (1 mg.kg-1) 30 minutes before the procedure, the child was monitored and, afterwards, a 24G catheter was used for venipuncture. After oxygenation, anesthesia was induced with remifentanil, propofol, and cisatracurium. A 4.5-mm ETT with balloon was used for the rhinoscopeguided (Olimpus® ENF P3) nasotracheal intubation without intercurrences. Anesthesia was maintained with the infusion of remifentanil and propofol. The surgery lasted 120 minutes, without intercurrences. CONCLUSIONS: The present report described an alternative for the access of the upper airways in children undergoing general anesthesia and who, for some reason, cannot be ventilated with a laryngeal mask. Since the rhinolaryngoscope has a reduced diameter, it allows the insertion of ETTs that could not be used with conventional fiberscopes.

JUSTIFICATIVA Y OBJETIVOS: La Osteogénesis Imperfecta (OI) es una rara enfermedad genética de herencia autosómica dominante. La anestesia para el paciente portador de la OI incluye diversos retos, entre ellos el manejo de la vía aérea y la elección de la técnica anestésica. El objetivo del presente artículo, fue describir el caso de un niño portador de esa enfermedad asociada a la hidrocefalia, y sometido a la anestesia venosa total e intubación nasotraqueal, guiada por rinoscopio para la realización de la derivación ventrículo-peritoneal. RELATO DEL CASO: Paciente del sexo masculino, un año y tres meses de edad, con diagnósticos de OI (tipo III) e hidrocefalia sometido a la derivación ventrículo-peritoneal. Después de la administración de midazolam (1 mg.kg-1) por vía oral, 30 minutos antes del procedimiento, el niño fue monitorizado, con posterior venoclisis con catéter 24G. Después de la oxigenación, se procedió a la inducción anestésica con remifentanil, propofol y cisatracurio. La intubación nasotraqueal fue guiada por rinolaringoscopio (Olimpus® ENF P3) y cánula de 4,5 mm con balón e insertada sin intercurrencias. La anestesia se mantuvo con infusión de remifentanil y propofol. La operación duró 120 minutos sin intercurrencias. CONCLUSIONES: El presente relato describió una alternativa de acceso a la vía aérea en niños sometidos a la anestesia general y que por algún motivo no pueden ser ventilados a través de la máscara laríngea. El rinolaringoscopio, por presentar un diámetro reducido, permite la inserción de cánulas traqueales que no podrían ser utilizadas con el uso del fibroscopio convencional.

Bougie / Bougie / Bougie

JUSTIFICATIVA E OBJETIVOS: As situações de via aérea difícil expõem o anestesiologista à necessidade de rápida atuação, muitas vezes necessitando de dispositivos complementares para garantir a permeabilidade destas vias. Porém muitos destes dispositivos são dispendiosos e necessitam treinamento para seu emprego. É apresentado aqui dispositivo simples, descartável e que pode ser confeccionado pelo próprio anestesiologista, tornando-o ferramenta de baixo custo: o bougie. CONTEÚDO: O bougie consiste de introdutor que, inserido na traquéia, ajuda a orientar a introdução da cânula traqueal. Por ser ferramenta simples, de fácil manipulação e de baixo custo, mostra-se extremamente útil nas situações de via aérea difícil inesperada. CONCLUSÕES: O bougie mostrou-se uma valiosa ferramenta no arsenal anestesiológico, estando bem indicado num amplo espectro de situações.

BACKGROUND AND OBJECTIVES: Difficult airways require fast action by the anesthesiologist often requiring complementary devices to ensure patent airways. However, several of those devices are expensive and require training in order to be used. The bougie, a simple and disposable device can also be manufactured by the anesthesiologist, making it a low cost tool. CONTENTS: Bougies are composed of one introducer that when inserted in the trachea helps orienting the introduction of the tracheal tube. It is a simple tool, easy to use, low in cost, and has been shown to be very useful in unexpected difficult airways. CONCLUSIONS: The bougie has shown to be a valuable tool in the armamentarium of the anesthesiologist, and it is indicated in a wide range of situations.

JUSTIFICATIVA Y OBJETIVOS: Las situaciones de vía aérea difícil obligan al anestesiólogo a actuar rápidamente, muchas veces necesitando dispositivos complementarios para garantizar la permeabilidad de esas vías. Sin embargo, muchos de esos dispositivos son caros y necesitan un entrenamiento para su uso. Aquí presentamos un dispositivo sencillo, desechable y que puede ser confeccionado por el mismo anestesiólogo, convirtiéndolo así en una herramienta de bajo coste: el bougie. CONTENIDO: El bougie es un introductor que insertado en la tráquea, ayuda a orientar la inserción de la cánula traqueal. Por ser una herramienta muy sencilla, de fácil manejo y de bajo coste, es muy útil en las situaciones de vía aérea difícil inesperada. CONCLUSIONES: El bougie fue una valiosa herramienta en el arsenal anestesiológico, siendo muy bien indicada en una amplia gama de situaciones.

Compressão da cartilagem cricóide: aspectos atuais: [revisão] / Compresión del cartílago cricoides: aspectos actuales: [revisión] / Compression of the cricoid cartilage: current aspects: [review]

JUSTIFICATIVA E OBJETIVOS: Sellick descreveu a importância da pressão aplicada na cartilagem cricóide para a prevenção da regurgitação do conteúdo gástrico durante a indução da anestesia. Desde então a manobra tem sido universalmente aceita pelos anestesiologistas como um passo fundamental durante a indução com a técnica de seqüência rápida. O presente artigo teve como objetivo discutir as indicações, a técnica, as complicações e os motivos pelos quais alguns autores têm contestado a eficácia dessa técnica. CONTEÚDO: Foram revisadas as indicações, a técnica e as complicações da manobra de compressão da cartilagem cricóide. Também foram discutidos os aspectos que têm motivado alguns autores a abandonar a manobra de Sellick durante a indução anestésica com a técnica de seqüência rápida. CONCLUSÕES: A aplicação da manobra de compressão da cartilagem cricóide exige o conhecimento da anatomia da via aérea superior e da força correta a ser empregada. Estudos endoscópicos e radiológicos, assim como pacientes que apresentaram aspiração pulmonar a despeito da aplicação da manobra de Sellick, têm colocado em questão a utilidade da técnica. Além disso, quando mal empregada, pode causar deformidade dessa cartilagem, fechamento das cordas vocais e dificuldade de ventilação. Apesar do papel de destaque representado pela manobra de Sellick na prevenção da aspiração pulmonar, não há garantia de proteção das vias aéreas para todos os pacientes, sobretudo quando a técnica não é corretamente aplicada.

BACKGROUND AND OBJECTIVES: Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS: The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS: The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.

JUSTIFICATIVA Y OBJETIVOS: Sellick describió la importancia de la presión aplicada en el cartílago cricoides para la prevención de la regurgitación del contenido gástrico durante la inducción de la anestesia. Desde entonces, la maniobra ha sido universalmente aceptada por los anestesiólogos como un paso fundamental durante la inducción con la técnica de secuencia rápida. El presente artículo, tuvo el objetivo de discutir las indicaciones, la técnica, las complicaciones y los motivos por los cuales algunos autores han refutado la eficacia de la mencionada técnica. CONTENIDO: Han sido revisadas las indicaciones, la técnica y las complicaciones de la maniobra de compresión del cartílago cricoides. También se analizaron los aspectos que han hecho con que algunos autores abandonen la maniobra de Sellick durante la inducción anestésica con la técnica de secuencia rápida. CONCLUSIONES: La aplicación de la maniobra de compresión del cartílago cricoides exige el conocimiento de la anatomía de la vía aérea superior y de la fuerza correcta a ser empleada. Estudios endoscópicos y radiológicos, como también pacientes que presentaron aspiración pulmonar pese al uso de la maniobra de Sellick, han colocado en tela de juicio la utilidad de la técnica. Además de eso, cuando se usa mal, puede causar deformidad de ese cartílago, el cierre de las cuerdas vocales y dificultad de ventilación. A pesar del papel de destaque representado por la maniobra de Sellick en la prevención de la aspiración pulmonar, no se garantiza la protección de las vías aéreas para todos los pacientes, principalmente cuando la técnica no está correctamente aplicada.

Difficult Endotracheal Intubation Due to Unrecognized Dysfunction of Temporomandibular Joint: A case report / 대한구급학회지

In association with facial trauma, fracture of mandibular condyle occurs frequently. From that injury, the dysfunction of temporomandibular joint and the following limitation of mouth opening causing difficult intubation can result. So the anesthesiologists should have the capability of recognizing such problems. But in the case of facial trauma, pain and muscle spasm also cause similar but reversible conditions posing difficulty in differential diagnosis. In this case the patient showed some degree of limitation in mouth opening (1 finger breath) at the preoperative evaluation, so the author performed routine induction expecting the occurrence of full mouth opening after muscle relaxation. But the patient's mouth couldn't be opened any further and the exposure of epiglottis was impossible. Now since we have no reliable predictive criteria of irreversible temporomandibular joint dysfunction, awake fiberoptic intubation should be strongly considered in the case of condylar fracture with any limitations in mouth opening.

The Development of an Inspiratory Time Adjustable Transtracheal Jet Ventilator and Evaluation in a Human Adult Trachea-Lung Model / 대한마취과학회지

BACKGROUND: Transtracheal jet ventilation (TTJV) has been used for 'Cannot Ventilate/Cannot Intubate' situation, lefe-saving situations, by simply introducing an IV catheter (angiocatheter) through the cricothyroid membrane. To decrease the occurrence of barotrauma caused by a continuous high pressure oxygen supply while applying TTJV, it would be ideal to have a TTJV system equipped with an inspiration time adjustable function which any currently commercially available TTJV does not have. METHODS: Recently, we made a prototype of an inspiration time adjustable TTJV and measured the corresponding injection volumes and peak inflation pressures according to the changes of oxygen supply pressure and inspiration time using catheters ranging from 14 to 20 G in a simulated human adult trachea-lung model. RESULTS: A 16 G angiocatheter provided 465 +/- 5 ml of injected volume with a peak inflation pressure of 25 cmH2O under a 50 psi oxygen supply at 1 second of inspiration, which would be adequate for an adult tidal volume. When a 14 G catheter was used under the same conditions as above, the injected volume was 1128 +/- 9 ml. All injected volumes were under 310 ml when 18 and 20 G angiocathers were used at variosus driving pressures (10 - 50 psi) and inspiration time (0.5, 0.75, and 1 s). CONCLUSIONS: An inspiration time adjustable TTJV can easily provide enough tidal volume to maintain oxygenation, and could be expected to prevent or reduce barotraumatic complications such as pneumothorax.

The Two Step Fiberoptic Approach in the Management of a Difficult Pediatric Airway due to a Vallecular Cyst / 대한마취과학회지

A 6-yr-old male weighing 20 kg with the diagnosis of a large vallecular cyst in the oropharynx was scheduled for surgical excision. After a slight loss of consciousness following an IV injection of ketamine 10 mg while maintaining spontaneous respiration, 4% lidocaine was sprayed into the right nostril. An uncuffed 4 mm OD wire-reinforced endotracheal tube was advanced through the right nostril and positioned in the nasopharynx. An ultrathin 60 cm Olympus LF-P fiberoptic bronchoscope (OD: 2.2 mm) was threaded and the vocal cords and surrounding structures were identified as intact. The endotracheal tube and fiberscope were withdrawn. Ketamine 10 mg was injected intravenously again. Following direct insertion of an Olympus fiberoptic bronchoscope (OD: 3.8 mm) through the right nostril without tube placement and visualization of the vocal cords, topical anesthesia of the larynx was achieved by spraying 1 ml 2% lidocaine through the biopsy channel. Thirty seconds later, it was passed into the trachea and 1 ml 2% lidocaine was sprayed intratracheally. The bronchoscope was withdrawn. The 4 mm uncuffed wire-reinforced tube was passed again through the right nostril and an ultrathin fiberoptic bronchoscope (OD: 2.2 mm) was threaded over the tube, and passed smoothly without resistance. There was neither laryngeal spasm nor cough. Anesthesia was maintained with enflurane 2.0 vol%, N2O (1.5 L/min) and O2 (1.5 L/min). The mass was successfully excised and extubated without compromise. The patient was uneventfully discharged the next day.

Intubating Layngeal Mask Airway in Awake Intubation / 대한마취과학회지

The incidence of difficult intubation varies from 1.5% to 13%, and failed intubation has been identified as one of the anesthesia-related causes of death or permanent brain damage. The Intubating Laryngeal Mask Airway (ILMA) is a new modified laryngeal mask airway with the capability for guided tracheal intubation while maintaining ventilation. The ILMA was designed to improve blind endotracheal intubation through a laryngeal mask airway. It does not require head and neck manipulations on insertion. The success rate of blind intubation using the ILMA was up to 99.3% in patients with or without airway problems. We experienced two cases of the difficult endotracheal intubation due to cervical spine 1 2 fractured 34 years old female patient and cervical spine 5 6 fractured 62 years old female patient were done successful awake airway management through the ILMA with superior laryngeal nerve block with pharyngeal and endotracheal topical spray of lidocaine. These cases suggest that awake tracheal intubations through the ILMA is a safe and useful method for airway management in anesthetic care of cervical spine fracture patients.

The Experiences of Airway Management for Anesthesia of Patients with Involved Cervical Spine Ankylosing Spondylitis / 대한마취과학회지

Ankylosing spondylitis is a chronic and systemic disease involving the axial skeleton. In patients with involved cervical spine ankylosing spondylitis, endotracheal intubation by direct laryngoscope may be difficult because they have a limitation of cervical movement and anatomical anomalies. We experienced the evaluation of thirteen patients with involved cervical spine ankylosing spondylitis by the Mallampati classification, Cormack and Lehane grade, thyromental distance and orolaryngeal angle. By Mallampati class and Cormack and Lehane grade, patients were almost class 3 or 4. Thyromental distance was 5.3 +/- 0.4 cm, and orolaryngeal angle was 90.4 +/- 8.0o.

Pneumothorax and Pneumomediastinum Occurred after Esophageal Perforation by a Stylet during Difficult Endotracheal Intubation / 대한마취과학회지

Pneumothorax and pneumomediastinum can occur spontaneously, secondary to trauma, or from dissection of air from the neck or retroperitoneal space. The most common cause of traumatic pneumomediastinum is a rupture of the esophagus, which can occur during an episode of severe vomiting or, less frequently, following esophageal instrumention. We experienced a case of pneumothorax and pneumomediastinum, developed after esophageal perforation by stylet during difficult endotracheal intubation even though an esophagogram did not reveal the perforation site.

Effect of Nicardipine on Hemodynamic Responses to Endotracheal Intubation / 대한마취과학회지

BACKGROUD: Laryngoscopy and tracheal intubation often provoke an undesirable increase in blood pressure and heart rate. This study was done to examine the blunting effect of nicardipine on the adverse hemodynamic changes following a direct laryngoscopy and tracheal intubation. METHODS: Thirty ASA physical status 1 adult patients were allocated into two groups; the control group (n = 15) and nicardipine group (n = 15). In the control group, normal saline, and in the nicardipine group, 20microgram/kg of nicardipine were given 2 minutes before endotracheal intubation. Blood pressure and heart rate were measured after arrival at the operating room, before endotracheal intubation and after intubation under anesthesia (enflurane-N2O-O2). RESULTS: Systolic, diastolic and mean arterial blood pressure were significantly lower in the nicardipine group than in the control group before and after intubation (P < 0.05). The heart rate showed significantly higher values in the nicardipine group than in the control group before and after intubation (P < 0.05). CONCLUSIONS: Compared with no pretreatment before the IV induction of general anesthesia, the peak increase in blood pressure after a laryngoscopy and tracheal intubation is blunted by nicardipine. However, the increase in heart rate is not blunted by nicardipine.

A Comparison of Two Types of Tracheal Tube for Use in Intubating Laryngeal Mask Airway Assisted Blind Orotracheal Intubation / 대한마취과학회지

BACKGROUND: The conventional laryngeal mask airway (LMA) has been used to facilitate blind tracheal intubation in numerous situations where laryngoscopy and conventional intubation has been difficult, but it has the disadvantage that its airway tube is too long and narrow for intubation. The intubating laryngeal mask airway (ILM) has been specifically designed to increase the success rate of blind intubation. A specially constructed ILM tracheal tube is available for use with the ILM, But this tube is in short supply and expensive. Thus, this study was performed to compare the success rate and time of blind intubation through ILM with reinforced tracheal tube or specially-designed tracheal tube, and to assess the use of reinforced tracheal tube as a substitute for specially-designed tracheal tube. METHODS: After acquiring informed consent, 60 ASA grade 1 or 2 patients undergoing anesthesia for elective surgical procedures who normally required tracheal intubation were randomized into two groups. In group 1 (n = 30), the patients were intubated with a specially-designed tracheal tube through ILM. In group 2 (n = 30), reinforced tracheal tubes were used. The patients were induced and relaxed with an iv injection of thiopental sodium, fentanyl-ketamine-midazolam mixture and vecuronium. When an adequate level of anesthesia was achieved, the ILM was inserted. After adequate ventilation was confirmed, blind tracheal intubation with either of the two types of tracheal tubes through the ILM was attempted. Then we recorded success rate, intubation time and adjusting maneuvers. RESULTS: The ILM was successfully inserted at first attempt in 59/60 (98%) patients, but in 1 patient, adequate ventilation was not acheived. The success rate of tracheal intubation was 27 (93%) in group 1 and 28 (93%) in group 2. In group 1, 21 (72%) patients were successfully intubated on the first attempt, 1 (4%) patient on the second attempt, and 5 (17%) patients on the third attempt. In group 2, 20 (67%) patients were successfully intubated on the first attempt, 2 (6%) patients on the second attempt, and 6 (20%) patients on the third attempt. The mean time taken for intubation was 116.9 sec in group 1 and 122.3 sec in group 2. CONCLUSIONS: The authors conclude that the reinforced tracheal tube can be substitute for a specially- designed tracheal tube.

Difficult Endotracheal Intubation by Airway Trauma / 대한마취과학회지

We report a case of unsuspected difficult intubation in an adult due to anatomical abnormalities caused by a thermal burn injury on the right anterior pillar of the pharynx. After induction of anesthesia, vocal cords and epiglottis were not seen and the right half of the pharyngeal cavity was obstructed by a narrowed palatoglossal arch on the laryngoscopic view. Endotracheal intubation trials failed by oral and nasal routes. The laryngeal mask airway could not be passed into the narrowed oropharynx. We awaked the patient and took the patient's past history precisely and an otolaryngologic evaluation was taken. We found that at the age of six, the patient experienced a thermal burn injury on the right anterior pillar of the pharynx by heated iron and anatomical deformities by scar contracture formed thereafter. The next day a partial palatoglossal resection was done in sitting position under local anesthesia and then endotracheal intubation by direct laryngoscopy could be completed successfully.

Evaluation of Predictive Factors for the Difficult Intubation in Pregnant Women / 대한마취과학회지

BACKGROUND: Difficult tracheal intubation during anesthetic induction can be a lifethreatening situation, especially in pregnant women. This is the leading cause of anesthetic related maternal mortality. The ability to predict such cases preoperatively would be of great value. We conducted a prospective study to investigate the incidence of difficult intubation and the usefulness of various predictive factors for difficult intubation in pregnant women. Metoods: Predictive studies on three hundred nine pregnant women who underwent general anesthesia and tracheal intubation for an elective caesarean section were conducted using airway measurements such as a modified Mallampati classification (m-MP), interincisor gap (IG), thyromental distance (TMD), and sternomental distance (SMD). Then direct laryngoscopic gradings (LG) and difficult intubation (DI) were determined. All patients were evaluated on the basis of these studies, and the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of each study were calculated. RESULTS: DI was observed in 5 patients (1.62%) and failed intubtion was observed in 1 patient (0.32%). The sensitivity and specificity of the m-MP were 80% and 82% respectively, and those of the IG were 80% and 77% respectively. A combination of the m-MP and IG resulted in high sensitivity and specificity (100% and 76% respectively), but low PPV (5%). CONCLUSIONS: This study concluded that m-MP and IG were the most sensitive and specific tests when used alone or in combination.

Total Intravenous Anesthesia for Freeman-Shelden Syndrome / 대한마취과학회지

Freeman-Sheldon syndrome (FSS) is a rare congenital myopathy and dysplasia characterized by a whistling mouth and hand-foot anomalies. There are several anesthetic challenges like difficult airway and intravenous access, and the possibility of malignant hyperthermia. We controlled the anesthetic management of a patient with FSS undergoing contractured thumb correction. Intubation was done with a tracheal tube by direct laryngoscopy after three failed attempts. An anesthetic technique triggering malignant hyperthermia was not used. Anesthetic agents used were ketamine, propofol, fentanyl and nitrous oxide under spontaneous respiration. The child had an uneventful anesthetic course and no sign or symptoms of malignant hyperthermia.

A Endotracheal Intubation in a Child with Mocopolysaccharidoses Using the Fiberoptic Laryngoscopy / 대한마취과학회지

Mucopolysaccharidoses are a group of inherited disorders of metabolism resulting in the deposition of mucopolysaccharide in various tissues. This leads to organ dysfunction and anatomical abnormalities which can be important to the anesthetist. These abnormalities result in airway difficulty and difficult intubation. We successfully performed endotracheal intubation in a case of mucopolysaccharidoses in a 9-year-old female patient using fiberoptic laryngoscopy.

A Comparative Easiness of Blind Orotracheal Intubation Using Intubating Lacryngeal Mask Airway with Two Different Head Positions / 대한마취과학회지

BACKGROUND: The position for tracheal intubation using direct laryngoscopy is extension of the head with flexion of the neck, the classical 'sniffing position'. If necessary, an extra pillow can be used to keep the neck flexed. By adopting this position the oral, pharyngeal, and laryngeal axes is a almost straight line to facilitate tracheal intubation. Also, this position is ideal for conventional laryngeal mask airway (LMA) insertion. However, insertion of intubating laryngeal mask airway (ILM) and intubation through ILM may be achieved from any position relative to the patient's head. As recommended by the manufacturer, when possible a pillow should be placed under the head to achieve a neutral position. The purpose of this study was therefore to compare the easiness of intubation through ILM without support and with the patient's head supported by a pillow. METHODS: After acquiring informed consent, 80 ASA grade 1 or 2 patients undergoing general anesthesia for elective surgical procedures who normally required tracheal intubation were randomized into two groups. In group 1 (n = 40), insertion of ILM and intubation was conducted with the head supported by a pillow, while there was no support in group 2 (n = 40). The patients were induced and relaxed with an IV injection of thiopental sodium, fentanyl-ketamine-midazolam mixture and vecuronium. When adequate level of anesthesia was achieved, the ILM was inserted. After adequate ventilation was confirmed, a blind tracheal intubation through the ILM was attempted. Then we recorded success rate, insertion time, intubation time and adjusting maneuvers. RESULTS: The ILM was successfully inserted on the first attempt in 79/80 patients, but 1 patient of group 1 failed to be adequately ventilated. The mean time for ILM insertion of group 2 was shorter than that of group 1. The success rate of tracheal intubation was 37(95%) in group 1 and 40 (100%) in group 2. In group 1, 30 (81%) patients were successfully intubated on the first attempt, 1 (3%) patient on the second attempt, and 6(16%) patients on the third attempt; in group 2, 35 (87%) patients on the first attempt, and 5 (13%) patients on the third attempt. There was no significant diffrence of mean time taken for endotracheal intubation through ILM between group 1 (105.1 sec) and group 2 (88.1 sec). CONCLUSIONS: The authors conclude that ILM insertion is significantly easier with the patient's head not supported by a pillow compared with the patient's head supported by a pillow and there is no difference in ease of intubation through ILM by the patient's head position.