Tracheal tube cuff inflation guided by pressure volume loop closure associated with lower postoperative cuff-related complications: Prospective, randomized clinical trial.

BACKGROUND: The main function of an endotracheal tube (ETT) cuff is to prevent aspiration. High cuff pressure is usually associated with postoperative complications. We tried to compare cuff inflation guided by pressure volume loop closure (PV-L) with those by just to seal technique (JS) and assess the postoperative incidence of sore throat, cough and hoarseness. MATERIALS AND METHODS: In a prospective, randomized clinical trial, 100 patients' tracheas were intubated. In the first group (n = 50), ETT cuff inflation was guided by PV-L, while in the second group (n. = 50) the ETT cuff was inflated using the JS technique. Intracuff pressures and volumes were measured. The incidence of postoperative cuff-related complications was reported. RESULTS: Demographic data and durations of intubation were comparable between the groups. The use of PV-L was associated with a lesser amount of intracuff air [4.05 (3.7-4.5) vs 5 (4.8-5.5), P < 0.001] and lower cuff pressure than those in the JS group [18.25 (18-19) vs 33 (32-35), P ≤ 0.001]. The incidence of postextubation cuff-related complications was significantly less frequent among the PV-L group patients as compared with the JS group patients (P ≤ 0.009), except for hoarseness of voice, which was less frequent among the PV-L group, but not statistically significant (P ≤ 0.065). Multiple regression models for prediction of intra-cuff pressure after intubation and before extubation revealed a statistically significant association with the technique used for cuff inflation (P < 0.0001). CONCLUSIONS: The study confirms that PV-L-guided ETT cuff inflation is an effective way to seal the airway and associates with a lower ETT cuff pressure and lower incidence of cuff-related complications.

Addition of dexmedetomidine to bupivacaine in transversus abdominis plane block potentiates post-operative pain relief among abdominal hysterectomy patients: A prospective randomized controlled trial.

BACKGROUND: Dexmedetomidine is an alpha 2 adrenergic agonist, prolongs analgesia when used in neuraxial and peripheral nerve blocks. We studied the effect of addition of dexmedetomidine to bupivacaine to perform transversus abdominis plane (TAP) block. MATERIALS AND METHODS: A total of 50 patients scheduled for abdominal hysterectomy were divided into two equal groups in a randomized double-blinded way. Group B patients (n = 25) received TAP block with 20 ml of 0.25% bupivacaine and 2 ml of normal saline while Group BD (n = 25) received 0.5 mcg/kg (2 ml) of dexmedetomidine and 20 ml of 0.25% bupivacaine bilaterally. Time for first analgesic administration, totally used doses of morphine, pain scores, hemodynamic data and side-effects were recorded. RESULTS: Demographic and operative characteristics were comparable between the two groups. The time for the first analgesic dose was longer in Group BD than Group B (470 vs. 280 min, P < 0.001) and the total doses of used morphine were less among Group BD patients in comparison to those in Group B (19 vs. 29 mg/24 h, P < 0.001). Visual analog scores were significantly lower in Group BD in the first 8 h post-operatively when compared with Group B, both at rest and on coughing (P < 0.001). In Group BD, lower heart rate was noticed 60 min from the induction time and continued for the first 4 h post-operatively (P < 0.001). CONCLUSIONS: The addition of dexmedetomidine to bupivacaine in TAP block achieves better local anesthesia and provides better pain control post-operatively without any major side-effects.

Anesthesia for tracheostomy for huge maxillofacial tumor.

Providing sedation for patients with compromised upper airway is challenging. A 19-year-old female patient with huge maxillofacial tumor invading the whole pharynx scheduled for elective tracheostomy under local anesthesia due to compromised airway. The patient had gastrostomy tube for feeding. Venous cannulation was totally refused by the patient after repeated trials for exhausted sclerosed veins. Pre-operative mixture of dexmedetomidine with ketamine was administered through the gastrostomy tube with eutectic mixture of local anesthetics cream application over the planned tracheostomy site. The patient was sedated with eye opening to command. Local infiltration followed by tracheostomy was performed without patient complaints or recall of operative events.

Use of pressure volume loop closure to check for endotracheal tube cuff function. Randomized clinical trial.

OBJECTIVE: To assess the efficacy of pressure volume loop (PV-L) closure as an indicator of adequate endotracheal tube cuff (ETTc) function, and to compare this with commonly used methods of checking cuff pressure. METHODS: We conducted a randomized clinical trial at the Department of Anesthesia, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia from October 2011 to February 2012. One hundred and forty patients were intubated, and the ETTc was inflated using one of 3 techniques. The intubating anesthesiologist inflated the cuff at his discretion until he detected no further air leak in the first technique. In the second technique, we maintained the ETTc pressure at 20 centimeter water, while the third technique used PV-L closure. RESULTS: The PV-L technique required lower amounts of air to inflate the ETTc than the other 2 techniques (3.89+/-0.26 for PV-L versus 4.4+/-0.36 for fixed preset pressure, and 5.26+/-0.46 for pilot balloon palpation, p=0.00001) and the mean cuff pressure was lower than other techniques (18.67+/-0.72 for PV-L versus 20 for fixed preset pressure, and 33.48+/-3.49 for pilot balloon palpation, p=0.00001). CONCLUSION: The PV-L closure technique is an alternative way to check for ETTc function with a significantly lower ETTc pressure and volume than those recorded with a manually inflated cuff, or with preset cuff pressure of 20 cmH2O.

Adding a conduit to GlideScope blade facilitates tracheal intubation. Prospective randomized study.

OBJECTIVE: To determine the effect of modifying the GlideScope (GVL) blade on the intubation time. METHODS: This prospective study was conducted at the Department of Anesthesia, King Abdulaziz University Hospital, Jeddah, Saudi Arabia between June 2011 and October 2011. Sixty patients requiring endotracheal tube (ETT) intubation for elective surgery in whom airway was anticipated normal were randomly allocated to one of 2 groups. Group M (n=30): intubated via a modified GVL blade in which a tube conduit along the side of the GVL blade was created to allow the passage of ETT through the cords. Group C (n=30): intubated with the conventional GVL blade and rigid intubating stylet. RESULTS: Time to successful tracheal intubation (TTI) was 39.6+/-2.1 seconds in Group M versus 66.4+/-8.3 seconds in Group C (p=0.0001), tracheal intubation was deemed more easily in Group M than in Group C (VAS 2+/-1 versus 6+/-1, p=0.0001), and all patients in Group M were successfully intubated on the first attempt when compared with 90% in Group C (p=0.009). CONCLUSION: The addition of a conduit to the GVL blade made the passage of the ETT easier and TTI shorter without increasing adverse events or intubation failure.

Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery.

OBJECTIVES: Peribulbar anesthesia is associated with delayed and/or incomplete orbital akinesia compared with retrobulbar anesthesia. This study examined the effects of adding rocuronium 5 mg to two different concentrations of lidocaine-bupivacaine mixture on onset time of orbital and eyelid akinesia in patients undergoing cataract surgery. METHODS: In a double-blind study, 90 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group I), a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group II), or a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 1%, and 4 ml bupivacaine 0.25% (group III). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean±SD. RESULTS: Ocular movement score decreased during the assessment period in all groups. However, at 2 min after block administration, the score decreased to 4±2 (95% CI 3,5) in groups II and III compared with 5±2 (95% CI 4,6) in group I (P<0.01). Time to adequate condition to begin surgery was 9.8±2.9 vs. 6.9±4.1 vs. 7.9±3.9 min for groups I, II, and III, respectively (P=0.01). CONCLUSION: The addition of rocuronium 5 mg to a mixture of lidocaine 2% and bupivacaine 0.5% shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.

Use of Airtraq, C-Mac, and Glidescope laryngoscope is better than Macintosh in novice medical students' hands: A manikin study.

BACKGROUND AND AIM: Obtaining patent airway is a crucial task for many physicians. When opportunities to practice intubations on patients are really limited, skill gaining methods are needed. We conducted a study among novice 6(th) year medical students to assess their ability to intubate the trachea in normal airway in manikin using four airway tools. SETTING AND DESIGN: Prospective, cohort study conducted at simulation center of university-based, tertiary care hospital. METHODS: FIFTY MEDICAL STUDENTS PERFORMED EITHER ORAL OR NASAL TRACHEAL INTUBATION USING THE FOLLOWING FOUR INTUBATING TOOLS: C-Mac videolaryngoscope, Glidescope, and Airtraq in comparison with regular Macintosh laryngoscope. Intubation time, visualization of glottic opening, ease of intubation, satisfaction of participants, incidence of dental trauma, and the need for optimization manoeuvres' use among different airway tools were recorded. RESULTS: In oral intubation, Airtraq was better than others in regard to intubation time, glottic opening, ease of intubation, and the need for external laryngeal pressure application, followed by Glidescope, C-Mac, and finally Macintosh laryngoscope (P<0.001). Airtraq and Glidescope associated with less dental trauma than C-Mac and Macintosh. In nasal route, fastest intubation time was reported with Airtraq followed by Glidescope, C-Mac, and lastly Macintosh. Airtraq, Glidescope, and C-Mac were similar to each other and better than the Macintosh in regard to ease of intubation, satisfaction, and number of attempts (P≤0.008). CONCLUSIONS: New devices like Airtraq, Glidescope, and C-Mac are better than the regular Macintosh when used by novice medical students for oral and nasal intubation on manikin.

Reduced hemodynamic responses to tracheal intubation by the Bonfils retromolar fiberscope: a randomized controlled study.

The Bonfils retromolar intubation fiberscope is a rigid endoscope designed to enable glottic visualization and facilitate intubation under endoscopic vision. Theoretically, avoiding direct-vision laryngoscopy and thus could produce less stimulation during intubation than the conventional direct laryngoscopic procedure. This prospective randomized study was designed to compare the effect of tracheal intubation with direct vision laryngoscopy (Macintosh blade) and the Bonfils retromolar intubation fiberscope on the hemodynamic responses in ASA I patients. Forty patients scheduled for elective surgery and requiring endotracheal intubation were randomly allocated to one of two groups according to the intubating tool under sevoflurane nitrous oxide Anaesthesia (n=20 each). The retromolar group received tracheal intubation with the Bonfils retromolar fiberscope, while the direct laryngoscopy group received tracheal intubation by the direct vision laryngoscope (Macintosh blade). Heart rate and arterial blood pressure (systolic BP, diastolic BP, mean ABP) were recorded before induction of Anaesthesia, 3 minutes after induction of Anaesthesia (before intubation) and 5 successive recordings at one-minute interval after intubation. All the systolic BP, diastolic Bp, mean ABP and heart rate values in the direct laryngoscopy group were significantly higher in the 5 successive minutes after intubation in comparison with the retromolar group (P = 0.00). This might be attributed to the gentle intubating technique, by the Bonfils retromolar fiberscope, which allows quick endotracheal intubation without manipulations of the base of the tongue or epiglottis.

Does patient position influence the reading of the bispectral index monitor?

BACKGROUND: Bispectral index (BIS) was developed to monitor patients' level of consciousness under general anesthesia. Several factors have been found to alter BIS readings without affecting the depth of anesthesia. We conducted a study to assess the impact of changing patients' position on BIS readings. METHODS: General anesthesia was administered to 40 patients undergoing minor surgeries. Patients were kept in neutral position (supine) for 15 min and BIS readings, mean arterial blood pressure, heart rate, end-tidal carbon dioxide, and end-tidal isoflurane were recorded. Patients were then shifted to head-down position (30 degrees), neutral position, and lastly head-up position (30 degrees) each of 15-min duration and the data were recorded. RESULTS: There was a significant increase in BIS values in head-down position (median 47 vs 40) compared with neutral position, whereas head-up position significantly decreased BIS (39 vs 41) compared with neutral position (P < 0.05). CONCLUSION: Changing a patient's position significantly affects the BIS values, which might affect the interpretation of anesthetic depth.