Comparison of direct and video-assisted views of the larynx during routine intubation.

OBJECTIVE: To compare the direct and indirect (video monitor) views of the glottic opening using a new Macintosh blade that is modified to provide a video image of airway structures during laryngoscopy. DESIGN: Prospective multicenter trial. SETTING: 11 university-affiliated hospitals. PATIENTS: 867 adults undergoing elective surgery requiring general anesthesia and tracheal intubation. INTERVENTIONS: Patients received general anesthesia and were paralyzed. Direct laryngoscopy was supervised by one of the investigators at each institution. The best possible view was obtained with a Macintosh video laryngoscope during direct vision using standard techniques such as external laryngeal manipulation and backward, upward, and rightward pressure, if necessary. The laryngoscopist then looked at the video monitor and performed any necessary maneuvers to obtain the best view on the video monitor. Thus, 2 assessments were made during the same laryngoscopy (direct naked-eye view vs video monitor view). Tracheal intubation was then performed using the monitor view. Glottic views were rated according to the Cormack-Lehane scoring system, as modified by Yentis and Lee. A questionnaire was completed for each patient. MEASUREMENTS AND MAIN RESULTS: Data from 865 patients were suitable for analysis. Visualization was considered easy (Cormack-Lehane score<3) in 737 patients and difficult (Cormack-Lehane score=3 or 4) in 21 for both direct and video-assisted views. In 7 patients, the view was considered easy during direct visualization yet difficult on the video monitor view. On the other hand, the view was considered difficult in 100 patients during direct visualization yet easy on the video monitor view (P<0.001). CONCLUSIONS: Video-assisted laryngoscopy provides an improved view of the larynx, as compared with direct visualization. This technique may be useful for cases of difficult intubation and reintubation as well as for teaching laryngoscopy and intubation.

Nicardipine versus nitroprusside for deliberate hypotension during idiopathic scoliosis repair.

STUDY OBJECTIVE: To compare coagulation, blood loss, and transfusion requirements between patients receiving nicardipine and nitroprusside for deliberate hypotension during idiopathic scoliosis repair. DESIGN: Prospective, randomized study. SETTING: University hospital. PATIENTS: 51 ASA physical status I patients presenting for spine fusion for idiopathic adolescent scoliosis. INTERVENTIONS: Patients were randomized to two groups to receive nicardipine or nitroprusside to maintain mean arterial pressure (MAP) between 55 and 65 mmHg. MEASUREMENTS: Blood loss, blood transfusions, and coagulation studies (thromboelastogram and platelet aggregation) before starting vasodilator, 30 minutes and 90 minutes after starting vasodilator, and 30 minutes after stopping vasodilator, were all recorded. MAIN RESULTS: There was no difference between the groups in blood loss [nicardipine = 1,129 cc (893 to 1,480), nitroprusside = 960 cc (704 to 1,473)] and only one patient required a nonautologous transfusion. There were no differences in prothrombin time (pT, partial thromboplastin time (pTT), platelet count, or platelet aggregation between groups. There were more episodes of severe hypotension (MAP <45 mmHg) in the nitroprusside group (0% vs. 28%, p = 0.0175). On average, patients in the nicardipine group spent 21 minutes less in the recovery room than did the nitroprusside group (p = 0.043). CONCLUSIONS: Nitroprusside's effect on platelet aggregation produces no increase in blood loss compared with nicardipine. Nicardipine causes less transient severe hypotension than nitroprusside, although both drugs are acceptable choices for obtaining the goals of deliberate hypotension.

Preoperative stress testing: new guidelines.

To date, there are no well controlled trials in the literature that demonstrate an outcome benefit using stress testing as a screening procedure before noncardiac surgery. Perioperative beta-blockade significantly decreases morbidity and mortality, and thus reduces any potential benefit stress testing may have in identifying patients who may advance to more invasive treatment. Preoperative percutaneous coronary intervention has unproven perioperative benefit, and coronary artery bypass graft carries risks that often offset the risk of noncardiac surgery. Unless an outcome benefit from cardiac testing and procedures can be demonstrated in a properly designed trial, their use should generally be restricted to situations in which symptoms or other cardiac findings warrant cardiac evaluation and treatment, regardless of upcoming surgery.