The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients.

BACKGROUND: The GlideScope Video Laryngoscope is a new intubating device. It was designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. The aim of the study was to describe the use of the GlideScope in comparison with direct laryngoscopy for elective surgical patients requiring tracheal intubation. METHODS: Two hundred patients were randomly assigned to intubation by direct laryngoscopy using a Macintosh size 3 blade (DL, n=100) or intubation using the GlideScope (GS, n=100). Prior to intubation all patients were given a Cormack and Lehane (C&L) grade by a separate anaesthetist using a Macintosh size 3 blade. The patient was then intubated, using direct laryngoscopy or the GlideScope, by a different anaesthetist during which the larynx was inspected and given a laryngoscopy score. Time to intubate was measured. RESULTS: In the GS group, laryngoscopy grade was improved in the majority (28/41) of patients with C&L grade >1 and in all but one of patients who were grade 3 laryngoscopy (P<0.001). The overall mean time to intubate was 30 (95% CI 28-33) s in the DL group and 46 (95% CI 43-49) s in the GS group. The time to intubate for C&L grade 3 was similar in both groups, being 47 s for the DL group and 50 s for the GS group respectively. CONCLUSION: In most patients, the GlideScope provided a laryngoscopic view equal to or better than that of direct laryngoscopy, but it took an additional 16 s (average) for tracheal intubation. It has potential advantages over standard direct laryngoscopy for difficult intubations.

Chiari type I malformation and postoperative respiratory failure.

PURPOSE: To present a case of respiratory failure following suboccipital craniectomy for Chiari type I malformation. CLINICAL FEATURES: A 22-yr-old man presented with a two year history of symptoms and signs suggestive of brainstem compression at the level of the foramen magnum. This was confirmed with magnetic resonance imaging. The procedure of suboccipital craniectomy, upper cervical laminectomy and fourth ventricle exploration was performed. Three hours postoperatively the patient experienced episodes of apnea and subsequently became drowsy. Blood gas analysis revealed hypercapnic respiratory failure. Chest X-ray revealed evidence of pulmonary aspiration. The trachea was re-intubated and the lungs ventilated in intensive care for 72 hr. He was discharged home two weeks postoperatively. CONCLUSION: Chiari type I malformation is associated with a number of associated anomalies. These patients are at considerable risk of respiratory depression and bulbar dysfunction in the perioperative period. The anesthetic issues are reviewed and discussed.

Preoperative dextromethorphan reduces intraoperative but not postoperative morphine requirements after laparotomy.

UNLABELLED: N-methyl-D-aspartate (NMDA) antagonists combined with opioids are thought to be effective in the control of pain states. We evaluated morphine use and analgesia in 37 patients postlaparotomy. Patients received 60 mg of oral dextromethorphan or placebo the night before and again 1 h before surgery. Morphine was titrated intraoperatively to maintain blood pressure and heart rate within 20% of baseline and postoperatively via patient-controlled analgesia (PCA). The dextromethorphan and placebo groups were compared for morphine use intraoperatively, in recovery, via PCA in the first 4 and 24 h, and total use over the study period. Pain scores at rest and on activity for the first 4 and 24 h were also compared. Intraoperatively, the dextromethorphan group required less morphine: 13.1+/-4.3 vs 17.6+/-6.0 mg (P = 0.012). Postoperatively, there was no significant difference between the dextromethorphan and placebo groups for morphine use: in the recovery room 10.9+/-7.7 vs 12.1+/-7.7 mg; the first 4 h of PCA 15.9+/-9.3 vs 12.7+/-5.1 mg; the first 24 h of PCA 76.4+/-44.7 vs 61.8+/-27.5 mg; or in total morphine use 100.4+/-49.5 vs 91.5+/-3.1 mg. Pain scores for the two groups were not statistically different throughout the study period. We conclude that 60 mg of oral dextromethorphan given the night before and repeated an hour before surgery does not provide a postoperative morphine-sparing effect or improve analgesia after laparotomy. IMPLICATIONS: Patients given dextromethorphan before surgery had significantly reduced intraoperative morphine requirements. However, postoperative morphine requirements were unaltered. Dextromethorphan may need to be continued postoperatively to improve postoperative analgesia.

Postoperative pain management in the neurosurgical patient.

We hope to have inspired an interest in approaching the pain management issues in this challenging group of patients. Despite significant progress in understanding the pathophysiology of pain, the development of therapeutic options, and the publication and dissemination of guidelines, this progress does not seem to have been adopted into clinical practice. Bonica has stated "for many years I have studied the reasons for inadequate management of postoperative pain, and they remain the same.... Inadequate or improper application of available information and therapies is certainly the most important reason". Let us accept the challenge to re-evaluate pain management in the postoperative neurosurgical patient. Future development may provide enhanced multimodal analgesia with the development of enantioselective NSAIDs and peripherally acting opioids that do not cross the blood-brain barrier. Targeted inhibition of the central neuroplasticity that underlies sensitization, rather than attempts to use pre-emptive analgesics, may be more fruitful. Inhibition of excitatory amino acids may prove beneficial for perioperative neuroprotection and pain management. In addition, longer-acting local anesthetics show significant promise. The importance of understanding the specific benefits available and matching these characteristics to the particular patient is emphasized. Evaluation of outcomes, including morbidity and patient satisfaction, will determine if effective and rational provision of analgesia may indeed be safer than withholding analgesia. However, it is clear that re-evaluation and refinement of conventional therapy is necessary.