Awake fiberoptic intubation and self-positioning in patients at risk of secondary cervical injury: a pilot study.

BACKGROUND: This study was designed to document the feasibility of self-positioning after awake fiberoptic intubation of the trachea using primarily effective topical anesthesia rather than sedation. METHODS: We investigated 14 patients (ASA physical status 1 to 3) with a neurosurgical diagnosis of cervical instability or at risk of secondary cervical injury, who were scheduled for awake fiberoptic intubation and self-positioning prone. Topical anesthesia was accomplished using an oropharyngeal spray of lidocaine alone or in combination with a transtracheal injection of lidocaine for awake fiberoptic intubation and self-positioning prone. Patients evidencing anxiolysis were given midazolam 2 to 4 mg, i.v.. We assessed the need for sedation, tolerance of the endotracheal tube, patient comfort, incidence of coughing or gagging, and changes in heart rate, blood pressure, and oxygen saturation. In addition, patients were interviewed on the first postoperative day and asked to categorize the experience of awake intubation and positioning as a positive, neutral, or negative experience, or to have no recall. RESULTS: Eleven of the 14 patients turned themselves prone after awake fiberoptic intubation. No additional sedation was necessary for accomplishing positioning. Whereas 50% of the patients (7/14) showed mostly slight coughing or gagging during fiberoptic intubation, none of the patients who were positioned awake had coughing or gagging during tube fixation and prone positioning. The technique was unsuccessful in 3 patients. None of the patients viewed this as a negative experience. CONCLUSIONS: Our study demonstrates that awake fiberoptic intubation and patient self-positioning was feasible in this sample of patients at risk of secondary cervical injury. This technique may extend the opportunity of continuous neurological monitoring in patients with a risk of position-related cervical injury, especially where electrophysiological monitoring is not possible or is unavailable.

Incidence, time course, and predictors of early malignant ventricular arrhythmias after non-ST-segment elevation myocardial infarction in patients with early invasive treatment.

AIMS: The incidence of non-ST-segment elevation myocardial infarction (NSTEMI) is increasing. With the limited intensive care facilities, knowledge of the total risk and predictors of acute life-threatening arrhythmias is of major interest to guide the decision on the intensity of care at the time of admission. METHODS AND RESULTS: We continuously monitored 588 consecutive patients with NSTEMI admitted to the coronary care unit of a primary and tertiary care centre for malignant ventricular arrhythmias requiring defibrillation. Ninety-seven per cent of the patients underwent coronary angiography during the index hospital admission. Total rate of malignant ventricular arrhythmias and mortality was 2.6% (n=15) and 3.6% (n=21), respectively. More than two-thirds of arrhythmias occurred within the first 12 h after onset of symptoms. In a bootstrapped multivariable regression analysis, the only factor associated with the occurrence of malignant ventricular arrhythmia was higher white blood cell count on admission. Popular risk assessment tools such as Thrombolysis in Myocardial Infarction, Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy, and Predicting Risk of Death in Cardiac disease Tool were predictive of mortality but not of early arrhythmia. CONCLUSION: Patients with NSTEMI treated aggressively with early revascularization are at low risk for developing life-threatening arrhythmias. The occurrence of such events remains difficult to predict. The role of baseline inflammatory status as a determinant merits further investigations.