The efficacy and safety of EMLA cream for awake fiberoptic endotracheal intubation.

EMLA Cream (EC; Astra, Westborough, MA) has been widely used as a local anesthetic. Limited safety information is available with respect to the application of EC to the oral mucous membranes. The purpose of this pilot study was to evaluate the efficacy and safety of EC when applied to oral mucosa for fiberoptic intubation. Twenty ASA physical status I-IV patients (11 women and 9 men), 28-57 yr old, who were scheduled for awake, fiberoptic, intubation participated in this open-label study. A total of 4 g of EC was used for 5 min until the patient showed no evidence of a gag reflex (this was evaluated clinically by the patient's acceptance of the William's airway and considered the endpoint for assessing adequate topicalization of the oropharynx). The measured peak plasma concentration of lidocaine or prilocaine did not reach toxic levels in any patient. Methemoglobin levels did not exceed normal values (1.5%) in any patient, and there was no relationship between methemoglobin levels and patient weight, amount of EC used, measured peak plasma concentration, or times to measured peak concentrations of prilocaine or lidocaine. We conclude that EC provided satisfactory topical anesthesia allowing for successful oral fiberoptic intubation in all patients and should be considered a safe alternative for anesthetizing the airway of patients requiring awake oral fiberoptic intubation.

Jejunostomy tube feedings should not be stopped in the perioperative patient.

BACKGROUND: Anesthetic standard of care is to restrict oral intake for 8 hours before elective surgery. There is no research addressing appropriate preoperative discontinuation of jejunostomy tube (J-tube) feedings. We hypothesized that patients could be fed safely, via a J-tube, until the time of surgery. METHODS: Patients admitted to a Level I Trauma Center, having J-tubes and undergoing a nonabdominal operation, were prospectively evaluated. Group I patients received J-tube feedings until transport to the operating room. Group II patients had tube feedings discontinued for at least 8 hours before surgery. Data were compared using the Student's t test and contingency table analysis. RESULTS: There were 46 patients in group I and 36 in group II. There was no incidence of aspiration. Patient groups did not differ in age, mortality, length of stay, injury severity score, or ventilator days. Group I patients had tube feedings discontinued for fewer hours before and after surgery than group II patients (before surgery: 1.40 +/- 1.20 vs 11.61 +/- 5.01, respectively; p < .001; after surgery: 2.99 +/- 7.49 vs 7.11 +/- 9.03, respectively; p = .043); received more kilocalories/ grams of protein on the day of surgery (group I vs group II, 1676.15/89.57 +/- 1133.21/38.04 vs 791.14/57.58 +/-498.66/79.87, respectively; p = .001/p = .032) and more kilocalories/grams of protein on the first postoperative day (group I vs group II, 1580.74/92.57 +/- 600.53/37.96 vs 1152.47/63.53 +/- 733.96/39.40, respectively; p = .006/p = .001). CONCLUSIONS: Patients receiving J-tubes who are undergoing nonabdominal operations may safely continue enteral nutrition at maximum protein and caloric intake until surgery.

Difficult intubation from gastroesophageal reflux disease in adults.

Two cases of difficult intubation are presented. Both cases presented with red swollen arytenoids, swollen false vocal cords, and subglottic stenosis. Tracheal intubation could not be achieved for these reasons. Both patients were placed on gastrointestinal prokinetic drugs and histamine-two blocker, as a diagnosis of gastroesophageal reflux disease (GERD) was made. In one case, follow-up by an otolaryngotic surgeon showed reversal of the above findings. In the other case, one tracheal intubation was achieved eventually. GERD occurs frequently. Clinicians need to maintain a high index of suspicion for GERD-related airway changes so as to avoid potential difficult intubations.

Discography: an element of decision. Surgery versus chemonucleolysis.

It is a well known fact that both surgery and chemonucleolysis can cure a patient suffering from root pain due to a prolapsed intervertebral disc. However, the failure rate after intradiscal injection of chymopapain remains important. Analysis of the cases operated after unsuccessful chemonucleolysis show that about two thirds are due to a remaining discal fragment. Considering the possibility of a bad penetration of the enzyme in the herniated area, neither computed tomography (CT) scan nor myelography, but only discography, can demonstrate invasion of the prolapsed area. On a series of 165 patients injected with chymopapain in only one disc, discographic data were correlated with the result of the treatment on the root pain. Three items were analyzed: the size of the protruding area located at the back of the disc (closely related to operative findings, as shown on a previous study), the density of the contrast medium filling the protruding area, and the pain response during the injection. A large, well-filled protruding area characterizes a "good" image and correlated with 76% of good results. Likewise when the pain response is lateralized (in the buttock or the affected lower limb), it correlates with 42% of success and 13% of failures. In 24.8% of the cases a combination of good images and lateralized pain correlates with 97.5% of good results. Therefore discography should be an element of decision between surgery and chemonucleolysis, and should be considered as a preoperative examination.