A structured training program for awake fiber optic intubation: teaching the complete package.

BACKGROUND: We organized a training program for oral fiber optic intubation (FOI) under conscious sedation. The efficacy of the program was evaluated by comparing the performances of experts and novices. METHODS: The training procedure was divided into two sessions: a theoretical session on difficult airways, the fiber optic bronchoscope (FOB), remifentanil, topical anesthesia and patient interactions; and a session involving simulations of the FOI technique on dummies. For in vivo FOI, we enrolled patients requiring orotracheal intubation for elective surgery. Electrocardiograms, mean arterial pressure (MAP) values, peripheral O(2) saturation (SpO(2)) values, respiratory rates (RR) and sedation scores (OAA/S) were acquired. Remifentanil infusion was started at 0.05-0.1 microg*kg(-1)*min(-1), and patients' upper airways were anesthetized with lidocaine. Remifentanil was titrated to achieve an OAA/S of 9-12. FOBs were inserted, and topical laryngeal anesthesia was achieved ("spray as you go" technique). The instrument was passed into the trachea, the OT tube was railroaded over the fiberscope, and tracheal intubation was completed. The procedure duration and patients' vital parameters and satisfaction were recorded. RESULTS: Three experts and four less-experienced anesthesiologists who performed 29 (10, 10 and 9) and 25 (6, 6, 6 and 7) FOIs, respectively, joined the study. To reach the target OAA/S, the remifentanil dosage was progressively increased to an average dose of 0.15+/-0.05 microg*Kg(-1)*min(-1). MAP and SpO(2) values were stable throughout the procedures, HR was slightly increased (from 77+/-16 to 90+/-23 bpm, P=0.02), and RR was decreased (from 16+/-3 to 12+/-4 bpm, P<0.05). No differences were recorded between the experts and less-experienced anesthesiologists. The average duration of FOI was 3.3+/-2.0 min for experts and 4.2+/-2.4 min for novices (P=0.03). Procedures were successful in both groups, with patients in each group being equally satisfied with the procedures. CONCLUSION: This study highlights the importance of a structured FOI training program, demonstrating that it is possible to learn to perform FOI proficiently by practicing on dummies.

[Anesthesia in hypertrophic pyloric stenosis]. / Anestesia nella stenosis ipertrofica del piloro.

Hypertrophic pyloric stenosis is one of the most common gastrointestinal abnormalities occurring in the first six months of life. It is a medical emergency and surgical therapy is considered only after correction of fluid and electrolyte deficits. Careful preoperative therapy to correct deficits may require several days to ensure safe general anaesthesia and surgery. The anaesthetic management of 58 consecutive infants (51 male, 7 female) with congenital hypertrophic pyloric stenosis over a 4-year period is reviewed. Mean age was 39.5 days (range 13-100), mean weight was 3.95 kg (range 2.4-5.3). Elective Ramstadt's fibromyotomy was performed after water-electrolyte balance restoration. Inhalation induction was made and oro-tracheal intubation achieved with succinylcholine 1.5 mg/kg-1. General anaesthesia was performed without complications. All patients were discharged during the period between the 2nd and 7th day after surgery, except one who was discharged after 16 days because of dehiscence of the surgical wall. Preoperative preparation is the primary factor contributing to the low perioperative complication rates, and the necessity to recognize fluid and electrolyte imbalance is the key for a successful anaesthetic management.

[Preanesthesia in elderly patients undergoing subarachnoid anesthesia: chlordesmethyldiazepam versus diazepam]. / La preanestesia nei soggetti anziani sottoposti ad anestesia sub-aracnoidea: clordemetildiazepam vs diazepam.

Forty patients over 65 undergoing subarachnoid anesthesia with bupivacaine 0.50% (5 mg) and fentanyl (0.1 mg) were subdivided into two equal groups: one was premedicated with atropine and chlordesmethyldiazepam (0.03 mg/kg-1) and the other with atropine and diazepam (0.015 mg/Kg-1). A statistically significant difference was found in the group treated with diazepam which required an increase for anesthetic drugs during surgery. The authors suggest a probable synergic or an enhanced effect between intramuscular chlordesmethyldiazepam and opiates in spinal anesthesia.

Comparison of nimesulide and diclofenac in the prevention and treatment of painful inflammatory postoperative complications of general surgery.

In a double-blind study, 40 patients scheduled for saphenectomy or inguinal hernioplasty were randomly assigned to treatment with nimesulide (200mg 3 times daily) or diclofenac (100mg 3 times daily) administered rectally. Therapy with either drug resulted in significantly less pain, oedema and hyperaemia, and resolution of mild fever. No adverse reactions attributable to treatment were observed.