Assessment of Mini-dose Succinylcholine Effect on FacilitatingLaryngeal Mask Airway Insertion

A Comparative Study of the Effect of Anesthesia Induction with the Use of Four Drug Combinations Including "Propofol," "Etomidate-Propofol," "Thiopental," and "Midazolam-Thiopental" on Hemodynamic Changes during the Insertion of Laryngeal Mask in Eye Surgery

Background:

This study aimed to compare the efficacies of four anesthetic induction drugs (thiopental, propofol, midazolam-thiopental, and etomidate-propofol) on cardiovascular response during laryngeal mask airway (LMA) placement in eye surgery.

Materials and Methods:

The present clinical trial study included 128 patients who were candidates for ophthalmic surgery in four groups. Patients in the first group were given a combination of midazolam (0.04 mg/kg) with thiopental (2.5 mg/kg) (Group T + M). We administered propofol alone (2.5 mg/kg) to patients in the second group (Group P). The third group received a combination of etomidate (0.1 mg/kg) with propofol (1 mg/kg) (ET + P group) and patients in the fourth group received thiopental drug (5 mg/kg) alone (Group T). Then, the stability of patients' hemodynamic parameters before anesthesia was evaluated and compared immediately after anesthesia, 1, 3, and 5 min after LMA placement.

Results:

There was no significant difference between the four groups in changes in oxygen saturation level (P > 0.05). Furthermore, the difference between decreased systolic blood pressure and diastolic blood pressure over time was not significant in 5 min in both Groups T + M and T (P > 0.05). In addition, the stability of these two groups was higher than the other two groups (P < 0.05) and the most unstable group was Group P. The changes pulse ratein the P group were significant (P < 0.05).

Conclusion:

According to the results of the current study, thiopental and Midazolam can be used as an effective induction compound to facilitate LMA insertion with higher hemodynamic stability compared to propofol alone, propofol and etomidate, and thiopental alone.

Airway management using LMA-evaluation of three insertional techniques-a prospective randomised study

Background and Aims

Laryngeal Mask Airway [LMA] insertion has become as a basic procedural skill needed for all health care providers. Search for the most successful insertion technique continues. We evaluated the success rate of the three LMA insertion techniques- standard, 90 degree rotational and 180 degree rotational technique.

Material and Methods

A total of 180 patients of ASA I-II aged 18-65 years undergoing open superficial surgical procedures with (LMA® Unique™ Airway, Teleflex®, Teleflex Medical Europe Ltd, Ireland) as an airway management device and with neuromuscular blocking agents, were randomly allocated to three groups, in this prospective randomized study. In the standard technique group (n = 60), the LMA was inserted by standard digital intraoral method. In the 90 degree rotational technique group (n = 60), the LMA was rotated counter-clockwise through 90 degree in the mouth and advanced until the resistance of the hypopharynx was felt, and then straightened out in the hypopharynx. In 180 degree rotational technique, LMA was inserted back-to-front, like a Guedel airway. The parameters studied were: the LMA placement success at first attempt, insertion time, need for more than one attempt at insertion, need for external airway manipulations, postoperative sore throat, blood staining and other post-operative (airway related) complications.

Results

The first attempt success rate in the standard technique was 83.9%, in 90 degree rotational technique was 75% and 180 degree rotational was 93.5%. The first attempt success rate was higher in 180 degree rotational group compared to 90 degree rotational group (P < 0.05), but there was no statistically significant difference (P > 0.05) between 90 degree rotational group and the standard technique group. There was no statistically significant difference among the two groups in terms of the secondary outcomes.

Conclusion

We conclude that 180 degree rotational technique of LMA insertion is more successful than 90 degree rotational technique in adult patients under general anaesthesia.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

Comparing the safety and efficacy of three different doses of atracurium in facilitating the insertion of laryngeal mask airway in patients undergoing phacoemulsification cataract surgery: A randomized clinical trial

Background

In this study, we aimed to evaluate the safety and efficacy of three different doses of atracurium on conditions of laryngeal mask airway (LMA) insertion, first-try success rate, and possible complications.

Materials and Methods

A total of 120 patient's ≥18 years old were randomly divided into three groups of 40. The study groups received fentanyl 2 μg/kg thiopental 5 mg/kg and atracurium in doses 0.2 mg/kg, 0.4 mg/kg, and 0.6 mg/kg, respectively, based on the patient group. The conditions of LMA insertion, hemodynamic responses, and complications were evaluated and compared in the groups.

Results

In the study groups, the LMA placement was difficult in 15%, 7.5%, and 2.5%, respectively (P = 0.13). There was no statistically significant difference among the groups regarding the success rate in the first attempt to the insertion of LMA. Of the three groups, 5%, 2.5%, and 2.5% had bleeding at the place of mask insertion (P = 0.77). 17.5%, 7.5%, and12.5% had sore throat, respectively (P = 0.4). No patient experienced laryngospasm during the study. Furthermore, changes in blood pressure, heart rate, and oxygen saturation were not significant in the three groups.

Conclusion

All three doses of atracurium have similar effects on the condition of LMA insertion. Atracurium 0.4 mg/kg accompanied by higher success on LMA insertion in the first attempt and lower airway complications (bleeding and sore throat), increasing this dose had no significant effect on the success rate of LMA insertion.

Low-dose Succinylcholine to Facilitate Laryngeal Mask Airway Insertion: A Comparison of Two Doses

Background and Aims:

Around the world, the use of the laryngeal mask airway (LMA) is becoming more common for different surgeries accounting for it being the dominant choice of airway in numerous surgeries. Although propofol is known to blunt the laryngeal reflexes often patient movement, coughing, and gagging occur on insertion. This study aims to identify the optimum dose of succinylcholine required to facilitate LMA insertion comparing placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. Further objectives were to compare (a) the overall insertion conditions of the LMA, (b) the number of insertion attempts, (c) the amount of propofol consumption, and (d) the hemodynamics in the three groups.

Setting and Design:

This is a prospective, double-blinded, randomized control trial of 283 patients randomized into three groups-placebo, 0.1 mg/kg and 0.25 mg/kg of succinylcholine. It was done in the day case theatres of a tertiary hospital in Southern India.

Subjects and Methods:

Patients were induced with 2 mg/kg of propofol, after 2 μg/kg of fentanyl. The study drug was given after loss of consciousness. After 60 s, a classic LMA was inserted by the standard method by a single investigator. Jaw relaxation, coughing, gagging, movement, laryngospasm, ease of insertion, number of attempts, propofol usage, and hemodynamics were assessed.

Statistical Analysis:

Statistical methods used were analysis of variance with Bonferroni's t-test, Chi-square test, and Fisher's test. P < 0.05 was considered statistically significant.

Results:

Jaw relaxation was significantly better in the 0.25 mg/kg succinylcholine group. There was no significant difference in coughing and gagging in the groups, but patient movement was more in the placebo group. Two patients in the placebo group experienced partial laryngospasm. Overall insertion conditions were significantly better in the 0.25 mg/kg group compared to the other two groups. Propofol consumption was significantly more in the placebo group.

Conclusions:

The study concludes that 0.25 mg/kg succinylcholine facilitates insertion of the LMA.

Optimal dose of succinylcholine for laryngeal mask airway insertion: systematic review, meta-analysis and metaregression of randomised control trials

OBJECTIVES

To evaluate the optimal dose of succinylcholine for laryngeal mask airway (LMA) insertion and all related morbidities.

DESIGN

Systematic review, meta-analysis and metaregression of randomised controlled trials (RCTs).

DATA SOURCE AND STUDY ELIGIBILITY CRITERIA

A comprehensive search of RCTs in the PubMed, Embase, the Cochrane Library and the ClinicalTrials.gov registry up to July 2016 and articles that evaluated the use of succinylcholine chloride for LMA insertion were included in the analyses. The relative risk (RR) and the corresponding 95% CIs were determined.

INTERVENTION

Succinylcholine as the coinduction agent and the doses were divided into mini (≤0.3 mg/kg) and low (0.3-1.0 mg/kg) doses for dose-dependent effect analyses.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the first-attempt LMA insertion failure rate. Secondary outcomes included all related adverse events.

RESULTS

Data from 10 RCTs comprising 625 participants showed that succinylcholine reduced the first-attempt LMA insertion failure rate (RR, 0.22; 95% CI 0.12 to 0.43), coughing and gagging (RR, 0.26; 95% CI 0.15 to 0.45) and laryngospasm (RR, 0.14; 95% CI 0.05 to 0.39). The use of succinylcholine did not result in a significant increase of postoperative myalgia (RR, 2.58; 95% CI 0.79 to 8.44) and did not reduce the risk of postoperative sore throat (RR, 0.76; 95% CI 0.55 to 1.03). Subgroup analysis further showed that low-dose succinylcholine reduced the LMA insertion failure rate and its related coughing and gagging when compared with mini dose.

CONCLUSION

The use of succinylcholine compared with none can facilitate LMA insertion and reduce insertion-related reflexes without significant postoperative myalgia. However, additional prospective studies with a larger sample size are required to fully evaluate the dose-dependent effect and complications of succinylcholine for LMA insertion.

Comparison of Dexmedetomidine-Propofol versus Fentanyl-Propofol on Insertion Conditions of Proseal Laryngeal Mask Airway

INTRODUCTION

Proseal Laryngeal Mask Airway (PLMA) is a newer supraglottic airway device that requires adequate depth of anaesthesia and suppression of upper airway reflexes thereby providing optimal insertion conditions.

AIM

To compare dexmedetomidine and fentanyl for co-induction with propofol with respect to PLMA insertion conditions, haemodynamic variation and the total dose requirement of propofol.

MATERIALS AND METHODS

This was a prospective randomized double-blinded study conducted in 60 cases of American Society of Anaesthesiologists (ASA) class I/II undergoing elective surgery under general anaesthesia. They were randomly divided into two equal groups, D and F, each receiving 1μg/kg of dexmedetomidine and fentanyl respectively followed by Propofol 2.5mg/kg as per protocol. The ease of PLMA insertion was Young's Criteria and Modified scheme of Lund and Stovener. The haemodynamic parameters (mean heart rate, mean arterial pressure, Respiratory rate, SPO₂) were monitored at: Baseline, Pre-medication, Pre PLMA, Post LMA (at insertion), 1, 3, 5, 10, 15 and 20 minutes.

RESULTS

PLMA insertion conditions and haemodynamics were comparable between the dexmedetomidine-propofol and fentanyl-propofol groups according to the Young's criteria and Modified scheme of Lund and Stovener. Total induction dose of propofol and its increments were significantly reduced in the dexmedetomidine group.

CONCLUSION

Dexmedetomidine and fentanyl when both used individually for co-induction with propofol for PLMA insertion give excellent overall insertion conditions with haemodynamic stability. Dexmedetomidine also significantly reduces the requirements of induction dose propofol for PLMA insertion.

Effects of adenotonsillar hypertrophy corrective surgery on nocturnal enuresis of children

BACKGROUND

Nocturnal enuresis is considered a common urological complaint especially among children. Respiratory obstructive diseases have been one of the possible etiologies of such a condition. The most common type of upper respiratory obstructive diseases in childhood is adenotonsillar hypertrophy. In this study, it was tried to estimate the prevalence of nocturnal enuresis in adenotonsillar hypertrophy as an upper obstructive airway disease and cure rate after corrective operation.

MATERIALS AND METHODS

In this longitudinal study, 184 children with adenotonsillar hypertrophy as case group and 200 healthy children as control group were randomly compared for nocturnal enuresis incidence and risk factors. Then they were followed after 6 months to estimate the cure rate after corrective operation.

RESULTS

In case group, nocturnal enuresis was more common than control group (26% vs. 17%, P = 0.1). Factors which had a role in enuresis in case group were family history (P = 0.03) and male sex (P = 0.05). Three months after surgery, 48% of children totally cured from enuresis (P = 0.001) and 71% cured both partially or totally (P = 0.03). The response rate after moderate obstruction relieving was 100% while that in severe cases was 60% (P = 0.2).

CONCLUSIONS

Nocturnal enuresis due to upper obstructive airway disease occurs more in male and in the presence of family history. The cure rate after 6 months of operation was more prominent in moderate obstruction which suggests enuresis in severe airway obstruction may need a longer time to subside. Cure rate of primary enuresis due to obstructive airway disease after 6 months of relieving was 48% in children over 5 years old.

Which Form of Medical Training is the Best in Improving Interns' knowledge Related to Advanced Cardiac Life Support Drugs Pharmacology? An Educational Analytical Intervention Study Between Electronic Learning and Lecture-Based Education

Background:

Conventional educational systems seem to be improper throughout the cardiopulmonary resuscitation (CPR) teaching process. The most common causes of failed resuscitation are unfamiliarity with cardiopulmonary resuscitation algorithms, poor performance of leader of the CPR team and lack of skilled personnel, coordination among members during resuscitation, and responsibility of staff.

Objectives:

Electronic learning, as a new educational method is controversial issue in medical education for improving physicians’ practical knowledge and it is inevitable that further research on its effectiveness should be done.

Materials and Methods:

The present study is a prospective, pre- and post-educational, cross-sectional research, in which 84 interns were randomly divided into two groups. pre- and post- educational interventions that took place in the Department of Emergency Medicine, interns were evaluated by 21 multiple choice questions related to American Heart Association guidelineson cardiopulmonary resuscitation drugs. Questions were assessed in terms of routes for CPR drugs administration, CPR drug dosage forms, clinical judgment and appropriate CPR drug administration, and the alternative drugs in emergency situations. Data were analyzed by generalized estimating equations regression models and P < 0.05 was considered statistically significant.

Results:

Evaluating the effectiveness of both educational methods revealed that the mean answering score for 21 questions before education was 7.5 ± 2.6 and no significant difference was observed in groups (P = 0.55). However, after education, the average scores significantly increased to 11.0 ± 3.9 (P < 0.001). Electronic learning method was not associated with considerable increase in the knowledge of interns in this group compared with the lecture-based group (P = 0.49).

Conclusions:

No significant differences were observed between electronic learning and lecture-based education in improving interns’ knowledge of CPR drugs.

Comparison between the effects of alfentanil, fentanyl and sufentanil on hemodynamic indices during rapid sequence intubation in the emergency department

Background:

Laryngoscopy and tracheal intubation lead to the alteration of hemodynamic parameters, including blood pressure and heart rate, in traumatic patients who sustain rapid sequence intubation (RSI). Various drugs such as fentanyl, alfentanil and sufentanil have been used to modify these hemodynamic responses.

Objectives:

The aim of the present study is to compare the effects of fentanyl, sufentanil and alfentanil in trauma patients who require RSI in the emergency department (ED).

Patients and Methods:

This was a randomized double-blinded study conducted on 90 patients (18-65 years old, ASA I, II), who needed intubation following trauma. The patients were randomly divided into three groups, Group I, Group II and Group III, who have received alfentanil, fentanyl and sufentanil, respectively. Heart rate, blood pressure, saturation of peripheral oxygen and end-tidal carbon dioxide were measured 5 minutes before and 3, 5 and 10 minutes after intubation, respectively. The changes of the hemodynamic parameters were compared in between groups. Data were analyzed by One-way ANOVA, General Linear Model Repeated Measure and Mauchly’s Sphericity Test. A P < 0.05 was considered statistically significant.

Results:

There was no significant statistical difference among groups with respect to hemodynamic parameters.

Conclusions:

Alfentanil, fentanyl and sufentanil can be used safely as premedication drugs for trauma patients who need intubation.

Warming Endotracheal Tube in Blind Nasotracheal Intubation throughout Maxillofacial Surgeries

INTRODUCTION

Blind nasotracheal intubation is an intubation method without observation of glottis that is used when the orotracheal intubation is difficult or impossible. One of the methods to minimize trauma to the nasal cavity is to soften the endotracheal tube through warming. Our aim in this study was to evaluate endotracheal intubation using endotracheal tubes softened by hot water at 50 &deg;C and to compare the patients in terms of success rate and complications.

METHODS

60 patients with ASA Class I and II scheduled to undergo elective jaw and mouth surgeries under general anesthesia were recruited.

RESULTS

success rate for Blind nasotracheal intubation in the control group was 70% vs. 83.3% in the study group. Although the success rate in the study group was higher than the control group, this difference was not statistically significant. The most frequent position of nasotracheal intubation tube was tracheal followed by esophageal and anterior positions, respectively.

CONCLUSION

In conclusion, our study showed that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during blind nasotracheal intubation; however it could not facilitate blind nasotracheal intubation.

Hemodynamic Changes following Anesthesia Induction and LMA Insertion with Propofol, Etomidate, and Propofol + Etomidate

INTRODUCTION

LMA is a simple supra-laryngeal device which is used to establish and maintain airway. Despite the common use of the LMA, there are no optimal methods for induction of anesthesia that can guarantee a proper insertion. The purpose of this study is comparing three methods of induction of anesthesia (Propofol, Etomidate, Propofol+Etomidate) in the hemodynamic stability after LMA insertion in elective surgeries.

METHODS

A total of 90 patients with ASA classes I and II undergoing elective surgeries were randomly allocated into one of the following three groups. Before anesthesia induction, all patients were premedicated. Anesthesia induction methods included: Group P (propofol 2.5 mg/kg), Group E (etomidate 0.3 mg/kg) and Group P+E (propofol 1 mg/kg plus etomidate 0.2 mg/kg). Heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure were measured before induction and 30 seconds after induction. Apnea time is recorded in all patients. Number of attempts to laryngeal mask insertion, ease of placement, were compared in three groups.

RESULTS

There was no significant difference between demographic data and BIS, SaO2, Etco2 associated diseases, in three group (P>0.5).There is significant difference in hemodynamic (Systolic, diastolic and mean blood pressures) changes between group 1 in comparison with group 2 and group 3. HR was significantly lower in group 1 than group 2 (P=0.16). There was significant difference in the number of attempts and ease of LMA insertion between group 2 in comparison with group 3 and group 1. The duration of apnea in group 2 was a (8.67± 6) min, where as it was (18.10±6.25) min in group 1 and (12.03±6.4) min group 3.

CONCLUSION

Etomidate plus propofol is an effective and alternative to propofol and etomidate for facilitating LMA insertion with the added advantage of lack of cardio-vascular depression.

Sensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation

BACKGROUND

This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation.

METHODS

In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests.

RESULTS

Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation (P : 0.004); however, other demographic characteristics didn't have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity (96.46%) and modified Mallampati of highest sensitivity (98.40%). In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together.

CONCLUSIONS

Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together.