Tachycardia, hypertension and dysrythymias all occur during laryngoscopy and intubations. The consequent rise in rate/pressure product may result in a myocardial oxygen demand which exceeds the oxygen supply resulting in myocardial ischeamia 2 .This response is sympathetically mediated and can be attenuated by various drugs that block sympathetic activity and other drugs like calcium channel blocking drugs, lignocaine and magnesium. Studies have documented myocardial ischeamic changes due to reflex sympatho adrenal response immediately following laryngoscopy and intubation with a mean increase in systemic pressure of 40mmHg even in normotensive patients.
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A prospective study comparing Diltiazem and Lignocaine in attenuating the haemodynamic response to laryngoscopy and intubation in E.N.T. patients comprised of 40 patients aged between 20 to 50 years. Both male and female patients who were scheduled for E.N.T. procedures like FESS, mastoidectomy, myringoplasty, Stepedectomy etc. requiring endotracheal intubation were chosen for the study. All patients belonged to ASA I physical status. Patients with cardio-respiratory problems and patients suspected to have a difficult intubation were excluded from the study. All the patients were informed of the study and their consent was obtained. The surgeon was also informed of the study.
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Since fentanyl in large doses that were initially used to attenuate circulatory responses to intubation produce many side effects, small dose Fentanyl is increasingly being used to effectively attenuate the stress response during anaesthetic induction. However there has been no evaluation of the optimal time of injection of small dose Fentanyl to effectively obtund the secondary circulatory responses to laryngoscopy and endotracheal intubation. Hence this study was designed to evaluate the optimal time for injecting small dose Fentanyl to effectively attenuate the circulatory responses accompanying laryngoscopy and intubation during anaesthetic induction. For this study I used Inj. Fentanyl 2 µg / kg body weight before induction based on the study made by Nishina.K & Mikawa.K et al (1995) 37 who showed that this dose
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The larynx is a heavily innervated sensory structure, so laryngoscopy and tracheal intubation stimulates these structures leading to the stress response. Hemodynamic stress response to laryngoscopy and intubation occurs as increase in heart rate and blood pressure due to reflex sympathetic discharge. The force and duration of laryngoscopy, hypoxia, hypercarbia, stimulation of carina by endotracheal tube , repeated and prolonged attempts affect the stress response.
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were removed from the study, 6 mins prior to the start of induction injection fentanyl citrate 2 mcg/kg was given in designated groups (Group 1 and Group 3) and same volume of saline was given in the no fentanyl group (Group 2 and Group 4)by the anesthesiologists, all the events on the trend graph of the multiparamonitor were recorded. The patient was preoxygenated with 100% oxygen for 3 min. Then anaesthesia was induced with 2 mg/kg of propofol . After ventilation is confirmed with a face mask, injection succinylcholine 2 mg/kg was administered, and the patient was ventilated with 100% oxygen for 1 minute,Then laryngoscopy and intubation were carried out in classical sniffing position by a single, experienced anesthesiologist & Endotracheal cuff was inflated with minimal leak. Anaesthesia was maintained with controlled ventilation with Nitrous oxide 60% and oxygen 40%. No surgical simulation was permitted for 7 minutes after intubation HR,SBP,DBP,MAP were noted at different time points- baseline, after induction, immediately after intubation, and subsequently at1, 2,3,4,5,6,7 minutes interval after intubation.
the preferred pre-treatment and induction agents, the operators selected the sedatives and dosages after con- sidering each patient’s condition. A sedative was admin- istered 2 min after pre-treatment agent injection, and tracheal intubation was performed 20–30 s later. The operators chose either a curved Macintosh laryngoscope with metal reusable blade or a GlideScope video laryngo- scope (Verathon, Bothell, WA, USA) as the initial device. Tracheal intubation was supervised by an experienced operator when performed by an inexperienced operator. If the second intubation attempt was unsuccessful, the experienced operator performed the third attempt. How- ever, for the patient safety, supervisors tended to intubate directly if the patient was expected to have difficult air- way or hemodynamically unstable. It is presumed that relatively less severe patients were intubated by inexpe- rienced operators and with direct laryngoscopy for the training purpose. Correct tracheal tube placement was assessed using careful auscultation, end-tidal carbon dioxide measurement, and chest radiography. The end- tidal carbon dioxide level was measured using an EMMA Emergency Capnograph (Masimo Corp., Irvine, CA, USA). After each tracheal intubation, intubation-related information was recorded on a data collection sheet by MET nurses, and all tracheal intubations were reviewed in regular weekly meetings.
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During induction of general anaesthesia, the act of laryngoscopy and tracheal intubation stimulates the sympathetic nervous system resulting in an increase in blood pressure and heart rate which may be harmful especially in elderly patients with pre-existing ischaemic heart disease. Several drugs have therefore been used to obtund this increase including esmolol, nicardipine, magnesium sulphate and lignocaine. This prospective, double blind randomised clinical trial compared the efficacy of magnesium sulphate and esmolol in attenuating haemodynamic responses to laryngoscopy and tracheal intubation. One hundred and twenty six ASA I-II patients scheduled for elective surgery requiring general anaesthesia with tracheal intubation were enrolled and randomised into two groups: Group 1 (n = 67) received MgSO 4 40 mg/kg diluted in 100 ml normal saline administered over ten minutes, whereas Group 2 (n =
Background : In 1986 esmolol, an ultra-short acting β1-cardioselective adrenergic receptor blocker was introduced which gained quick popularity for its short duration of action and nil risk of developing perioperative bradycardia or hypotension and found to be quite suitable to control the detrimental effects of laryngeal and tracheal stimulation. AIM: To compare the efficacy and safety of esmolol with normal saline in attenuating hemodynamic responses to laryngoscopy and intubation in patients of elective surgical procedures under general anesthesia. Materials and method: 60 patients of age 20 to 60 yrs,ASA physical status I and II posted for surgical procedures under general anaesthesia, randomized into two groups of 30 each to receive esmolol (Group E) 1.5mg/kg diluted to a total volume of 20 ml with 0.9% saline and control (Group C) 20 ml 0.9% saline ,both infused IV over a period of 10 min before 3 mins of induction. Changes in heart rate , systolic and diastolic blood pressure, r ate pressure product (RPP), any side effects associated with the drugs during the study period i.e.,20 mins of intubation,were observed and statistically analysed. Result : between groups E & C there was statistically significant difference (P< 0.0001) in mean heart rate d uring intubation ,mean SBP (P=0.0001), mean DBP (P=0.0001) and mean RPP (P=0.0001) was observed.Conclusion: infusion of esmolol was found to attenuate the haemodynamic response to laryngoscopy and tracheal intubation significantly.
Airway management and intubation are important in both elective and emergency situations for which a secure airway is required. The current practice is to use direct laryngoscopy to facilitate intu- bation; however, indirect laryngoscopy, or videolaryngoscopy, has the potential to facilitate successful intubation while improving in- tubation outcomes. Kim and associates reported that in children, videolaryngoscopy provided a view of the larynx equal to or better than that provided by the direct laryngoscope at the expense of longer intubation times (Kim 2008). Videolaryngoscopy is easier for investigators to use and results in a lower alteration in heart rate (Maharaj 2006; Riad 2012). To date, no systematic reviews have addressed the effects of indirect laryngoscopy, or videolaryn- goscopy, on only paediatric intubation outcomes. A recent meta- analysis that assessed both adults and children suggested that vide- olaryngoscopy is a good alternative to conventional direct laryn- goscopy but included only a few paediatric studies (Su 2011). Sun and coworkers concluded from a recent meta-analysis includ- ing both children and neonates that videolaryngoscopies were as- sociated with improved visualization of the glottis in children with normal airways or with potentially difﬁcult airways, but with a signiﬁcantly increased incidence of failed intubation (Sun 2014). Our review excludes neonatal intubations, as children in this age group have different airway anatomy and require different intu- bation techniques.
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change of blade size. Gum elastic bougie used for facilitating intubation in Cormac and Lehane grade III and IV and were subsequently intubated without any significant events or difficulty. All intubations were done by a senior anaesthesiologist. There was neither any significant airway trauma nor episode of desaturation noted. All had no difficulty in mask ventilation. The discriminant analytic study which we applied identified the clinical risk factors [modified mallampati class, inter incisor gap, thyromental distance, sternomental distance and Wilson’s risk score] were predictors of difficult laryngoscopy and intubation. In our study the sensitivity and specificity of clinical factors are 97.2% and 95.3%. the combination of clinical and radiological variables have the high sensitivity of 100% and specificity of 95.3%.
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Difficult intubation, inadequate ventilation and esophageal intubation are the principal causes of death or brain damage related to airway manipulation. The objective of this cross-sectional study was to correlate a preanesthetic evaluation that may be capable of predicting a difficult intubation with the conditions encountered at laryngoscopy and endotra- cheal intubation. Eighty-one patients submitted to general anesthesia were evaluated at a preanesthetic consultation ac- cording to the modified Mallampati classification, the Wilson score and the American Society of Anesthesiologists (ASA) difficult airway algorithm. Findings were then correlated with the Cormack-Lehane classification and with the number of attempts at endotracheal intubation. No statistically significant correlations were found between the patients’ Mallampati classification and their Cormack-Lehane grade or between the Mallampati classification and the number of attempts required to achieve endotracheal intubation. Laryngoscopy proved difficult in four patients and in all of these cases the Wilson score had been indicative of a possibly difficult airway, highlighting its good predicting sensitivity. However, the specificity of this test was low, since another 24 patients had the same Wilson score but were classified as Cormack-Lehane I/II. Moreover, two patients who had a Wilson score ≥ 4 were also classified as Cormack-Lehane grade I/II. The study concluded that the Wilson score, although seldom used in clinical practice, is a highly sensitive predictor of a difficult airway; its specificity, however, is low.
Tracheal intubation is a lifesaving procedure frequently performed in the intensive care unit (ICU). Multiple anatomic and physiologic factors make airway manage- ment in the ICU more challenging than elective intu- bation in the controlled setting of the operating room [1-3]. Patients are often hemodynamically unstable or hypoxemic, and may have anatomic characteristics, such as distorted airway anatomy or abnormal body habitus, associated with difficult intubation [3-5]. Traditionally, orotracheal intubation has been performed in the ICU with a direct laryngoscope (DL), which requires align- ment of the oral, pharyngeal and laryngeal axes to allow direct visualization of the glottic inlet. When performed in the ICU, DL has been associated with a high inci- dence of difficult intubations and complications [6-10]. Video laryngoscopy (VL) was developed to obviate the need for direct visualization of the glottic inlet by transporting the view of the airway to a monitor via a micro video camera placed on the under surface of the blade. This allows the operator to see “around the cor- ner” when alignment of the axes is difficult. VL has been shown to improve first attempt success and grade of laryngoscopic view when compared to DL in the simula- tion lab, operating room, emergency department and ICU [11-22]. When used by anesthesiologists in the ICU setting, VL improved success rate and grade of view compared to DL in the presence of difficult airway pre- dictors .
was used in Airtraq group while such maneuvers were tried in 23.3% of Macintosh group. The ease of instrument use as denoted by the patient‘s subjective feeling of pain measured by Visual Analog Score was less in the Airtraq group (1.2 ± 1.4) than the Macintosh group (2.0 ± 1.5). Yoshihiro Hirabayashietal 45 study on 20 patients where nasotracheal intubation was performed by a non-anaesthesia physician to compare the intubating conditions between Macintosh and Airtraq laryngoscopes. Results observed from the study that nasotracheal intubation was achieved by using Airtraq laryngoscopy is shorter time(65 seconds) than using Macintosh laryngoscopy(123 seconds) with Magill forceps. No esophageal intubation experienced in the Airtraq group, while one resident performed an esophageal intubation in the Macintosh group. It was concluded from the study that in comparison with the Macintosh laryngoscope, the Airtraq laryngoscope provides superior intubation conditions for personnel who are training in airway management, resulting in less time to secure the airway .
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The main cause of transient hemodynamic instability and interruption of patient air way reflex is laryngoscopy and intubation. The reflex cardiovascular responses to laryngoscopy and tracheal intubation were known to anaesthesiologists since a long time, so the haemodynamic stability is an integral and essential goal of any anaesthetic management plan , as well as endotracheal intubation stimulates the laryngeal and tracheal sensory receptors, resulting an increase of sympathetic stimulation.
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The major disadvantage of RTL use, as in the case of rigid bronchoscopy, is the reduced visual field which can be improved by increasing the tube diameter. The RTL is easier to use, safer and offers a better view than the rigid bronchoscope because of its smaller size. Dental injury and bleeding during the procedure might be higher with the use of RTL as compared to classical laryngoscopy. We did not experience such incidents. The bougie intubation carries the risk of vocal cord injury and the impossibility of advancing the tracheal tube if the respiratory space is too narrow as well as airway perforation if it is inserted too deep. 12–14 This is the
The present study was designed as a single-blind randomized controlled trial to investigate the effect of lornoxicam on the changes in blood pressure and heart rate (HR) observed during laryngoscopy and tracheal intubation in 50 ASA I & II patients. They were divided into two groups of 25 each, one being the study group receiving 16 mg iv lornoxicam and the other the control group receiving iv placebo. Heart rate and blood pressure were recorded at various intervals during laryngoscopy and endotracheal intubation. It was observed that there was a statistically significant attenuation in heart rate and blood pressure response to laryngoscopy and intubation for the lornoxicam group. Hence we can conclude that iv lornoxicam 16 mg 30 minutes before surgery is a simple and practical method for the attenuation of the stress response to laryngoscopy and endotracheal intubation.
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This increase in pulse rate and blood pressure are usually transitory, variable and unpredictable and probably of no consequences in healthy individuals. But some patientsrequire careful hemodynamic control during laryngoscopy and intubation. The complications that occur include left ventricular failure (Masson 1946), myocardial ischemia (Editorial BJA 1969), cerebral hemorrhage (Davidson 1986) and even sudden death. These changes had been ascribed to b due to vago-vagal reflex or due to stimulation of cardiac response. Subsequently it has been postulated that these reflexes are mediated by increased sympathetic nervous system activity. This is reflected by an increase in the level of International Journal of Current Research
This is to certify that the dissertation entitled, “A Prospective, Randomized Study Comparing The Video Laryngoscope And Standard Direct Laryngoscopy For Intubation In The Paediatric Airway. " submitted by Dr.KARTHIKEYAN.J in partial fulfilment for the award of the degree of Doctor of Medicine in Anaesthesiology by Tamilnadu Dr.M.G.R Medical University, Chennai is a bonafide record of the work done by him in the Institute of Anaesthesiology & Critical Care, Madras Medical College, during the Academic year 2012-2015.
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Laryngoscopy and intubation are associated with significant increases in pulse rate, blood pressure, mean arterial pressure, and sinus tachycardia. In present study show the maximum increases in parameters occur at 1 minute post intubation with values returning to baseline at 10 min post intubation in case of pulse rate and at 5 minutes post intubation in case of systolic, diastolic and mean arterial pressure. 10% Lidocaine spray provided consistent and reliable protection from increases in pulse rate, blood pressure, & mean arterial pressure and is most reliable drug for attenuation of cardiovascular response to laryngoscopy and intubation under G.A. without any complication when used in proper doses and time.
The haemodynamic response to laryngoscopy and intubation is the acute change in haemodynamics that occurs within seconds of the stimulus, lasting up to 5 mi- nutes after stimulation has ceased [24,25]. The generally accepted anaesthetic objective is to maintain a stable blood pressure within 10 to 20% of baseline levels . Patients with changes outside this are at increased risk of complications [27,28] and acute elevations in blood pressure (>20%) are typically considered hypertensive emergencies . We defined a hypertensive response as a greater than 20% increase in systolic blood pressure (SBP) or mean arterial pressure (MAP) above baseline and a hypotensive response as a greater than 20% reduc- tion in SBP or MAP below baseline. Absolute hypotension was defined as a reduction in SBP to less than 90 mmHg. Similarly, a tachycardic response was defined as a greater than 20% increase in HR above baseline, and a bradycardic response as a drop in HR to less than 60 bpm. These defi- nitions are consistent with other studies investigating the response [29,30].
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