Vol 4 No 3 (2018): Summer
Comparison of Four Methods for Predicting Difficult Laryngoscopy: A Prospective Study of Validity Indexes
Background: Considering that a simple yet valid airway predictor is basically preferred to a multivariable test with the same level of validity, we designed a study to compare the validity indexes of the TMHT, as a single variable test, with that of Wilson, Arne, and Naguib tests.
Methods: 270 consecutive ASA physical statues I and II patients aged ≥16 years, candidate to receive general anesthesia for elective surgeries, were enrolled in the study. All patients preoperatively were evaluated using four airway predictor tests including Wilson, Arne, Naguib, and Thyromental height test (TMHT). Cut-off points to predict a difficult laryngoscopy were extracted from previous published studies for each test. Based on each predictor, all patients were classified into either easy or difficult. Based on Cormack-lehane scoring system, as the gold standard, all patients during laryngoscopy were categorized into two groups of “easy, grades I, II” and “difficult, grades III, IV”. Finally, validity indexes for each test were calculated and compared to one another.
Results: The incidence of difficult laryngoscopy according to Cormack-lehane grading was 17.4% (47/270). The predicted rates of difficult laryngoscopy were 47 (17.4%), 2 (0.7%), 10 (3.7%) and 61 (22.6%) for TMHT, Wilson, Arne and Naguib respectively. Based on Chi-square test, the TMHT as well as the Naguib could significantly predict difficult laryngoscopy. However, the highest rate of sensitivity, positive predictive value, negative predictive value, and accuracy belonged to TMHT.
Conclusion: Both TMHT and Naguib are acceptable predictors of difficult laryngoscopy while the TMHT is a more accurate predictor of difficult laryngoscopy than the other multivariable models.
Comparison of Ventilation Quality during Induction of General Anesthesia through Nasal and Face Mask Methods in Patients with Body Mass Index of Greater than 25
Background: Face mask ventilation has a distinct place in anesthesiology. One of the difficulties (obstacles, problems) with a mask, is laryngeal airway obstruction caused by the backward displacement of the tongue and soft tissue which is further exacerbated by obesity (body mass index over 25). Considering the fact that ventilation using a nasal mask appears to cause fewer problems especially in obese patients, we decided to compare the quality of ventilation after the induction of general anesthesia using ventilation through an anatomical face mask and anatomical nasal mask in patients with a body mass index (BMI) over 25 in this study.
Methods: The study was a clinical trial, conducted on 70 patients between the ages of 18 and 70 years, with a BMI over 25, who were candidates for elective orthopedic surgery under general anesthesia at the Alzahra Hospital operating room. After evaluation of the inclusion criteria, the subjects were selected. Once placed on the operating table, the patients were administered 100% oxygen using a face mask held at proximity to the face for 3 minutes, after which anesthesia induction medication were administered to all patients. Subsequently, the patients were randomly divided into 2 groups. In the first group, ventilation was undertaken using the standard mask ventilation with 100 % oxygen for 3 minutes. In the second group, ventilation was performed through an anatomical nasal mask. The mean expiratory volume, mean SpO2, mean end tidal CO2 (Et CO2) and mean airway pressure were measured, recorded and compared in both groups.
Results: From the ventilation parameters, maximum airway pressure during the 2nd minute after initiation of mask ventilation was significantly higher in the face mask group compared to the nasal mask group (4.6 +/- 1.6 and 12.5 +/- 1.7 respectively, p< 0.001) and the SpO2 at this time was higher in the nasal mask group compared to the face mask group (97.6 +/- 1.7 and 95.3 +/- 3 respectively, p< 0.001). Other parameters related to ventilation did not show any significant difference.
Conclusion: According to the findings in this study, it can be concluded that ventilation with a nasal mask is more efficient than a face mask in patients with a BMI> 25 and is followed by a reduced amount of risk and complications.
Comparison of the Effect of Chlorhexidine Mouthwash with Matrika Mouthwash Drop on Probable Ventilator-associated Pneumonia in Intensive Care Unit
Background: Daily use of Chlorhexidine mouthwash following endotracheal intubation is done routinely in intensive care units (ICU). Matrika (Chamomile extract) has shown antibiotic activities, and several articles report it has similar preventive effect as Chlorhexidine on ventilator associated pneumonia, and also on oral cavity hygiene. Our study aimed to compare rate of VAP occurrence in two groups of intubated patients receiving Chlorhexidine and Matrika in Alzahra hospital’s ICU.
Methods: In this trial 90 ICU patients who were intubated endotracheally, were randomly divided into two groups who will receive one of Chlorhexidine (group A) or Matrika (group B) mouthwash every 8 hours. Occurrence of VAP was determined in the following 5 days after intubation, using the standard VAP diagnosis criterion.
Results: 8 of 45 (17%) patients experienced VAP in the first five days after intubation in the Chlorhexidine group, and, 9 of 45 (20%) patients in the Matrika group experienced the same condition. VAP rate was not significantly lower in the Chlorhexidine group (p value= 0.73).
Conclusion: The results show that VAP occurs in Chlorhexidine and Matrika group approximately at a similar rate. Our findings recommend further studies on Matrika as an alternative to Chlorhexidine.
Effect of Ketamine-Sufentanil and Ketamine-Midazolam to Induce Sedation and Analgesia in Pediatric with Lumbar Puncture or Bone Marrow Aspiration
Background: The combination of sedative and analgesic drugs has a favorable effect on pain management and sedation during painful procedures in pediatrics. Therefore, our aim was to compare the effect of sedation and analgesia of ketamine-sufentanil and ketamine-midazolam in painful procedures in children with blood malignancies.
Methods: This double-blind, clinical trial was performed on 82 children with malignancy who had indication of painful diagnostic intervention; patients were randomly divided into two groups of ketamine-sufentanil (KS) and ketamine -midazolam (KM).
In KS group, sufentanil 0.5mcg/ kg and ketamine 1mg/ kg and in the KM group, ketamine 1mg/ kg, and midazolam 0.1mg/ kg bolus were prescribed. In either group, hemodynamic indicators of sedation, side effects, duration of effectiveness were recorded. Data were analyzed using SPSS 20.
Results: Sedation based on Ramsay sedation score was not significantly different between the two groups (p= 0.39). The average recovery time in the midazolam-ketamine group was higher (p-value= 0.076).
Conclusion: The combination of ketamine-sufentanil and ketamine-midazolam was effective in sedation and analgesia in bone marrow aspiration and lumber puncture; side effects were however, lower in ketamine-midazolam group.
The Effect of Selenium High Dose Intravenous on Rapid Shallow Breathing Index (RSBI) in Ill Patients: A Clinical Trial Study
Background: Selenium (Se), mainly through its incorporation into selenoproteins, plays an important role in in ammation and immunity. Evidence has emerged regarding roles for individual selenoproteins in regulating in ammation and immunity: The aim of the study was to evaluate of the effect of selenium administration on rapid shallow breathing index (RSBI) in ill patients.
Methods: In this single blinded clinical trial study, 105 patients under mechanical ventilation were randomly divided into three groups, a received 1mg of Selenium, group B received 0/5 mg of selenium and group C received 2cc normal saline daily. Patients at the time of breathing spontaneously, and when receiving pressure support ventilation 8 and 5 cmH2o, and at the time of extubation were evaluated for Rapid Shallow Breathing Index and then compared between the groups.
Results: There were no significant differences in the three groups in terms of distribution of age, sex, and cause of hospitalization and the mean of RSBI index at breathing spontaneously and when ventilator setting were reached to pressure support ventilation 8 cmH2o, however the difference was significant between the three groups from the pressure support ventilation 5 cmH2o until the extubation time.
Conclusion: The results of the study showed a positive effect of selenium high dose (1mg) on the reduction of extubation time and RSBI, but due to the limitations of our study, further studies are recommended.
Anticipated and Unanticipated Difficult Airway: A Practical and Logical Approach: A Narrative Review
Stability of the airway is a fundamental element of acute care medical practice. While airway management is conceptually straightforward, the wide variety of clinical circumstances, patients, and tools can make the task of ensuring a stable, open airway under all clinical conditions extremely challenging. Care providers involved in airway management must therefore not only be technically skilled but also sufficiently flexible to adjust changing the conditions, risk/benefit balances, and goals. One aspect of airway management that requires particular attention is the airway that is difficult to secure or keep patent. For clinical or anatomic reasons, both bag mask ventilation and tracheal intubation in such a patient population may be difficult without specialized expertise or tools. Because adequate oxygen delivery through a patent airway is critical to life support and resuscitative efforts, the risks of inadequate airway management are high, adding to the challenge. One significant advance in difficult airway management is the development of algorithms to standardize the technical approach to successful endotracheal intubation in a patient with a difficult airway. Such algorithms are relatively recent (The American Society of Anesthesiologists difficult airway algorithm updated in 2015), and integrate clinical experience, evidence, and technical expertise into a stepwise approach to anticipated and unanticipated airway challenges.
Fentanyl is a strong opioid and it is widely used for pain relief. In this review, we evaluated the efficacy of fentanyl in pain management in the emergency department. For this review, we searched scientific search engines including google, google scholar, Cochrane library, Medline, and PubMed and collected original articles, including randomized controlled trials, comparative studies, cohort and case series related to fentanyl and its administration in the emergency department from 2010 to 2016. In this review, 8 articles and 44493 patients were evaluated. Four articles were retrospective and 4 articles were prospective of these four articles were randomized placebo controlled and double blinded. Among eight articles, six of them compared the efficacy and adverse events of fentanyl with other opioids. We found fentanyl significantly decreases pain intensity in patient with acute pain in the emergency department. Moreover, it is more effective than morphine and methoxyflurane.
“Cannot Intubate_Cannot Ventilate” Emergency: Airway Management of Difficult Airway in a Patient; A Case Report
The present study reports a 42 years old male patient with modular thyroid cancer. The patient became candidate for direct laryngoscopy (DL) in order to observe the condition of the lesion in the trachea and probable biopsy, and subsequent surgery. After a few moments, it was observed that the patient cannot be ventilated. Immediately, the patient was tried to be intubated but was not successful and thus, quick track was put for the patient rapidly and he was connected to the jet ventilation machine. But after a short time, suddenly the patient got bradycardia and respiratory interruption and drop in saturation that the patient underwent CPR operation which continued for 30 seconds which resulted finally in the patient’s heart rate reaching 100 and spontaneous breathing began. After auscultation of lungs, bilateral pneumothorax was diagnosed that according to previous studies, is probably a complication resulting from trans tracheal jet ventilation (TTJV). This complication was resolved through needle aspiration. After 4 hours, the surgery was over and the patient, with stable vital signs and spontaneous breathing, was sent to the intensive care unit.
In some previous studies, the researchers have suggested using open surgical technique in order to reduce the complications resulting from cannot intubate, cannot ventilate (CICV), and the present study also supports this suggestion and recommends it to other anesthesiologists when facing CICV situation, in order to reduce the complications resulting from jet ventilation and its subsequent damages.