A lexicon for endoscopic adverse events: report of an ASGE workshop.

National High Blood Pressure Education Program.

This is a retrospective study of patients whose tracheas were impossible to intubate on a previous occasion. There is a correlation between the degree of difficulty and the anatomy of the oropharynx in the same patient. The study was initially on obstetric patients but was extended to nonobstetric surgical patients in order to increase the number of cases investigated. The incidence of failed intubations in the obstetric group over a 3-year period was seven out of 1980 cases, whereas in the surgical group the results were six out of 13,380 patients. Any screening test which adds to our ability to predict difficulty in intubation must be welcomed, as failure to intubate can potentially lead to fatality.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.1987.tb04039.x

Difficult tracheal intubation: a retrospective study

The objective of this study was to systematically determine the diagnostic accuracy of bedside tests for predicting difficult intubation in patients with no airway pathology. Thirty-five studies (50,760 patients) were selected from electronic databases. The overall incidence of difficult intubation was 5.8% (95% confidence interval, 4.5‐7.5%). Screening tests included the Mallampati oropharyngeal classification, thyromental distance, sternomental distance, mouth opening, and Wilson risk score. Each test yielded poor to moderate sensitivity (20‐62%) and moderate to fair specificity (82‐97%). The most useful bedside test for prediction was found to be a combination of the Mallampati classification and thyromental distance (positive likelihood ratio, 9.9; 95% confidence interval, 3.1‐31.9). Currently available screening tests for difficult intubation have only poor to moderate discriminative power when used alone. Combinations of tests add some incremental diagnostic value in comparison to the value of each test alone. The clinical value of bedside screening tests for predicting difficult intubation remains limited.

/pdf/predicting-difficult-intubation-in-apparently-normal-1kor8ihpxe.pdf

Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance.

Background:A quantitative scale of intubation difficulty would be useful for objectively comparing the complexity of endotracheal intubations. The authors have developed a quantitative score that can be used to evaluate intubating conditions and techniques with the aim of determining the relative va

The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation.

It has been suggested that the size of the base of the tongue is an important factor determining the degree of difficulty of direct laryngoscopy. A relatively simple grading system which involves preoperative ability to visualize the faucial pillars, soft palate and base of uvula was designed as a means of predicting the degree of difficulty in laryngeal exposure. The system was evaluated in 210 patients. The degree of difficulty in visualizing these three structures was an accurate predictor of difficulty with direct laryngoscopy (p less than 0.001).

/pdf/a-clinical-sign-to-predict-difficult-tracheal-intubation-a-3shggw1jw9.pdf

A clinical sign to predict difficult tracheal intubation: a prospective study

A Clinical Sign to Predict Difficult Tracheal Intubation: A Prospective Study

A Clinical Sign to Predict Difficult Tracheal Intubation: A Prospective Study S. Mallampati;S. Gatt;L. Gugino;S. Desai;B. Waraksa;D. Freiberger;P. Liu; Obstetric Anesthesia Digest

A Clinical Sign to Predict Difficult Tracheal Intubation

Esmolol, an ultra-short-acting cardioselective beta-adrenergic blocker, was investigated in a double-blind prospective protocol for its ability to control haemodynamic responses associated with tracheal intubation after thiopentone and succinylcholine. Thirty ASA physical status I patients received a 12-minute infusion of esmolol (500 micrograms X kg-1 X min-1 for four minutes, then 300 micrograms X kg-1 X min-1 for 8 minutes) or saline. Five minutes after the start of the drug/placebo infusion, anaesthesia was induced with 4 mg X kg-1 thiopentone followed by succinylcholine for tracheal intubation. Prior to induction esmolol produced significant decreases in heart rate (HR) (9.3 +/- 1.8 per cent) and rate-pressure product (RPP) (13.1 +/- 1.8 per cent), systolic blood pressure (SAP) (4.3 +/- 1.5 per cent) and mean arterial blood pressure (MAP) (1.7 +/- 2.0 per cent). Increases in HR, SAP and RPP after intubation were approximately 50 per cent less in patients given esmolol compared to patients given placebo. There were highly significant differences in HR (p less than 0.0001), and RPP (p less than 0.0005) and significant differences in SAP (p less than 0.05) when the maximal esmolol post-intubation response was compared to the maximal placebo response. Infusion of esmolol in the dose utilized in this study significantly attenuated but did not completely eliminate cardiovascular responses to intubation.

/pdf/esmolol-for-control-of-increases-in-heart-rate-and-blood-1nm1y9f42b.pdf

Esmolol for control of increases in heart rate and blood pressure during tracheal intubation after thiopentone and succinylcholine

Background: Most patients suffer from moderate to severe pain after elective laparotomy. They often require opioids to alleviate their pain. Opiates invariably induce certain side effects and, occasionally, dependence. Intraoperative infusion of lidocaine and low-dose ketamine reduces postoperative pain and analgesic requirements. This study aims to evaluate the effects of simultaneous infusion of lidocaine and ketamine during open abdominal surgery on the postoperative pain severity and analgesic consumption. Methods: In this randomized, double-blinded, single-center study that was performed in Iran, 80 patients scheduled for elective open abdominal surgery under general anesthesia were enrolled in two LK and P groups. Group LK (n=40) received lidocaine-ketamine infusion, and group P (n=40) received placebo (normal saline). Both infusions were started thirty minutes after initiation of surgery and were terminated once the surgery was completed. For postoperative pain management, patient-controlled analgesia (PCA), including fentanyl and paracetamol, was administered for both groups. All patients were evaluated for pain visual analogue scale (VAS) and total adjunctive analgesic (diclofenac suppository) consumption within the first 24 hours after the surgery. The data were analyzed using SPSS. P values <0.05 were considered significant. Results: Intraoperative infusion of Lidocaine and Ketamine resulted in desirable postoperative pain control. Patients of LK group demonstrated a significant reduction in the pain score at 1, 6, 12, 18, and 24 hours after termination of surgery (p<0.001). It also resulted in a decreased requirement for postoperative analgesics, as cumulative analgesic consumption was decreased meaningfully in the patients of LK group (p<0.001). Conclusion: Intravenous infusion of lidocaine and ketamine during elective open abdominal surgery reduces pain intensity and analgesic requirements in the first 24 hours postoperatively, without major additional side effects.

Stephen P. Gatt

Papers

A clinical sign to predict difficult tracheal intubation: a prospective study

A Clinical Sign to Predict Difficult Tracheal Intubation: A Prospective Study

A Clinical Sign to Predict Difficult Tracheal Intubation

Esmolol for control of increases in heart rate and blood pressure during tracheal intubation after thiopentone and succinylcholine

Effects of Ketamine and Lidocaine Infusion on Acute Pain after Elective Open Abdominal Surgery, a Randomized, Double-Blinded Study