Theses (M Med.(Anaesthesiology))--University of Limpopo, 2007. / Comparison of Alfentanil and Lignocaine in blunting the pressor response during endotracheal intubation. Laryngoscopy and tracheal intubation produce marked increases in heart rate and blood pressure, which is potentially dangerous in certain patients. Various pharmacological agents have been used before laryngoscopy and tracheal intubation in an attempt to attenuate the adrenergic response, but with varying degree of success. OBJECTIVE To compare the efficacy of lignocaine to alfentanil in blunting the pressor response to endotracheal intubation. DESIGN An open label comparative study. POPULATION Seventy eight ASA I and II adult patients between the ages of 18 and 65 years booked for elective surgery which requires endotracheal intubation. SETTING Dr George Mukhari Hospital, a tertiary level training hospital in Gauteng, South Africa. 2 METHOD After obtaining ethical clearance the study was conducted on 78 ASA class I & II patients. The patients were randomly allocated to three groups according to their treatment regime. All patients were premedicated with diazepam 10mg 2 hours pre operatively. Anaesthesia was induced with Thiopentone 5mg/kg followed by Vecuronium 0,1mg/kg and maintained with Isoflurane in nitrous oxide and oxygen mixture. Group A patients received lignocaine 1.5mg/kg iv 3 minutes before intubation. Group B – alfentanil 15ug/kg iv 1 minute before intubation and group C patients did not receive any treatment before intubation. Heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded at the following intervals: pre- induction, pre- intubation 1, 2 and 3 minutes post intubation. STATISTICS Statistical analysis was done by Chi Square test followed by the normal approximation of the binomial distribution. Increase in blood pressure and heart rate in the three treatment groups were compared by analysis of variance, followed by pairwise comparisons. A p- value <_ 0,05 was considered significant. 3 MAIN RESULT The three treatment groups did not differ in relation of Gender ratio, Mean weight and Mean age. ALFENTANIL GROUP There was a non significant increase in heart rate 1 minute post intubation (P= 0,7625), and there was no increase 2 and 3 minutes post intubation. A decrease in SBP, DBP and MAP was observed at 1, 2 and 3 minutes post intubation. LIGNOCAINE GROUP There was an increase in all parameters 1 minute post intubation which was comparable to the control group. A decrease in all parameters which differed from that of the control group except for heart rate, was observed at 2 and 3 minutes post intubation. CONTROL GROUP There was an increase in all parameters 1 minute post intubation. A decrease in all parameters 2 and 3 minutes post intubation remained above the baseline. CONCLUSION Alfentanil is superior to lignocaine in blunting the pressor response to endotracheal intubation.

Thesis--Wisconsin. / Includes bibliographical references (leaves 82-83).

No description available.

<p>Over-inflation of an endotracheal tube (ETT) cuff may lead to tracheal necrosis, whereas under- inflation increases the risk of pulmonary aspiration. The objectives of this 2-phase study were to 1) identify the frequency of abnormal ETT cuff inflation in anesthetized dogs, 2) evaluate ETT cuff inflation with 3 devices (regular syringe, Tru-CuffTM syringe, AG Cuffill syringe) in achieving proper cuff pressure (20-30 cmH2O). Dogs undergoing general anesthesia at Purdue Veterinary Medicine Teaching Hospital (PVMTH) were included. The standard operating procedure (SOP) of PVMTH was used for ETT size selection and cuff inflation. The results of objective 1 showed that 50 of the 80 dogs required ETT cuff inflation. Among these 50 dogs, only 14% had proper cuff inflation; 76% of the cuffs were over-inflated and 10% were under-inflated. For objective 2, 90 dogs were equally assigned to the 3 devices for ETT cuff inflation and cuff pressure was assessed with an aneroid manometer. The results showed that 80% of the ETT cuffs were over-inflated with the regular syringe, whereas only 6.7% and 3.3% ETT cuffs were over-inflated with the Tru-CuffTM and AG Cuffill syringes, respectively. The AG Cuffill syringe treatment group had a significantly higher percentage of proper inflated ETT cuffs (86.7%; both p < 0.05) compared to the other two groups (regular [3.3%]; Tru-CuffTM [50%]). We concluded that there was a high frequency of improper ETT cuff inflation when using SOP coupled with a regular syringe. The use of an AG Cuffill syringe significantly reduced improper ETT cuff inflation.</p>

ABSTRACT Background When faced with an unexpected cardiac arrest the ambulance nurse is in responsible for taking advanced actions to create a clear airway. Two accepted methods for this is endotracheal intubation and application of laryngeal mask. Aim The purpose of this study was to examine the use of endotracheal intubation compared to application of the laryngeal mask in unexpected cardiac arrest. Method Literature study with quantitative approach. A systematic search of 21 articles comparing the laryngeal mask with the endotracheal intubation has been made using Pub-Med and CINAHL. A quality review according to Forsberg and Wengström has been made. Results Laryngeal mask had a higher rate of successful applications compared with endotracheal intubation. Time for applying the laryngeal mask was shorter in seven out of ten of the studied articles. Survival after application indicated that the endotracheal tube was associated with increased survival compared with the laryngeal mask in two of the five studied articles. In the remaining articles, no significant differences were seen. The laryngeal mask did not show any difference in air leakage and it could not be displaced from the position to a greater extent than the endotracheal tube when exposed to the same force. Conclusion Compared with endotracheal intubation the laryngeal mask had a higher rate of successful applications and faster time to established airway when used by prehospital personnel. Patients cared for by endotracheal intubation, were however, associated with increased survival after unexpected cardiac arrest. Keywords Endotracheal tube, laryngeal mask, prehospital, ambulance nurse, nursing.

The aspiration of oral and gastric substances is a well-known risk for ventilator associated pneumonia (VAP) in the intubated, mechanically ventilated (MV), patient of the intensive care unit (ICU) population. The gastric biomarker pepsin and the oral biomarker salivary amylase have been identified as evidence of aspiration prior to the manifestation of acute pulmonary illness. In an effort to decrease the risk for aspiration, several evidence based nursing practices are in place. Actions include 30 degree head of the bed positioning, oral care, suctioning, and circuit change interval protocols, as well as the administration of medication with the objective of reducing acid reflux. Additional recommendations concern the type of endotracheal tube (ETT) used to ventilate the intubated patient. The continuous subglottic suctioning endotracheal tube (CSS-ETT) features an additional port which continually suctions secretions that accumulate above the inflated endotracheal cuff. Patients with standard endotracheal tubes (S-ETT) receive manual, as needed suctioning of accumulated secretions in the mouth and the oropharynx per agency protocol. Research of the critical care population has demonstrated a decreased instance of VAP using CSS-ETT as compared to S-ETT utilization. This study sought to compare the incidence of the biomarkers pepsin and salivary amylase in the suctioned oral and tracheal secretions of patients with S-ETT compared to patients with CSS-ETT. Part of the protocol of a descriptive, comparative study of the clinical indicators for suctioning established the collection of the paired suctioned oral and tracheal aspirates. Those collected aspirates were analyzed for a pilot study of pepsin and amylase analysis. This study compares the incidence of aspirates in oral and tracheal secretions by endotracheal tube type.; The intention of this study was that it would assist in demonstrating beneficial aspects of the selection of the CSS-ETT. It is considered that further investigation with a larger population group could add statistical significance.; Tracheal aspirates were obtained with a closed tracheal suction device while oral secretions were obtained with a suction catheter designed to reach the oropharynx. Biomarkers assayed were the gastric marker pepsin and the oropharyngeal marker salivary amylase. Assays of pepsin and salivary amylase were performed using standard procedures in a specialty diagnostic laboratory. Specimens were obtained from 11 subjects: 8 male and 3 female. The majority were Caucasian (n=9), had a CSS-ETT (n=8), were on mechanical ventilation in the synchronized intermittent mandatory ventilation mode, and on tube feedings (n=9) located in the stomach (n=7). The mean age was 56 years. Feeding tubes were placed in 9 patients, and the majority of the tubes were Dobbhoff. Pepsin was found in the oral secretions of 62.5% (n = 5) of the CSS-ETT subjects, while 50.0% (n = 4) had pepsin in the tracheal aspirate. Pepsin was found in the oral secretions of 66.7% (n = 2) of the S-ETT subjects, and 66.7% (n = 2) had pepsin in their tracheal aspirate. All subjects of both groups (n = 11) had oral salivary amylase detected. Salivary amylase was detected in the tracheal aspirate of 100% (n = 3) of the S-ETT subjects versus 62.5% (n = 5) in CSS-ETT group. Based on the results of this study, there was a reduction in the number of subjects who had oral compared to tracheal aspirate pepsin in the CSS-ETT group (n = 5 oral versus n = 4 tracheal) tube type. The S-ETT group had equal number of subjects with oral (n = 2) and tracheal pepsin detected (n = 2). However, the results when comparing the S-ETT and the CSS-ETT groups were not statistically significant (p = 0.898 pepsin oral and 0.621 tracheal pepsin). There may be clinical significance. It appears that the CSS-ETT was beneficial in that group; two fewer subjects had pepsin in their tracheal aspirate (n = 5 oral versus n = 4 tracheal aspirate pepsin).

Neonatal Intensive Care Units have experienced profound advances in technology and treatment modalities over the last two decades. Infants born at the edge of viability are now surviving despite prolonged hospitalizations. These infants born preterm are prone to a high degree of stress from life sustaining and routine interventions. Much focus has been directed toward addressing noxious environmental factors such as noise, light, and infectious disease; however, little has been done to examine the stress experienced by the professional caregiver who work in these environments. Environmental press theory, which focuses on the interplay between human beings and their surroundings, is explored as a way to provide insight into understanding and mitigating the stress experienced by health care providers working in the newborn intensive care. A proposal for a research study with a cross-over design was approved to study the effect of “four handed care” on infants’ physiologic responses (oxygenation, heart rate, and stress) and behavioral responses (state, stress and defense, self-regulatory and approach behaviors) to and recovery from endotracheal suctioning when compared to routine care. Results of this study demonstrated no significant differences were noted when heart rate (HR) or oxygen saturation (SpO2) taken at baseline were compared to HR and SpO2 obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from pre-observation 95.49 to during observation saturation 97.75 (p = 0.001). Salivary cortisol did not differ between groups at baseline or post-suctioning. There was no significant difference in behavior state between the two conditions at any time point. More stress and defense behaviors were seen post-suctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care as opposed to routine care. There was no statistical difference in the number of monitor call-backs post-suctioning. In conclusion, four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. These findings, while based on a small sample, provide modest evidence that the four-handed care intervention for suctioning should receive further testing. Interventions such as four-handed care that are theoretically developmentally supportive of the sick preterm infant, need further research attention before recommending widespread adoption.

Critically ill patients who require MV are at risk for a number of complications, including the development of ventilator-associated events (VAE) and agitation that may require the use of sedation. Patients experience anxiety and discomfort during mechanical ventilation from a variety of sources including unfamiliar breathing assistance and an inability to communicate anxiety and pain verbally, but a primary cause of discomfort identified by these patients is the simply the presence of the endotracheal tube (ETT). Discomfort often leads to agitation and may be exacerbated by ETT movement. Management of agitation typically involves the use of sedative therapy and has been shown to increase the length of stay in the hospital. Additionally, when ETT cuff pressure is not adequately maintained, risk of microaspiration increases and these microaspirations increase the risk of ventilator-associated events. ETT movement may adversely affect the cuff seal against the tracheal mucosa, increasing leakage around the cuff and microaspiration. To date, no studies have described the effect of ETT movement on patient comfort and agitation. Noting the frequency of ETT movement during the provision of nursing care and plausible inadvertent consequences on discomfort and agitation, a research model was created and specific instruments selected in order to study this topic. This dissertation will provide a review of the literature regarding the role of the ETT in microaspiration, as well as detail a study that explores the frequency and amount of ETT movement and its potential effect on agitation.

Orientador: José Reinaldo Cerqueira Braz / Resumo: Justificativa: a hiperinsuflação do balonete do tubo traqueal, causada pela rápida difusão do óxido nitroso (N2O), pode determinar lesões traqueais. Objetivos: comparar as pressões de balonetes de tubos traqueais, contendo ou não válvula reguladora de pressão, durante anestesia com N2O e estudar as eventuais lesões da mucosa do segmento traqueal em contato com o balonete do tubo traqueal. Método: dezesseis cães foram submetidos à anestesia venosa com pentobarbital sódico e anestesia inalatória com N2O (1,5 L.min-1) e O2 (1,0 L.min -1). Os cães foram distribuídos aleatoriamente em dois grupos de acordo com o tubo traqueal utilizado: G1 (n=8) tubo traqueal convencional com balonete de baixa pressão (Portex Blue-Line, Inglaterra); G2 (n=8) tubo traqueal dotado de válvula reguladora de pressão de Lanz (Mallincrodt, EUA). Em ambos os grupos, a insuflação do balonete foi feita com ar até a pressão de 30 cm H2O. A medida da pressão do balonete foi realizada através de manômetro (Mallincrodt, EUA), antes e após 60, 120 e 180 minutos do início da... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Background: High endotracheal tube intracuff pressure caused by fast diffusion of nitrous oxide (N2O) may cause mucosal tracheal lesions. Objectives: We have studied the effects of endotracheal tubes intracuff pressures with or without pressure regulating valve on tracheal mucosa during anesthesia with N2O. Methods: Sixteen dogs were submitted to intravenous anesthesia with pentobarbital and inhalational anesthesia with N2O (1.5 L.min-¹) and O2 (1.0 L.min-¹). The dogs were randomly allocated to two groups according to the endotracheal tube: G1 (n=8) conventional endotracheal tube with low-pressure cuff (Portex Blue-line, England); G2 (n=8) endotracheal tube with pressure regulating valve of Lanz from Mallincrodt (USA). In both groups the cuff insufflation was done with air to adjust cuff pressure to 30 cm H2O. Intracuff pressure was measured using a manometer at zero (control) and 60, 120 and 180 minutes after inhation of the N2O. The animals were sacrificed and biopsy specimens from areas of the trachea in contact with the endotracheal cuff were... (Complete abstract, click electronic address below) / Doutor

The aim of this thesis is to quantify the intubation success rates and complication rates associated with GlideScope® video laryngoscopy in pediatric difficult airway patients. Difficult intubation is a major source of anesthesia-related morbidity and mortality in both adults and children (1-3). A number of studies have demonstrated that video laryngoscopy has helped to address this problem in adults, producing high intubation success rates with minimal complications (4-6). However, the literature on the use of videoscopes in children with difficult airways is sparse. We therefore sought to examine success and complication rates with the GlideScope®, a common type of video laryngoscope. To do so, we examined patient data from the Pediatric Difficult Intubation Registry, a collection of information on difficult airway incidents at fourteen pediatric teaching hospitals in the United States. From these data we calculated overall, first-pass, and rescue success rates on a per-attempt and per-patient basis, comparing them to success rates that resulted from using direct laryngoscopy. We also examined success rates for smaller groups of patients divided by Cormack-Lehane airway grade, weight, and muscle relaxant use. Finally, we assessed complication rates for patients undergoing GlideScope® intubation attempts and direct laryngoscopy. The GlideScope® produced lower success rates in our sample than those documented in adult difficult airway patients. This was particularly the case among smaller children and those with poor glottis visualization. However, the GlideScope® was superior to direct laryngoscopy by all measures and in all patient subgroups. We also found lower rates of hypoxemia and overall complications among patients receiving intubation attempts with only the GlideScope® versus only direct laryngoscopy. We believe this result may be related to the greater number of intubation attempts among patients receiving direct laryngoscopy.