A styletted tracheal tube with a posterior-facing bevel reduces epistaxis during nasal intubation: a randomized trial.

PURPOSE: Epistaxis is a common complication of nasal intubation. Ease of insertion of the tracheal tube may be influenced by bevel orientation and tip bending. We examined ease of insertion and epistaxis with two tubes with different orientations and with or without a stylet to modify tip bending. METHODS: Two hundred patients scheduled to undergo oral or maxillofacial surgery were randomized into four groups according to method of nasal intubation used after induction of anesthesia. In one group, a Portex(®) tracheal tube was inserted with bevel facing left (Portex Group). In the second group, a Parker Flex-Tip(®) tube (Parker Group) was inserted with the bevel facing posteriorly, and in the last two groups, a stylet bent at 60° anteriorly was used with the Portex tube (Stylet-Portex Group) or Parker tube (Stylet-Parker Group). When the tube advanced without resistance, insertion was defined as "smooth", and when resistance was encountered, insertion was defined as "impinged". Severity of epistaxis was evaluated as none, mild, moderate, or severe. RESULTS: Smooth insertion was observed in 60% of patients in the Portex Group; 80% in the Parker Group; 100% in the Stylet-Portex Group; and 100% in the Stylet-Parker Group. Epistaxis was found in 50%, 24%, 20%, and 4% of patients, respectively. The styletted tip (difference: 30%; 95% confidence interval [CI]: 20.3 to 38.5; P < 0.0001) was found to improve ease of insertion. Both the posterior-facing bevel (difference: 21%; 95% CI: 9.0 to 32.1; P = 0.0005) and stylet (difference: 25%; 95% CI: 13.1 to 35.9; P < 0.0001) contributed significantly to absence of epistaxis. CONCLUSIONS: Using a styletted tracheal tube with a posterior-facing bevel improves ease of insertion through the nasopharynx and decreases the severity of epistaxis during nasal intubation. CLINICAL TRIAL REGISTRATION NUMBER: UMIN Clinical Trials Registry (UMIN-CTR), UMIN000011327.

Appropriate head position for nasotracheal intubation by using lightwand device (Trachlight).

The purpose of this study was to determine the relationship between the head position and the subsequent ease of nasotracheal intubation by using the lightwand device Trachlight (TL). Patients requiring nasotracheal intubation were subdivided into 3 groups according to the intubated head position (group S: sniffing position; group E: extension position; and group N: neutral position). The number of attempts, the total intubation time, and the failures of the TL intubation were recorded. Intubation difficulty by means of TL was assessed by the ordinal 6-point scale. Of the 300 patients enrolled in the study, TL intubation was successful in 91.3% of them. There was no significant difference in the success rate of the first attempt between the groups. No correlation between the ordinal scale and the head position was observed. The total intubation time and the ratio of "unsuccessful" cases were not significantly different among the 3 groups. TL is an effective alternative for patients who require nasotracheal intubation. Our study did not determine the most favorable head position for nasotracheal intubation with the TL, so we recommend that nasotracheal intubation with TL be started with the head in the neutral position and then changed to a more appropriate position, if necessary, on an individual basis.

Perforation of the Nasal Septum Identified During a Preoperative Otorhinolaryngology Consultation: A Case Report.

Nasal intubation is often required during oral surgery; however, nasal intubation can cause various complications including bleeding associated with nasal mucosal trauma during intubation and obstruction of the endotracheal tube. Two days before surgery, a nasal septal perforation was identified using computed tomography during a preoperative otorhinolaryngology consultation for a patient planned to undergo a nasally intubated general anesthetic. Subsequently, nasotracheal intubation was successfully performed after confirming the size and location of the nasal septal perforation. We used a flexible fiber optic bronchoscope to safely perform the nasal intubation while assessing for inadvertent migration of the endotracheal tube or soft-tissue damage around the perforation site. Careful preoperative planning in cooperation with the otorhinolaryngology department and use of computed tomography is recommended when a nasal abnormality is suspected.

Unrecognized bronchial intubation associated with the uncuffed pediatric tracheal tube with bilateral Murphy eyes.

BACKGROUND: Unreliability of breath sounds auscultation after intubation is reportedly mainly related to the presence of the Murphy eye. This study was performed to ascertain whether an uncuffed pediatric tracheal tube with bilateral Murphy eyes increases the risk of unrecognized bronchial intubation, compared to an uncuffed tube without eyes. METHODS: Following induction of anesthesia in 50 toddlers, either an uncuffed tube without eyes or an uncuffed tube with bilateral eyes was inserted into the trachea. The tube was then slowly advanced while breath sounds were auscultated using a stethoscope. In study 1, when breath sounds changed and disappeared, the distance from the carina to the tube tip was measured using a fiberoptic bronchoscope. In study 2, when breath sounds changed, the tracheal tube was withdrawn 5, 10, 15 and 20 mm while using a fiberoptic bronchoscope to ascertain whether bronchial intubation had occurred. RESULTS: When breath sounds changed and disappeared, the tip of the tube with bilateral eyes was positioned more deeply below the carina than that of the tube without eyes. When the tube was withdrawn 10 mm from the point at which breath sounds changed, frequencies of bronchial intubation were 13% and 80% in the no eyes and double eyes groups, respectively. CONCLUSION: An uncuffed pediatric tracheal tube with bilateral Murphy eyes reduces the ability of breath sounds auscultation to detect bronchial intubation and may increase the risk of unrecognized bronchial intubation compared to an uncuffed tube without eyes.

The success rate of nasotracheal intubation using lightwand does not depend on the laryngoscopic view.

PURPOSE: The purpose of this study was to evaluate the usefulness of Trachlight (TL) for nasotracheal intubation and to determine the relationship between the grade of laryngeal view and the subsequent ease of nasotracheal intubation using TL. METHODS: Patients requiring nasotracheal intubation were enrolled in this study. Laryngoscopy was performed in all patients under topical anesthesia, with 8% lidocaine spray applied to the supraglottic region and the vocal cords. Glottic visualization during laryngoscopy was assessed using the Cormack and Lehane classification. Patients were allocated to four groups according to this classification. If the TL intubation was unsuccessful after three attempts, intubation was carried out using direct laryngoscopy. Intubation difficulty was assessed by the original 6-point scale and the total intubation time was also recorded. RESULTS: Trachlight intubation was successful in 89.1% of the 110 patients enrolled in the study. There was no observed correlation between the original 6-point scale and glottic visualization. The total intubation time and the ratio of "unsuccessful" cases were not significantly different among the four groups. CONCLUSION: No relationship was found between the ease of nasotracheal intubation using TL and glottic visualization.

[Case of fulminant-malignant hyperthermia occurring on sixth sevoflurane anesthesia].

We report a case of fulminant-malignant hyperthermia that occurred after five uneventful sevoflurane anesthetic procedures. A 7-year-old girl with bronchial asthma was scheduled for closure of palatal fistula under general anesthesia, after five previous uneventful operations under sevoflurane anesthesia. Anesthesia was induced with propofol and vecuronium, and maintained with nitrous oxide, oxygen, and sevoflurane. Body temperature at the beginning of operation was 37.0 degrees C. After 5 hr 10 min, sudden tachycardia and elevations in body temperature and PET(CO2) were noticed. Sevoflurane was discontinued and body surface cooling, hyperventilation with 100% oxygen, and administration of dantrolene sodium 2 mg x kg(-1), furosemide 4 mg, and 7% NaHCO3 solution 10 ml were started on a suspicion of malignant hyperthermia. Body temperature, heart rate, and PET(CO2) reached to 40.1 degrees C, 190 beats x min(-1), and 60 mmHg, respectively, with metabolic acidosis. Twenty minutes after starting dantrolene infusion, these values decreased to 38 degrees C, 150 beats x min(-1), and 39 mmHg, respectively. Laboratory examination showed that serum potassium, CK, AST, ALT, and LDH concentrations and urine myoglobin level were within normal ranges. Clinical symptoms of this patient fulfilled the diagnostic criteria of fulminant-malignant hyperthermia. The trigger drug was considered to be sevoflurane despite the five previous uneventful sevoflurane anesthetic procedures.

A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation.

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

Effects of glucose-insulin infusion during major oral and maxillofacial surgery on postoperative complications and outcomes.

BACKGROUND: Secretion of hormones, which antagonize the action of insulin, is facilitated in response to surgery, and acute resistance to the action of insulin develops. Our aim is to elucidate the effects of intraoperative glycemic control by glucose-insulin (GI) infusion on postoperative complications and outcomes in major oral and maxillofacial surgery. FINDINGS: Thirty patients aged ≥ 60 years undergoing a radical operation of oral malignant tumors with tissue reconstruction (≥ 8 h) were analyzed. In the GI group, regular insulin was continuously applied with glucose-added acetate Ringer's solution (5-10 g glucose per 500 mL). Blood glucose was adjusted within the target concentration of 80-120 mg/dL. In the control group, combination of acetate Ringer's solution containing 1% (W/V) glucose and lactate Ringer's solution, which contains no glucose, was employed. Perioperative clinical parameters, incidence of hypoalbuminemia, and postoperative complications, i.e., surgical site infection, necrosis of a reconstructed flap, bacteremia, hypotension, or pneumonia, were compared. Both serum total protein and albumin concentrations (postoperative day 1 [Day1]) were higher in the GI group. The mean infusion rate of glucose during surgery (mg/kg/h) was independently associated with the decrease in both serum total protein and albumin concentrations from the control to Day1. No difference was found between the groups in the incidence of postoperative complications and the days required until discharge, except less incidence of hypoalbuminemia in the GI group. CONCLUSIONS: Application of additional glucose during major oral and maxillofacial surgery preserved serum albumin concentration. However, it did not lead to less postoperative complications and less days until discharge.

Associations between the autonomic nervous system and the second derivative of the finger photoplethysmogram indices.

AIM: The indices of the second derivative of the finger photoplethysmogram(SDPTG) denote stiffness of large arteries, peripheral vascular resistance and vascular aging. However, the association between the autonomic nervous activity and the SDPTG indices has not yet been elucidated. METHODS: The SDPTG and heart rate variability(HRV) were consecutively measured in the sitting position on the day before surgery in 168 patients 18-89 years of age. The relationships between the SDPTG indices(b/a, c/a, d/a and e/a) and HRV indices(power spectral analysis and time domain analysis parameters) were analyzed. The relationships between c/a and atherosclerosis-based conditions and risk factors for atherosclerosis were also evaluated. RESULTS: The SDPTG index b/a was negatively associated and the d/a index was positively associated with the low-frequency(LF)(R=-0.44 and 0.42, respectively) and high-frequency(HF) components(R=-0.31 and 0.35, respectively). The SDPTG index c/a was also positively associated with the LF(R=0.40) and HF(R=0.44) components. A multivariate regression analysis showed that the LF, HF and heart rate were independent determinants of the c/a. Furthermore, the c/a values were significantly lower in the patients with hypertension, diabetes mellitus and hyperlipidemia than in those without these diseases, and a reduced c/a was significantly associated with increased serum triglyceride and total cholesterol concentrations. CONCLUSIONS: These findings suggest that a decrease in c/a is associated with a reduced baroreflex response of the peripheral vasomotor activity and a decreased cardiac parasympathetic activity. Furthermore, a decrease in c/a was found to be associated with atherosclerosis-based conditions, such as hypertension, diabetes mellitus and hyperlipidemia.

Autonomic nervous system activity during autologous blood donation for orthognathic surgery.

PURPOSE: The aim of this study was to assess by means of power spectral analysis the immediate response of autonomic regulation that occurs with postural change from supine to sitting position (modified head-up tilt test [m-HUT]) during autologous blood donation (ABD) and postphlebotomy infusion. PATIENTS AND METHODS: We investigated 37 healthy adults who required preoperative ABD before elective orthognathic surgery. Measurements were conducted with m-HUT during ABD and postphlebotomy infusion. The data were analyzed using the maximum entropy method and the difference between supine and tilt was determined by analysis of variance. RESULTS: When m-HUT was conducted at the resting state, cardiac parasympathetic nervous activity was significantly decreased, whereas cardiac and vascular sympathetic nervous activities were significantly increased. When m-HUT was conducted following blood collection, cardiac parasympathetic nervous activity showed a tendency to increase, whereas vascular sympathetic nervous activity was significantly increased. These changes were not observed during postphlebotomy infusion. CONCLUSIONS: The m-HUT, which involves postural change from supine to sitting position, may be useful for observing autonomic nervous activity in the clinical setting. ABD carries the risk of imbalance of autonomic regulation. However, postphlebotomy infusion may reduce this imbalance.