Uses of simulation-based education for anesthesiology training, certification and recertification: A scoping review.

Objectives: To conduct a comprehensive scoping review focusing on published anesthesiology-specific training based on simulation to assess up-to-date uses of simulation-based education in anesthesiology training. Our goal was to establish a solid ground for building standardized and accredited curricula for simulation-based education in the specialty of anesthesia in the near future. Methods: We searched the PubMed, CINAHL and EMBASE databases on May 10, 2021 for relevant articles. We followed the five-stage scoping review methodology: identifying a research question, identifying relevant studies, study selection, charting the data, and synthesis of results. Results: Our initial electronic search identified 5609 potential articles. After abstract screening and removing duplicates, 636 articles were evaluated in full text for inclusion or exclusion. Based on this strategy, 283 articles were included in this review. We mapped the current practice of simulation in training and certification across different anesthesiology subspecialties. Conclusions: Significant effort has been placed into the use of simulation for training, certification, and recertification in anesthesiology. Future effort to develop simulation-based training that can be generalized to trainees in this specialty, similar to other fields such as aviation and space sciences, will enhance the standardization of training and hence patient safety.

Comparison of Cardiac Auscultation Features on Four Different Simulation Mannequins Performed by Pediatric Residents.

INTRODUCTION: Cardiac murmurs are a common problem in pediatric clinical practice. Studies demonstrated low accuracy in detecting and diagnosing various cardiac murmurs at all levels of medical training. So, supplementary training methods started to evolve, including simulation for auscultation skills training. Over the years, mannequins have evolved with different types of technology. Therefore, we decided to compare cardiac auscultation accuracy among high-fidelity mannequins as the primary objective and compare the performance of various postgraduate-level residents as a secondary objective. METHOD: Pediatric residents at King Abdulaziz University Hospital were given a lecture on the basics of cardiac auscultation and then requested to auscultate four mannequins, namely SimJumior® (Laerdal Medical, Stavanger, Norway), SimBaby™ (Laerdal Medical), Pediatric HAL® (Gaumard Scientific, Miami, FL, USA), and Cardiac Patient Simulator K-Plus (Kyoto Kagaku Co. Ltd., Kyoto, Japan). The accuracies of murmur type, diagnosis, and auscultation time were compared.  Results: A total of 56 pediatric residents were enrolled. Median murmur accuracy ranged from 50% to 53% (p-value 0.79), and median diagnosis accuracy ranged from 33% to 36% (p-value 0.77), with a nonsignificant difference between mannequins. Comparing resident levels in all mannequins, median murmur accuracy ranged from 49% to 56% (p-value 0.70), and median diagnosis accuracy ranged from 29% to 41% (p-value 0.09). While the median average auscultation time was between 41 and 50 seconds (p-value 0.34). CONCLUSION: Auscultation skills can be taught through simulation on any mannequin used in this comparison, not necessarily the cardiac one. For better accuracy, future comparisons might include more advanced cardiac mannequins based on cardiac auscultation expertise (i.e., consultant level). The introduction of an auscultation program from the undergraduate level throughout the training process and monitoring of these skills are mandated.

Rapid cycle training for non-critical care physicians to meet intensive care unit staff shortage at an academic training center in a developing country during the COVID-19 pandemic.

BACKGROUND: The sudden unexpected increase in critically ill COVID-19 patients admitted to Intensive Care Units (ICUs), resulted in an urgent need for expanding the physician workforce. A COVID-19 critical care crash (5C) course was implemented to introduce physicians without formal critical care training to care for critically ill COVID-19 patients. Upon successful completion of the course, physicians were recruited to work in a COVID-19 ICU under the supervision of a board-certified critical care physician. The aim of this study is to describe the methods of a novel course designed specifically to teach the management critically ill COVID-19 patients, while assessing change in knowledge, skill competency, and self-reported confidence. METHODS: The blended focused 5C course is composed of both virtual and practical components. Candidates may register for the practical component only after successful completion of the virtual component. We assessed knowledge acquisition using a multiple-choice question test (pre- and post-test assessment), skill competency, and self-reported confidence levels during simulated patient settings. Paired T-test was used to compare before and after course results. RESULTS: Sixty-five physicians/trainees from different specialties were included in the analysis. Knowledge significantly increased from 14.92± 3.20 (out of 20 multiple-choice questions) to 18.81± 1.40 (p< 0.01), skill competence during practical stations had a mean minimum of 2 (out of 3), and self-reported confidence during a simulated patient setting increased significantly from 4.98± 1.15 (out of 10) to 8.76± 1.10 (out of 10) (p< 0.01). CONCLUSION: We describe our initiative in increasing the ICU physician workforce in the midst of the COVID-19 pandemic. The blended 5C course is a valuable educational program designed by experts from different backgrounds. Future research should be directed at examining outcomes of patients associated with graduates of such program.

Formulating interprofessional anesthesiology and operating room clinical management pathway during COVID-19 pandemic using experiential learning theory in a university hospital in Saudi Arabia.

As the number of COVID-19 cases is rapidly increasing internationally, management, recommendations and guidelines of COVID-19 are rapidly evolving and changing. Formulating local clinical management policies among institutions adopting these recommendations is vital to staff as well as the patients' safety. Also, training multidisciplinary teams on these policies is an important, yet challenging, part of the process. The purpose of this paper is to present the process that has been followed to formulate COVID-19-specific response anesthesiology and operating room (OR) policies at King Abdulaziz University Hospital, by applying David A. Kolb's experiential learning theory during simulation-based training. This project had a total of six simulation-based sessions (four simulation scenarios and two clinical drills) designed to test the efficacy and efficiency of the then current practice in the hospital, facing the COVID-19 pandemic. Qualitative data analysis was completed using qualitative thematic data analysis. To apply experiential Kolb's theory, session's checklist (two raters per session), outcomes, and participants' feedback to develop and improve clinical management pathway in the department were used. The 12 reports and participants' feedback highlighted three main areas for improvement. These are Personal Protective Equipment implementation, team dynamics, and airway management. This process then guided in creating a new understanding of the multidisciplinary clinical management pathway, in addition to enhancing viability of the current practice and clinical management guidelines and protocols, which were already established and adapted at the hospital before the COVID-19 pandemic crisis. The alignment with Kolb's experiential theory helped formulate anesthesiology and OR effective clinical management pathway has been demonstrated. Applying experiential learning theory by a clinical institute using interprofessional, multidisciplinary simulations and clinical drills can guide the process of formulating clinical management pathways during pandemic outbreaks.

Effect of training using high-versus low-fidelity simulator mannequins on neonatal intubation skills of pediatric residents: a randomized controlled trial.

BACKGROUND: Mounting evidence supports the effective acquisition of skills through simulation-based training including intubation skills of neonates. Our aim is to compare the effect of using high- versus low-fidelity mannequin simulation-based training on the acquisition and retention of neonatal intubation skills by junior pediatric residents. METHODS: Randomized controlled trial involving first- and second-year pediatric residents from two centers in Jeddah, Saudi Arabia. RESULTS: Twenty-eight junior pediatric residents (12 low- and 16 high-fidelity mannequins) completed the study. A significantly greater number of residents achieved and retained the required skills after completing the training course in both arms. There was no significant difference in the achieved skills between residents trained on high- versus low-fidelity mannequins at the baseline, immediately after training, and at 6-9 months after training. CONCLUSION: Simulation-based training resulted in improving pediatric residents' intubation skills regardless of the level of fidelity.

Perioperative total intravenous anesthesia in a child with Walker-Warburg syndrome: A case report.

Purpose: Walker-Warburg syndrome is a rare autosomal recessive congenital muscular dystrophy presenting with hydrocephalus, type II lissencephaly, cerebellar malformation, and ocular anomalies. Here, we describe the use of perioperative total intravenous anesthesia in a pediatric patient with Walker-Walburg syndrome. Clinical Features: A 2-month-old girl with Walker-Walburg syndrome was admitted for urgent ventriculoperitoneal shunt insertion. Anesthesia was induced using intravenous atropine (100 µg), ketamine (10 mg), and fentanyl (15 µg). The patient was monitored for various clinical parameters based on American Society of Anesthesiologists standards. Anesthesia was maintained using intermittent doses of 0.5 mg intravenous midazolam and 5-10 µg fentanyl in incremental boluses. The postoperative course was uneventful. Conclusions: To our knowledge, no published cases have reported the use of total intravenous anesthesia in patients with Walker-Walburg syndrome who have potential risks for anesthetic-induced malignant hyperthermia. This report described the key features, potential anesthetic management plan, and current literature review of Walker-Walburg syndrome.

COVID-19 Critical Care Simulations: An International Cross-Sectional Survey.

Objective: To describe the utility and patterns of COVID-19 simulation scenarios across different international healthcare centers. Methods: This is a cross-sectional, international survey for multiple simulation centers team members, including team-leaders and healthcare workers (HCWs), based on each center's debriefing reports from 30 countries in all WHO regions. The main outcome measures were the COVID-19 simulations characteristics, facilitators, obstacles, and challenges encountered during the simulation sessions. Results: Invitation was sent to 343 simulation team leaders and multidisciplinary HCWs who responded; 121 completed the survey. The frequency of simulation sessions was monthly (27.1%), weekly (24.8%), twice weekly (19.8%), or daily (21.5%). Regarding the themes of the simulation sessions, they were COVID-19 patient arrival to ER (69.4%), COVID-19 patient intubation due to respiratory failure (66.1%), COVID-19 patient requiring CPR (53.7%), COVID-19 transport inside the hospital (53.7%), COVID-19 elective intubation in OR (37.2%), or Delivery of COVID-19 mother and neonatal care (19%). Among participants, 55.6% reported the team's full engagement in the simulation sessions. The average session length was 30-60 min. The debriefing process was conducted by the ICU facilitator in (51%) of the sessions followed by simulation staff in 41% of the sessions. A total of 80% reported significant improvement in clinical preparedness after simulation sessions, and 70% were satisfied with the COVID-19 sessions. Most perceived issues reported were related to infection control measures, followed by team dynamics, logistics, and patient transport issues. Conclusion: Simulation centers team leaders and HCWs reported positive feedback on COVID-19 simulation sessions with multidisciplinary personnel involvement. These drills are a valuable tool for rehearsing safe dynamics on the frontline of COVID-19. More research on COVID-19 simulation outcomes is warranted; to explore variable factors for each country and healthcare system.

Anaesthesia and Critical Care Department at a Major Academic Centre's Adaptation to Face the COVID-19 Pandemic.

The new novel coronavirus is having a major impact on healthcare systems internationally. Hospitals are struggling to manage the sudden influx of critical patients. Anaesthesiologists and critical care physicians are front liners in the fight against COVID-19 and carry the highest risk of getting infected. Due to the rapid response of the Saudi government to the WHO's early warning, we were fortunate at our hospital to see a slower rise in COVID-19 cases allowing us some time to prepare. We had to make room for the expected rise in highly infectious and critical patients, while at the same time protecting non-COVID-19 patients, staff and trainees. Additionally, the team continued to provide essential and specialized care to all patients in the hospital and maintain its academic and non-clinical services within the university. This review presents the different protocols, challenges and lessons learned during the development of a COVID-19 anaesthesia and critical care department plan in a major teaching hospital in Jeddah, Saudi Arabia. Our ultimate aim is to share our experience with other similar institutions.

Gaps identification in Saudi anesthesia residency training during early time of pandemic: Trainee view.

BACKGROUND: COVID-19 pandemic was declared a worldwide crisis, as a response the community established new protocols and clinical pathways to prepare the health system in adapting to the expected surge of cases. OBJECTIVES: In this study, we aim to assess the effect of the pandemic on the anesthesia training program residents from their own view. Identification of gaps in training programs will help to overcome the challenge like pandemic in order to have competent anesthesia practitioners. METHODS: We deployed an online survey in early May 2020 targeting the anesthesia residents in Saudi Arabia. We used mixed methods, containing both quantitative and qualitative questions. Our survey had 3 main sections: demographics, pandemic effect on the training, and pandemic effect on the trainees. RESULTS: Our survey showed that in the first 2 months of the pandemic there was a vast decrease in educational activities and clinical activities. However, after that both the Saudi Commission for Health Speciality (SCFHS) and local hospitals employed alternative education methods like electronic learning and simulation to adopt these changes. We also found the average stress level among residents was 6.5 out of 10 with number one stressor is transmitting Covid-19 to family or self. Finally, Wellbeing resources were available to residents however were not used sufficiently by residents. CONCLUSION: During times of pandemic, assessment and gap identification in postgraduate training programs are necessary to help overcome challenges of training anesthesiologists. Other than the clinical competency residents' wellbeing needs to be monitored and make available resources easy to reach for the residents.

Prevalence of COVID-19 antibodies among operating room and critical care staff at a tertiary teaching hospital: A cross-sectional study.

OBJECTIVES: To identify the prevalence of COVID-19 antibodies among operating room and critical care staff. METHODS: In this cross-sectional study, we recruited 319 Healthcare workers employed in the operation theater and intensive care unit of King Abdulaziz University Hospital (KAUH), a tertiary teaching hospital in Jeddah, Saudi Arabia between August 9, 2020 and November 2, 2020. All participants completed a 20-item questionnaire on demographic data and COVID-19 risk factors and provided blood samples. Antibody testing was performed using an in-house enzyme immunoassay and microneutralization test. RESULTS: Of the 319 participants, 39 had detectable COVID-19 antibodies. Five of them had never experienced any symptoms suggestive of COVID-19, and only 19 were previously diagnosed with COVID-19. The odds of developing COVID-19 or having corresponding antibodies increased if participants experienced COVID-19 symptoms (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-7.5) or reported contact with an infected family member (OR, 5.3; 95% CI, 2.5-11.2). Disease acquisition was not associated with employment in the ICU and involvement in the intubation of or close contact with COVID-19 patients. Of the 19 previously diagnosed participants, 6 did not possess any detectable COVID-19 antibodies. CONCLUSIONS: Healthcare workers may have undiagnosed COVID-19, and those previously infected may not have long-lasting immunity. Therefore, hospitals must continue to uphold strict infection control during the COVID-19 pandemic.

Patients' concerns and perceptions of anesthesia-associated risks at University Hospital: A cross-sectional study.

BACKGROUND/AIM: The expectation of undergoing general anesthesia triggers fear in many individuals, and such anxiety can even exceed anxiety about surgery. The only opportunity patients usually have to express their concerns and ask questions is during a preoperative visits to their anesthesiologist. Therefore, a good anesthesiologist-patient relationship is important to reduce patients' anxiety. Achieving this end requires information on patients' attitudes and concerns regarding anesthesia. This study aimed to assess patients' knowledge, attitudes, and concerns about preoperative assessment and fear associated with anesthesia at University Hospital, Jeddah, Saudi Arabia. METHODS: This cross-sectional study used a self-administered questionnaire distributed to 399 outpatients. Data were collected on patient's characteristics, perceptions about anesthesiologists, preferences for anesthetic management, and preoperative concerns regarding anesthesia. RESULTS: Most patients thought that anesthesiologists spent only 3 years in medical school and 2 years in a residency program. Survey participants had several misconceptions about anesthesiologists' role, but it did not affect ratings of their importance. Although, the confidence of patients in anesthesiologists was high, it was significantly lower than their confidence in surgeons. The most common concern expressed by the patients was based on whether anesthesiologists had sufficient experience and qualifications. CONCLUSIONS: Discussing anesthetic forms preoperatively can help decrease patients' anxiety. More efforts should be made preoperatively to address patients' high level of fear about rare side effects and discuss common side effects they tend to ignore. Preoperative preparation must allow the anesthesiologists enough time to reassure patients about their concerns, as they obtain patients' informed consent.

Variability in risk tolerance and adherence to guidelines in "go or no-go" decisions among anesthetists in Saudi Arabia.

BACKGROUND: Anesthetists deal with many situations where they decide whether proceeding with anesthesia is safe or not. These are termed "go or no-go" decisions. Although guidelines have been developed to ensure safe anesthesia, many factors affect anesthetists' decision in practice. Therefore, we aimed to assess the variability in risk tolerance when making "go or no-go" decisions among anesthetists in Saudi Arabia. MATERIALS AND METHOD: A questionnaire-based study that included anesthetists practicing in Saudi Arabia from 1--14th October 2017 was conducted. The questionnaire presented 11 clinical scenarios that involved deviation from guidelines, followed by four questions where the participants were asked to decide whether they would proceed with administering anesthesia, write a comment explaining their decision, to predict whether a colleague would make the same decision, and if they had a previous similar experience. RESULTS: A total of 124 anesthetists responded, of which 56.5% were consultants. There was no absolute consensus over the decision to proceed in any scenario. Most of the respondents who would proceed (67.35%) expected a colleague to make the same decision. Anesthetists who encountered a previous similar experience were more likely to proceed (P = 0.000). There was no significant difference among the respondents' decisions according to years of experience (P = 0.121). Analysis of the comments showed that procedure urgency and presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decision. CONCLUSION: There is a wide variation in risk tolerance among anesthetists. Further simulation-based studies are needed to identify and address factors that affect anesthetists' decisions.

Evaluation of a communication skills training course for medical students using peer role-play.

OBJECTIVE: To evaluate the effect of using peer role-playing in learning the communication skills as a step in the development of the communication skills training course delivered to pre-clinical medical students. METHODS: This study was conducted at the King Abdulaziz University, Jeddah, Saudi Arabia, between September 2014 and February 2015 and comprised medical students. Mixed methods design was used to evaluate the developed communication skills training course. Tests were conducted before and after the communication skills training course to assess the students' self-reported communication. After the course, the students completed a satisfaction survey. Focus groups were conducted to assess the behavioural and organisational changes induced by the course. SPSS 16 was used for data analysis.. RESULTS: Of the293 respondents, 246(84%) were satisfied with the course. Overall, 169(58%) subjects chose the lectures as the most helpful methods for learning the communication skills while 124(42%) considered practical sessions as the most helpful method. Besides, 237(81%) respondents reported that the role-play was beneficial for their learning, while 219(75%) perceived the video-taped role-play as an appropriate method for assessing the communication skills. CONCLUSIONS: Peer role-play was found to be a feasible and well-perceived alternative method in facilitating the acquisition of communication skills..

Integration of simulation in postgraduate studies in Saudi Arabia: The current practice in anesthesia training program.

The educational programs in the Saudi Commission for Health Specialties are developing rapidly in the fields of technical development. Such development is witnessed, particularly in the scientific areas related to what is commonly known as evidence-based medicine. This review highlights the critical need and importance of integrating simulation into anesthesia training and assessment. Furthermore, it describes the current utilization of simulation in anesthesia and critical care assessment process.

Clinical exposure and organization of the Critical Care rotation during the Hajj periods in 1434-1435; perspectives of Arabian Saudi Anesthesiology Program Residents.

Background: Background: The nature of massive mass gathering during Hajj was expected to provide a challenging and stimulating working experience for anesthesiology training program residents. An new rotation arrangement was reached between the Ministry of Health and the Saudi Commission of Health Specialties to recruit anesthesia resident to provide critical care services during the Hajj seasons in 1434 and 1435. Objectives: This study aimed to explore the perspectives of anesthesia residents on their experience working among critical care teams during Hajj seasons in 1434H and 1435H at various locations of Makkah city and Al-Mashaer. Subjects and methods: This cross-sectional study was conducted using a self-administered questionnaire distributed to all residents (n = 35) enrolled in anesthesia residency training program of the SCFHS and participated in critical care areas as locum during the Hajj seasons of 1434H and 1435H. Data was analyzed by using the statistical package of social science. Results: The mean score of residents agreement on being treated with respect from both nurses and administration was the highest among the surveyed item (6.13 and 6.22 respectively). It was observed that, satisfaction of the residents with the direct observations and feedback provided to them (p = 0.01), the adequacy of the services components (p = 0.01) being treated with respect by the senior doctors and nurses (p = 0.03, p = 0.002) was significantly increased in the year 1435 compared to that of the year 1434. The satisfaction was generally higher in Makkah hospitals when compared to that of Al-Mashaer (Arafat and Menna) hospitals although this difference was of no statistical significance. Conclusion: Hajj critical care rotations in 1434 and 1435 were well perceived by anesthesia residents. They found them useful as they give them the chance to gain self-confidence and experience the provision of healthcare services for mass gathering sessions.

Obstetric and gynecologic patients' attitudes and perceptions toward medical students in saudi arabia.

OBJECTIVE: To identify patients' attitudes, preferences and comfort levels regarding the presence and involvement of medical students during consultations and examinations. METHODS: A cross-sectional descriptive study was conducted from September 2011 to December 2011 at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Participants were randomly selected from the outpatient and inpatient clinics at the Department of Obstetrics and Gynecology and the Emergency Department, provided they were admitted for obstetric or gynecology-related conditions. Data were collected using a structured questionnaire, and data analysis was performed using the Statistical Package for Social Sciences. RESULTS: Of the 327 patients who were recruited, 272 (83%) were elective patients who were seen at the outpatient and inpatient clinics of the Department of Obstetrics and Gynecology (group I). The other 55 (16.8%) were seen at the Emergency Department or the Labor and Delivery Ward (group II). One hundred seventy-nine participants (160 [58.8%] in group I and 19 [34.5%] in group II) reported positive attitudes about the presence of female medical students during consultations. Fewer participants (115 [42.3%] were in group I and 17 [30.9%] in group II) reported positive attitudes regarding the presence of male medical students during consultations (p=0.095). The gender of the medical student was the primary factor that influenced patients' decision to accept or decline medical student involvement. No significant associations were observed between patients' attitudes and perceptions toward medical students and the patients' age, educational level, nationality or the gender of the consultant. CONCLUSION: Obstetrics and Gynecology patients are typically accepting of female medical student involvement during examinations. Student gender is the primary factor that influences patient attitudes regarding student involvement during physical examinations.

A novel approach to manage patients with compromised airway. Videoscopic assisted retromolar intubation.

Aids to difficult airway management are essential for safe practice of anesthesia particularly for high-risk patients. This case series described a novel approach of combined use of complementing tools (videolaryngeoscopic assisted retromolar intubation) to enhance airway management of a subset of various high-risk patients with extremely difficult airway. It also addressed the rational for the combination of such approaches as well as the advantages and disadvantages of this technique. In all of the 4 patients, the use of the combined approach resulted in a successful intubation without the need for surgical airway. This technique showed many advantages making it possible to use in cases with life threatening airway obstruction.

Use of Airtraq, C-Mac, and Glidescope laryngoscope is better than Macintosh in novice medical students' hands: A manikin study.

BACKGROUND AND AIM: Obtaining patent airway is a crucial task for many physicians. When opportunities to practice intubations on patients are really limited, skill gaining methods are needed. We conducted a study among novice 6(th) year medical students to assess their ability to intubate the trachea in normal airway in manikin using four airway tools. SETTING AND DESIGN: Prospective, cohort study conducted at simulation center of university-based, tertiary care hospital. METHODS: FIFTY MEDICAL STUDENTS PERFORMED EITHER ORAL OR NASAL TRACHEAL INTUBATION USING THE FOLLOWING FOUR INTUBATING TOOLS: C-Mac videolaryngoscope, Glidescope, and Airtraq in comparison with regular Macintosh laryngoscope. Intubation time, visualization of glottic opening, ease of intubation, satisfaction of participants, incidence of dental trauma, and the need for optimization manoeuvres' use among different airway tools were recorded. RESULTS: In oral intubation, Airtraq was better than others in regard to intubation time, glottic opening, ease of intubation, and the need for external laryngeal pressure application, followed by Glidescope, C-Mac, and finally Macintosh laryngoscope (P<0.001). Airtraq and Glidescope associated with less dental trauma than C-Mac and Macintosh. In nasal route, fastest intubation time was reported with Airtraq followed by Glidescope, C-Mac, and lastly Macintosh. Airtraq, Glidescope, and C-Mac were similar to each other and better than the Macintosh in regard to ease of intubation, satisfaction, and number of attempts (P≤0.008). CONCLUSIONS: New devices like Airtraq, Glidescope, and C-Mac are better than the regular Macintosh when used by novice medical students for oral and nasal intubation on manikin.

Reduced hemodynamic responses to tracheal intubation by the Bonfils retromolar fiberscope: a randomized controlled study.

The Bonfils retromolar intubation fiberscope is a rigid endoscope designed to enable glottic visualization and facilitate intubation under endoscopic vision. Theoretically, avoiding direct-vision laryngoscopy and thus could produce less stimulation during intubation than the conventional direct laryngoscopic procedure. This prospective randomized study was designed to compare the effect of tracheal intubation with direct vision laryngoscopy (Macintosh blade) and the Bonfils retromolar intubation fiberscope on the hemodynamic responses in ASA I patients. Forty patients scheduled for elective surgery and requiring endotracheal intubation were randomly allocated to one of two groups according to the intubating tool under sevoflurane nitrous oxide Anaesthesia (n=20 each). The retromolar group received tracheal intubation with the Bonfils retromolar fiberscope, while the direct laryngoscopy group received tracheal intubation by the direct vision laryngoscope (Macintosh blade). Heart rate and arterial blood pressure (systolic BP, diastolic BP, mean ABP) were recorded before induction of Anaesthesia, 3 minutes after induction of Anaesthesia (before intubation) and 5 successive recordings at one-minute interval after intubation. All the systolic BP, diastolic Bp, mean ABP and heart rate values in the direct laryngoscopy group were significantly higher in the 5 successive minutes after intubation in comparison with the retromolar group (P = 0.00). This might be attributed to the gentle intubating technique, by the Bonfils retromolar fiberscope, which allows quick endotracheal intubation without manipulations of the base of the tongue or epiglottis.