Haemodynamic response to endotracheal intubation in coronary artery disease: Direct versus video laryngoscopy

Comparison of haemodynamic response to tracheal intubation with two different videolaryngoscopes: A randomized clinical trial

BACKGROUND

Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI.

METHODS

Fifty ASA II...III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24...hours following extubation.

RESULTS

The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p...=...0.024; p...=...0.012; p...=...0.030; p...=...0.009, respectively). In group analyses, T1...T2, T2...T3 and T1...T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1...T3) (p...=...0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p...<...0.001), but the duration of intubation and total intubation were similar (p...=...0.36; p...=...0.79).

CONCLUSIONS

Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.

Comparative Study of Gabapentin, Clonidine and Placebo in Alleviating the Hemodynamic Changes Due to Tracheal Intubation and Laryngoscopy

INTRODUCTION

Hemodynamic changes during laryngoscopy and tracheal intubation must be reduced for safe and effective anesthesia. The present study was conducted to compare the efficacy of oral clonidine, gabapentin and placebo in alleviating the hemodynamic changes due to tracheal intubation and laryngoscopy.

METHODS

This was a double-blinded randomized controlled trial conducted on 90 patients who were undergoing elective surgery and were randomized into three groups. Group I (n=30) received a placebo, group II (n=30) received gabapentin and group III (n=30) received clonidine as premedication before anesthesia induction. Patient heart rate and pressor response were recorded periodically and compared between the groups.

RESULTS

There was no significant difference in the baseline heart rate (HR) and mean arterial pressure (MAP) between the groups. HR elevation was observed in all three groups and found to be significant (p=0.0001) but the increase was higher in the placebo (15 min: 80.80± 15.41) and lower in the clonidine group (15 min: 65.53± 12.43). The elevation in systolic and diastolic blood pressure was least and transient in the gabapentin group, as compared to placebo and clonidine group. Intra-operatively, the requirement of opioids was higher in the placebo as compared to clonidine and gabapentin (p < .001).

CONCLUSION

Clonidine and gabapentin were effective in reducing the hemodynamic changes during laryngoscopy and intubation.

Hemodynamic response related to the Airway Scope versus the Macintosh laryngoscope: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

It is important to reduce the hemodynamic response during tracheal intubation. We performed a systematic review and meta-analysis of the Airway Scope and Macintosh laryngoscope to determine whether they reduce the hemodynamic responses of heart rate (HR) and mean blood pressure (MBP) after tracheal intubation under general anesthesia.

METHODS

We performed a comprehensive literature search of electronic databases for clinical trials comparing hemodynamic response to tracheal intubation. The primary aim of our meta-analyst is to determine if the Airway Scope reduces hemodynamic responses (HR and mean MBP) 60 seconds after tracheal intubation compared to the Macintosh laryngoscope. We expressed pooled differences in hemodynamic responses between the 2 devices as weighted mean differences with 95% confidence intervals. We conducted trial sequential analysis. Secondarily, we investigated the ability of the Airway Scope and Macintosh laryngoscope to reduce hemodynamic responses at 120 seconds, 180 seconds, and 300 seconds after tracheal intubation.

RESULTS

We identified clinical trials comparing hemodynamic response via a comprehensive literature search. Of 185 articles found in the search, we selected 8. In comparison to the Macintosh laryngoscope, the Airway Scope significantly reduced HR and MBP at 60 seconds after tracheal intubation (HR; weighted mean difference = -7.29; 95% confidence interval, -10.9 to -3.62; P < .0001; I2 = 57%, MBP; weighted mean difference = -11.5; 95% confidence interval, -20.4 to -2.65; P = .01; I2 = 91%). At the secondary outcome, the Airway Scope significantly reduced the fluctuation of HR after 120 seconds and 180 seconds of tracheal intubation. However, the Airway Scope did not significantly reduce MBP 120 seconds, 180 seconds, and 300 seconds after tracheal intubation. Trial sequential analysis suggested that the total sample size reached the required information size for heart rate.

CONCLUSIONS

Our finding suggested that the Airway Scope attenuated hemodynamic responses at 60 seconds after tracheal intubation in comparison with that of the Macintosh laryngoscope. However, the MBP sample size is small and further research is needed.

Factors predicting difficulty in insertion of real-time-three-dimensional transesophageal echocardiography probe in adult patients undergoing cardiac surgery

Background

Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion.

Methods

A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick's maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients' predictive factors such as demographic characteristics and factors related to difficult intubation.

Results

Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P-value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P-value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001).

Conclusion

Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Comparison of the stress response and intubating performance in endotracheal intubation with Macintosh and McCoy laryngoscopes

Introduction: Laryngoscopy and intubation cause stress response and sympathetic stimulation within the body. Attenuation of these changes by pharmacological means and improved technique with modified instruments is of absolute importance, for stable hemodynamics of the patients. Aim: Comparison of stress response to laryngoscopy and intubation, Intubation Difficulty Score (IDS) using Macintosh and McCoy laryngoscopes. Material and methods: After obtaining institutional ethical committee approval and patient consent in this randomized study, sixty patients of ASA grade I and II, posted for elective surgery under general anaesthesia were intubated with Macintosh or McCoy laryngoscopes. Changes in heart rate, mean arterial pressure, systolic and diastolic blood pressure were observed upto 15 minutes after laryngoscopy, along with IDS. Results: McCoy group when compared with Macintosh group had significant reduction in heart rate at T0 (p value <0.0001), systolic blood pressure at T0, T1 and T15 (p value < 0.001), diastolic blood pressure at T0, T10 and T15 (p value <0.05), mean arterial blood pressure at T0, T10 and T15 (p value <0.05) was observed in this study. Conclusion: Hemodynamic stress response with McCoy blade laryngoscope was reduced in magnitude in comparison with Macintosh blade laryngoscope.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation

BACKGROUND

Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation.

MAIN RESULTS

We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit.  We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%).

AUTHORS' CONCLUSIONS

VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.

Hemodynamic Response to Laryngoscopy and Intubation Using McCoy Laryngoscope: A Descriptive Cross-sectional Study

Introduction:

Laryngoscopy and intubation are stressful as they lead to a rise in heart rate and blood pressure. Though transient, it may be detrimental to the cardiac and neurosurgical patients. There is a need to explore the possibility of obtunding the pressor response to laryngoscopy and intubation with the use of McCoy blade laryngoscope. We aimed to find out the hemodynamic response to laryngoscopy and intubation using McCoy laryngoscope in adult patients undergoing general anesthesia.

Methods:

The descriptive cross-sectional study was conducted in 37 American Society of Anesthesiologists' Physical Status I/IIpatients, with normal airway from December 2019-May 2020 in a tertiary care hospital. Ethical approval was obtained from Institutional Research Committee (reference number.: MEMG/IRC/290/GA). Convenience sampling method was used. The mean systolic and diastolic blood pressures were measured at baseline, one, three and five minutes after laryngoscopy and intubation. Data were analyzed using the Statistical Package for the Social Sciences Version 21.0.

Results:

In the first minute after laryngoscopy and intubation, the rise in mean blood pressure was noted in 14 (37.83%) cases. The peak rise in mean blood pressure was 3%, note done minute after laryngoscopy and intubation.

Conclusions:

We noted better attenuation of pressor response to laryngoscopy and intubation using McCoy blade laryngoscope in adult patients undergoing general anesthesia.

Use of Preoperative Single Dose Ivabradine for Perioperative Hemodynamic Stabilization During Non-Cardiac Elective Surgery Under General Anaesthesia: A Pilot Study

BACKGROUND

Peri-anesthetic hemodynamic fluctuations during non-cardiac surgeries are sometimes of serious consequences and associated with increased morbidity and mortality, especially in undiagnosed vulnerable patients. Currently used drugs like β-blocker, α2 agonist or sedative analgesic have their own limitations like combined negative ionotropic and chronotropic action, and unwanted bradycardia associated with hypotension, respectively. In this context, ivabradine has been used extensively in cases of cardiac failure, myocardial ischemia and cardiomyopathies for its funny channel associated dependable heart rate reducing property. Hence, for the first time, in search of a better agent for perioperative hemodynamic stabilization, the present study evaluated the role of ivabradine in patients undergoing non-cardiac surgeries.

METHODS

This was a prospective, observer blind, randomized, interventional pilot study, conducted among 50 patients belonging undergoing elective abdominal laparoscopic surgeries, under general anesthesia. The study group patients received ivabradine tablet 7.5 mg, 2 h before scheduled time of surgery with a sip of water. All the patients received standardized balanced general anesthesia as practiced in our institute with all standard monitoring with additional minimum alveolar concentration (MAC) monitoring to ensure an adequate depth of anesthesia, and neuromuscular monitoring to ensure adequate and standard muscle relaxation. Hemodynamic stability of the groups was tested by comparing them at time points like induction, incision and operation, and extubation. Mean values of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were compared between groups, and also for variation with lapse of time, using RMANOVA analysis, using baseline parameters as covariate so as to standardize them.

RESULTS

On multivariate analysis using Wilk's lambda multivariate test, there was a statistically significant difference (F = 3.587, P = 0.036) in HR between the groups with time, while no significant difference of SBP, DBP and MAP between the groups with time.

CONCLUSIONS

The study revealed a significant attenuation of HR response to stressful events like laryngoscopy, intubation and surgical incision with ivabradine. Also, a good intraoperative protection against cardiovascular ischemic and arrhythmic episodes in perioperative period was achieved with this drug ivabradine.

Pharmacological strategies to prevent haemodynamic changes after intubation in parturient women with hypertensive disorders of pregnancy: A network meta-analysis

Objective : This network meta-analysis (NMA) aimed to determine the relative efficacy and safety of pharmacological strategies used to mitigate haemodynamic instability by intubation for general anaesthesia in hypertensive parturient women undergoing caesarean section. Methods : We considered randomised controlled studies comparing the effects of pharmacological strategies used to alleviate haemodynamic instability during intubation in parturient women with hypertensive disorders of pregnancy. The primary endpoints were maximum blood pressure and heart rate after intubation, and secondary endpoints were the Apgar scores at 1 and 5 min. NMA allowed us to combine direct and indirect comparisons between strategies. Results : Twelve studies evaluating nine pharmacological strategies in 619 patients were included. According to the surface under the cumulative ranking curve, the maximal mean arterial pressure was lowest for high-dose remifentanil (99.4%) followed by nitroglycerin (73.6%) and labetalol (60.9%). The maximal heart rate was lowest for labetalol (99.9%) followed by high dose of remifentanil (81.2%) and fentanyl (61.6%). Apgar score at 1 min was higher with low-dose than with high-dose remifentanil (mean difference, 0.726; 95% confidence interval, 0.056 to 1.396; I2=0.0%). Conclusions : High-dose remifentanil produces minimum blood pressure changes, while labetalol is most effective in maintaining normal heart rate in parturient women with hypertensive disorders of pregnancy during caesarean section under general anaesthesia.

Perioperative management of pheocromocytoma/ paraganglioma: a comprehensive review

Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this condition and undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.

Evaluation of King's vision videolaryngoscope and glidescope on hemodynamic stress response to laryngoscopy and endotracheal intubation

Background and Aims:

We hypothesis that the use of novel airway devices would decrease hemodynamic stress response (HDSR) to laryngoscopy and endotracheal (ET) intubation. The aim of our study was to evaluate the hemodynamic stress response (HDSR) to laryngoscopy and tracheal intubation using the King vision video laryngoscope (KVVL) versus glidescope (GLS).

Material and Methods:

A prospective randomized, comparative study that was conducted on 80 patients of both sexes; American Society of Anesthesiologists physical status I and II with no anticipated difficult airway, aged 20–60 years; who were scheduled for elective surgical procedure under general anesthesia. Patients were randomly allocated into two groups (40 each). Group I: laryngoscopy and tracheal intubation were carried out using KVVL, Group II: laryngoscopy and tracheal intubation were carried out using GLS. The two groups were compared for noninvasive hemodynamic data such as heart rate and mean arterial pressure. Time to successful intubation and number of attempts were recorded. Hemodynamic parameters were recorded at the preinduction, after induction, at intubation, 1 min, 3 min, 5 min, 10 min, and 15 min.

Results:

There was significant decrease (P < 0.05) in HR and MBP in both groups just before intubation. In comparison with the baseline, HR and MBP in group I and group II increased but this difference was not significant at 3 min and 5 min after intubation and returned to the baseline at 10 min after intubation and below the baseline at 15 min after intubation. Also, there were no significant differences in the hemodynamic response between the studied groups.

Conclusion:

Novel airway devices either KVVL or GLS are efficient in reducing HDSR to laryngoscopy and ET intubation.

The effect of laryngoscope types on hemodynamic response and optic nerve sheath diameter. McCoy, Macintosh, and C-MAC video-laryngoscope

OBJECTIVES

This study aims to investigate the effect of McCoy, Macintosh laryngoscope, and C-MAC video-laryngoscopes on optic nerve sheath diameter (ONSD) and hemodynamic responses to laryngoscopy and intubation.

METHODS

This prospective randomized study was conducted in Zonguldak Bülent Ecevit University Hospital, Zonguldak, Turkey, between July 2019 and January 2020. Informed written consent was obtained from all patients. Patients with previous intracranial/ocular surgery or glaucoma were excluded from the study. The patients were randomized to use McCoy, Macintosh, and C-MAC (30 per group). Intubations were performed by the same person. Mean arterial pressure, heart rate (HR), and ONSD were recorded before the induction and repeated in 1, 3, 5, and 10 minutes after the intubation.

RESULTS

The effects of laryngoscopy and intubation on hemodynamic responses and ONSD were similar between groups (p greater than 0.05). While the comparison within groups showed ONSD increase in McCoy group and HR and ONSD increase in the Macintosh group compared to baseline 1 min after the intubation, no change was observed in hemodynamic responses and ONSD measurements in the C-MAC® group (p greater than 0.05).

CONCLUSIONS

In this study, there was no significant difference between the groups in terms of ONSD and hemodynamic responses to laryngoscopy and intubation. It was observed that there were no significant changes in ONSD values just in C-MAC® video-laryngoscope group. Therefore, intubations with C-MAC® video-laryngoscope are thought to be more appropriate for patients with an increase in intracranial pressure.

Comparative evaluation of oral melatonin and oral clonidine for the attenuation of haemodynamic response to laryngoscopy and tracheal intubation-A prospective randomised double blind study

BACKGROUND AND AIMS

Laryngoscopy and endotracheal intubation cause significant derangement of the haemodynamic parameters proving detrimental for some patients. Clonidine, an α-2 adrenoreceptor agonist, and melatonin, the pineal hormone, have been used for the attenuation of these haemodynamic responses. This study was designed to evaluate the effect of oral melatonin and clonidine in attenuating the haemodynamic responses to laryngoscopy and intubation.

MATERIALS AND METHODS

In this prospective randomised double-blind study, 60 American Society of Anaesthesiologists (ASA) grade I and II patients aged 20-60 years of either gender scheduled to undergo elective surgery under general anaesthesia were randomly divided into Group M and Group C and orally received 6 mg of melatonin and 0.2 mg of clonidine, respectively, 120 min before the induction of anaesthesia. The haemodynamic parameters-heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure and rate -pressure product(RPP) were recorded before and 120 min after the administration of the study drug, before induction, immediately after intubation and at 1, 3, 5 and 10 min following intubation. Sedation was assessed using the Ramsay Sedation Scale. The qualitative and quantitative variables were analysed using Chi square test and unpaired student t test, respectively. For intragroup comparison of quantitative data, paired t test was applied. A P value <0.05 was considered as statistically significant.

RESULTS

A significant difference was noted between the groups regarding HR and RPP 0, 1, 3 and 5 min after intubation. The Ramsay sedation score ranged between 2 and 3 at all time intervals.

CONCLUSION

Although both the drugs are effective, oral melatonin proved superior to oral clonidine in attenuating the haemodynamic response to laryngoscopy and tracheal intubation without any side effects.

Comparison of Nitroglycerin versus Lignocaine Spray to Attenuate Haemodynamic Changes in Elective Surgical Patients Undergoing Direct Laryngoscopy and Endotracheal Intubation: A prospective randomised study

Objectives

This study aimed to compare the effects of nitroglycerin (NTG) versus lignocaine spray in blunting the pressor response during direct laryngoscopy and endotracheal intubation.

Methods

This study was conducted between January and June 2018 in the Department of Anesthesiology, Teerthankar Mahaveer Medical College, Moradabad, India. A total of 90 elective surgical patients of American Society of Anesthesiologists physical status grades I or II were divided into three groups, comprising two treatment groups and one control group. Patients in the treatment groups received either one puff (1.5 mg/kg) of lignocaine 10% spray or one puff (400 μg) of NTG spray in the oropharynx one minute prior to the induction of anaesthesia. Haemodynamic variables and mean rate pressure product at baseline and one, two, three, four and five minutes post-induction were compared.

Results

There was a significant reduction in mean heart rate at 3–5 minutes in both treatment groups compared to the control group (P <0.050), as well as lower increases in mean arterial pressure at 1–3 minutes (P <0.050). However, at 2–4 minutes, there was a significantly greater decrease in mean systolic blood pressure in the NTG group compared to both the lignocaine and control groups (P <0.050). Moreover, a greater decrease in mean rate pressure product response at 1–5 minutes was observed in the NTG group compared to the lignocaine and control groups (P = 0.001).

Conclusion

The NTG spray was more effective than lignocaine in attenuating blood pressure increases and rate pressure product during elective laryngoscopy and intubation.

Comparative evaluation of hemodynamic responses and ease of intubation with airtraq video laryngoscope versus macintosh laryngoscope in patients with ischemic heart disease

Introduction:

Hemodynamic responses during laryngoscopy can potentially precipitate ischemia in patients with coronary artery disease. There are conflicting reports regarding the hemodynamic stress responses between the conventional Macintosh and video laryngoscopes. There is a paucity of studies regarding the same in cardiac surgical patients.

Materials and Methods:

A prospective, randomized control study to compare the hemodynamic responses and ease of intubation using Airtraq video laryngoscope and Macintosh laryngoscope in patients with ischemic heart disease.

Results:

Seventy patients were randomized into two groups. Baseline variables including age, weight, Mallampati score, and comorbidities were comparable between the two groups. There was statistically significant elevation in mean heart rate in the Macintosh group at 2^nd-min (P = 0.02) and 3^rd-min (P = 0.05) postintubation. Similarly, there was a significant increase in mean arterial pressure at 2^nd (P = 0.06), 3^rd (P = 0.03), and 4^th (P = 0.03) in the Macintosh group. The time for laryngoscopy and Intubation Difficulty Scale was significantly better in the Airtraq group (P = 0.001 and 0.001). However, the median time to intubation was longer in the Airtraq group (13 s vs. 11 s, P = 0.05). Laryngoscopy view was better with Airtraq even in patients with Mallampati score 3 (ten patients). The incidence of trauma was same in both the groups.

Conclusion:

Airtraq provides the better hemodynamic stability and ease of intubation and may be considered superior to conventional Macintosh laryngoscope for intubation in patients with ischemic heart disease.

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review

Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intubations (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways (OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these outcomes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI 0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR 0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an 'intubation difficulty score' (OR 7.13, 95% CI 3.12-16.31). Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a videolaryngoscope affects time required for intubation.

Comparison of hemodynamic responses to endotracheal intubation with the GlideScope video laryngoscope and Macintosh laryngoscope in patients undergoing cardiovascular surgery

Background

This study aimed to compare hemodynamic response to endotracheal intubation using GlideScope and Macintosh laryngoscopes in patients who underwent cardiovascular surgery.

Methods

A total of 74 patients were enrolled in the study. Patients were randomly assigned into two groups either a GlideScope (n=37) or a Macintosh laryngoscope (n=37). Laryngoscopy time, heart rate, invasive arterial pressure and rate pressure product were compared during induction and until five minutes after laryngoscopy at 11 time points.

Results

Seventy patients completed the study. The intubation time was similar in both groups (14.1±4.0 sec vs. 13.2±4.2 sec; p=0.22). Hemodynamic values including heart rate, systolic, diastolic and mean arterial pressure and rate pressure product were similar at all-time points. The laryngoscopy time was also similar between groups.

Conclusion

The GlideScope video laryngoscope did not show any advantage on hemodynamic response in patients undergoing cardiovascular surgery when compared to Macintosh laryngoscope.

Effect of C-MAC Video Laryngoscope-aided intubations Using D-Blade on Incidence and Severity of Postoperative Sore Throat

Background:

Video laryngoscope-aided intubations require less force to align oral, pharyngeal, and laryngeal planes to visualize the glottis opening during intubation.

Aim:

The primary objective of the study was to assess the incidence and severity of postoperative sore throat (POST) in patients who were intubated with C-MAC video laryngoscope using D-blade versus traditional Macintosh laryngoscope.

Settings and Design:

This prospective, randomized, open label study was conducted in a tertiary care institution.

Subjects and Methods:

A total of 130 patients undergoing short elective laparoscopic surgeries lasting <2 h were recruited. All patients received general anesthesia as per a standardized protocol. Laryngoscopy was performed using traditional Macintosh laryngoscope in Group M and with Storz^® C-MAC video laryngoscope using D-Blade in Group V. The endotracheal tube cuff pressure was maintained at 20–22 cm of H2O intraoperatively.

Statistical Analysis Used:

Pearson's Chi-square test, Fisher's exact test, and Independent sample t-test were used in this study.

Results:

As compared to Group M, number of patients who had POST, hoarseness of voice, and cough was significantly low in Group V at 2, 6, 12, and 24 h. Severity, as well as the incidence of all these symptoms, showed a downward trend in both groups with time. Significantly more number of patients in Group M required rescue therapy for POST (44.6% as compared to 7.7%, P < 0.001).

Conclusion:

C-MAC video laryngoscope-aided intubations using D-blade significantly reduced the incidence and severity of POST, hoarseness of voice, and cough following orotracheal intubation as compared to use of traditional Macintosh laryngoscope.

Ease of Intubation with C-MAC Videolaryngoscope: Use of 60° Angled Styletted Endotracheal Tube versus Intubation over Bougie

Background:

Although videolaryngoscopes improve glottic visualization, their actual usefulness in intubation is not yet established.

Aims:

The primary objective was to compare the ease of oral intubation with the use of 60° angled styletted endotracheal tube versus that performed over bougie inserted under videolaryngoscopic guidance. The secondary objectives were assessment of incidence of airway loss, hemodynamic changes, and time and number of attempts at intubation.

Settings and Design:

This prospective randomized study was conducted in a tertiary care institution.

Patients and Methods:

Seventy surgical patients requiring oral intubation were randomly allotted to Group S or Group B. Laryngoscopy was performed with Storz^® C-MAC videolaryngoscope using D-Blade. In Group S, patients were intubated with a 60° angled stylletted endotracheal tube. In Group B, a bougie was introduced into the trachea and endotracheal tube was railroaded over the bougie.

Statistical Analysis Used:

Chi-square test and independent sample t-test were used as applicable.

Results:

The ease of intubation was significantly more in patients of Group S as compared to Group B (88.6% vs. 25.7%, respectively, P < 0.001) with significantly shorter intubation time (16.97 ± 7.91 vs. 77.43 ± 35.55 s, respectively, P < 0.001). The requirement of more than one attempt at intubation was significantly higher in Group B [57.1% vs. 5.7% P < 0.001, respectively]. Group B showed a significantly high mean arterial pressure at 1 and 3 min following intubation with no significant change in heart rate.

Conclusion:

Use of 60° angled styletted endotracheal tube resulted in easier and faster intubation as compared to intubation over a bougie when used with C-MAC videolaryngoscope.

Cardiovascular response and backward, upward, right push maneuver during laryngoscopy: comparison between CMAC® video laryngoscopy and conventional Macintosh

Background: Increased blood pressure and heart rate are the most frequent response to laryngoscopy which sometimes causes serious complications. Laryngoscopy technique and tools modification lessen the nociceptive stimulation, thus preventing hemodynamic response. BURP maneuver is used to lower Cormack-Lehane level, but it can cause additional pain stimulation during laryngoscopy. The aim of this study was to compare the cardiovascular response and the need of BURP maneuver during laryngoscopy between CMAC® and conventional Macintosh.Methods: A randomized, single blinded, control trial was performed to 139 subjects who underwent general anesthesia with endotracheal tube. Subjects were randomised into a control group (conventional Macintosh) and an intervention group (CMAC®). The cardiovascular parameters (systolic, dyastolic, mean arterial pressure, and heart rate) were measured prior to induction (T1). Midazolam 0.05 mg/kg and Fentanyl 2 micrograms/kg were given 2 minutes before the induction. Moreover, they were given propofol 1 mg/kg followed by propofol infusion of 10 mg/kg/hour and Atracurium 0.8–1 mg/kg. After TOF-0 cardiovascular parameters (T2) were remeasured, it was proceeded to laryngoscopy. When Cormack-Lehane 1–2 was reached (with or without BURP maneuver), cardiovascular parameters were measured again (T3).Results: Unpaired T-test showed that cardiovascular response during laryngoscopy were significantly lower in the intervention group compared to the control group (p<0.05). The need of BURP maneuver was significantly lower in the CMAC® group compared to the Convensional Macintosh group (13.9% vs 40.3%; p<0.05).Conclusion: Cardiovascular response and BURP maneuver during laryngoscopy with CMAC® were significantly lower compared to conventional Macintosh.

A randomized clinical trial comparing hemodynamic responses to ketamine-propofol combination (ketofol) versus etomidate during anesthesia induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery

INTRODUCTION

Anesthesia induction is often accompanied by a period of hemodynamic instability, which could be a significant problem in patients with compromised ventricular function. The aim of this study is to compare the hemodynamic responses to etomidate versus a combination of ketamine and propofol (ketofol) for anesthetic induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft (CABG) surgery.

MATERIAL AND METHODS

In a double-blind randomized clinical study, a total of 84 patients with ischemic left ventricular dysfunction (EF < 40%) were randomly assigned to two groups (A and B). Patients in group A received etomidate 0.2 mg/kg and a placebo (normal saline); group B received a combination of ketamine (1 mg/kg) and propofol (1.5 mg/kg) at the induction of anesthesia. Two minutes after induction, hemodynamic variables, including systolic, diastolic, mean arterial pressure (SAP, DAP, MAP) and heart rate (HR), were measured immediately before and after the laryngoscopy, and before intubation and post-intubation at 1, 2, and 3 min.

RESULTS

The decrease in all hemodynamic parameters (SBP, DBP, MAP and HR) from induction time to laryngoscopy was greater in the ketofol group (group B) than in the etomidate group (group A) (p < 0.05). The ephedrine prescription rate due to hemodynamic changes was 24.4% (10 patients) and 5% (2 patients) in group B and group A, respectively (p = 0.03).

CONCLUSIONS

We found that etomidate provides superior hemodynamic stability as compared to ketofol in patients with left ventricular dysfunction undergoing CABG surgery under general anesthesia.

A Comparative Study of Clonidine and Lignocaine for Attenuating Pressor Responses to Laryngoscopy and Endotracheal Intubation in Neurosurgical Cases

BACKGROUND AND AIMS

Laryngoscopy and endotracheal intubation are associated with reflex sympathetic stimulation, known as pressor response and can cause major complications. We compared the attenuating effect of time-tested lignocaine versus clonidine on the hemodynamic response to laryngoscopy and intubation in neurosurgical cases.

DESIGN

A prospective, randomized, comparative, double-blind study with a sample size of sixty patients.

METHODS

Sixty patients undergoing elective neurosurgery were randomly allocated into one of the two groups: Group L (n = 30) received lignocaine 1.5 mg/kg intravenous (i.v.) before induction and Group C (n = 30) received clonidine 2 μg/kg i.v. before induction. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at baseline, after drug, after induction and 1, 2, 3,5,10, and 15 min after intubation.

STATISTICAL ANALYSIS

Statistical software, namely, SPSS, version 15.0 by SPSS Inc., Chicago, USA was used for the analysis of data with Chi-square test to compare intergroup hemodynamic parameters.

RESULTS

Mean HR remained above baseline at all times after intubation in lignocaine group but decreased at 2 min after intubation and remained below baseline at all times in the clonidine group. SBP, DBP, and MAP all increased above baseline at 1 min after intubation in lignocaine group, and decreased below baseline at 2 min after intubation, whereas in the clonidine group they all decreased below baseline after drug administration and remained below baseline at all times. Therefore, clonidine is very effective in attenuating pressor responses and this difference between the groups is statistically very significant with P < 0.001.

CONCLUSION

Clonidine is more effective than lignocaine for attenuating the pressor responses to laryngoscopy and endotracheal intubation in neurosurgical cases.

ProSeal Laryngeal Mask Airway versus Cuffed Endotracheal Tube for Laparoscopic Surgical Procedures under General Anesthesia: A Random Comparative Study

Context

The Proseal LMA(PLMA), which has been designed especially for positive pressure ventilation and protection against aspiration can act as an alternative to Endotracheal Tube (ETT) as an effective airway device for patients undergoing elective Laparoscopic surgeries.

Aims

To compare the efficacy and safety of PLMA with ETT in patients undergoing Laparoscopic surgeries under general anaesthesia.

Settings and Design

A prospective, randomized study was conducted in a tertiary care teaching hospital with 60 patients of ASA grade I/II undergoing elective Laparoscopic surgery under general anaesthesia. Ethical committee clearance and written consent taken. The patients were randomly divided into two equal groups to the PLMA group (Group S) and to the ETT group (Group C) Heart rate (HR), mean blood pressure (MAP), ETCO₂ values, intraoperative complications such as regurgitation- aspiration, and Postoperative complications such as nausea or vomiting, throat soreness and oral injuries were monitored.

Results

There was no difference demographically. Insertion success rate was 100% for both the groups. The mean increase in HR was seen all throughout the duration of the surgery to 8 % above the baseline in Group C and to 3% above the baseline in Group S. On comparing the MAP in Group C, there was a increased by 2.5% to 78.300 ± 14.2615 mmHg as compared to an increase by 5% to 76.233 ± 6.2072 mmHg in Group S. EtCO2 showed a rise in both groups after pneumoperitoneum, which returned to baseline values after completion of surgery. Gastric aspirate values showed no difference in each group. Post op complications were seen mainly in Group C with statistical significance.

Conclusions

A properly positioned PLMA is a suitable and safe alternative to ETT for airway management in adequately fasted, adult patients undergoing elective Laparoscopic surgeries.

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation

BACKGROUND

Successful tracheal intubation during general anaesthesia traditionally requires a line of sight to the larynx attained by positioning the head and neck and using a laryngoscope to retract the tongue and soft tissues of the floor of the mouth. Difficulties with intubation commonly arise, and alternative laryngoscopes that use digital and/or fibreoptic technology have been designed to improve visibility when airway difficulty is predicted or encountered. Among these devices, a rigid videolaryngoscope (VLS) uses a blade to retract the soft tissues and transmits a lighted video image to a screen.

OBJECTIVES

Our primary objective was to assess whether use of videolaryngoscopy for tracheal intubation in adults requiring general anaesthesia reduces risks of complications and failure compared with direct laryngoscopy. Our secondary aim was to assess the benefits and risks of these devices in selected population groups, such as adults with obesity and those with a known or predicted difficult airway.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase on 10 February 2015. Our search terms were relevant to the review question and were not limited by outcomes. We carried out clinical trials register searches and forward and backward citation tracking. We reran the search on 12 January 2016; we added potential new studies of interest from the 2016 search to a list of 'Studies awaiting classification', and we will incorporate these studies into the formal review during the review update.

SELECTION CRITERIA

We considered all randomized controlled trials and quasi-randomized studies with adult patients undergoing laryngoscopy performed with a VLS or a Macintosh laryngoscope in a clinical, emergency or out-of-hospital setting. We included parallel and cross-over study designs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data, consulting a third review author to resolve disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias.

MAIN RESULTS

We included 64 studies identified during the 2015 search that enrolled 7044 adult participants and compared a VLS of one or more designs with a Macintosh laryngoscope. We identified 38 studies awaiting classification and seven ongoing studies. Of the 64 included studies, 61 included elective surgical patients, and three were conducted in an emergency setting. Among 48 studies that included participants without a predicted difficult airway, 15 used techniques to simulate a difficult airway. Seven recruited participants with a known or predicted difficult airway, and the remaining studies did not specify or included both predicted and not predicted difficult airways. Only two studies specifically recruited obese participants. It was not possible to blind the intubator to the device, and we noted a high level of inevitable heterogeneity, given the large number of studies.Statistically significantly fewer failed intubations were reported when a VLS was used (Mantel-Haenszel (M-H) odds ratio (OR), random-effects 0.35, 95% confidence Interval (CI) 0.19 to 0.65; 38 studies; 4127 participants), and fewer failed intubations occurred when a VLS was used in participants with an anticipated difficult airway (M-H OR, random-effects 0.28, 95% CI 0.15 to 0.55; six studies; 830 participants). We graded the quality of this evidence as moderate on the basis of the GRADE system. Failed intubations were fewer when a VLS was used in participants with a simulated difficult airway (M-H OR, random-effects 0.18, 95% CI 0.04 to 0.77; nine studies; 810 participants), but groups with no predicted difficult airway provided no significant results (M-H OR, random-effects 0.61, 95% CI 0.22 to 1.67; 19 studies; 1743 participants).Eight studies reported on hypoxia, and only three of these described any events; results showed no differences between devices for this outcome (M-H OR, random-effects 0.39, 95% CI 0.10 to 1.44; 1319 participants). Similarly, few studies reported on mortality, noting no differences between devices (M-H OR, fixed-effect 1.09, 95% CI 0.65 to 1.82; two studies; 663 participants), and only one study reporting on the occurrence of respiratory complications (78 participants); we graded these three outcomes as very low quality owing to lack of data. We found no statistically significant differences between devices in the proportion of successful first attempts (M-H OR, random-effects 1.27, 95% CI 0.77 to 2.09; 36 studies; 4731 participants) nor in those needing more than one attempt. We graded the quality of this evidence as moderate. Studies reported no statistically significant differences in the incidence of sore throat in the postanaesthesia care unit (PACU) (M-H OR, random-effects 1.00 (95% CI 0.73 to 1.38); 10 studies; 1548 participants) nor at 24 hours postoperatively (M-H OR random-effects 0.54, 95% CI 0.27 to 1.07; eight studies; 844 participants); we graded the quality of this evidence as moderate. Data combined to include studies of cross-over design revealed statistically significantly fewer laryngeal or airway traumas (M-H OR, random-effects 0.68, 95% CI 0.48 to 0.96; 29 studies; 3110 participants) and fewer incidences of postoperative hoarseness (M-H OR, fixed-effect 0.57, 95% CI 0.36 to 0.88; six studies; 527 participants) when a VLS was used. A greater number of laryngoscopies performed with a VLS achieved a view of most of the glottis (M-H OR, random-effects 6.77, 95% CI 4.17 to 10.98; 22 studies; 2240 participants), fewer laryngoscopies performed with a VLS achieved no view of the glottis (M-H OR, random-effects 0.18, 95% CI 0.13 to 0.27; 22 studies; 2240 participants) and the VLS was easier to use (M-H OR, random-effects 7.13, 95% CI 3.12 to 16.31; seven studies; 568 participants).Although a large number of studies reported time required for tracheal intubation (55 studies; 6249 participants), we did not present an effects estimate for this outcome owing to the extremely high level of statistical heterogeneity (I2 = 96%).

AUTHORS' CONCLUSIONS

Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VLS reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VLS affects time required for intubation.

Comparison of hemodynamic responses to laryngoscopy and intubation with Truview PCD™, McGrath® and Macintosh laryngoscope in patients undergoing coronary artery bypass grafting: A randomized prospective study

CONTEXT

We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation.

AIM

Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope.

SETTING AND DESIGN

Superspecialty tertiary care public hospital; prospective, randomized control study.

METHODS

Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview™. Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra-/post-operative complications were also recorded and compared between groups.

STATISTICAL ANALYSIS

SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant.

RESULTS

Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively).

CONCLUSIONS

Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.

Evaluation of the Hemodynamic Response to Endotracheal Intubation Comparing the Airtraq(®) with Macintosh Laryngoscopes in Cardiac Surgical Patients

Introduction:

Cardiac patients are more prone to develop hemodynamic instability on induction of anesthesia and endotracheal intubation. The Airtraq^® optical laryngoscope is a single-use rigid video laryngoscope that has been developed to facilitate tracheal intubation. There are limited studies comparing differences in the circulatory responses to Airtraq^® and direct Macintosh larynngoscopy in cardiac patients.

Aim:

The purpose of our study was to evaluate whether there was clinically significant difference between the hemodynamic response to orotracheal intubation guided by either of the two devices (Airtraq^® and Macintosh laryngoscopes) in patients who underwent coronary artery bypass grafting surgery.

Material and methods:

In this clinical study we analyzed the hemodynamic response to endotracheal intubation performed with Airtraq^® or Macintosh laryngoscopes in patients who underwent elective coronary artery bypass graft surgery under general anesthesia.

Results:

We analyzed: blood pressure (systolic, diastolic, mean), heart rate and peripheral oxygen saturation (all notified before induction in anesthesia, immediately after induction, at the time of intubation and thereafter one and five minutes after intubation). We also recorded the maximal values of blood pressure and heart rate, as well as calculated the product of heart rate and systolic blood pressure. There were statistically significant differences in the hemodynamic response between the groups. At the time of intubation, there was significant inter-group difference in heart rate, systolic, diastolic and mean blood pressure. Endotracheal intubation with Macintosh laryngoscope was accompanied by significant increase in blood pressure and heart rate compared to Airtraq^® group.

Conclusion:

The Airtraq^® laryngoscope performed better than the Macintosh laryngoscope in terms of hemodynamic to the patient undergoing routine coronary artery bypass graft surgery.

Hemodynamic responses to endotracheal intubation performed with video and direct laryngoscopy in patients scheduled for major cardiac surgery

This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance < 6 cm, upper lip bite test class 3, Wilson risk sum score ≥ 2, Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses.

Hemodynamic responses to etomidate versus ketamine-thiopental sodium combination for anesthetic induction in coronary artery bypass graft surgery patients with low ejection fraction: a double-blind, randomized, clinical trial

BACKGROUND

During induction of anesthesia and intubation, hemodynamic changes are very important; especially in patients with coronary artery disease (CAD) and left ventricular dysfunction. A little information is available on the hemodynamic effects of a combination of ketamine-thiopental for induction of anesthesia in patients undergoing coronary artery bypass graft (CABG) surgery, with impaired ventricular function.

AIM

The aim of this study was to compare the hemodynamic responses to etomidate versus ketamine-thiopental sodium combination for anesthetic induction in CABG surgery patients with low ejection fraction (EF<45%).

MATERIALS AND METHODS

In a double blind randomized clinical trial, a total of 100 patients, scheduled for elective CABG surgery were randomly assigned into two groups. These patients received either etomidate or ketamine-thiopental sodium combination at induction of anesthesia. Hemodynamics variable were measured and recorded at baseline, immediately before and after laryngoscopy and intubation, one, two and three minutes after intubation. Also, muscle twitching incidence among patients in two groups was evaluated.

RESULTS

No significant differences between the two groups regarding the changes of hemodynamic variables including systolic and diastolic arterial blood pressure, mean arterial pressure and heart rate, were notice (p>0.05). Muscle twitching was not observed in the two groups.

CONCLUSION

Hemodynamic stability after administration of ketamine-thiopental sodium combination for induction of anesthesia in patients undergoing CABG surgery, with impaired ventricular function, supports the clinical impression that this combination is safe in CABG surgery patients with low EF.

Comparing GlideScope Video Laryngoscope and Macintosh Laryngoscope Regarding Hemodynamic Responses During Orotracheal Intubation: A Randomized Controlled Trial

BACKGROUND

To determine if the GlideScope® videolaryngoscope (GVL) could attenuate the hemodynamic responses to orotracheal intubation compared with conventional Macintosh laryngoscope.

OBJECTIVES

The aim of this relatively large randomized trial was to compare the hemodynamic stress responses during laryngoscopy and tracheal intubation using GVL versus MCL amongst healthy adult individuals receiving general anesthesia for elective surgeries.

PATIENTS AND METHODS

Ninety five healthy adult patients with American Society of Anesthesiologists physical status class I or II that were scheduled for elective surgery under general anesthesia were randomly allocated to either Macintosh or GlideScope arms. All patients received a standardized protocol of general anesthesia. Hemodynamic changes associated with intubation were recorded before and at 1, 3 and 5 minutes after the intubation. The time taken to perform endotracheal intubation was also noted in both groups.

RESULTS

Immediately before laryngoscopy (pre-laryngoscopy), the values of all hemodynamic variables did not differ significantly between the two groups (All P values > 0.05). Blood pressures and HR values changed significantly over time within the groups. Time to intubation was significantly longer in the GlideScope (15.9 ± 6.7 seconds) than in the Macintosh group (7.8 ± 3.7 sec) (P< 0.001). However, there were no significant differences between the two groups in hemodynamic responses at all time points.

CONCLUSIONS

The longer intubation time using GVL suggests that the benefit of GVL could become apparent if the time taken for orotracheal intubation could be decreased in GlideScope group.