C. H. Maharaj

The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial.

BACKGROUND:The transversus abdominis plane (TAP) block is an effective method of providing postoperative analgesia in patients undergoing midline abdominal wall incisions. We evaluated its analgesic efficacy over the first 48 postoperative hours after cesarean delivery performed through a Pfannensteil incision, in a randomized controlled, double-blind, clinical trial. METHODS:Fifty women undergoing elective cesarean delivery were randomized to undergo TAP block with ropivacaine (n = 25) versus placebo (n = 25), in addition to standard postoperative analgesia comprising patient-controlled IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a standard spinal anesthetic, and at the end of surgery, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side. Each patient was assessed postoperatively by a blinded investigator: in the postanesthesia care unit and at 2, 4, 6, 12, 24, 36, and 48 h postoperatively. RESULTS:The TAP block with ropivacaine compared with placebo reduced postoperative visual analog scale pain scores. Mean (± sd) total morphine requirements in the first 48 postoperative hours were also reduced (66 ± 26 vs 18 ± 14 mg, P < 0.001), as was the 12-h interval morphine consumption up to 36 h postoperatively. The incidence of sedation was reduced in patients undergoing TAP blockade. There were no complications attributable to the TAP block. CONCLUSIONS:The TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia when compared with placebo block up to 48 postoperative hours after elective cesarean delivery.

A comparison of tracheal intubation using the Airtraq or the Macintosh laryngoscope in routine airway management: A randomised, controlled clinical trial.

The Airtraq® laryngoscope is a novel single use tracheal intubation device. We compared the Airtraq® with the Macintosh laryngoscope in patients deemed at low risk for difficult intubation in a randomised, controlled clinical trial. Sixty consenting patients presenting for surgery requiring tracheal intubation were randomly allocated to undergo intubation using a Macintosh (n = 30) or Airtraq® (n = 30) laryngoscope. All patients were intubated by one of four anaesthetists experienced in the use of both laryngoscopes. No significant differences in demographic or airway variables were observed between the groups. All but one patient, in the Macintosh group, was successfully intubated on the first attempt. There was no difference between groups in the duration of intubation attempts. In comparison to the Macintosh laryngoscope, the Airtraq® resulted in modest improvements in the intubation difficulty score, and in ease of use. Tracheal intubation with the Airtraq® resulted in less alterations in heart rate. These findings demonstrate the utility of the Airtraq® laryngoscope for tracheal intubation in low risk patients.

Comparison of Macintosh, Truview EVO2®, Glidescope®, and Airwayscope® laryngoscope use in patients with cervical spine immobilization

BACKGROUND The purpose of this study was to evaluate the effectiveness of the Pentax AWS, Glidescope, and the Truview EVO2, in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. METHODS One hundred and twenty consenting patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n=30), Glidescope (n=30), Truview EVO2 (n=30), or AWS (n=30) laryngoscope. All patients were intubated by one of the three anaesthetists experienced in the use of each laryngoscope. RESULTS The Glidescope, AWS, and Truview EVO2 each reduced the intubation difficulty score (IDS), improved the Cormack and Lehane glottic view, and reduced the need for optimization manoeuvres, compared with the Macintosh. The mean IDS was significantly lower with the Glidescope and AWS compared with the Truview EVO2 device, and the IDS was lowest with the AWS. The duration of tracheal intubation attempts was significantly shorter with the Macintosh compared with the other devices. There were no differences in success rates between the devices tested. The AWS produced the least haemodynamic stimulation. CONCLUSIONS The Glidescope and AWS laryngoscopes required more time but reduced intubation difficulty and improved glottic view over the Macintosh laryngoscope more than the Truview EVO2 laryngoscope when used in patients undergoing cervical spine immobilization.

Evaluation of intubation using the Airtraq® or Macintosh laryngoscope by anaesthetists in easy and simulated difficult laryngoscopy – a manikin study*

The Airtraq® Laryngoscope is a novel intubation device which allows visualisation of the vocal cords without alignment of the oral, pharyngeal and tracheal axes. We compared the Airtraq® with the Macintosh laryngoscope in simulated easy and difficult laryngoscopy. Twenty‐five anaesthetists were allowed up to three attempts to intubate the trachea in each of three laryngoscopy scenarios using a Laerdal® Intubation Trainer followed by five scenarios using a Laerdal SimMan® Manikin. Each anaesthetist then performed tracheal intubation of the normal airway a second time to characterise the learning curve. In the simulated easy laryngoscopy scenarios, there was no difference between the Airtraq® and the Macintosh in success of tracheal intubation. The time taken to intubate at the end of the protocol was significantly lower using the Airtraq® (9.5 (6.7) vs. 14.2 (7.4) s), demonstrating a rapid acquisition of skills. In the simulated difficult laryngoscopy scenarios, the Airtraq® was more successful in achieving tracheal intubation, required less time to intubate successfully, caused less dental trauma, and was considered by the anaesthetists to be easier to use.

Evaluation of the Airtraq® and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation*

The Airtraq®, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope.

Learning and performance of tracheal intubation by novice personnel: a comparison of the Airtraq® and Macintosh laryngoscope

Direct laryngoscopic tracheal intubation is taught to many healthcare professionals as it is a potentially lifesaving procedure. However, it is a difficult skill to acquire and maintain, and, of concern, the consequences of poorly performed intubation attempts are potentially serious. The Airtraq® Laryngoscope is a novel intubation device which may possess advantages over conventional direct laryngoscopes for use by novice personnel. We conducted a prospective trial with 40 medical students who had no prior airway management experience. Following brief didactic instruction, each participant took turns in performing laryngoscopy and intubation using the Macintosh and Airtraq devices under direct supervision. Each student was allowed up to three attempts to intubate in three laryngoscopy scenarios using a Laerdal® Intubation Trainer and one scenario in a Laerdal® SimMan® Manikin. They then performed tracheal intubation of the normal airway a second time to characterise the learning curve for each device. The Airtraq provided superior intubating conditions, resulting in greater success of intubation, particularly in the difficult laryngoscopy scenarios. In both easy and simulated difficult laryngoscopy scenarios, the Airtraq decreased the duration of intubation attempts, reduced the number of optimisation manoeuvres required, and reduced the potential for dental trauma. The Airtraq device showed a rapid learning curve and the students found it significantly easier to use. The Airtraq appears to be a superior device for novice personnel to acquire the skills of tracheal intubation.

Endotracheal intubation in patients with cervical spine immobilization: a comparison of macintosh and airtraq laryngoscopes.

Background:The Airtraq laryngoscope (Prodol Ltd., Vizcaya, Spain) is a novel single-use tracheal intubation device. The authors compared ease of intubation with the Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization in a randomized, controlled clinical trial. Methods:Forty consenting patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of four anesthesiologists experienced in the use of both laryngoscopes. Results:No significant differences in demographic or airway variables were observed between the groups. All but one patient, in the Macintosh group, were successfully intubated on the first attempt. The Airtraq reduced the duration of intubation attempts (mean ± SD: 13.2 ± 5.5 vs. 20.3 ± 12.2 s), the need for additional maneuvers, and the intubation difficulty scale score (0.1 ± 0.5 vs. 2.7 ± 2.5). Tracheal intubation with the Airtraq caused fewer alterations in blood pressure and heart rate. Conclusions:These findings demonstrate the utility of the Airtraq laryngoscope for tracheal intubation in patients with cervical spine immobilization.

Preoperative Intravenous Fluid Therapy Decreases Postoperative Nausea and Pain in High Risk Patients

The potential for preoperative IV rehydration to reduce postoperative nausea and vomiting (PONV) and pain in patients undergoing ambulatory surgery remains unclear, with conflicting results reported. We sought to determine whether preoperative IV rehydration with a balanced salt solution would decrease the incidence of PONV in patients at increased risk for these symptoms. Eighty ASA grade I–III patients presenting for gynecologic laparoscopy were randomized to receive large (2 mL/kg per hour fasting) or small (3 mL/kg) volume infusions of compound sodium lactate solution over 20 min preoperatively. A standardized balanced anesthetic was used. The incidence and severity of PONV and pain, and need for supplemental antiemetic and analgesic therapy, were assessed by a blinded investigator at 0.5, 1, and 4 h postoperatively, and on the first and third postoperative days. The incidence (control 87% versus large volume 59%) and severity of PONV were significantly reduced in the large volume infusion group at all time intervals. The large volume infusion group also had decreased postoperative pain scores and required less supplemental analgesia. Preoperative correction of intravascular volume deficits effectively reduces PONV and postoperative pain in high risk patients presenting for ambulatory surgery. We recommend the preoperative administration of 2 mL/kg of compound sodium lactate for every hour of fasting to patients with an increased PONV risk presenting for ambulatory surgery.

Randomized controlled trial of the Pentax AWS®, Glidescope®, and Macintosh laryngoscopes in predicted difficult intubation

BACKGROUND The purpose of this study was to determine the potential for the Pentax AWS and the Glidescope to reduce the difficulty of tracheal intubation in patients at increased risk for difficult tracheal intubation, in a randomized, controlled clinical trial. METHODS Seventy-five consenting patients presenting for surgery requiring tracheal intubation, and who were deemed to possess characteristics indicating an increased risk for difficult tracheal intubation, were randomly assigned to undergo intubation using a Macintosh, AWS, or Glidescope laryngoscope (n=25 patients per group). All patients were intubated by one of three anaesthetists experienced in the use of each laryngoscope. RESULTS Both the Glidescope and the AWS significantly reduced the intubation difficulty score compared with the Macintosh. The rate of successful tracheal intubation was lower with the Macintosh (84%) compared with the Glidescope (96%) or the AWS (100%). There were no differences in the duration of tracheal intubation attempts between the devices. Both the Glidescope and the AWS significantly reduced the need for additional manoeuvres and improved the Cormack and Lehane view obtained at laryngoscopy, compared with the Macintosh. Tracheal intubation with the AWS but not the Glidescope reduced the degree of haemodynamic stimulation compared with the Macintosh laryngoscope. CONCLUSIONS The AWS and the Glidescope laryngoscopes reduced the difficulty of tracheal intubation to a similar extent compared with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation.

Comparison of the Glidescope®, the Pentax AWS®, and the Truview EVO2® with the Macintosh laryngoscope in experienced anaesthetists: a manikin study

BACKGROUND The Pentax Airwayscope, the Glidescope, and the Truview EVO2 constitute three novel laryngoscopes that facilitate visualization of the vocal cords without alignment of the oral, pharyngeal, and tracheal axes. We compared these devices with the Macintosh laryngoscope in a simulated easy and difficult laryngoscopy. METHODS Thirty-five experienced anaesthetists were allowed up to three attempts to intubate in each of four laryngoscopy scenarios in a Laerdal SimMan manikin. The time required to perform tracheal intubation, the success rate, number of intubation attempts and of optimization manoeuvres, and the severity of dental compression were recorded. RESULTS In the simulated easy laryngoscopy scenarios, there was no difference between the study devices and the Macintosh in success of tracheal intubation. In more difficult tracheal intubation scenarios, the Glidescope and Pentax AWS, and to a lesser extent the Truview EVO2 laryngoscope demonstrated advantages over the Macintosh laryngoscope including a better view of the glottis, greater success of tracheal intubation, and ease of device use. The Pentax AWS was more successful in achieving tracheal intubation, required less time to successfully perform tracheal intubation, caused less dental trauma, and was considered by the anaesthetists to be easier to use. CONCLUSIONS The Pentax AWS laryngoscope demonstrated more advantages over the Macintosh laryngoscope than either the Truview EVO2 or the Glidescope laryngoscope, when used by experienced anaesthetists in difficult tracheal intubation scenarios.