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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patient


Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.

Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).

Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).

Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube.

Key words: colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia

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The feasibility of vasopressin administration via laryngeal mask airway using a porcine model


Background. In pre-hospital situations, delay in resuscitation might carry extra risks for patients, so resuscitative measures should be rapid, easy-to use, and effective. A laryngeal mask airway (LMA) is a quickly placed supraglottic airway that may be used as a route for drug administration. Vasopressin is a vasopressor and might be absorbed well via the mucosa of the airways and alveoli. We conducted this animal study to verify the feasibility of administering vasopressin via a LMA.

Methods. Twenty-four Yorkshire pigs were anesthetized and randomly divided into four groups. The pigs in Groups Placebo and tracheal tube (TT) were intubated with a cuffed tracheal tube, and those in Groups LMA and laryngeal mask airway and a catheter (LMAC) underwent a size 4 LMA insertion. In the LMAC group, an aerosolized catheter was placed into the trachea through a LMA to deliver the drug. All pigs were able to breathe spontaneously without the assistance of a ventilator. The placebo group received 5 ml of distilled water via a tracheal tube. The other groups received 1 U/kg vasopressin, which was diluted to a total volume of 5 ml with distilled water via the varied routes. The heart rates and arterial pressures were recorded before and after drug administration.

Results. The mean arterial pressure (MAP) and diastolic arterial pressure (DAP) increased significantly and maintained a plateau from 3 to 7 min in Group TT and 2 to 29 min in Group LMAC. Group LMA and Group Placebo demonstrated only one occasional elevation in MAP and no changes in DAP. Furthermore, the heart rate decreased significantly from 2 to 29 min in Group LMAC.

Conclusions. In this porcine model, vasopressin administered via an aerosolized catheter and ventilated with a LMA demonstrated a positive and prolonged pressor effect. The results suggest that an aerosolized catheter placed through a LMA, may be a practical alternative route for vasopressin administration, and that the effective duration of vasopressin is long enough to cover the period of pre-hospital management.

Key words: laryngeal mask airway, vasopressin, airway, pre-hospital

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A prospective randomized high fidelity simulation center based side-by-side comparison analyzing the success and ease of conventional versus new generation video laryngoscope technology by inexperienced laryngoscopists


Introduction. Indirect video laryngoscopes are altering the landscape of airway management.  The primary aim of this prospective randomized patient simulator analysis was to objectively compare video laryngoscopes to standard airway management techniques in novice users.
Methods.  “First year medical students were exposed to high-fidelity simulated normal and difficult airway scenarios while using an array of indirect video laryngoscopes (e.g., the GlideScope, McGRATH or Pentax AWS-100) that were compared to Macintosh laryngoscope and fiberoptic bronchoscope (i.e., historic gold standards for normal and difficult airways, respectively).”
Results.  In the normal airway scenario, the best glottic view (both subjective and objective) was obtained with the video laryngoscopes and intubation success rates were highest with the video laryngoscopes (100% success rate for each device) and Macintosh (80%).  In the difficult airway scenario, the best glottic view was achieved with all video laryngoscopes and the fiberoptic bronchoscope; however, tracheal intubation was best achieved with the video laryngoscopes (100% success rate for each device) whereas the success rate with the bronchoscope was only 36%.
Discussion.  Our findings support the use of the GlideScope, McGRATH, or Macintosh laryngoscopes for novice users managing a normal airway.  When managing the difficult airway, there was no difference between any video or Macintosh laryngoscope in the time to successfully intubate the trachea.  Over time, study participants demonstrated learned behavior as they became more facile with all devices.  When comparing the video laryngoscopes, all three performed similarly overall and proved useful in the hands of novice users.  Regardless of airway difficulty, the fiberoptic bronchoscope yielded the worst results.

Key words: airway, airway management, airway equipment, patient simulation, success, tracheal intubation

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Epinephrine administration via a laryngeal mask airway: what is the optimal dose?


Background. The aim of this animal study was to clarify the effects of laryngeal mask airway (LMA)-administrated epinephrine and to assess the optimal dose.
Methods. Thirty pigs were anesthetized and intubated with a cuffed tracheal tube (TT) and an LMA. Then they were assigned to one of five groups. The control group received distilled water 10 mL via the TT; the TT group received epinephrine 50 μg/kg via the TT; and the other three groups received two, four or six times the TT dose of epinephrine via the LMA. Heart rate (HR) and arterial pressure were monitored before and after drug administration for 15 minutes.
Results. After epinephrine administration, the LMA-6 and TT groups had elevated systolic, diastolic and mean arterial pressures at 1 min and there was no significant difference between the two groups. In the TT group, these parameters peaked at 2 min then declined rapidly. In the LMA-6 group, they increased more slowly, and then maintained a plateau. The control, LMA-2 and LMA-4 groups failed to display significant persistent (>2 min) hemodynamic changes.
Conclusions. We could not identify an optimal LMA-administrated epinephrine dose. The TT route is suitable when a high peak drug effect is required and the LMA route may be preferable if a persistent plateau effect is desired. Effective LMA administration of drugs may require larger doses than those given via TT.

Keywords: airway, drug delivery, epinephrine, laryngeal mask airway (LMA), tracheal tube

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Anaesthesiological problems in children with congenital laryngeal stenosis


Congenital laryngeal stenosis is a rare condition, which can be diagnosed in the early neonatal period. Manifest stenosis can be life threatening. Severe (“critical”) types of stenosis require securing an adequate airway just after the birth, as well as early tracheotomy as a life-saving procedure.
This paper presents a case report of a preterm newborn with severe laryngeal stenosis diagnosed at birth. It was not possible to secure the airway even with endotracheal tubes of the smallest diameter, thus a laryngeal mask (LMA) was placed to provide adequate ventilation and oxygenation. Anaesthesia was administered in the same way during the tracheotomy procedure, which was performed in the earliest hours of the baby’s life.

Key words: laryngeal stenosis, laryngeal mask, newborn, airway

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