Materials and methods
General information: From April of 20 1 1 year to June of 20 1 year, 3567 patients completed tracheal intubation under general anesthesia, among which 25 patients failed to complete routine tracheal intubation due to other factors, and all tried to use Shikani laryngoscope for tracheal intubation. Male 14, female 1 1. Age 18 ~ 65 years old; Weight 41~ 95 kg; Elective operation 18 cases, emergency operation in 7 cases. Preoperative evaluation showed airway difficulty 17 cases and no airway difficulty in 8 cases. 5 cases kept spontaneous breathing intubation.
Anesthesia method: After the patient enters the operating room, open the venous channel, routinely monitor ECG, blood pressure and SPO2 _ 2, and continue to fully inhale oxygen and remove nitrogen with a mask. At the same time, propofol 2mg/kg, fentanyl 1μg/kg and midazolam 0.02mg/kg were used for intravenous anesthesia. If mask oxygen inhalation can maintain normal ventilation, vecuronium bromide 0.08mg/kg should be injected intravenously, and intubation should be done with Macintosh laryngoscope after 3 minutes. Record the exposure classification under laryngoscope (Cormac &; Lehane classification: 1 grade can see most glottis; In grade 2, only the trailing edge of glottis was seen; Only epiglottis was seen in grade 3; Grade 4 epiglottis is also invisible). If intubation fails twice, you can try to intubate with Shikani laryngoscope. Sometimes it is necessary to maintain spontaneous breathing and try Shikani laryngoscope intubation, while carefully monitoring the changes of SPO2. If SpO 2 is below 90%, provide oxygen to the mask.
Operation method: Shikani laryngoscope (produced by CLARUS Medical Company, USA) is a kind of visible plastic hard optical fiber laryngoscope, including optical fiber guide rod, eyepiece, independent light source and endotracheal tube fixer. Its mirror rod is T-shaped and covered with a layer of malleable stainless steel, which has good flexibility and plasticity. The metal rod is sealed with optical fiber bundle, and the image carrier frequency of the optical fiber bundle reaches 30000, and the image is clear. Select an appropriate tracheal catheter according to gender, evenly lubricate the Skani laryngoscope shaft and tracheal catheter with sterile paraffin oil, coat anti-fog oil on the lens, lock the tracheal catheter in different parts of the shaft according to the catheter model, and the head end protrudes from the lens by 0.5 ~ 1.0 cm. At the same time, the endotracheal tube holder is also attached with an interface, so that the spontaneous breathers can freely inhale oxygen during intubation. Intubation should keep the patient's head neutral. During the operation, the doctor is located on the left side of the patient. The left hand opens the patient's mouth and lifts the patient's mandible upward and forward, and the right hand holds the laryngoscope from the left corner of the patient and rotates clockwise. Keep the front end of the catheter always in the midline position and find the brightest point in the middle of the neck. After finding the brightest spot, confirm the position of the front end of the fibrolaryngoscope through the eyepiece. If it is above the glottis or has entered the trachea, put the endotracheal tube into the trachea along the mirror rod, fix the endotracheal tube with the left hand, and exit the mirror rod with the right hand. The correct position of catheter was determined by auscultation and ETCO2 monitoring curve. The above operations need to be completed by an anesthesiologist with rich experience in SCANEY laryngoscope. At the same time, the success rate of intubation, intubation time, changes of vital signs of patients and intubation complications were observed and recorded.
result
Among 25 patients, 24 cases were inserted with Shikani laryngoscope, among which 23 cases were successfully inserted once (92%), and the intubation time was 10 ~ 32 seconds. 1 case changed to direct laryngoscope intubation because of excessive oral secretion, obesity, large tongue and unclear light spot. In addition, 1 patient was in a coma due to brain injury, the cervical vertebra could not move, and the mandible and mask were difficult to ventilate, so he maintained spontaneous breathing intubation. After three attempts, the intubation time was 1.83 seconds. During intubation, all patients' vital signs were stable, and SPO2 _ 2 was maintained above 90%. No complications caused by intubation were found in postoperative follow-up.
discuss
Shikani visual laryngoscope, as a kind of optical fiber plastic core laryngoscope, has the advantages of good hardness and plasticity of the mirror shaft, as well as bare rod and fiberoptic bronchoscope, and is suitable for clinically difficult tracheal intubation [2], such as difficulty in opening mouth, limited neck extension, short neck, missing teeth, cleft palate, small jaw and raised throat.
All the 25 patients in this group were operated by an anesthesiologist experienced in Shikani laryngoscope. Except 1 patient, all the other patients successfully completed tracheal intubation, and the overall success rate was 96%. 1 case was not successfully inserted, which may be due to the patient's excessive oral secretion, obesity, large tongue, unclear eyepiece and serious limitation of oral space. After three unsuccessful attempts, tracheal intubation was completed with ordinary laryngoscope under direct vision. The data in this group showed that HR and MAP had no obvious changes before anesthesia induction intubation and after tracheal intubation, indicating that the hemodynamic changes of indirect laryngoscope were lighter than those of direct laryngoscope. It may be because the axes of the mouth, pharynx and trachea do not need to be consistent, and the stress on the base of the tongue is small. Direct laryngoscope encountered difficulties. Intubation requires more force than ordinary tracheal intubation [3].
Shikani laryngoscope also has its own shortcomings, which can not be used for nasal intubation, expensive, complicated preparation and long training time. However, it has strong plasticity, and it is easy to adapt to different airway characteristics by adjusting the radian of the front end of the tracheal catheter. It is not only fast but also accurate to determine the glottis through point guidance and eyepiece direct vision, especially suitable for the above difficult intubation. The success rate of intubation was 1 time (92%), which indicated that Shikani laryngoscope was easy to use and had a high success rate. The traditional direct laryngoscope often adopts the methods of awakening, blind exploration and retrograde when dealing with this kind of tracheal intubation, which is not only time-consuming and laborious, but also harmful to the throat mucosa. At present, fiberoptic bronchoscopy has become the gold standard for difficult tracheal intubation, which is suitable for almost all difficult airways with little damage and high success rate. There are many methods to deal with difficult airway in clinical work. Anesthesiologists must be familiar with two or more tools, and at the same time, when dealing with difficult airway, they should follow the knowledge of difficult airway management experts to ensure the ventilation safety of patients in emergency [4].
To sum up, Skarny laryngoscope is a kind of equipment with strong light guide visual plasticity, simple operation, high safety and high intubation success rate. There are many advantages in difficult airway, which is worth popularizing.
refer to
1 Xu Clinical anesthesiology [M]. Second edition. Beijing: People's Health Publishing House. 2005:34.
2 Xu Kerui, Chen Zhijun, et al. Airway management of difficult airway in children [J]. Journal of Respiratory Medicine, 2002. Journal of Pediatrics, 2005, 15(4):342-345.
3 stones. Video intubation equipment and clinical application [C]. Kunming: 20 1 1 National Annual Conference on Oral Anesthesia, 201/.65.
Anesthesiology Branch of Chinese Medical Association. Expert knowledge of difficult airway management [J]. Journal of clinical anesthesiology, 2009, 25:200-203.