응급센터에서의 기관내 삽관

서길준 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.4

Background. Endotracheal intubation is one of the most important and challenging tasks that an emergency physician has to perform. Complications associated with this procedure range from local trauma of the airway to death caused by unrecognized misplacement of the endotracheal tube. This study was designed to investigate complications of intubation including rapid sequence intubation in the emergency department. Method. One hundred four consecutive patients requiring endotracheal intubation in the emergency department of the Stanford Medical Center over a 8-month period were studied prospectively. Result. The indications for intubation were acute respiratory failure(60.5%), airway protection(30.8%), and cardiopulmonary arrest(8.7%). 97(93.3%) intubations were inserted orally, remaining 7(6.7%) were intubated via the nasotracheal route. Of 97 orotracheal intubations, rapid sequence intubation was used in 71(73.2%) cases. Grouped by level of training, junior residents attempted 69(66.3%) intubations, senior residents 21(20.2%), and staff 13(12.5%). Of the 104 intubations, 92(88.5%) were successful on the first or second attempt. 12 procedures(11.5%) required more than two attempts at intubation. A total of 36(34.6%) complications occurred. Esophageal intubations occurred in 13 cases, right main stem intubation in 13, pulmonary aspiration in 4, and others in 6. Fourteen patients(13.5%) died after intubation. Conclusion. The complication rate of endotracheal intubation in the emergency department is high. In order to decrease the complication, detailed knowledge, skill, and equipments about endotracheal intubation are required. The good condition of a patient before intubation appears to be important for survival.

Clinical Research Article : Cardiovascular and arousal responses to single-Lumen endotracheal and double-Lumen endobronchial intubation in the normotensive and hypertensive elderly

( Kyung Yeon Yoo ),( Cheol Won Jeong ),( Woong Mo Kim ),( Hyung Kon Lee ),( Seong Tae Jeong ),( Seok Jae Kim ),( Hong Beum Bae ),( Dong Yun Lim ),( Sung Su Chung ) 대한마취과학회 2011 Korean Journal of Anesthesiology Vol.60 No.2

Background: Endotracheal intubation usually causes transient hypertension and tachycardia. The cardiovascular and arousal responses to endotracheal and endobronchial intubation were determined during rapid-sequence induction of anesthesia in normotensive and hypertensive elderly patients. Methods: Patients requiring endotracheal intubation with (HT, n=30) or without hypertension (NT, n=30) and those requiring endobronchial intubation with (HB, n=30) or without hypertension (NB, n=30) were included in the study. Anesthesia was induced with intravenous thiopental 5 mg/kg followed by succinylcholine 1.5 mg/kg. After intubation, all subjects received 2% sevoflurane in 50% nitrous oxide and oxygen. Mean arterial pressure (MAP), heart rate (HR), plasma catecholamine concentration, and Bispectral Index (BIS) values, were measured before and after intubation. Results: The intubation significantly increased MAP, HR, BIS values and plasma catecholamine concentrations in all groups, the peak value of increases was comparable between endotracheal and endobronchial intubation. However, pressor response persisted longer in the HB group than in the HT group (5.1±1.6 vs. 3.2±0.9 min, P<0.05). The magnitude of increases in MAP and norepinephrine from pre-intubation values was greater in the hypertensive than in the normotensive group (P<0.05), while there were no differences in those of HR and BIS between the hypertensive and normotensive groups. Conclusions: Cardiovascular response and arousal response, as measured by BIS, were similar in endobronchial and endotracheal intubation groups regardless of the presence or absence of hypertension except for prolonged pressor response in the HB group. However, the hypertensive patients showed enhanced cardiovascular responses than the normotensive patients. (Korean J Anesthesiol 2011; 60: 90-97)

임상연구 : Bonfils Intubation Fibrescope과 후두경을 이용한 기관내 삽관 시 혈압과 심박수 변화의 비교

윤지환 ( Ji Hwan Yun ),이덕희 ( Deok Hee Lee ) 대한마취과학회 2006 Korean Journal of Anesthesiology Vol.51 No.5

Background: The hemodynamic changes associated with orotracheal intubation may result from direct laryngoscopy and the endotracheal intubation. This study evaluated and compared the cardiovascular changes after either Bonfils intubation fiberscope or conventional laryngoscopic endotracheal intubation. Methods: Sixty patients, aged 20 to 30 years, were randomly allocated into two groups, the Bonfils intubation fiberscope group (BF group, n = 30) and conventional intubation using a rigid laryngoscope (LS group, n = 30). Bonfils intubation fiberscope or laryngoscopic oral endotracheal intubation was performed after inducing anesthesia. The systolic and diastolic arterial pressures, heart rate, peripheral oxygen saturation and intubation time were recorded before and after orotracheal intubation. Results: In both groups, the systolic and diastolic arterial pressures increased significantly after endotracheal intubation. The heart rate increased significantly after the induction of anesthesia in both groups. However, the arterial blood pressure, heart rate and intubation time were similar in both groups. Conclusions: The use of a Bonfils intubation fibrescope does not modify the hemodynamic response associated with endotracheal intubation compared with conventional laryngoscopy. (Korean J Anesthesiol 2006; 51: 547~51)

Levitan FPS scope와 Macintosh 후두경 하 기관내 삽관이 혈압 및 심박수에 미치는 영향

박상용,김상태,신영덕 대한마취통증의학회 2010 Anesthesia and pain medicine Vol.5 No.2

Background:The hemodynamic changes associated with orotracheal intubation may result from direct laryngoscopy and the endotracheal intubation.This study was designed to compare the hemodynamic changes after the endotracheal intubation with either the Levitan FPS scope or Macintosh laryngoscope. Methods:Sixty patients, aged 20 to 60 years, were randomly allocated into two groups, the Levitan FPS scope group (LF group, n = 30) and the Macintosh group (M group, n = 30).The endotracheal intubation with the Levitan FPS scope or Macintosh blade was performed after inducing anesthesia.The heart rate and arterial pressure were measured before induction, just before intubation and at 1, 3 and 5 min after intubation. Results:There were no significant differences in the arterial pressure and heart rate responses to tracheal intubation with the Levitan FPS scope and the Macintosh laryngoscope.In both groups, the arterial pressures at 1 and 3 and 5 min after intubation were increased significantly compared with the preintubation values, and the heart rates at 1 and 3 min after intubation were increased significantly compared with the preintubation values. Conclusions:The Levitan FPS scopic intubation does not attenuate the hemodynamic responses associated with endotracheal intubation compared with the Macintosh laryngoscopy.

정상 기도와 선상 도수 고정법(Manual in-line stabilization)을 이용한 경추손상이 의심되는 환자에서 기관내삽관시 매킨토시 후두경과 Disposcope endoscope®의 유용성 비교: 마네킹을 이용한 시뮬레이션 연구

손성호,백광제,박상오,최필조 대한응급의학회 2011 大韓應急醫學會誌 Vol.22 No.6

Purpose: We conducted a comparative evaluation in the ease of endotracheal intubation when using the Macintosh laryngoscope (ML) versus the new Disposcope endoscope®(DE) (Disposcope Taiwan, Hsinchuang city, Taiwan), a video-laryngoscope, during simulated normal airway and manual in-line stabilization of suspected cervical spine injury patients. Methods: Forty-three medical interns participating in an endotracheal intubation training program used both the DE and the ML as part of their lessons. In each of the two simulated patient scenarios, endotracheal intubation was performed using each endoscope, in random order. The rate of successful intubation, time required for visualizing the glottis,time to complete endotracheal intubation, results of a modified Cormack & Lehane classification (CL grade), and a measure of dental injury were all recorded and analyzed. Results: In the normal airway scenario, there was no difference in the rate of successful completion of intubation (both 100%) between the two endoscopes. Time to complete endotracheal intubation using the DE was shorter than that with the ML (10.7 versus 12.6 sec; p=0 010). In the trauma scenario, despite similar success rates (95.3% in ML versus 100% in DE), the time required to complete endotracheal intubation using the DE was shorter than that with the ML (17.6 versus 24.1 sec; p=0.010). Rate of dental injury using the DE was significantly less than that observed with the ML (0.0% versus 30.2%; p<0.0001). In both scenarios,the DE provided higher achievement of CL grade 1 (93%versus 67.4% in normal airway; p=0.006 and 55.8% versus 0% in trauma airway; p<0.0001). Conclusion: Compared to the ML, the DE provided a better view of the glottis, provided decreased dental trauma, and offered faster completion time for endotracheal intubation.

우리나라 응급의학과에서의 Rapid Sequence Intubation

송근정,김병철,안무업 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.3

Background : Assessing and securing airway is the beginning of the treatment for emergency patients. Rapid Sequence Intubation is a technique that uses sedatives and neuromuscular blockers to perform endotracheal intubation. This is a basic technique that all emergency physicians must master. Therefore, we investigated the recent circumstance of Rapid Sequence Intubation in patients at the emergency department. Methods : Ten-item surveys were mailed to the board certified emergency physicians in the emergency department of 45 hospitals. Among the 45 surveys, 37 surveys were returned. The rate of reply was 82.2%. Results : Throughout the hospital, 35/37 of the endotracheal intubation was performed in the emergency department. Anesthesiologists were not called for endotracheal intubation in 34/37 emergency department, and anesthesiologists were not called for the use of neuromuscular blockers in 36/37 emergency departments. 35 emergency departments used sedatives. The sedatives used were as follows : midazolam(48.6%), diazepam(25.7%), thiopental sodium(22.9%), and ketamine(2.9%). 30 emergency departments used neuromuscular blockers. The neuromuscular blockers used were as follows : succinylcholine(46.7%), vecuronium(43.3%), and pancuronium(10.0%). The rate of Rapid Sequence Intubation was 33.8%. Various monitoring devices were used during Rapid Sequence Intubation ; cardiac monitors 90.5%, pulse oximeters 80.4%, noninvasive blood pressure monitors 64.9%, and ETCO₂12.8%. Only 6 of 37 hospitals had the assessment program for endotracheal intubations and 60% was the assessment rate in these hospitals ; however, there was no proctocol for the quality assurance assessment. Conclusion : Emergency endotracheal intubation was performed independently by the physician of the emergency department. The Rapid Sequence Intubation was effective and had low adverse effect. We recommended that Rapid Sequence Intubation should be used more aggressively in patients. Also, applying these assessment proctocol in patients, we could improve the quality of assurance assessment.

Comparison of dexmedetomidine and remifentanil for attenuation of hemodynamic responses to laryngoscopy and tracheal intubation

이정한,김효중,김현태,김명훈,조광래,임세훈,이군무,김영재,신치만 대한마취통증의학회 2012 Korean Journal of Anesthesiology Vol.63 No.2

Background: This study was designed to compare the effect of dexmedetomidine and remifentanil used in anesthetic induction on hemodynamic change after direct laryngoscopy and tracheal intubation. Methods: A total of 90 ASA class 1 or 2 patients were randomly assigned to one of 3 groups to receive one of the following treatments in a double-blind manner: normal saline (Group C, n = 30), dexmedetomidine 1 μg/kg (Group D, n = 30), remifentanil 1 μg/kg (Group R, n= 30). Anesthesia was induced with propofol 2 mg/kg and rocuronium 0.6 mg/kg and maintained with 2 vol% sevoflurane and 50% nitrous oxide in oxygen. In group D, dexmedetomidine 1 μg/kg was infused for 10 min before tracheal intubation. Patients in group R was received 1 μg/kg of remifentanil 1 minute before tracheal intubation. The systolic blood pressure, diastolic blood pressure and heart rate were recorded from entrance to operation room to 5 min after tracheal intubation. Results: The percent increase in systolic and diastolic blood pressure due to tracheal intubation in group D and R were significantly lower than that of group C (P < 0.05). The heart rate 1 min after tracheal intubation was lower in groups R and D than in the group C (P < 0.05). Conclusions: In healthy normotensive patients, the use of dexmedetomidine during anesthetic induction suppressed a decrease in blood pressure due to anesthetic induction and blunted the hemodynamic responses to endotracheal intubation. Background: This study was designed to compare the effect of dexmedetomidine and remifentanil used in anesthetic induction on hemodynamic change after direct laryngoscopy and tracheal intubation. Methods: A total of 90 ASA class 1 or 2 patients were randomly assigned to one of 3 groups to receive one of the following treatments in a double-blind manner: normal saline (Group C, n = 30), dexmedetomidine 1 μg/kg (Group D, n = 30), remifentanil 1 μg/kg (Group R, n= 30). Anesthesia was induced with propofol 2 mg/kg and rocuronium 0.6 mg/kg and maintained with 2 vol% sevoflurane and 50% nitrous oxide in oxygen. In group D, dexmedetomidine 1 μg/kg was infused for 10 min before tracheal intubation. Patients in group R was received 1 μg/kg of remifentanil 1 minute before tracheal intubation. The systolic blood pressure, diastolic blood pressure and heart rate were recorded from entrance to operation room to 5 min after tracheal intubation. Results: The percent increase in systolic and diastolic blood pressure due to tracheal intubation in group D and R were significantly lower than that of group C (P < 0.05). The heart rate 1 min after tracheal intubation was lower in groups R and D than in the group C (P < 0.05). Conclusions: In healthy normotensive patients, the use of dexmedetomidine during anesthetic induction suppressed a decrease in blood pressure due to anesthetic induction and blunted the hemodynamic responses to endotracheal intubation.

The effect of beta1-adrenergic receptor gene polymorphism on prolongation of corrected QT interval during endotracheal intubation under sevoflurane anesthesia

박경수,Seong Bok Jang,권태동,Jun Ho Kim,한동우 대한마취통증의학회 2011 Korean Journal of Anesthesiology Vol.61 No.2

Background: The hemodynamic responses to endotracheal intubation are associated with sympathoadrenal activity. Polymorphisms in the beta1-adrenergic receptor (β_1AR) gene can alter the pathophysiology of specific diseases. The aim of this study is to investigate whether the Ser49Gly and Arg389Gly polymorphism of the β_1AR gene have different cardiovascular responses during endotracheal intubation under sevoflurane anesthesia. Methods: Ninety-one healthy patients undergoing general anesthesia were enrolled. Patients underwent slow inhalation induction of anesthesia using sevoflurane in 100% oxygen. Vecuronium 0.15 mg/kg was given for muscle relaxation. Endotracheal intubation was performed by an anesthesiologist. The mean arterial pressure (MAP),heart rate (HR), and the corrected QT (QTc) interval were measured before induction, before laryngoscopy, and immediately after tracheal intubation. Genomic DNA was isolated from the patients’ peripheral blood and then evaluated for the β_1AR-49 and β_1AR-389 genes using an allele-specific polymerase chain reaction method. Results: No differences were found in the baseline values of MAP, HR, and the QTc interval among β_1AR-49 and β_1AR-389, respectively. In the case of β_1AR-49, the QTc interval change immediately after tracheal intubation was significantly greater in Ser/Ser genotypes than in Ser/Gly genotypes. No differences were observed immediately after tracheal intubation in MAP and HR for β_1AR-49 and β_1AR-389. Conclusions: We found an association between the Ser49 homozygote gene of β1AR-49 polymorphism and increased QTc prolongation during endotracheal intubation with sevoflurane anesthesia. Thus, β_1AR-49 polymorphism may be useful in predicting the risk of arrhythmia during endotracheal intubation in patients with long QT syndrome.

단기간 기간내 삽관후 음성지표의 변화

남순열,봉성근,서영일,유화경,유승주 대한이비인후과학회 1999 대한이비인후과학회지 두경부외과학 Vol.42 No.10

이동 중 구급차에서 1급 응급구조사의 기관내 삽관

심규식(Shim, Gyu-Sik) 한국산학기술학회 2012 한국산학기술학회논문지 Vol.13 No.11

본 연구는 이동 중 구급차에서 응급구조사의 삽관자세 변화에 따른 시야의 높이 변화가 기관내 삽관의 신 속성에 영향을 미치는지 비교하고 환자의 삽관자세 변화가 기관내 삽관의 신속성에 영향을 미치는지 분석하여 심정 지 및 외상성 응급 환자에게 효과적인 전문기도관리를 시행하는데 목적이 있다. 연구대상은 C도 13개 소방서에 근무 하고 있는 1급 응급구조사 60(대조군30명, 실험군30명)명을 편의추출하여 시행하였으며, 자료 분석은 SPSS WIN 14.0 Version을 사용하여 하였다. 연구결과 전문기도관리의 신속성 향상을 위해서는 환자의 냄새맡기 자세와 주들것 과 응급구조사 시트 사이 공간에서의 기관내 삽관이 효과적일 것으로 사료되고 실험 후의 삽관 자신감이 유의하게 상승 하였으므로 전문기도관리의 효율성 향상을 위해서는 구급차 내에서의 삽관자세와 방법에 대한 지속적인 교육 (훈련)이 필요할 것으로 사료된다. The purpose of this study is to perform the effectively advanced airway management in an emergency patient with cardiac arrest and trauma by comparing the appearance of influence in a change of visual-field height upon endotracheal intubation according to a change in position with intubation of paramedics in a moving ambulance and by analyzing the appearance of the influence in a patient's change in position with intubation upon speed in endotracheal intubation. Research subjects were randomly extracted 60(30 people for control group, 30 people for experimental group) people as the paramedics who are working at 13 fire stations in C Province. Data analysis was carried out χ2-test, independent t-test, paired t-test by using SPSS WIN 14.0 Version. As a result of research, to improve speed of the advanced airway management, it is considered to be likely effective in a patient's sniffing position and in the endotracheal intubation in the upper space of the main stretcher. The self-confidence in intubation after experiment increased significantly. Thus, the continuous education(training) on the intubation position and method within ambulance is considered to be likely needed for improving efficiency of the advanced airway management.