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This study is aimed to conduct a randomised controlled trial comparing endotracheal intubation (ETI) in bed up head elevation BUHE position versus sniffing position in simulated rapid sequence induction (RSI).
Objective is to determine if the time taken for intubation in the bed up head elevated position is non-inferior to time taken for intubation in the sniffing position.
The hypotheses:
Terminology:
Direct laryngoscopy (DL) and Endotracheal intubation (ETI): Is a method of inserting a breathing tube into the trachea (windpipe) once patient undergo general anaesthesia.
Bed up head elevation (BUHE): Bed up at 20-30 degree aiming alignment between the external auditory meatus with sternal notch.
Sniffing position: Maintaining supine position with head elevation with head rest.
Rapid sequence induction (RSI): An established method of inducing anaesthesia in patients who are at risk of aspiration of gastric contents into the lungs. It involves loss of consciousness during cricoid pressure followed by intubation without face mask ventilation. The aim is to intubate the trachea as quickly and as safely as possible.
POGO score: Percentage of glottic opening
Cricoid Pressure (CP): Maneuvre to prevent regurgitation of gastric contents during induction of anaesthesia by temporary occlusion of the upper end of the esophagus by backward pressure of cricoid cartilage against bodies of cervical vertebrae.
All patients from age 18 years old to 75 years old undergoing elective surgery under general anaesthesia in operating theater of University Malaya Medical Centre over a period of 15 months, from April 2018 to June 2019 will be included and recruited based on inclusion and exclusion criteria.
Those patient that fulfilled the criteria and consented for the study will be randomized to 2 group.
i) BUHE group: Bed up at 20-30 degree aiming alignment between the external auditory meatus with sternal notch.
ii) Sniffing group: Maintaining supine position with head elevation with head rest (foam donut).
Induction of anaesthesia starts with:
(IV Fentanyl 2mcg/kg,IV Propofol 2-3mg/kg,IV Rocuronium 1mg/kg).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Sniffing position | No Intervention | Subject will be maintained in standard intubation position which is supine position with head elevation with head rest (foam donut). | |
| Bed up head elevation position | Experimental | Subject will be maintained at bed up 20-30 degree aiming alignment between the external auditory meatus with sternal notch |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| comparison between two different intubating position | Other | Comparing to different position (sniffing and BUHE) in endotracheal intubation for rapid sequence induction in simulated emergency cases |
| Measure | Description | Time Frame |
|---|---|---|
| Time in seconds measured from when the laryngoscopy blade passes through the incisors to the first measured end tidal CO2 wave | Measured from when the laryngoscopy blade passes through the incisors to the first measured end tidal CO2 wave | Intraoperatively , during induction of anaesthesia |
| Measure | Description | Time Frame |
|---|---|---|
| Number of laryngoscopy and intubation attempt | Number of attempts taken by investigator to obtain successful endotracheal intubation in both arms | Intraoperatively , during induction of anaesthesia |
| Laryngeal exposure measured via POGO score |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Shahmini Ganesh, MD | Contact | 0379492052 | shahminig2805@gmail.com | |
| Samuel Tsan Ern Hung, MD | Contact | 0379492052 | samuel.tsan@gmail.com |
| Name | Affiliation | Role |
|---|---|---|
| Shahmini Ganesh, MD | UMMC | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University Malaya Medical Centre | Recruiting | Kuala Lumpur | Kuala Lumpur | 59100 | Malaysia |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 12568178 | Background | Brodsky JB. Positioning the morbidly obese patient for anesthesia. Obes Surg. 2002 Dec;12(6):751-8. doi: 10.1381/096089202320995510. | |
| 13749923 | Background | SELLICK BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961 Aug 19;2(7199):404-6. doi: 10.1016/s0140-6736(61)92485-0. No abstract available. |
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Individual participant data that already summarized and analysed in the form of schematic diagram will be available to other researchers
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Only participant is masked from knowing the assigned group
Percentage of glottic opening during laryngoscopy
| Intraoperatively , during induction of anaesthesia |
| Occurrence of difficult intubation | Defined as ≥3 attempts at intubation | Intraoperatively , during induction of anaesthesia |
| Occurrence of hypoxia | Hypoxia defined as pulse oximetry reading less than 95 percents | Intraoperatively , during induction of anaesthesia |
| The use of any other airway adjunct or external laryngeal manipulation to assist in intubation | Change of blade size, bougie, magill forcep, video assisted laryngoscope,external laryngeal manipulation (Use of any airway adjunct is grouped as one) | Intraoperatively , during induction of anaesthesia |
| Occurrence of esophageal intubation | Unsuccessful intubation into esophagus | Intraoperatively , during induction of anaesthesia |
| Occurrence of airway trauma | broken tooth, bleeding or injury from oral cavity, tongue or lips, etc | Intraoperatively , during induction of anaesthesia |
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