CIS-ATRACURIUM WITH MASSETER MUSCLE SPASM: AN UNANTICIPATED DIFFICULT ENDOTRACHEAL INTUBATION AND TEMPOROMANDIBULAR JOINT DISPLACEMENT: A CASE REPORT

Masseter muscle spasm and displacement of temporomandibular joint under anaesthesia could be life threatening if an anaesthesiologist is not prepared. We present a case of 23 years old young lady, who otherwise healthy, having symptoms of abdominal pain and vomiting. Initial baseline workup showed a solitary gallstone and was then planned for urgent laparoscopic cholecystectomy. The challenges faced in the perioperative period were the management of unanticipated masseter muscle spasm and difficult endotracheal intubation after administration of cisatracurium, and temporomandibular joint displacement.

A predictive formula for difficult endotracheal intubation in the emergency department

Background Current predictors for evaluating difficult endotracheal intubation had poor accessibility or sensitivity at the emergency department, so we evaluated the incidence and predictive factors, then built an easy-to-use predictive formula. Methods This was a 17-month prospective observational study. For the 110 patients, difficult airway was defined as Cormack & Lehane classification grade III and IV at first attempt of intubation. The univariate associations between patient characteristics and difficult endotracheal intubation were then analyzed, and the significantly associated factors were included in a multivariate binary logistic regression model then a predictive formula was generated. Generalized association plot (GAP) was used to show the relationship between each variable. Results The incidence of difficult intubation in our study was 35.5%. In the difficult airway group, significantly higher rates (p < 0.05) of high body mass index (BMI); double chin; thick, short neck; Mallampati difficulty; smaller inter-incisors distance; smaller thyromental distance; and upper airway obstruction were noted. Finally, a predictive formula for difficult intubation was successfully established by the combination of four predictors: BMI (odds ratio [OR] = 1.270), thyromental distance (OR = 0.614), upper airway obstruction (OR = 4.038), and Mallampati difficulty (OR = 5.163). A cut-off score of 4 provided the best sensitivity (79.5%) and specificity (81.7%)(95% CI: 0.794 to 0.938). Conclusions Our predictive formula could be used by emergency physicians to quickly identify and carefully manage patients with potentially difficult intubation. Early expert consultation could be sought when necessary.

A Predictive Formula for Difficult Endotracheal Intubation in the Emergency Department

Background Current predictors for evaluating difficult endotracheal intubation had poor accessibility or sensitivity at the emergency department, so we evaluated the incidence and predictive factors, then built an easy-to-use predictive formula.Methods For the 110 patients, difficult airway was defined as Cormack & Lehane classification grade III and IV at first attempt of intubation. The univariate associations between patient characteristics and difficult endotracheal intubation were then analyzed, and the significantly associated factors were included in a multivariate binary logistic regression model then a predictive formula was generated. Generalized association plot (GAP) was used to show the relationship between each variables.Results The incidence of difficult intubation in our study was 35.5%. In the difficult airway group, significantly higher rates (p<0.05) of high body mass index (BMI); double chin; thick, short neck; Mallampati difficulty; smaller inter-incisors distance; smaller thyromental distance; and upper airway obstruction were noted. Finally, a predictive formula for difficult intubation was successfully established by the combination of four predictors: BMI (odds ratio [OR]=1.270), thyromental distance (OR=0.614), upper airway obstruction (OR=4.038), and Mallampati difficulty (OR=5.163). A cut-off score of 4 provided the best sensitivity (79.5%) and specificity (81.7%)(95% CI: 0.794 to 0.938).Conclusions Our predictive formula could be used by emergency physicians to quickly identify and carefully manage patients with potentially difficult intubation. Early expert consultation could be sought when necessary.Trial registration This 17-month (2011/11/1-2013/3/31) prospective observational study was approved by the Institutional Review Board of MacKay Memorial Hospital (11MMHISO64).

Predictors of difficult endotracheal intubation in the emergency department: a single-center pilot study

Background: Identifying patients who are at risk of difficult endotracheal intubation is crucial in the emergency department. Therefore, this study evaluated the incidence and predictive factors of difficult tracheal intubation in the emergency department. Methods: This was a 17-month prospective observational study. A difficult airway was defined as Cormack & Lehane classification grades III and IV at the first attempt of intubation. Patients who visited the emergency department, underwent traditional endotracheal intubation from participating physicians, and provided informed consent by themselves or via their delegates were enrolled in this study. Univariate associations between patient characteristics and difficult endotracheal intubation were identified, and statistically significant factors were included in a multivariate binary logistic regression model. A generalized association plot was used to show the relationships between variables. Results: A total of 110 patients were enrolled in the study. The incidence of difficult intubation was 35.5% (39/110). In the difficult airway group, significantly higher body mass index (BMI), and incidence of double chin, thick short neck, Mallampati difficulty, small interincisor distance, small thyromental distance, and upper airway obstruction were noted on univariate analysis. A predictive formula for difficult tracheal intubation was successfully established by the combination of four independent predictors: BMI (odds ratio [OR] = 1.270), thyromental distance (OR = 0.614), upper airway obstruction (OR = 4.038), and Mallampati difficulty (OR = 5.163). A cutoff score of four maximized Youden’s index, providing sensitivity (79.5%) and specificity (81.7%) (95% CI: 0.794 to 0.938). Conclusions: We used four predictors of difficult tracheal intubation, namely, BMI, thyromental distance, upper airway obstruction, and Mallampati difficulty, to create a predictive formula. This formula could help emergency physicians to quickly identify and carefully manage patients with difficult endotracheal intubation and consult experts early if necessary.

Comparison of Upper Lip Bite Test with Modified Mallampati Classification for Prediction of Difficult Endotracheal Intubation

with the full text.