Ossigenazione ed intubazione per sia 2010 ultima versione 2 dic

Sicurezza in
anestesia:preossigenazi
one ed intubazione
Claudio Melloni
Anestesista libero professionista
Bologna

Scopo della lettura
• Dimostrare la utilità della preossigenazione;deve
essere obbligatoria sempre!
• Ricordare … la rapidità della di desaturazione in
apnea,dopo preossigenazione;(figuriamoci senza…!)
• Mostrare i tempi di apnea dopo succinilcolina e della
combinazione rocuronium/sugammadex.
• Dimostrare la difficoltà della ripresa del respiro
spontaneo dopo antagonismo nella situazione ci/cv
• Indicare sequenze induttive “sicure” dal punto di
vista della respirazione con diverse combinazioni di
(propofol) e remifentanil

Definizione di IPOSSIEMIA
• SaO2 <90 (correlata a PaO2 <60 mmHg)
• Severa quando SaO2<85%
– Xue FS, Huang YG, Tong SY, et al. A comparative study of early postoperative hypoxemia in
infants, children, and adults undergoing elective plastic surgery. Anesth Analg 1996; 83: 709-
15.
– Xue FS, An G, Tong SY, Liao X, Liu JH, Luo LK. Influence of surgical technique on early
postoperative hypoxaemia in children undergoing elective palatoplasty. Br J Anaesth 1998;
80: 447-51.
– Cote CJ, Rolf N, Liu LM, et al. A single-blind study of combined pulse oximetry and
capnography in children. Anesthesiology 1991; 74: 980-7.

• intraoperative hypoxemia
occurs at a significant rate.
• 7.9% (> 20.000 pts) Moller JT, Johannessen NW,
Espersen K, et al. Randomized evaluation of pulse oximetry in 20, 802 patients: II.
Perioperative events and postoperative complications. Anesthesiology 1993;78: 445-53.-
• 7.2-9.3%(>95000 pts) Ehrenfeld JM, Funk LM, Van
Schalkwyk J, et al. The incidence of hypoxemia during surgery: evidence from two
institutions. Can J Anesth 2010; 57: 877–881.

The distribution of SpO2 readings from the 95,407 anesthesia cases. Of the 15,985,965
SpO2 readings, 99.63% were within the normal range (>90%) and 0.37% of all readings
represented values <90%
Ehrenfeld JM, Funk LM, Van Schalkwyk J, et al. The incidence of hypoxemia during surgery: evidence from two institutions. Can J Anesth 2010;
57: 877–881.

Ehrenfeld JM, Funk LM, Van Schalkwyk J, et al. The incidence of
hypoxemia during surgery: evidence from two institutions. Can J
Anesth 2010; 57: 877–881.
induction maintenance emergence
Patient % with
saO2<90%
7,4 7,2 9,3
Patient % with
SaO2<85%
4,1 3,8 5,4
Patient %
experiencing
hypoxemia > 2 min
1,6%
Patient %
experiencing severe
hypoxemia > 2 min
0.8%

Conclusions from study:
Ehrenfeld JM, Funk LM, Van Schalkwyk J, et al. The incidence of hypoxemia during surgery:
evidence from two institutions. Can J Anesth 2010; 57: 877–881
• Our data suggest that a surprisingly high percentage of
patients experience sustained hypoxemia during surgery.
• Even in highly advanced surgical settings, approximately 1/ 15
patients experienced hypoxemia for at least 2 consecutive
minutes, and 1/64 patients experienced hypoxemia for at
least 5 consecutive minutes.
• These frequencies are likely higher in resource-limited settings
throughout the world where pulse oximetry is often
unavailable, and hypoxemia may not be recognized by the
perioperative team.

Do transient hypoxemic events impact on
outcomes?
• Reduced cerebral oxygen saturation levels have been
correlated with higher postoperative complication
rates in thoracic surgery.
– Kazan R, Bracco D, Hemmerling TM. Reduced cerebral oxygen saturation measured
by absolute cerebral oximetry during thoracic surgery correlates with
postoperative complications. Br J Anaesth 2009; 103: 811-6 27
Perioperative administration of supplemental
oxygen has been shown to reduce the
incidence of surgical-wound infections,
• Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the
incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000; 342:161-
7.
• Belda FJ, Aguilera L, Garcia de la Asuncion J, et al. Supplemental perioperative oxygen and the
risk of surgical wound infection: a randomized controlled trial. JAMA 2005; 294: 2035- 42.

Benefits of supplemental periop oxygen
• improve immune function
– Kotani N, Hashimoto H, Sessler DI, et al. Supplemental
intraoperative oxygen augments antimicrobial and
proinflammatory responses of alveolar macrophages.
Anesthesiology 2000; 93:15-25.
• decrease the incidence of PONV :
– Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI. Supplemental
oxygen reduces the incidence of postoperative nausea and
vomiting. Anesthesiology 1999; 91: 1246-52.

Effects of hypoxemia
• Animal models:
• acute heart failure:Cross CE, Rieben PA, Barron CI, Salisbury PF. Effects of arterial hypoxia on the heart and circulation: an integrative study. Am J
Physiol 1963; 205: 963-70.
• pulmonary hypertension:Zielinski J. Effects of intermittent hypoxia on pulmonary haemodynamics: animal models versus studies in humans.
Eur Respir J 2005; 25: 173-80.
• acute renal failure: Brezis M, Rosen S. Hypoxia of the renal medulla–its implications for disease. N Engl J Med
1995; 332: 647-55.
• decreased cognitive function:D, Daniel JM, Dohanich GP. Behavioral and anatomical correlATES OF of
chronic episodic hypoxia during sleep in the rat.J Neurosci 2001; 21: 2442-50.
• Humans:
• even modest fluctuations in oxygen delivery may lead to cognitive dysfunction.
– Bass JL, Corwin M, Gozal D, et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the
evidence. Pediatrics 2004; 114: 805-16.
• intraoperative desaturation (measured by cerebral oxygen monitoring) with a
decline in postoperative cognitive function (POCD).
– Casati A, Fanelli G, Pietropaoli P, et al. Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing
major abdominal surgery minimizes brain exposure to potential hypoxia. Anesth Analg 2005; 101: 740-7.
• patients who experienced a drop in cerebral oxygen levels of C 25% were found to
have a statistically significant decline in their Mini Mental State Examination scores
measured seven days after surgery.5-12% of patients demonstrate POCD at three-
month follow-up visits:Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction

Damaging events associated with death and permanent brain
damage(1986-2000,1414 cases) Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB.
Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology 2006;
105: 1081-6
Resp damaging event num % of total
resp.events
Less than
appropriate care
%
Difficult intubation 115 23 50
Inadeg oxygenation/ventilation 111 22 74
Esophageal intub 66 13 91
Premature extub. 58 12 81
aspiration 50 10 42
Airway obstruction 47 9 53
Other resp 50 11 52
total 503 100 64

Respiratory and cardiovascular claims as a % of total death and
brain damage claims Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends in
anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology 2006; 105: 1081-6

Ossigenazione:
oxygen delivery
• DO2(ml/min)=CO(ml/min*Hb(
gr/lt)*SaO2*1.34(mlO2/grHb)

Approximate FiO2 delivered by nasal
cannula
• Flow rate lt/min approx FiO2
• 1 0.24
• 2 0.28
• 3 0.32
• 4 0.36
• 5 0.40

Approximate FiO2 delivered by face
mask
• 5-6 0.40
• 6-7 0.50
• 7-8 0.60
• A minimum flow of 5-6 lt/min necessary to prevent
rebreathing

Berry, C. B.; Myles, P. S.Preoxygenation in healthy
volunteers: a graph of oxygen ''washin'' using end–tidal
oxygraphy .Br. J. Anaesth. 1994; 72:116-118 .

The 3 reservoirs of low flow O2 therapy
Pharynx
Mask
Reservoir bag

Approximate FiO2 delivered by face
mask with reservoir
• 6 0.60
• 7 0.70
• 8 0.80
• 9 >0.80
• 10 >0.80

Some (simple)calculation:
• O2 flow :6 lt/min
• Mask (dead) space:50 ml
• Pharynx (dead) space:50 ml
• TV:500 ml
• RR:20/min,I/E ratio ½
• Insp time:1 sec
• O2 flow/sec= 100 ml
• In the next inspiration( 1 sec) the patient will get 500
ml,of which 50 ml(mask)+ 50 ml (pharynx) + 100 ml (O2
flow in 1 sec) of pure Oxygen:
• Then 200 ml of FiO2 =1 and 300 ml of FiO2= 0.21:Total
260 ml of O2= FinspO2=260/500=0.52 FiO2

Some working variables
• Higher O2 flows may increase FiO2
• Lower TV increase FiO2
• Larger TV decrease FiO2
• Faster RR decrease FiO2
• Lower RR increase FiO2
• L’equazione completa è un integrale………..

Vt 250 ml,mask
• Mask (dead) space:50 ml
• TV:250 ml
• Insp time:1 sec
ml,of which 50 ml(mask)+ 50 ml (pharynx) + 100 ml
(O2 flow in 1 sec) of pure Oxygen:
• Then 200 ml of FiO2= 1 and 50 ml of FiO2 = 0.21:Total
210 ml of O2= FinspO2=210/250=0.84 FiO2

VT 500 ml,nasal cannula
• Nasal cannula:no (dead) space
• TV:500 ml
• Insp time:1 sec
ml,of which 0 from cannula+ 50 ml (pharynx) + 100 ml
(O2 flow in 1 sec) of pure Oxygen:
• Then 150 ml of FiO2 = 1 and 350 ml of FiO2 = 0.21:Total
150 +73,5 ml of O2= FinspO2=223/500=0.44 FiO2

NON TUTTI I SISTEMI SONO
EGUALI….

Tidal volume breathing with the Vital Signs and the Sims bags resulted in significantly lower inspired
O2 than the Laerdal, Kirk, and Ruben valve bags. During the 5-min period, the inspired O2 for these
two bags never exceeded 40%. Duck bill without exhalation valves

Canadian recommendations:
Tanoubi I, Drolet P, Donati F.Optimizing preoxygenation in adults. Can J Anaesth. 2009
;56:449-66.).
•3 min or 8 deep breaths
(max.Vt)
•No 4 DB…

New equipment to prevent carbon dioxide rebreathing during eye
surgery under retrobulbar anaesthesia.Schlager A, Staud H
Br J Ophthalmol. 1999 Oct;83(10):1131-4

Farmery, A. D.; Roe, P. G.A Model to describe the rate of
oxyhaemoglobin desaturation during apnoea . Br. J. Anaesth. 1996;
76:284-291
• a model to describe the rate of oxyhaemoglobin desaturation during apnoea.
• This model takes into account the non–steady–state kinetics which pertain to this
situation.
• We first derived a mathematical expression for instantaneous oxygen flux rate from the
alveolar compartment.
• We then derived an expression to describe the effect of shunt on this flux.
• The effect of circulation time on real–time arterial mixed venous oxygen content
difference and oxygen flux in the lung was determined graphically.
• We finally described a manoeuvre to accommodate the effect of the Bohr shift which is
related to the increase in FACO2 during apnoea.
• We present plots of arterial oxyhaemoglobin saturation (SaO2) vs duration of apnoea to
illustrate the individual effects of the initial fractional concentration of oxygen in the
alveolus (FAO2initial), alveolar volume (VA), shunt fraction (S/T), oxygen consumption
rate (O2), total blood volume (QT) and haemoglobin concentration (Hb). The model is
illustrated by examples of paediatric, morbidly obese and postoperative scenarios. The
postoperative scenario is particularly notable for the effect of a combination of small
changes in individual variables leading to a large overall effect on the rate of
oxyhaemoglobin desaturation.
•

oxyhaemoglobin desaturation during apnoea
Farmery, A. D.; Roe, P. G.A Model to describe the rate of oxyhaemoglobin desaturation during apnoea . Br. J. Anaesth.
1996; 76:284-291

oxyhaemoglobin desaturation during apnoea
Farmery, A. D.; Roe, P. G.A Model to describe the rate of oxyhaemoglobin desaturation during
apnoea . Br. J. Anaesth. 1996; 76:284-291

Time(sec) to oxyhaemoglobin desaturation 85% during
apnoea(Dati da Farmery & Roe)
0
50
100
150
200
250
300
350
400
450
500
adulto
bimbo 10 kg
obeso 127 kg
no preO2
preO2

Effect of initial lung volume and initial FAO2 on SaO2 time
course during apnea

Effect of Hb concentration and total blood volume on SaO2
time course during apnea
Farmery, A. D.; Roe, P. G.A Model to describe the rate of oxyhaemoglobin desaturation during apnoea .
Br. J. Anaesth. 1996; 76:284-291

Effect of shunt fraction and O2 consumption on SaO2 time
course during apnea

Hardman, Jonathan G., Wills, Jonathan S., Aitkenhead, Alan R.,
Factors Determining the Onset and Course of Hypoxemia During
Apnea: An Investigation Using Physiological Modelling. Anesth
Analg 2000; 90:619–
• ABSTRACT: We used the Nottingham Physiology Simulator to examine the onset and
course of hypoxemia during apnea after pulmonary denitrogenation. The following
factors, as possible determinants of the hypoxemia profile, were varied to examine their
effect: functional residual capacity, oxygen consumption, respiratory quotient,
hemoglobin concentration, ventilatory minute volume, duration of denitrogenation,
pulmonary venous admixture, and state of the airway (closed versus open). Airway
obstruction significantly reduced the time to 50% oxyhemoglobin
saturation (8 vs 11 min). Provision of 100% oxygen rather than air
to the open, apneic patient model greatly prolonged time to 50%
oxy-hemoglobin saturation (66 vs 11 min).
• Hemoglobin concentration, venous admixture, and respiratory quotient had small,
insignificant effects on the time to desaturation. Reduced functional residual capacity,
short duration of denitrogenation, hypoventilation, and increased oxygen consumption
significantly shortened the time to 50% oxyhemoglobin saturation during apnea.
Implications: Reduction in oxygen levels during cessation of breathing is dangerous and
common in anesthetic practice. We used validated, mathematical, physiological models
to reveal the impact of physiological factors on the deterioration of oxygen levels. This
study could not be performed on patients and reveals important information.
•

Effect of varying denitrogenation time on hypoxemia profile during apnea with
a closed or open airway.
SaO2 90
SaO2 90

Effect of varying oxygen consumption on hypoxemia profile during apnea with a
closed or open airway
SaO2 90
SaO2 90

Effect of varying FRC on hypoxemia profile during apnea with a closed
or open airway
SaO2 90
SaO2 90

Effect of varying Ventilatory minute volume preceding apnea on
hypoxemia profile during apnea with a closed or open airway
SaO2 90
SaO2 90

DISCREPANZA MODELLI-REALTÀ
CLINICA

Apnea time to reach a critical SaO2 endpoint(89-91)(from
Benumof ,Anesthesiology 87:979-82, 1997)

Come ritardare l’ipossiemia durante
apnea?
• Apneic Diffusion Oxygenation.
• Baraka, Anis, Salem, M. Ramez, Joseph, Ninos J., Benumof, Jonathan L. Critical
Hemoglobin Desaturation Can Be Delayed by Apneic
Diffusion Oxygenation.Anesthesiology 90:332-33, 1999.
• Transcricoid oxygen insufflation
– insert a 2-inch 16-gauge catheter through the cricothyroid membrane preinduction, electively,
using local anesthesia and achieve apneic oxygenation by insufflation of oxygen through this
catheter. In addition, the transcricothyroid-membrane, 16-gauge catheter provides an immediate-
ventilation plan B by connection to a jet ventilator preset at 25 psi using a 0.5-s inspiratory tim

Insufflare O2 attraverso cannula…..
• Manujet™ and the ENK Oxygen Flow Modulator™
(ENK)
• Anesth Analg. 2010 ;111:922-4..Oxygen delivery during transtracheal oxygenation: a comparison of two manual
devices.Lenfant F, Péan D, Brisard L, Freysz M, Lejus C.
• Pressures available for transtracheal jet ventilation from
anesthesia machines and wall-mounted oxygen flowmeters.
– Anesth Analg. 2010 ;110:94-100.Pressures available for transtracheal jet ventilation from anesthesia machines and wall-mounted
oxygen flowmeters.Fassl J, Jenny U, Nikiforov S, Murray WB, Foster PA.
• Can an anesthesia machine flush valve provide for effective
jet ventilation?
– Gaughan SD, Benumof JL, Ozaki GT.Can an anesthesia machine flush valve provide for effective jet ventilation? Anesth
Analg. 1993 Apr;76(4):800-8.
• Bould MD, Bearfield P.Techniques for emergency ventilation
through a needle cricothyroidotomy. Anaesthesia. 2008
May;63(5):535-9

Ma … l’ossigenazione fa
sempre bene?

Atelectasis increase with FiO2(CT scan above the
diaphragm)

Anche loro confermano… Edmark L, Kostova-Aherdan K, Enlund, M, Hedenstierna G.Optimal
Oxygen Concentration during Induction of General Anesthesia Anesthesiology 98:28-33, 2003

Clinical endpoints indicating optimal
denitrogenation/oxygen saturation:
• Clinical endpoints that indicate a sealed
system :
– movement of the reservoir bag in and out with
each inhalation and exhalation
– presence of a normal capnogram and an end-tidal
partial pressure of carbon dioxide (PETCO2)
– End tidal oximetry indicating appropriate inspired
and end-tidal values(0.85-0.90)
• SaO2 100%.

Time to reach SaO2 90 vs % of ideal body weight
Jense, Holly G., Dubin, Stevin A.,Silverstein, Paul I., O'Leary-Escolas, Una.Effect of Obesity on Safe Duration of Apnea in
Anesthetized Humans.Anesth Analg 1991; 72:89–93
80 120 160 200 240
100
200
300
400
preoxygenated for 5 min or until expired nitrogen
was <5%.
induction of anesthesia
muscle relaxation
Patients apneic until arterial saturation eached 90%.

Times to arterial desaturation :normal, within 20% of
their ideal body weight. Obese, > 20% but less than 45.5 kg over ideal body weight;morbidly
obese > 45.5 kg over ideal body weight. Jense, Holly G., Dubin, Stevin A.,Silverstein, Paul I., O'Leary-Escolas, Una.Effect of
Obesity on Safe Duration of Apnea in Anesthetized Humans.Anesth Analg 1991; 72:89–93
0
50
100
150
200
250
300
350
400
time to reach SaO2 90
normal
obese
morbid obese
Sec:

PEEP 10 during spont.resp * 5 min + IPPV with PEEP 10 * 5 min
before apnea up to 92%. Positive End-Expiratory Pressure During Induction of General
Anesthesia Increases Duration of Nonhypoxic Apnea in Morbidly Obese Patient.
Anesth Analg 2005; 100:580-4.Gander S,Frascarolo P,Suter M, Spahn DR., ,Magnusson Ls

Correlation between BMI and duration of nonhypoxic apnea.
Anesth Analg 2005; 100:580-4.
Gander S,Frascarolo P,Suter M, Spahn DR ,Magnusson Ls
Non PEEP!

preO2 with 8 deep breaths * 60 s (O2 10 litre min-1.) After rapid sequence induction
of anaesthesia in decubitus position, the trachea was intubated and the patient was
left apneic and disconnected from the anaesthesia circuit until SpO2 decreased to
90%.
Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea . Altermatt F R,Muñoz HR,Delfino
AE,Cortínez LI. Br. J. Anaesth. 2005; 95:706-709

The “Intubating Dose” of Succinylcholine.
The Effect of Decreasing Doses on Recovery Time The “Intubating Dose” of Succinylcholine.
The Effect of Decreasing Doses on Recovery Time Kopman AF,Zhaku B,Lai KS.Anesthesiology,99:1050-4, 2003
0.4 mg/kg 0.6 mg/kg 1 mg/kg
Max effect 105 ± 23 s ** 81 ± 19 s 71 ± 22 s,
T190% recovery 6.6 ± 1.5 min 7.6 ± 1.6 min 9.3 ± 1.2 min
**:did not reliably
produce 100%
twitch depression

Tabella sulla qualità della intubazione durata della
apnea(min),onset(sec) e dosaggi di succinilcolina (mg/kg)
autore Dose di
succi
Apnea durata Qualità iot onset osservazioni
Kopman 2003 0.4 6.6 ± 1.5 min,. modesta 105 ± 23 s, desflurano
0.6 7.6 ± 1.6 min, ok 81 ± 19 s,
1 9.3 ± 1.2 min, ok 71 ± 22 s
Naguib 2005 0.56 4.8 +/- 2.5, ok SaO2<90 in 65%
1 4.7 +/- 1.3 Ok SaO2<90 in 85%
Heier 1 5.2+1.8 No Disturbi
emozionali in
volontari
40%(tiopentale)

Tempi di ripresa in min.dopo succi 1 mg/kg
Benumof J. Preoxygenation: Best Method for Both Efficacy and Efficiency.
Anesthesiology 91:603-5, 1999.)
Tempi di ripresa al
10%
Tempi di ripresa al 50% Tempi di ripresa al 90% Ripresa 10-
90%/min
6.8
(5.6—7.2)
8.5
(7.8—10.1)
10.2
(9.3—12.1)
25%
/min

Morale:
• In caso di ci/cv
• una media di 8.5 min per la ripresa al 50%
dopo succi 1 mg/kg
• Significa…
•††opp decerebrazione……….

ALTERNATIVE ALLA
SUCCI:ROCURONIUM

Perry JJ, Lee JS, Sillberg VAH, Wells GA.Rocuronium versus succinylcholine
for rapid sequence induction intubation (Review) The Cochrane
Library,2009, Issue 4,http://www.thecochranelibrary.com
• analisi sistematica :
• il rocuronium è statisticamente inferiore alla
succinilcolina sia nei punteggi di intubazione
espressi come “eccellente” sia “clinicamente
accettabili”

Rocuronium versus succinylcholine for rapid sequence
induction intubation (Review).
Perry JJ, Lee JS, Sillberg VAH, Wells GAThis is a reprint of a Cochrane review,
prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 4
• Authors’ conclusions
• Succinylcholine created superior intubation conditions to rocuronium when comparing both excellent
and clinically acceptable intubating conditions.
• P L A I N L A N G U A G E S U M M A R Y
• Comparison of two muscle relaxants, rocuronium and succinylcholine, to facilitate rapid sequence
induction intubation
• In emergency situations some patients need a general anaesthetic with an endotracheal tube (tube to help them breathe). It is
important to have fast acting medications to allow physicians to complete this procedure quickly and safely. Currently, the muscle
relaxant medication most often used to accomplish this is succinylcholine. Succinylcholine is fast acting and lasts for only a fewminutes
which is very desirable in this setting. However, some patients cannot use thismedication as it can cause serious salt imbalances or
reactions, so an equally effective medication without these side effects is desired. This meta-analysis compared
one possible alternative, rocuronium, for the quality of intubation conditions (the
ease with which physicians can quickly and safely pass the endotracheal tube). In
this review, we have combined the results of 37 studies, with a total of 2690
patients, which compared the effects of succinylcholine versus rocuronium on
intubation conditions. We have found that rocuronium is less effective than
succinylcholine for creating excellent intubation conditions. Rocuronium should
therefore only be used as an alternative to succinylcholine when it is known that
succinylcholine should not be used.

Rocuronium duration of action and
onset ………
• Ovviamente non possiamo aspettare la ripresa
spontanea dopo la dose”intubante” di
nessuno dei miorilassanti competitivi
attualmente in commercio ……….

Utilità del sugammadex
• nel rovesciamento di un blocco profondo,definito come
blocco neuromuscolare non esplorabile con il TOF,ma solo
con il PTC 1-2;
– Rex C, Wagner S, Spies C, Schol J, Rietbergen H, Heeringa M,
Wulf H. Reversal of Neuromuscular Blockade by Sugammadex
after Continuous Infusion of Rocuronium in Patients
Randomized to Sevoflurane or Propofol Maintenance
Anesthesia.Anesthesiology 2009; 111:30–5
– Groudine SB, Soto R, Lien C, Drove D, Roberts K, Randomized,
Dose-Finding, Phase II Study of the Selective Relaxant Binding
Drug, Sugammadex, Capable of Safely Reversing Profound
Rocuronium-Induced Neuromuscular Block. Anesth Analg
2007;104:555–62.
•

Rex C, Wagner S, Spies C, Schol J, Rietbergen H, Heeringa M, Wulf H. Reversal of
Neuromuscular Blockade by Sugammadex after Continuous Infusion of Rocuronium in Patients
Randomized to Sevoflurane or Propofol Maintenance Anesthesia.Anesthesiology 2009; 111:30–5

Antagonismo con sugammadex a diversi dosaggi(mg/kg
)somministrato 3 min dopo rocuronium a diversi dosaggi(mg/kg)
Autore e anno Dose di rocu Dose di
sugammadex
Tof raggiunto Media e(ds)
min.
mediana range
Sparr 2007 0.6 4 0.70 2.1(0.5)
6 1.3(0.5)
8 1.2(0.3)
Puhringer 2009 1.2 8 2.4(0.9) 2.6 0.8-4
12 1.6(0.8) 1.3 1-3.6
16 1.2(0.2) 1.3 0.8-1.5
Gjisenbergh
2007
0.6 4 0.90 2.6/3.3
(2 pazienti) 8 1.2/1.0
Lee 2009 1.2 16 0.70 1.3(0.6)
De Boer 2007 1.2 8 0.90 2.8(0.6) 2.5 2.2-3.7
12 1.4(0.3) 1.3 1-1.9
16 1.9(2.2) 1.3 0.7-6.9

Lee C, Jahr JS, Candiotti KA, Warriner B, Zornow MH, Naguib M..Reversal of
profound neuromuscular block by sugammadex administered three minutes
after rocuronium: a comparison with spontaneous recovery from
succinylcholine..Anesthesiology. 2009 ;110:1020-5

TANTO PER FARE UN CONFRONTO
CON LA TRADIZIONE……

Sugammadex Reversal of Rocuronium-Induced
Neuromuscular Blockade: A Comparison with Neostigmine–
Glycopyrrolate and Edrophonium–Atropine. Anesth Analg.
2007 Mar;104(3):569-74. Sacan O, White PF, Tufanogullari B, Klein K

Fattore tempo
• A favore :
– Lavori pubblicati con sugammadex di salvataggio iniettato 3 min
dopo rocuronium;si potrebbe anticipare a 1,5-2
min,immediatamente dopo aver riconosciuto la condizione c/i/cv……
– Supponiamo che basti un tof 0.70 per una respirazione efficace…
• Ali HH, Wilson RS, Savarese JS, et al: The effect of tubocurarine on indirectly elicited train-of four muscle
response and respiratory measurement in humans. Br J Anaesth 47:570-574, 1975.)
• Brand JB, Cullen DJ, Wilson NE, Ali HH.Spontaneous recovery from nondepolarizing neuromuscular blockade:
correlation between clinical and evoked responses. Anesth Analg. 1977 ;56:55-8. )
• a sfavore:
– Sugammadex flaconcini da 100 mg/ml,da 2 e 5 ml(Bridion( R)
– per sommistrare la dose efficace più alta,16 mg/kg ,cioè 1120 mg per il nostro paziente tipo di 70 kg
– sarà necessario aspirare 3 flaconcini del prodotto commerciale,ed iniettare
rapidamente…
– Costi??? ,:il prezzo del Bridion(Bridion 2 ml:100 mg/ml 1221 euro,10 flaconcini;Bridion 5 ml ,cioè
500 mg ,3053 euro ,10 flaconcini ) essendo di 122 euro per il flacone da 200 mg e 305 per quello da
500 mg,il costo dei 1120 mg sarebbe di:122 +305+305=732 euro.-
– bisogna aspirare in una siringa da 20 ml 3 flaconcini ed iniettarli.
– Un anestesista allenato ( e non può essere che un secondo professionista,
chè il I sta tentando di ventilare,ossigenare e forse preparare la
cricotirotomia o altro.) quanto impiega ?

Ma ….l’anestesia dove è?
• Miorisoluzione…….
• Ipnosi
• Analgesia
• Protezione dai riflessi

Concentrazioni soglia di remifentanil(nanogr/ml) alle quali si
mantiene un respiro spontaneo
• Lee:1.5-2
– Lee B, Lee JR, Na S..Targeting smooth emergence: the effect site concentration of
remifentanil for preventing cough during emergence during propofol-remifentanil
anaesthesia for thyroid surgery. Br J Anaesth. 2009 ;102:775-8.
• Niewenhuijs:1 propofol microgr/ml e 1 remifentanil
(<2 per remif da solo)
– Nieuwenhuijs, DJ F, ,Olofsen E,Romberg RR, Sarton E, Ward D, Engbers F, et
al.Response Surface Modeling of Remifentanil—Propofol Interaction on
Cardiorespiratory Control and Bispectral Index . Anesthesiology 2003 ;98:312-22.
• Glass: 1.2 (CI 0.95—1.45)
– Egan TD, Minto CF, Hermann DJ, Barr J, Muir KT, Shafer SL: Remifentanil versus
alfentanil: comparative pharmacokinetics and pharmacodynamics in healthy adult
male volunteers. ANESTHESIOLOGY 1996; 84:821-33.
• Nho:1.5
– Nho JS, Lee SY, Kang JM, Kim MC, Choi YK, Shin OY, Kim DS, Kwon MI. Effects of
maintaining a remifentanil infusion on the recovery profiles during emergence from
anaesthesia and tracheal extubation. Br J Anaesth. 2009 Dec;103(6):817-21

Concentrazioni soglia di fentanil(nanogr/ml) alle quali si
mantiene un respiro spontaneo
• 1.5-2:letteratura
• 2.9 (but < 10 RR /min)
• Eur J Anaesthesiol. 2005 Jan;22(1):56-61.Target-controlled
infusion of remifentanil or fentanyl during extra-corporeal
shock-wave lithotripsy.Cortínez LI, Muñoz HR, De la Fuente
R, Acuña D, Dagnino JA.

Tempo
0
100 mcg
Fentanile
1
1mg/kg Succinilcolina
2 mg/kg Propofol
2,5
Per Risveglio occorre:
Propofol < 1 – 1.6 µg /ml
8
6
SUCCINILCOL.Recupero 50%
miorisoluzione da succinilcolina
1,2 mg/kg Rocuronio
2 mg/kg Propofol
SUG
16mg/kg
Recupero
Succinilcolina (naguib;
Hereir)
TOF 0,9 (Lee)
TOF 0,7 (Sparr)
9
TOF 0,9 (Sparr)
recupero
succinilcolina
Sa O2 = 80 % apnea per:
•Paziente adulto sano 8.7 ‘
•Bambino 10 Kg sano 3.7 ‘
•Paziente adulto obeso 3.1 ‘
Succi.Vs Roc.
T 2 NON si Intuba !
T 2,5 NON si Ventila !
3 5 8,5
2

Chinese Medical Journal 2009;122(13):1507-1512 1507
Median effective dose of remifentanil for awake laryngoscopy and
intubation.XU Ya-chao, XUE Fu-shan, LUO Mao-ping, YANG Quan-yong, LIAO Xu,
LIU Yi and ZHANG Yan-ming
midazolam 0.1 mg/kg +atropine 0.01 mg/kg
Posterior pharynx anesthetized with 3 intra-oral lidocaine
sprays (10 mg per spray).
10’ min after midaz bolus remifentanil
over a 30 sec

Rai MR, Parry TM, Dombrovskis A, Warner OJ.Remifentanil target-
controlled infusion vs propofol target-controlled infusion for conscious
sedation for awake fibreoptic intubation: a double-blinded randomized
controlled trial. Br J Anaesth. 2008; 100:125-30 .
• The mean effect-site concentration for the
remifentanil group :
• 3.2 (2.8–3.5) ng ml
• No episodes of desaturation(but O2
supplementation during the procedure)

Marie T. Aouad,Achir A. Al-Alami, Viviane G. Nasr,Fouad G. Souki,
Reine A. Zbeidy, Sahar M. Siddik-Sayyid, The Effect of Low-Dose Remifentanil
on Responses to the Endotracheal Tube During Emergence from General
Anesthesia., Anesth.Analg.. 108;2009,1157-60
• End of nasal surgery
• remifentanil infusion rate during emergence
ranged between 0.01 and 0.05 microg /kg/min.
mean 0.014 +- 0.011 microg/kg/min.
• Spont resp.

Remifentanil for awake intubation
• Various combination of
midazolam,atropine,topical anesthesia
• Remif infusion:2-5 microgr/min
– Anaesthesia. 2010 May;65(5):525-8.Awake tracheal
intubation using the Sensascope in 13 patients with
an anticipated difficult airway.Greif R, Kleine-
Brueggeney M, Theiler
• 0.1 microgr/kg/min
• Anaesthesia. 2009 Apr;64(4):387-91.Awake intubation using
the LMA-CTrach in patients with difficult airways.López AM,
Valero R, Pons M, Anglada

Caution with Remifentanil dosage
• Possibly a low dose remifentanil infusion
(0.05–0.1 microg/kg/min (P. C. Hudson,A. T. Norman,D. J.
Freeman Anaesthesia, 2009, 64, pages 216–229)
• vs
• 0.3 microg/kg/min(range 0.2–0.5
microg/kg/min(Mingo OH, Ashpole KJ, Irving CJ,Rucklidge MWM.
Remifentanil sedation for awake fibreoptic intubation with limited application of
local anaesthetic in patients for elective head and neck surgery. Anaesthesia 2008;
63: 1065–9).

Tempo
0
Propofol
TCI 3 mcg/ml
1
Remifentanil
TCI 4 mcg/ml
2
Fallimento Intubazione
No Ventilazione
Totale
Recupero
Respiro
Spontaneo
6
3,5
2,5
Sa O2 = 80 % apnea per:
•Paziente adulto sano 8.7 ‘
•Bambino 10 Kg sano 3.7 ‘
•Paziente adulto obeso 3.1 ‘
STOP
Infusioni
5
Remifentanil
2 -1.5 nanog/ml
Inizio respiro
spontaneo
Propofol
e
Remifentanil
NO Curaro

Remifentanil TCI vs propofoL TCI ,for conscious sedation for awake fibreoptic intubation:
a double-blinded randomized controlled trial .Bja 2007 M. R. Rai et al.
Cafiero,T,Fraioli G, Gargiulo G, Frangiosa A, Cavallo LM, et al..Remifentanil-TCI
and propofol-TCI for conscious sedation during fibreoptic intubation in the
acromegalic patient. Eur J Anaesthesiol. 2008;25:670-4.
Conclusioni.
• Remifentanil TCI appears to provide better conditions for AFOI when
compared with propofol TCI.
• The conditions obtained for AFOI are significantly better when using
remifentanil when compared with propofol for conscious sedation.
• A high incidence of recall is to be expected when using remifentanil, but
does not appear to affect patient satisfaction with the procedure. ..
– TCI al sito effettore rispettivamente 1.3 µg/ ml (CI 1–1.6, SD 0.2) per il propofol e
3.2 ng/ml (CI 2.8–3.5, SD 0.2) per il remifentanil (Rai e coll) con
– concentrazioni al sito effettore di propofol di 2± 1 µg/ml e di remifentanil
3.2± 0.3 ng/ml: la tosse presentata dal 60% dei pazienti nonostante lo spray
sulle corde con lidocaina testimonia del mantenimento dei riflessi
– .La dose media utilizzata dagli autori era di 74 ± 13 µg di remifentanil e 131 ± 26
di propofol(cafiero e coll)

Tempo
0
Targe Remif.TCI ( Cp) 3 µg/ml
1
Target Propof TCI (Cp )1 µg/ml
2
STOP
Infusioni
spontaneo
Awake Intubat.(Rai et al )
Propof vs remif TCI
endpoint 1-intubazione 2-score di intubaz
Premedeicaz Glicopirrol
Midaxz 0,2 mg/kg e Anest
Topica ecc
Remif Cp=Ce : inser Fibrobronc
PropCp= Ce
Fibrobronc

• Br J Anaesth. 2009 Dec;103(6):811-6.
• Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates
with postoperative complications.
• Kazan R, Bracco D, Hemmerling TM.
• ITAG (Intelligent Technology in Anaesthesia Group), Department of Anaesthesiology, Montreal General Hospital,
McGill University, Montreal, Canada.
• Abstract
• BACKGROUND: Regional cerebral oxygen saturation (S(ct)O(2)) has recently been shown to decrease significantly
during thoracic surgery. The present study investigates whether these desaturations are related to postoperative
complications.
• METHODS: Fifty patients undergoing thoracic surgery with a single-lung ventilation (SLV) of >45 min duration were
enrolled. Regional cerebral oxygen saturation was measured using absolute oximetry; standard clinical variables,
and SOFA and Clavien scores were recorded. Correlation between minimum S(ct)O(2) during SLV and
postoperative complication scores was analysed using Pearson's correlation test, chi(2) test, and logistic
regression.
• RESULTS: Forty-seven patients underwent lobectomy, two patients a pneumonectomy and 1 patient a chest wall
resection. Eighty-two per cent of the patients had a decrease in S(ct)O(2) of >15% from baseline value, and 10% of
the patients had a minimal absolute S(ct)O(2) value between 45% and 55%. The minimal absolute S(ct)O(2) values
during SLV correlated with the Clavien score (R(2)=0.098, P=0.0201) and the non-respiratory SOFA score
(R(2)=0.090, P=0.0287). By defining a threshold of S(ct)O(2)=65%, the odds ratio of having a non-respiratory organ
failure was 2.37 (95% CI 1.18-4.39, P=0.043) and a complication according to the Clavien score (Clavien score >0)
was 3.19 (95% CI 1.60-6.34, P=0.0272).
• CONCLUSIONS: Thoracic surgery with SLV seemed to be associated with a significant decrease in S(ct)O(2), and
minimal S(ct)O(2) values correlated positively with postoperative complications

• N Engl J Med. 2000 Jan 20;342(3):161-7.
• Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection.
• Greif R, Akça O, Horn EP, Kurz A, Sessler DI; Outcomes Research Group.
• Collaborators (42) Feil W, Koller L, Laciny S, Neumark J, Niedermayer F, Rapf S, Seisenbacher S, Wasinger T, Akça L, Erlacher W, Fugger R, Goll V,
Herbst F, Hetz H, Hieber C, Imhof M, Lackner FX, Lampl K, Lenhardt R, Marker E, Nagele P, Panzer O, Petschnigg B, Plattner O, Roka S, Schoellkopf A,
Schultz AM, Seibt F, Wallner T, Wang J, Werba A, Wiesenger KH, Zacherl J, Zimpfer M, Burmeister M, Redmann G, Schulte am Esch J, Standl T, Hopf H,
Scheuenstuhl H, Tayefeh F, Arkiliç CF.
• Department of Anesthesiology and Intensive Care Medicine, Donauspital, Vienna, Austria.
• Comment in:
• N Engl J Med. 2000 May 25;342(21):1613; author reply 1613-4.
• N Engl J Med. 2000 May 25;342(21):1613; author reply 1613-4.
• N Engl J Med. 2000 Jan 20;342(3):202-4.
• Abstract
• BACKGROUND: Destruction by oxidation, or oxidative killing, is the most important defense against surgical pathogens and depends on the partial
pressure of oxygen in contaminated tissue. An easy method of improving oxygen tension in adequately perfused tissue is to increase the
concentration of inspired oxygen. We therefore tested the hypothesis that the supplemental administration of oxygen during the perioperative
period decreases the incidence of wound infection.
• METHODS: We randomly assigned 500 patients undergoing colorectal resection to receive 30 percent or 80 percent inspired oxygen during the
operation and for two hours afterward. Anesthetic treatment was standardized, and all patients received prophylactic antibiotic therapy. With use of
a double-blind protocol, wounds were evaluated daily until the patient was discharged and then at a clinic visit two weeks after surgery. We
considered wounds with culture-positive pus to be infected. The timing of suture removal and the date of discharge were determined by the
surgeon, who did not know the patient's treatment-group assignment.
• RESULTS: Arterial oxygen saturation was normal in both groups; however, the arterial and subcutaneous partial pressure of oxygen was significantly
higher in the patients given 80 percent oxygen than in those given 30 percent oxygen. Among the 250 patients who received 80 percent oxygen, 13
(5.2 percent; 95 percent confidence interval, 2.4 to 8.0 percent) had surgical-wound infections, as compared with 28 of the 250 patients given 30
percent oxygen (11.2 percent; 95 percent confidence interval, 7.3 to 15.1 percent; P=0.01). The absolute difference between groups was 6.0 percent
(95 percent confidence interval, 1.2 to 10.8 percent). The duration of hospitalization was similar in the two groups.
• CONCLUSIONS: The perioperative administration of supplemental oxygen is a practical method of reducing the incidence of surgical-wound infections

• Minerva Anestesiol. 2005 Jan-Feb;71(1-2):21-5.
• Does supplemental perioperative oxygen administration reduce the incidence of wound infection in elective
colorectal surgery?
• Mayzler O, Weksler N, Domchik S, Klein M, Mizrahi S, Gurman GM.
• Department of General Surgery A, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the
Negev, Beer Sheva, Israel.
• Abstract
• AIM: An association has been proposed between perioperative administration of 80% oxygen and a lower
incidence of wound infection after colorectal surgery. The present study was conducted to assess this hypothesis.
• METHODS: Thirty-eight patients (ASA classification 1 and 2) undergoing elective colorectal cancer surgery were
allocated at random to 2 groups. Group 1 consisted of 19 patients who received an admixture of 80% oxygen and
20% nitrogen during anesthesia through an orotracheal tube and during the 2 first hours in the recovery room
through a tight facemask with reservoir. Group 2 consisted of 19 patients who received an admixture of 70%
nitrous oxide and 30% oxygen during anesthesia, followed by administration of 30% oxygen delivered by a blender
through a tight facemask with reservoir in the same manner than group 1, during the first 2 hours in the recovery
room. Wound infection was evaluated daily during hospital stay and after 7 days, 2 weeks, and 1 month.
• RESULTS: The incidence of wound infection was 12.5% in group 1 and 17.6% in group 2 (p=0.53).
• CONCLUSIONS: The results of this study showed no reduction in the incidence of wound infection following
elective colorectal surgery in patients receiving 80% oxygen during the perioperative period

• JAMA. 2005 Oct 26;294(16):2035-42.
• Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial.
• Belda FJ, Aguilera L, García de la Asunción J, Alberti J, Vicente R, Ferrándiz L, Rodríguez R, Company R, Sessler DI, Aguilar G, Botello SG, Ortí R; Spanish Reduccion de la Tasa de Infeccion
Quirurgica Group.
• Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain. fjbelda@uv.es
• Erratum in:
• JAMA. 2005 Dec 21;294(23):2973.
• Comment in:
• Can J Surg. 2007 Jun;50(3):214-6.
• Evid Based Nurs. 2006 Apr;9(2):52.
• JAMA. 2006 Apr 12;295(14):1642; author reply 1642-3.
• JAMA. 2006 Apr 12;295(14):1641-2; author reply 1642-3.
• JAMA. 2005 Oct 26;294(16):2091-2.
• Abstract
• CONTEXT: Supplemental perioperative oxygen has been variously reported to halve or double the risk of surgical wound infection.
• OBJECTIVE: To test the hypothesis that supplemental oxygen reduces infection risk in patients following colorectal surgery.
• DESIGN, SETTING, AND PATIENTS: A double-blind, randomized controlled trial of 300 patients aged 18 to 80 years who underwent elective colorectal surgery in 14 Spanish hospitals from
March 1, 2003, to October 31, 2004. Wound infections were diagnosed by blinded investigators using Centers for Disease Control and Prevention criteria. Baseline patient characteristics,
anesthetic treatment, and potential confounding factors were recorded.
• INTERVENTIONS: Patients were randomly assigned to either 30% or 80% fraction of inspired oxygen (FIO2) intraoperatively and for 6 hours after surgery. Anesthetic treatment and
antibiotic administration were standardized.
• MAIN OUTCOME MEASURES: Any surgical site infection (SSI); secondary outcomes included return of bowel function and ability to tolerate solid food, ambulation, suture removal, and
duration of hospitalization.
• RESULTS: A total of 143 patients received 30% perioperative oxygen and 148 received 80% perioperative oxygen. Surgical site infection occurred in 35 patients (24.4%) administered 30%
FIO2 and in 22 patients (14.9%) administered 80% FIO2 (P=.04). The risk of SSI was 39% lower in the 80% FIO2 group (relative risk [RR], 0.61; 95% confidence interval [CI], 0.38-0.98) vs the
30% FIO2 group. After adjustment for important covariates, the RR of infection in patients administered supplemental oxygen was 0.46 (95% CI, 0.22-0.95; P = .04). None of the secondary
outcomes varied significantly between the 2 treatment groups.
• CONCLUSIONS: Patients receiving supplemental inspired oxygen had a significant reduction in the risk of wound infection. Supplemental oxygen appears to be an effective intervention to
reduce SSI in patients undergoing colon or rectal surgery. Trial Registration ClinicalTrials.gov Identifier: NCT00235456

• Obstet Gynecol. 2008 Sep;112(3):545-52.
• High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled
trial.
• Gardella C, Goltra LB, Laschansky E, Drolette L, Magaret A, Chadwick HS, Eschenbach D.
• Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington 98119, USA. cgardel@u.washington.edu
• Erratum in:
• Obstet Gynecol. 2008 Dec;112(6):1392.
• Abstract
• OBJECTIVE: Most postcesarean infections are caused by anaerobic bacteria. Oxidative killing, an important defense against surgical infections,
depends on the oxygen level in contaminated tissue. Among patients undergoing colorectal surgery, perioperative supplemental oxygen decreased
infection rates by 50%. We tested the hypothesis that high-concentration inspired oxygen decreases the incidence of surgical site infection in women
undergoing cesarean delivery.
• METHODS: Using a double blind technique, 143 women undergoing cesarean delivery under regional anesthesia after the onset of labor were
randomly assigned to receive low- or high-concentration inspired oxygen via nonrebreathing mask during the operation and for 2 hours after.
Surgical site infection was defined clinically as administration of antibiotics for postpartum endometritis or wound infection during the initial hospital
stay or within 14 days of surgery. Interim statistical analysis was performed after 25% of the planned sample size (143 of 550) accrued using
intention-to-treat principle. The stopping rule P value for futility was P>.11 with two planned interim analyses.
• RESULTS: Postcesarean infection occurred in 17 (25%, 95% confidence interval [CI] 15-35%) of 69 women assigned to high-concentration oxygen
compared with 10 (14%, 95% CI 6-22%) of 74 women assigned to low-concentration inspired oxygen (relative risk 1.8, 95% CI 0.9-3.7, P=.13). The P
value exceeded the P value for futility, suggesting these differences were unlikely to reach statistical significance with continued recruitment.
• CONCLUSION: High-concentration perioperative oxygen delivered through a nonrebreathing mask did not decrease the risk of postcesarean surgical
site infection

• JAMA. 2009 Oct 14;302(14):1543-50.
• Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI
randomized clinical trial.
• Meyhoff CS, Wetterslev J, Jorgensen LN, Henneberg SW, Høgdall C, Lundvall L, Svendsen PE, Mollerup H, Lunn TH, Simonsen I, Martinsen KR,
Pulawska T, Bundgaard L, Bugge L, Hansen EG, Riber C, Gocht-Jensen P, Walker LR, Bendtsen A, Johansson G, Skovgaard N, Heltø K, Poukinski A,
Korshin A, Walli A, Bulut M, Carlsson PS, Rodt SA, Lundbech LB, Rask H, Buch N, Perdawid SK, Reza J, Jensen KV, Carlsen CG, Jensen FS, Rasmussen LS;
PROXI Trial Group.
• Collaborators (12) Kirkegaard PR, Berg V, Petersen HD, Schiødt O, Stougaard H, Pedersen HS, Pedersen SK, Gaarden M, Rosenberg J, Bøgevig S, Juul C,
Krzak JM.
• Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
• Comment in:
• JAMA. 2010 Feb 10;303(6):515; author reply 515.
• JAMA. 2009 Oct 14;302(14):1588-9.
• Abstract
• CONTEXT: Use of 80% oxygen during surgery has been suggested to reduce the risk of surgical wound infections, but this effect has not been
consistently identified. The effect of 80% oxygen on pulmonary complications has not been well defined.
• OBJECTIVE: To assess whether use of 80% oxygen reduces the frequency of surgical site infection without increasing the frequency of pulmonary
complications in patients undergoing abdominal surgery.
• DESIGN, SETTING, AND PATIENTS: The PROXI trial, a patient- and observer-blinded randomized clinical trial conducted in 14 Danish hospitals between
October 2006 and October 2008 among 1400 patients undergoing acute or elective laparotomy.
• INTERVENTIONS: Patients were randomly assigned to receive either 80% or 30% oxygen during and for 2 hours after surgery.
• MAIN OUTCOME MEASURES: Surgical site infection within 14 days, defined according to the Centers for Disease Control and Prevention. Secondary
outcomes included atelectasis, pneumonia, respiratory failure, and mortality.
• RESULTS: Surgical site infection occurred in 131 of 685 patients (19.1%) assigned to receive 80% oxygen vs 141 of 701 (20.1%) assigned to receive
30% oxygen (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.72-1.22; P = .64). Atelectasis occurred in 54 of 685 patients (7.9%) assigned to
receive 80% oxygen vs 50 of 701 (7.1%) assigned to receive 30% oxygen (OR, 1.11; 95% CI, 0.75-1.66; P = .60), pneumonia in 41 (6.0%) vs 44 (6.3%)
(OR, 0.95; 95% CI, 0.61-1.48; P = .82), respiratory failure in 38 (5.5%) vs 31 (4.4%) (OR, 1.27; 95% CI, 0.78-2.07; P = .34), and mortality within 30 days
in 30 (4.4%) vs 20 (2.9%) (OR, 1.56; 95% CI, 0.88-2.77; P = .13).
• CONCLUSION: Administration of 80% oxygen compared with 30% oxygen did not result in a difference in risk of surgical site infection after abdominal
surgery.
• TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00364741

• Can J Surg. 2007 Jun;50(3):214-6.
• Canadian Association of General Surgeons and American College of Surgeons Evidence Based Reviews in
Surgery. 21: the risk of surgical site infection is reduced with perioperative oxygen.
• Brasel K, McRitchie D, Dellinger P; EBRS Group.
• EBRS, Mount Sinai Hospital, Toronto, Ontario, Canada.
• Comment on:
• JAMA. 2005 Oct 26;294(16):2035-42.
• Abstract
• OBJECTIVE: Does supplemental perioperative oxygen reduce the risk of surgical wound infection after colorectal
surgery?
• DESIGN: Randomized controlled trial.
• SETTING: Multicentre trial that included 14 hospitals in Spain.
• PATIENTS: 300 patients aged 18-80 years who underwent elective colorectal resection. Patients who had surgery
performed laparoscopically or who had minor colon surgery were excluded.
• INTERVENTION: Patients were randomly allocated to either 30% or 80% fraction of inspired oxygen (FiO2)
intraoperatively and for 6 hours postoperatively. Anesthetic treatment and antibiotic administration were
standardized.
• MAIN OUTCOME MEASURE: Surgical site infection (SSI) as defined by the Center for Disease Control.
• RESULTS: SSI occurred in 35 of 143 patients (24.4%) who were administered 30% FiO2 and in 22 of 148 patients
(14.9%) who were administered 80% FiO2 (p = 0.04). The risk of SSI was 39% lower in the 80% group (relative risk
[RR], 0.61; 95% confidence interval [CI], 0.38-0.98) versus the 30% FiO2 group.
• CONCLUSIONS: Patients receiving supplemental oxygen have a significant reduction in risk of surgical site
infection.

• J Eval Clin Pract. 2009 Apr;15(2):360-5.
• Supplemental perioperative oxygen for reducing surgical site infection: a meta-analysis.
• Al-Niaimi A, Safdar N.
• Department of Medicine, University of Wisconsin Medical School, Madison, WI, USA.
• Abstract
• OBJECTIVE: To assess the efficacy of supplemental perioperative oxygenation for prevention of surgical site
infection (SSI). Data sources Computerized PUBMED and MEDLINE search supplemented by manual searches for
relevant articles. Study selection Randomized, controlled trials evaluating efficacy of supplemental perioperative
oxygenation versus standard care for prevention of SSI in patients' undergoing colorectal surgery. Data synthesis
Data on incidence of SSI were abstracted as dichotomous variables. Pooled estimates of the relative risk (RR) and
95% confidence interval (CI) were obtained using the DerSimonian and Laird random effects model and the
Mantel-Haenzel fixed effects model. Heterogeneity was assessed using the Cochran Q statistic and I(2).
• RESULTS: Four randomized controlled trials met the inclusion criteria. Supplemental perioperative oxygenation
resulted in a reduced incidence of SSI [RR 0.70 (95% CI 0.52-0.94), P = 0.01], using a fixed effects model. Using the
more conservative random effects model, the point estimate was similar [RR 0.74 (95% CI 0.39-1.43), P = 0.37],
but the results failed to achieve statistical significance. The I(2) test showed moderate heterogeneity.
• CONCLUSIONS: Our analysis showed that supplemental perioperative oxygenation is beneficial in preventing SSI in
patients undergoing colorectal surgery. Because of heterogeneity in study design and patient population,
additional randomized trials are needed to determine whether this confers benefit in all patient populations
undergoing other types of surgery. Supplemental perioperative oxygenation is a low-cost intervention that we
recommend be implemented in patients undergoing colorectal surgery pending the results of further studies.
Further research is needed to determine whether or not supplemental hyperoxia may cause unanticipated
adverse effects

• J Surg Res. 2009 Jul 10. [Epub ahead of print]
• Perioperative Supplemental Oxygen in Colorectal Patients: A Meta-Analysis.
• Brar MS, Brar SS, Dixon E.
• Department of Surgery.
• Abstract
• BACKGROUND: Perioperative supplemental oxygen has been proposed to decrease the incidence of surgical site
infection (SSI) in colorectal surgery. A number of randomized controlled trials (RCTs) have been reported with
inconsistent results. In addition, relevant clinical outcomes other than SSIs have been collected in these studies
and have been equivocal. A meta-analysis of RCTs was performed to elucidate the effects of perioperative
supplemental oxygen in colorectal surgery on SSI incidence, mortality, ICU admission, and length of stay.
• MATERIALS AND METHODS: A literature search of MEDLINE, PubMed, EMBASE, the Cochrane Library, and the
Cochrane Clinical Trials Registry was performed in duplicate. In addition, bibliographic searches were performed,
and experts were contacted for unpublished data. RCTs involving colorectal patients that included perioperative
supplemental oxygen as a treatment arm and defined SSI as an outcome were included.
• RESULTS: Five studies met inclusion criteria. Using a random-effects model, perioperative supplemental oxygen did
not significantly reduce SSIs (OR=0.69, 95% CI [0.43, 1.10], P=0.12). However, a significant mortality benefit was
observed (OR=0.18, 95% CI [0.05, 0.69], P=0.01). There was no significant difference in the rate of ICU admission
or length of stay. Tests of heterogeneity were performed, and significant heterogeneity was only present with
respect to length of stay.
• CONCLUSIONS: Perioperative supplemental oxygen in colorectal surgery does not significantly reduce SSI.
However, supplemental oxygen appears to confer a mortality benefit, a previously unreported finding. Further
RCTs are required to confirm these conclusions.

• Arch Surg. 2009 Apr;144(4):359-66; discussion 366-7.
• Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials.
• Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr.
• Department of Surgery, Price Institute of Surgical Research, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA.
m0qada01@louisville.edu
• Abstract
• OBJECTIVE: To conduct a meta-analysis of randomized controlled trials in which high inspired oxygen concentrations were compared with standard
concentrations to assess the effect on the development of surgical site infections (SSIs).
• DATA SOURCES: A systematic literature search was conducted using the MEDLINE, EMBASE, and Cochrane databases and included a manual search
of references of original articles, poster presentations, and abstracts from major meetings ("gray" literature).
• STUDY SELECTION: Twenty-one of 2167 articles met the inclusion criteria. Of these, 5 randomized controlled trials (3001 patients) assessed the effect
of perioperative supplemental oxygen use on the SSI rate. Studies used a treatment-inspired oxygen concentration of 80%. Maximum follow-up was
30 days.
• DATA EXTRACTION: Data were abstracted by 3 independent reviewers using a standardized data collection form. Relative risks were reported using a
fixed-effects model. Results were subjected to publication bias testing and sensitivity analyses.
• DATA SYNTHESIS: Infection rates were 12.0% in the control group and 9.0% in the hyperoxic group, with relative risk reduction of 25.3% (95%
confidence interval [CI], 8.1%-40.1%) and absolute risk reduction of 3.0% (1.1%-5.3%). The overall risk ratio was 0.742 (95% CI, 0.599-0.919; P = .006).
The benefit from increasing oxygen concentration was greater in colorectal-specific procedures, with a risk ratio of 0.556 (95% CI, 0.383-0.808; P =
.002).
• CONCLUSIONS: Perioperative supplemental oxygen therapy exerts a significant beneficial effect in the prevention of SSIs. We recommend its use
along with maintenance of normothermia, meticulous glycemic control, and preservation of intravascular volume perioperatively in the prevention of
SSIs

• JAMA. 2004 Jan 7;291(1):79-87.
• Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial.
• Pryor KO, Fahey TJ 3rd, Lien CA, Goldstein PA.
• Department of Anesthesiology, Weill Medical College of Cornell University, New York, NY 10021, USA. kopryor@yahoo.com
• Comment in:
• Abstract
• CONTEXT: Surgical site infection (SSI) in the general surgical population is a significant public health issue. The use of a high fractional inspired
concentration of oxygen (FIO2) during the perioperative period has been reported to be of benefit in selected patients, but its role as a routine
intervention has not been investigated.
• OBJECTIVE: To determine whether the routine use of high FIO2 during the perioperative period alters the incidence of SSI in a general surgical
population.
• DESIGN, SETTING, AND PATIENTS: Double-blind, randomized controlled trial conducted between September 2001 and May 2003 at a large university
hospital in metropolitan New York City of 165 patients undergoing major intra-abdominal surgical procedures under general anesthesia.
• INTERVENTIONS: Patients were randomly assigned to receive either 80% oxygen (FIO2 of 0.80) or 35% oxygen (FIO2 of 0.35) during surgery and for
the first 2 hours after surgery.
• MAIN OUTCOME MEASURES: Presence of clinically significant SSI in the first 14 days after surgery, as determined by clinical assessment, a
management change, and at least 3 prospectively defined objective criteria.
• RESULTS: The study groups were closely matched in a large number of clinical variables. The overall incidence of SSI was 18.1%. In an intention-to-
treat analysis, the incidence of infection was significantly higher in the group receiving FIO2 of 0.80 than in the group with FIO2 of 0.35 (25.0% vs
11.3%; P =.02). FIO2 remained a significant predictor of SSI (P =.03) in multivariate regression analysis. Patients who developed SSI had a significantly
longer length of hospitalization after surgery (mean [SD], 13.3 [9.9] vs 6.0 [4.2] days; P<.001).
• CONCLUSIONS: The routine use of high perioperative FIO2 in a general surgical population does not reduce the overall incidence of SSI and may have
predominantly deleterious effects. General surgical patients should continue to receive oxygen with cardiorespiratory physiology as the principal
determinant

Anesthesiology. 2000 Jul;93(1):15-25.
Supplemental intraoperative oxygen augments antimicrobial and
proinflammatory responses of alveolar macrophages.
Kotani N, Hashimoto H, Sessler DI, Muraoka M, Hashiba E, Kubota T,
Matsuki A.
• Department of Anesthesiology, University of Hirosaki, Japan. nao@cc.hirosaki-u.ac.jp
• Comment in:
• Anesthesiology. 2000 Jul;93(1):3-5.
• Abstract
• BACKGROUND: The first goal was to test the hypothesis that 100% inspired oxygen maintained for approximately 8
h intraoperatively is not associated with impaired pulmonary oxygenation. The authors also tested the hypothesis
that intraoperative inhalation of 100% oxygen augments proinflammatory and antimicrobial responses of alveolar
macrophages during anesthesia and surgery.
• METHODS: The authors studied patients administered 100% oxygen (n = 30) and 30% oxygen (n = 30) during
propofol-fentanyl general anesthesia. Alveolar macrophages were harvested by bronchoalveolar lavage
immediately, 2, 4, and 6 h after induction of anesthesia, and at the end of surgery. The authors measured
"opsonized" and "unopsonized" phagocytosis and microbicidal activity. RNA was extracted from harvested cells
and cDNA was synthesized. The expression of interleukin(IL)-1beta, IL-6, IL-8, interferon-gamma (IFN-gamma) and
tumor necrosis factor alpha (TNF-alpha) was measured by semiquantitative polymerase chain reaction.
• RESULTS: Gene expression of all proinflammatory cytokines except IL-6 increased fourfold to 20-fold over time in
both groups. However, expression of TNF-alpha and IL-8, IFN-gamma, and IL-6 and IL-1beta was 2-20 times greater
in patients administered 100% than in those administered 30% oxygen. Unopsonized and opsonized phagocytosis
and microbicidal activity decreased progressively, with the decreases being nearly twice as great during inhalation
of 30% oxygen versus 100% oxygen.
• CONCLUSION: Inhalation of 100% oxygen improved intraoperative decreases in phagocytic and microbicidal
activity possibly because expression of proinflammatory cytokines was augmented. These data therefore suggest
that intraoperative inhalation of 100% oxygen augments antimicrobial and proinflammatory responses in alveolar
macrophages during anesthesia and surgery

• Cheney FW, Posner KL, Lee LA, Caplan RA,
Domino KB. Trends in anesthesia-related
death and brain damage: a closed claims
analysis. Anesthesiology 2006; 105: 1081-6.
• Peterson GN, Domino KB, Caplan RA, Posner
KL, Lee LA, Cheney FW. Management of the
difficult airway: a closed claims analysis.
Anesthesiology 2005; 103: 33-9.

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As IV catThe effect of changing intravenous (IV) catheter size (xaxis) on tidal volume
(y-axis) is illustrated for all four anesthesia machines (z-axis) a,C,t = 50 mL/cm H20.
As the catheter size increases, tidal volume
increases for each anesthesia machine. The
Ohmeda Modulus I1 and Drager Narkomed 2
anesthesia machines generated the greatest
tidal volumes compared to the other two
anesthesia machines. The entrained volume is
represented by thediagonally striped bars as a
portion of total The Ohmeda Modulus I1 and
Drager Narkomed 2 anesthesia machines
generated the greatest tidal volumes compared
to the other two anesthesia machines. The
entrained volume is represented by the
diagonally stripd bars as a portion of total VT for
each experimental condition. The contribution
of entrained air to total Vr ranged from 049%
with the greatest contribution to total tidal
volume using the 14-gauge IV catheter/Ohmeda
Modulus I1 anesthesia machine combination.

The effect of changing jet stylet size (x-axis) on tidal volume
(y-axis) is illustrated for all four anesthesia machines (z-axis) at
C,, = 50 mL/cm H20..
As jet stylet size increases, tidal
volume increases for all four
anesthesia machines. The Ohmeda
Modulus I1 and Drager Narkomed 2
anesthesia machines generated the
greatest
tidal volumes of the four anesthesia
machines for any given jet stylet
size. The entrained volume is
represented by the diagonally striped
bars as a portion of total VT for each
experimental condition. The
contribution of entrained air to total
VT ranged from 0-3070 and
accounted for the greatest
contribution to total VT for the
medium jet
stylet/Ohmeda Modulus I1 anesthesia
machine combination

Ehrenfeld JM, Funk LM, Van Schalkwyk J, et al. The
incidence of hypoxemia during surgery: evidence from
two institutions. Can J Anesth 2010; 57: 877–881.
• Hypoxemia still a problem during surgery
• Researchers assess the rate of intra-operative hypoxemia in two hospitals.
• MedWire News: Hypoxemia remains “surprisingly” common, despite advances in monitoring technology, researchers reveal.
• “Anesthesia providers strive to avoid hypoxemia because of the risk of irreversible damage to the myocardium, brain, and other end organs”, say
Jesse Ehrenfeld (Massachusetts General Hospital, Boston, USA) and co-workers.
• “Despite these efforts, hypoxemia continues to occur in the operating room at a surprisingly high rate.”
• The researchers analyzed 95,407 electronic anesthesia records from two hospitals, finding that 6.8% of patients suffered hypoxemia, defined as
blood oxygenation (SpO2) levels below 90%, lasting 2 minutes or longer during surgery.
• Severe hypoxemia (SpO2 <85%) occurred in 3.5% of patients, they report in the Canadian Journal of Anesthesia. Hypoxemia or severe hypoxemia
occurred for at least 5 minutes in 1.6% and 0.8% of patients, respectively.
• The proportion of patients suffering hypoxemia was similar for the three phases of intra-operative care, namely induction, surgery, and emergence.
However, induction and emergence each lasted an average of 12 minutes, whereas surgery lasted 93 minutes, meaning that the risk for hypoxia was
highest during induction and emergence.
• Overall, the results suggest that anesthesiologists can expect to encounter hypoxemia lasting at least 2 minutes roughly once every 29 hours of intra-
operative time, say Ehrenfeld and team, with severe hypoxemia occurring once every 56 hours.
• They note that the frequency is probably far higher in resource-poor settings, in which anesthesiologists may not have access to pulse oximetry.
• Although hypoxemia was infrequent, Gregory Hare (St Michael’s Hospital, Toronto, Ontario, Canada) and Brian Kavanagh (The Hospital for Sick
Children, Toronto) said that it was “perhaps too common for an entity that anesthesiologists always try to avoid”.
• They added: “Practices that reduce the risk of hypoxemia in this setting, including pre-oxygenation, increased intra-operative F1O2 concentration, and
preserving adequate ventilation, are essential to prevent intra-operative hypoxemia”.
• “Finally, novel approaches must be sought to minimize the frequency of anesthesia-related hypoxemia, even as basic and clinical science research is
being pursued to elucidate further the perhaps more subtle contributing mechanisms.”

Hypoxemic maximal duration per patient in
Hospital A

Hypoxemic maximal duration per patient in Hospital B

Jense, Holly G., Dubin, Stevin A.,Silverstein, Paul I., O'Leary-
Escolas, Una.Effect of Obesity on Safe Duration of Apnea in
Anesthetized Humans.Anesth Analg 1991; 72:89–93
• ABSTRACT: Obese patients have a decreased functional residual capacity and,
hence, a reduced oxygen supply during periods of apnea. To determine whether
obese patients are at greater risk of developing hypoxemia during induction of
anesthesia than patients of normal weight, 24 patients undergoing elective
surgical procedures were studied. Group 1 (normal) were within 20% of their ideal
body weight. Group 2 (obese) were more than 20% but less than 45.5 kg over ideal
body weight. Group 3 (morbidly obese) were more than 45.5 kg over ideal body
weight. Patients were preoxygenated for 5 min or until expired nitrogen
was <5%. After induction of anesthesia and muscle relaxation the patients were
allowed to remain apneic until arterial saturation as measured by pulse oximetry
reached 90%. The time taken for oxygen saturation to decrease to 90% was 364 ±
24 s in group 1, 247 ± 21 s in group 2, and 163 ± 15 s in group 3; these times are
significantly different at P < 0.05 between groups. Regression analysis of the data
demonstrated a significant negative linear correlation (r = -0.83) between time to
desaturation and increasing obesity. These results show that obese patients are at
an increased risk of developing hypoxemia when apneic.
•

Baraka, Anis, Salem, M. Ramez, Joseph, Ninos J., Benumof, Jonathan L.
Critical Hemoglobin Desaturation Can Be Delayed by
Apneic Diffusion Oxygenation.Anesthesiology 90:332-33,
1999.
•
• To the Editor:-We read with interest the article by Benumof et al. and the related correspondence concerning the development of critical hemoglobin
desaturation after neuromuscular block with 1 mg/kg succinylcholine. Benumof et al. suggested that achievement of functional recovery from succinylcholine
block before significant desaturation is not a realistic possibility and a rescue option should be instituted aggressively and early, whereas Bourke considered that
this assumption may not be entirely justified and may, in some cases, lead to premature or potentially hazardous interventions.
• We agree with the recommendations of Benumof et al. that whenever attempts at tracheal intubation after preoxygenation and rapid-sequence induction of
anesthesia fail, we should not wait for recovery from succinylcholine block. Ventilation must be promptly initiated because the risk of critical hemoglobin
desaturation if apnea is prolonged is far more serious than the risk of regurgitation associated with controlled ventilation while cricoid compression is
performed.
• To delay critical hemoglobin desaturation during apnea in a patient with a suspected difficult
airway, we suggest combining preoxygenation with apneic diffusion oxygenation. This can be
easily achieved by pharyngeal insufflation of oxygen throughout the period of apnea. During
apneic diffusion oxygenation, oxygen will diffuse from the lung to the pulmonary capillaries
according to its concentration gradient. The oxygen molecules can diffuse from the pharynx into
the alveoli, even in the “cannot-intubate, cannot-ventilate” situation, in which the airway may not
be completely patent. The combination of preoxygenation and apneic diffusion oxygenation can
be particularly advantageous in patients with a suspected difficult airway and in patients with a
decreased safety margin secondary to decreased functional residual capacity (FRC) or increased
oxygen consumption, or both, such as small children, pregnant women, obese persons, and
patients with respiratory distress syndrome.

Transcricoid oxygen insufflation
• In Reply:-Drs. Baraka, Salem, and Ninos make an interesting and valid point, i.e., apneic oxygenation via
insufflation of oxygen through a pharyngeal catheter is a low-risk, possible high-benefit method of
increasing the duration of Normoxia during apnea that follows preoxygenation. I assume that Drs.
Baraka, Salem, and Ninos use this method when they have a high index of suspicion of difficulty with
management of the airway (for any reason) preoperatively, because one would not want to need to
locate an appropriate catheter (and connections to an oxygen source) while trying to solve a “cannot-
ventilate, cannot-intubate” situation. Another method that I have used very occasionally to prolong the
duration of normoxia during apnea is to insert a 2-inch 16-gauge catheter
through the cricothyroid membrane preinduction, electively,
using local anesthesia and achieve apneic oxygenation by
insufflation of oxygen through this catheter. In addition, the
transcricothyroid-membrane, 16-gauge catheter provides an
immediate-ventilation plan B by connection to a jet ventilator
preset at 25 psi using a 0.5-s inspiratory time. Wishing to avoid further
trivial semantic debates, I would be the first to admit that this preproblem solution could also be
considered as an atraumatic form of a very early, aggressive postproblem solution.
•

• Can J Anaesth. 2004 Jun-Jul;51(6):616-20.
• Contemporary anesthesia ventilators incur a significant "oxygen cost".
• Klemenzson GK, Perouansky M.
• Department of Anesthesia and Critical Care, Landspitalinn University Hospital of Iceland, Reykjavik,
Iceland.
• Abstract
• PURPOSE: Anesthesia ventilators use oxygen or oxygen/air mixtures to drive the bellows during
controlled ventilation. As a practitioner may find himself in a situation that the only available
oxygen source is a compressed oxygen cylinder, it is important to know the oxygen consumption of
anesthesia ventilators during controlled ventilation.
• METHODS: We tested the Datex-Ohmeda 7900 ventilator mounted on an Excel 210 anesthesia
machine under a variety of conditions. For comparison, we also tested the Ohmeda 7800 and the
Dräger AV-2 ventilator under control conditions. All experiments were performed using a test lung.
• RESULTS: The oxygen consumption of the AV-2 and the Datex-Ohmeda ventilators averaged 302 +/-
17 L x hr(-1) and 564 +/- 68 to 599 +/- 56 L x hr(-1), respectively (P < 0.01 AV-2 vs 7800 and 7900).
When using an E-type cylinder, this would result in a mean time to alarm of 93 min and 54 to 57
min, respectively. Decreased lung compliance increased the oxygen consumption to 848 +/- 16 L x
hr(-1).
• CONCLUSIONS: Machine-driven mechanical ventilation incurs a significant "oxygen cost." We show
that the amount of oxygen consumed by mechanical ventilation with contemporary anesthesia
ventilators is influenced by patient-dependent factors and may greatly exceed the amount of
oxygen delivered to the patient.

Anesth Analg. 2010 ;111:922-4.
Oxygen delivery during transtracheal oxygenation: a comparison of
two manual devices.Lenfant F, Péan D, Brisard L, Freysz M, Lejus C.
• Department of Anesthesiology, CHU de Dijon, General Hospital, Dijon Cedex, France. francois.lenfant@chu-dijon.fr
• Abstract
• BACKGROUND: The Manujet™ and the ENK Oxygen Flow Modulator™ (ENK) deliver oxygen during transtracheal
oxygenation. We sought to describe the ventilation characteristics of these 2 devices.
• METHODS: The study was conducted in an artificial lung model consisting of a 15-cm ringed tube, simulating the
trachea, connected via a flow analyzer and an artificial lung. A 15-gauge transtracheal wire reinforced catheter was
used for transtracheal oxygenation. The ENK and Manujet were studied for 3 minutes at respiratory rates of 0, 4,
and 12 breaths/min, with and without the artificial lung, in a totally and a partially occluded airway. Statistical
analysis was performed using analysis of variance followed by a Fisher exact test; P < 0.05 was considered
significant.
• RESULTS: Gas flow and tidal volume were 3 times greater with the Manujet than the ENK (approximately 37 vs 14
L · min(-1) and 700 vs 250 mL, respectively) and were not dependent on the respiratory rate. In the absence of
ventilation, the ENK delivered a 0.6 ± 0.1 L · min(-1) constant gas flow. In the totally occluded airway, lung
pressures increased to 136 cm H(2)O after 3 insufflations with the Manujet, whereas the ENK, which has a
pressure release vent, generated acceptable pressures at a low respiratory rate (4 breaths/min) (peak pressure at
27.7 ± 0.7 and end-expiratory pressure at 18.8 ± 3.8 cm H(2)O). When used at a respiratory rate of 12
breaths/min, the ENK generated higher pressures (peak pressure at 95.9 ± 21.2 and end-expiratory pressure at
51.4 ± 21.4 cm H(2)O). In the partially occluded airway, lung pressures were significantly greater with the Manujet
compared with the ENK, and pressures increased with the respiratory rate with both devices. Finally, the gas flow
and tidal volume generated by the Manujet varied proportionally with the driving pressure.
• DISCUSSION: This study confirms the absolute necessity of allowing gas exhalation between 2 insufflations and
maintaining low respiratory rates during transtracheal oxygenation. In the case of total airway obstruction, the
ENK may be less deleterious because it has a pressure release vent. Using a Manujet at lower driving pressures
may decrease the risk of barotrauma and allow the safe use of higher respiratory rates.

Anesth Analg. 2010 ;110:94-100.
Pressures available for transtracheal jet ventilation from anesthesia
machines and wall-mounted oxygen flowmeters.
Fassl J, Jenny U, Nikiforov S, Murray WB, Foster PA.
• Simulation Development and Cognitive Science Laboratory, Pennsylvania State University College of Medicine, 500
University Ave., Hershey, PA 17033, USA.
• Abstract
• BACKGROUND: Oxygen supplies capable of supporting transtracheal jet ventilators can be lifesaving. There is not
much information about which oxygen sources (readily available inside and outside operating rooms) have
sufficient driving pressure for transtracheal jet ventilation.
• METHODS: We measured driving pressures (upstream or residual oxygen pressure) in a specially designed jet
ventilation test system with a 2.25-mm (14-gauge) i.v. catheter. High-pressure oxygen sources evaluated included
wall-mounted (Puritan, Allied Health, Precision, and Datex-Ohmeda) and anesthesia machine auxiliary oxygen
flowmeters and oxygen flush valves from anesthesia machines (Draeger Narkomed 2B, Narkomed 4, Datex-
Ohmeda Excel, and Datex-Ohmeda Modulus).
• RESULTS: All 4 types of wall-mounted oxygen flowmeters, opened past their highest scale settings (15 L/min),
delivered sufficient working pressures (range, 103-282 kPa; 16-41 psi). Working pressures from auxiliary oxygen
flowmeters mounted on Datex-Ohmeda machines were adequate to support jet ventilation (range, 189-248 kPa;
27-36 psi), whereas those on tested Draeger machines did not supply sufficient pressure for jet ventilation:
Narkomed 2B, 14-28 kPa (2-4 psi); Narkomed 4, 24-28 kPa (3-4 psi). Working pressures delivered by oxygen flush
valves on tested Draeger machines were adequate to support jet ventilation, ranging from 96 to 117 kPa (14-17
psi), whereas pressures generated by tested Datex-Ohmeda flush valves were not (ranging from 50 to 62 kPa, 7-9
psi).
• CONCLUSION: Oxygen sources other than dedicated jet ventilator connectors to high-pressure pipeline oxygen
may supply adequate working pressure, but each type of oxygen source needs testing to ensure that it supplies
adequate working pressure

Gaughan SD, Benumof JL, Ozaki GT.Can an anesthesia machine
flush valve provide for effective jet ventilation? Anesth Analg. 1993
Apr;76(4):800-8.
• School of Medicine, Department of Anesthesiology, University of California at San Diego.
• Abstract
• Transtracheal jet ventilation (TTJV) using a percutaneously inserted intravenous (IV) catheter for the
patient who cannot be ventilated or tracheally intubated or, using a jet stylet for changing
endotracheal tubes (ETT) in patients for whom subsequent ventilation and/or tracheal reintubation
may be difficult, are extremely valuable therapeutic options. The jet ventilation system must have a
sufficiently high pressure-oxygen source to drive oxygen through noncompliant tubing and through
relatively small IV catheters and/or jet stylets in order to achieve adequate ventilation and
oxygenation. There is no evidence that using the common gas outlet of an anesthesia machine by
activating the flush valve can provide enough flow (V) and tidal volume (VT) for effective jet
ventilation. This in vitro study utilized a mechanical lung model that had a varying lung compliance
[Cset (10-100 mL/cm H2O)] to determine the VT (measured by integrating a pneumotachograph
flow signal) and corresponding minute ventilation (VE) through 14-, 16-, and 18-gauge IV catheters
and small, medium, and large jet stylets. The flow of O2 was generated by activating the flush valve
of Dräger Narkomed 2 and 2A and Ohmeda Modulus II and II Plus anesthesia machines at an
inspiratory:expiratory (I:E) ratio = 1:1 (unit of time = 1 s). We found that the largest VT
and resultant VE were consistently obtained by activating the flush valve
of the Ohmeda Modulus II and Dräger Narkomed 2 anesthesia machines.
The smallest VT and VE were produced using the Ohmeda Modulus II
Plus anesthesia machine

Bould MD, Bearfield P.Techniques for emergency ventilation through a
needle cricothyroidotomy. Anaesthesia. 2008 May;63(5):535-9
• St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada, M5B 1W8.
dylan.bould@utoronto.ca
• needle cricothyroidotomy.
• Flow through standard hospital wall oxygen supply, flowmeter, oxygen
tubing and a three-way tap vs a Manujet jet ventilator and a Sanders
injector.
• The construction performed similarly to the Manujet set at low pressures (0-
100 kPa).
• To achieve similar pressures and flow to the Manujet set at pressures higher
than 100 kPa required opening of the flowmeter beyond its
calibrated range. The flow through the transtracheal catheter
was almost three times higher when the flowmeters were fully
opened than when they were opened to the 15 l x min(-1) mark
(44.5 vs 15.8 l x min(-1), respectively; p < 0.0001).
• When the flowmeters were fully opened the pressure measured before the
catheter was over four times higher than when they were only opened to
the 15 l x min(-1) mark (285.3 vs 66.4 kPa, respectively; p < 0.0001). This
system of ventilation is inferior to a Manujet in terms of robustness and
calibration throughout its range of pressures and flows, but seems
appropriate for emergency use in the absence of a purpose-made jet
ventilator

The “Intubating Dose” of Succinylcholine. The Effect of
Decreasing Doses on Recovery Time Kopman AF,Zhaku B,Lai
KS.Anesthesiology,99:1050-4, 2003
• :
•
• This article is accompanied by an Editorial View. Please see: Donati F: The right dose of succinylcholine. ANESTHESIOLOGY 2003; 99:1037–8.
• * Professor of Anesthesiology, New York Medical College, Valhalla, New York. † Research Assistant, Department of Anesthesiology, St. Vincent's Hospital Manhattan, New York, New
York. ‡ Resident in Anesthesiology, St. Vincent's Hospital Manhattan, New York, New York.
• Received from the Department of Anesthesiology, St. Vincent's Hospital and Medical Center of New York, New York, New York. Submitted for publication April 21, 2003. Accepted for
publication June 3, 2003. Support was provided solely from institutional and/or departmental sources.
• Address correspondence to Dr. Kopman: Department of Anesthesiology (Room NR 408), St. Vincent's Hospital & Medical Center, 170 West 12th Street, New York, New York 10011.
Address electronic mail to: akopman@rcn.com. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.
•
• ABSTRACT: Background: The usually cited “intubation dose” of succinylcholine is 1.0 mg/kg. In the
majority of patients, this dose will produce apnea of sufficient duration that significant hemoglobin
desaturation may occur before neuromuscular recovery takes place in those whose ventilation is not
assisted. This study was undertaken to examine the extent to which reducing this dose would decrease the
duration of action of succinylcholine.
• Methods: During stable desflurane/oxygen/opioid anesthesia and after adequate twitch stabilization,
neuromuscular function was recorded with an acceleromyographic monitor. Supramaximal stimuli were
delivered at 0.10 Hz. Patients received 0.40, 0.60, or 1.0 mg/kg succinylcholine, and twitch height was
monitored for at least 20 min thereafter.
• Results: The onset times to maximal effect were 105 ± 23 s, 81 ± 19 s, and 71 ± 22 s, respectively. The
lowest dose (0.40 mg/kg) did not reliably produce 100% twitch depression. The times to 90% twitch
recovery at the adductor pollicis in the three groups were 6.6 ± 1.5 min, 7.6 ± 1.6 min, and 9.3 ± 1.2 min,
respectively.
• Conclusions: Reducing the dose of succinylcholine from 1.0 mg/kg to 0.60 mg/kg shortens the duration
of effect at the adductor pollicis by more than 90 s. The authors believe that even this modest decrease in
the duration of drug-induced paralysis is often worth pursuing.

Edmark L, Kostova-Aherdan K, Enlund, M, Hedenstierna
G.Optimal Oxygen Concentration during Induction of
General Anesthesia Anesthesiology 98:28-33, 2003
•
• This article is featured in “This Month in Anesthesiology.” Please see this issue of ANESTHESIOLOGY, page 5A.
• * Chief of Staff, Department of Anesthesiology and Intensive Care, Central Hospital, Västerås, and Research Associate, Department of Medical Sciences, Clinical Physiology, University Hospital,
Uppsala, Sweden. † Staff Radiologist, Department of Radiology, ‡ Senior Consultant/Lecturer, Department of Anesthesiology and Intensive Care, Central Hospital, Västerås, Sweden. § Professor
in Clinical Physiology, Department of Medical Sciences, Clinical Physiology, University Hospital, Uppsala, Sweden.
• Received from the Departments of Radiology and Anesthesiology and Intensive Care, Central Hospital, Västerås, Sweden. Submitted for publication March 25, 2002. Accepted for publication
July 30, 2002. Supported by the departments and institutions involved; grants from the Swedish Medical Research Council, Stockholm, Sweden (5315); and the Swedish Heart-Lung Foundation,
Stockholm, Sweden. Presented in part at the annual meeting of the American Society of Anesthesiologists, New Orleans, Louisiana, October 16, 2001.
• Address reprint requests to Dr. Edmark: Department of Anesthesiology and Intensive Care, Central Hospital, S-721 41 Västerås, Sweden. Address electronic mail to:
lennart.edmark@ltvastmanland.se. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org.
•
• ABSTRACT: Background: The use of 100% oxygen during induction of anesthesia may produce
atelectasis. The authors investigated how different oxygen concentrations affect the formation of
atelectasis and the fall in arterial oxygen saturation during apnea.
• Methods: Thirty-six healthy, nonsmoking women were randomized to breathe 100, 80, or 60%
oxygen for 5 min during the induction of general anesthesia. Ventilation was then withheld until
the oxygen saturation, assessed by pulse oximetry, decreased to 90%. Atelectasis formation was
studied with computed tomography.
• Results: Atelectasis in a transverse scan near the diaphragm after induction of anesthesia and
apnea was 9.8 ± 5.2 cm2 (5.6 ± 3.4% of the total lung area; mean ± SD), 1.3 ± 1.2 cm2 (0.6 ±
0.7%), and 0.3 ± 0.3 cm2 (0.2 ± 0.2%) in the groups breathing 100, 80, and 60% oxygen,
respectively (P < 0.01). The corresponding times to reach 90% oxygen saturation were 411 ± 84,
303 ± 59, and 213 ± 69 s, respectively (P < 0.01).
• Conclusion: During routine induction of general anesthesia, 80% oxygen for oxygenation
caused minimal atelectasis, but the time margin before unacceptable desaturation occurred was
significantly shortened compared with 100% oxygen.
•

Edmark L, Kostova-Aherdan K, Enlund, M, Hedenstierna
G.Optimal Oxygen Concentration during Induction of
General Anesthesia Anesthesiology 98:28-33, 2003

Efficacy of Preoxygenation with Tidal Volume Breathing:
Comparison of Breathing Systems
Nimmagadda U,Salem MR,Joseph N,Lopez G, Megally M, Lang D J,
Wafai Y. Anesthesiology,93:693-8, 2000
•
• Additional materialrelated to this article can be found on the Anesthesiology Web site. Go to the following address, click on Enhancements Index, and then scroll down to find the appropriate articleand link. http://www.anesthesiology.org
• * Attending Anesthesiologist.
• † Chair.
• ‡ Research Associate.
• § Resident Physician.
• Received from the Department of Anesthesiology, Illinois Masonic MedicalCenter, Chicago, Illinois. Submittedfor publicationOctober 4, 1999. Accepted for publicationApril 12, 2000. Support was provided solely from institutional and/or departmentalsources. Presented in part at the annual meeting of the
American Society of Anesthesiologists, Orlando, Florida, October 20, 1998, and the 75th Scientificand ClinicalCongress of the InternationalAnesthesia Research Society, Los Angeles, California, March 13—14, 1999.
• Address reprint requests to Dr. Salem: Departmentof Anesthesiology, Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, Illinois 60657. Address electronicmail to: ninosj@aol.com
• Individualarticle reprints may be purchased through the Journal Web site, www.anesthesiology.org
•
• ABSTRACT: Background: Preoxygenation before tracheal intubation is intended to increase oxygen reserves and delay the onset of
hypoxemia during apnea. Various systems are used for preoxygenation. Designed specifically for
preoxygenation, the NasOral system uses a small nasal mask for inspiration and a mouthpiece for exhalation.
One-way valves in the nasal mask and the mouthpiece ensure unidirectional flow. This investigation compares
the efficacy of preoxygenation using the standard circle system with the NasOral system and five different
resuscitation bags.
• Methods: Twenty consenting, healthy volunteers were studied in the supine position for 5-min periods of tidal
volume breathing using the circle absorber system, the NasOral system, and five resuscitation bags in a
randomized order. Data were collected during room air breathing and at 30-s intervals during 5 min of oxygen
administration. Inspired oxygen, end-tidal oxygen, and end-tidal nitrogen were measured by mass spectrometry.
• Results: At 2.5 min of oxygenation, end-tidal oxygen plateaued at 88.1 ± 4.8 and 89.3 ± 6.4% (mean ± SD) for
the circle absorber and NasOral systems, respectively. This was associated with inverse decreases in end-tidal
nitrogen. At no time did these end-tidal oxygen or nitrogen values differ from each other. Three of the
resuscitation bags (one disk type and two duck-bill type with one-way exhalation valves) delivered inspired
oxygen more than 90%, and the end-tidal oxygen plateaued between 77 and 89% at 2 min of tidal volume
breathing. The other two resuscitation bags (both duck-bill bags without exhalation valves) delivered inspired
oxygen less than 40%, and the end-tidal oxygen values ranged between 21.8 ± 5.0 and 31.9 ± 8.7%.
• Conclusions: The circle absorber and NasOral systems were equally effective in achieving maximal
preoxygenation during tidal volume breathing. Resuscitation bags differed markedly in effectiveness during
preoxygenation; those with duck-bill valves without one-way exhalation valves were the least effective. Thus, the use of these bags should be avoided for
preoxygenation.

Positive End-Expiratory Pressure During Induction of General
Anesthesia Increases Duration of Nonhypoxic Apnea in
Morbidly Obese Patient. Anesth Analg 2005; 100:580-4.
Gander S,Frascarolo P,Suter M, Spahn DR., ,Magnusson Ls
•
• Departments of *Anesthesiology and †Surgery, University Hospital, Lausanne, Switzerland
• This work is attributed to the Department of Anesthesiology, University Hospital, Lausanne, Switzerland.
• Accepted for publication August 10, 2004.
• Address correspondence and reprint requests to Lennart Magnusson, MD, PhD, Department of Anesthesiology, University Hospital, CHUV BH-10, CH-1011 Lausanne, Switzerland. Address e-mail to
lennart.magnusson@chuv.hospvd.ch.
•
• ABSTRACT: Positive end-expiratory pressure (PEEP) applied during induction of anesthesia
prevents atelectasis formation and increases the duration of nonhypoxic apnea in
nonobese patients. PEEP also prevents atelectasis formation in morbidly obese patients.
Because morbidly obese patients have difficult airway management more often and
because arterial desaturation develops rapidly, we studied the clinical benefit of PEEP
applied during anesthesia induction. Thirty morbidly obese patients were randomly
allocated to one of two groups. In the PEEP group, patients breathed 100% O2 through
a continuous positive airway pressure device (10 cm H2O) for 5 min. After induction of
anesthesia, they were mechanically ventilated with PEEP (10 cm H2O) for another 5 min
until tracheal intubation. In the control group, the sequence was the same but without
any continuous positive airway pressure or PEEP. We measured apnea duration until
SpO2 reached 90% and we performed arterial blood gases analyses just before apnea
and at 92% SpO2. Nonhypoxic apnea duration was longer in the PEEP group compared
with the control group (188 ± 46 versus 127 ± 43 s; P = 0.002). PaO2 was higher before
apnea in the PEEP group (P = 0.038). Application of positive airway pressure during
induction of general anesthesia in morbidly obese patients increases nonhypoxic apnea
duration by 50%.
•

Pre-oxygenation in the obese patient: effects of position
on tolerance to apnoea .
Respiration and the Airway
Altermatt F R,Muñoz HR,Delfino AE,Cortínez LI. Br. J. Anaesth. 2005; 95:706-709
•
• Departamento de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Chile
• *Corresponding author. E-mail: falterma@med.puc.cl
• Accepted for publication: August 1, 2005
•
• ABSTRACT: Background. In obese patients, reduced functional residual capacity exacerbated by supine
position might decrease the effectiveness of pre-oxygenation and the tolerance to apnoea. The aim
of this study was to compare the effect of body posture during pre-oxygenation, sitting or supine,
on its effectiveness in obese patients.
• Methods. Forty obese patients (BMI ³ 35 kg m-2) undergoing surgery with general anaesthesia were
randomly assigned to one of two groups: Group 1 (sitting, n=20) or Group 2 (supine, n=20). In the
predetermined body position, pre-oxygenation was achieved with eight deep breaths within 60 s
and an oxygen flow of 10 litre min-1. After rapid sequence induction of anaesthesia in decubitus
position, the trachea was intubated and the patient was left apneic and disconnected from the
anaesthesia circuit until SpO2 decreased to 90%. The time taken for desaturation to 90% from the
end of induction of anaesthesia was recorded. Arterial blood oxygen tension was measured before
(baseline) and after pre-oxygenation. Values were compared with two-way ANOVA and unpaired
Student's t-test.
• Results. Oxygen and carbon dioxide tensions were similar between groups, both at baseline and
after pre-oxygenation. However, the mean time to desaturation to 90% was significantly longer in
the sitting group compared with the supine group [mean (SD): 214 (28) vs 162 (38) s, P < 0.05].
• Conclusions. Pre-oxygenation in sitting position significantly extends the tolerance to apnoea in
obese patients when compared with the supine position.
•

• E’ evidente che quanto più profondo è il blocco neuromuscolare
e/o quanto maggiore è stata la dose sommistrata di rocuronium,
tanto più elevata debba essere il dosaggio del i sugammadex,vale a
dire 8-16 mg/kg.A questi dosaggi l’antagonismo della dose massima
di rocuronium di 1.2 mg/kg con sugammadex somministrato 3 min
dopo fa ritornare il TOF a 0.90 in tempi paragonabili a quelli della
succinilcolina(***Pu¨hringer FK, Rex C, Sielenka¨mper AW, Claudius
C, Larsen PB, Prins ME,Eikermann M, Khuenl-Brady KS: Reversal of
profound, high-dose rocuronium induced neuromuscular blockade
by sugammadex at two different time points:An international,
multi-center, dose-finding, safety assessor-blinded, phase II
trial.ANESTHESIOLOGY 2008; 109:188–97)senza che si
presentassero segni di ricurarizzazione successive e con minimi
effetti avversi (prolungamento del tratto QT,ipertensione
arteriosa…).

Pu¨hringer FK, Rex C, Sielenka¨mper AW, Claudius C, Larsen PB, Prins
ME,Eikermann M, Khuenl-Brady KS: Reversal of profound, high-dose
rocuronium induced neuromuscular blockade by sugammadex at two
different time points:An international, multi-center, dose-finding,
safety assessor-blinded, phase II trial.ANESTHESIOLOGY 2008;
109:188–97

• Lo studio di Lee (***Lee C, Jahr JS, Candiotti KA, Warriner B, Zornow MH, Naguib M..Reversal of
profound neuromuscular block by sugammadex administered three minutes after rocuronium: a
comparison with spontaneous recovery from succinylcholine..Anesthesiology. 2009 ;110:1020-5.) ha
dimostrato tempi di ripresa più rapidi dei vari parametri di ripresa neuromuscolare nel gruppo
rocuronium/ sugammadex rispetto al gruppo succinilcolina:
• 1)per la ripresa del T1 al 10% dopo 16 mg/kg di sugammadex :4.4 [0.7] vs.. 7.1 [1.6] min per la
succinilcolina; con differenza media di 2.7 min (95% CI, 3.1 -2.2 min) a vantaggio della associazione
rocuronium/sugammadex:
• 2)per la ripresa del T1 al 90% :6.2 [1.8] min) vs 10.9 [2.4] min dopo succinilcolina,con vantaggio
rispetto alla succinilcolina di 4.6 min (95% CI,5.5 -3.8 min).;
• 3)per la ripresa del tof 0.70 :4.4 (0.7) del tof 0.80: 4.6 (1.1) e del tof 0.90 5.4 (2.2) min.
• 4)Temporizzando dal momento della sommistrazione del sugammadex :3.1 (0.2) min dopo rocuronium,
media e (SD) per la ripresa del T1 al 10% era 1.2 (0.5) min e per la ripresa del T1 al 90% era 2.9 (1.7)
min..
• 5)temporizzando perla ripresa del tof 0.70; 1.3(0.6 );per il tof 0.80 1.5(1.1) ,per il Tof 0.90 2.2 (2.2)
min.
• Nell’insieme l’ 87% dei pazienti andavano incontro ad un tof 0.90 in 3 min:il 52% tra 1 e 2 min e il
13%entro 1 min dopo la iniezione del sugammadex.Le riprese del T110% in 4.4 min e del T1 90% in
6.2 min erano significativamente più brevi che la ripresa spontanea dopo succinilcolina ,attestata fra
7.1 e 10.9 min.Questi risultati rappresentano una diminuzione di 2.7 e 4.6 min per i due valori di
T1(10 e 90%)a favore del sugammadex.calcolando il tempo a partire dal bolo di sugammadex i tempi si
accorciano a 1.2 e 2.9 min.

Figure 1. Sample serial train-of-four (TOF) tracings from a patient receiving rocuronium for
neuromuscular relaxation during surgery followed by reversal with either r (A) neostigmine
(70 μg/kg IV), (B) edrophonium (1 mg/kg IV), or (C) sugammadex (4 mg/kg IV).
Sacan O et al. Anesth Analg 2007;104:569-574
©2007 by Lippincott Williams & Wilkins

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