Archive for July 16, 2014

Mac vs Miller blades in pediatric intubation

A common discussion point when deciding what equipment to use for a pediatric intubation. Anecdotally placing the tip of the miller blade in the vallecula is technically easier than lifting the epiglottis and will frequently provide a more than satisfactory view of the cords. This article agrees with this. See the abstract below.

Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?

Elsa Varghese, Ratul Kundu
Paediatric Anaesthesia 2014 April 2


BACKGROUND: Both Miller and Macintosh blades are widely used for laryngoscopy in small children, though the Miller blade is more commonly recommended in pediatric anesthetic literature. The aim of this study was to compare laryngoscopic views and ease and success of intubation with Macintosh and Miller blades in small children under general anesthesia.

MATERIALS AND METHOD: One hundred and twenty children aged 1-24 months were randomized for laryngoscopy to be performed in a crossover manner with either the Miller or the Macintosh blade first, following induction of anesthesia and neuromuscular blockade. The tips of both the blades were placed at the vallecula. Intubation was performed following the second laryngoscopy. The glottic views with and without external laryngeal maneuver (ELM) and ease of intubation were observed.

RESULTS: Similar glottic views with both blades were observed in 52/120 (43%) children, a better view observed with the Miller blade in 35/120 (29%) children, and with the Macintosh blade in 33/120 (28%). Laryngoscopy was easy in 65/120 (54%) children with both the blades. Restricted laryngoscopy was noted in 55 children: in 27 children with both the blades, 15 with Miller, and 13 with Macintosh blade. Laryngoscopic view improved following ELM with both the blades.

CONCLUSION: In children aged 1-24 months, the Miller and the Macintosh blades provide similar laryngoscopic views and intubating conditions. When a restricted view is obtained, a change of blade may provide a better view. Placing the tip of the Miller blade in the vallecula provides satisfactory intubating conditions in this age group.

Ketamine and increased ICP

Interesting article just published in J of Crit Care regarding ketamine effects on ICP…..feel free to keep using ketamine freely. See abstract below.

The ketamine effect on intracranial pressure in nontraumatic neurological illness

Frederick A Zeiler, Jeanne Teitelbaum, Michael West, Lawrence M Gillman

Journal of Critical Care 2014 June 4

PURPOSE: The purpose of the study was to perform a systematic review of the literature on the use of ketamine in nontraumatic neurological illness and its effects on intracranial pressure (ICP).

MATERIALS AND METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2014), and gray literature were searched. Two reviewers identified manuscripts on the administration of ketamine in nontraumatic neurological illness that recorded effects on ICP. The strength of evidence was adjudicated using the Oxford and Grading of Recommendation Assessment Development and Education (GRADE) methodology.

RESULTS: Our search produced a total of 179 citations. Sixteen articles, 15 manuscripts, and 1 meeting proceeding were included in the review. Across all studies, there were 127 adult and 87 pediatric patients described. Intracranial pressure did not increase in any of the adult studies reporting premedication during ketamine administration, with 2 studies reporting a decrease in ICP. No significant non-ICP-related adverse events from ketamine were recorded in any of the studies.

CONCLUSIONS: There exists Oxford level 2b, GRADE C evidence in adults and level 4, GRADE C in pediatrics to support that ketamine does not increase ICP in nontraumatic neurological illness when patients are sedated and ventilated, and in fact may lower it in selected cases.