IntroductionDifficult airway management during tracheal intubation can lead to severe hypoxic sequelae. Routine intubation practice is to use a strict supine position, whereas a 25° head-up or reverse Trendelenburg position increases efficacy of preoxygenation, seems more comfortable for the anaesthetist and may also provide better intubation conditions in direct laryngoscopy. The 25° head-up position could be used for the whole population rather than only for obese patients, but there is no prospective randomised controlled trial with a robust design and large number of patients comparing strict supine against 25° intubation in operating room. The objective of the InSize25 study is to test the effect of these two patient positions on intubation conditions during laryngoscopy in scheduled surgery on non-obese patients.Methods and analysisInSize25 is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial. The InSize25 study will randomise 1000 adult patients scheduled for surgery under general anaesthesia requiring intubation with neuromuscular-blocking drugs, candidates for direct laryngoscopy. The primary outcome variable is the view obtained during the first laryngoscopy without any external manipulation assessed using percentage of glottic opening. Important secondary outcomes are: Cormack-Lehane classification, number of attempts at laryngoscopy and at tracheal intubation, use of ancillary equipment (eg, bougies, alternative laryngoscope blades, videolaryngoscope) and manoeuvres (eg, laryngeal manipulation), comfort score for the anaesthetist, episodes of postinduction hypotension or desaturation and mechanical complications of intubation.Ethics and disseminationThe trial received appropriate approval from the ‘CPP Sud-Est II’ ethical review board. Informed consent is required. If the 25° head-up position proves superior for tracheal intubation without more complications, it may become the routine-standard intubation position rather than only for use with obese patients. The final results will be published in a peer-reviewed journal.Trial registration numberClinicaltrials.gov identifier (NCT03339141).
L’article propose d’investiguer la conduite d’entretiens soignants-patients basés sur les principes de l’ETP en matière d’abord du mourir. La revue de littérature pointe l’exclusivité palliative, un clivage de vue sur la sédation profonde via les autorités de santé, l’impasse des comités éthiques. Les auteurs orientent sur une éthique renouant avec sa base d’embarras, en appelant à la philosophie. La méthodologie expose le cadrage d’ateliers pédagogiques sur les directives anticipées basés sur les principes originels qui régulent le dialogue en ETP : écoute des verbalisations spontanées et l’interprétation de paroles vivantes par le médecin sont centrales. Le discours produit une réciprocité d’échanges entre savoirs expérientiels et savants pour parler du mourir et l’anesthésiste-réanimateur explicite l’intérêt de sa confrontation aux 21 sujets futurs patients/ futurs mourants : les conditions d’un ajustement intersubjectif soignants-citoyens convoque l’Homme. Les expressions recensées en ateliers prouvent que la mort, loin de drainer le tabou d’irreprésentabilité avancée comme frein à la rédaction de directives anticipées, fait se coïncider la part agissante des individus. Ceci parait possible si chacun, médecin compris, accepte d’entendre autrui. Les récits des participants révèlent toutefois une inégalité sociale face à la mort.
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