Efficacy and Safety of Melatonin as an Anxiolytic and Analgesic in the Perioperative Period

Abstract

M anual in-line stabilization (MILS) is recommended during direct laryngoscopy and intubation in patients with known or suspected cervical spine instability. It was hypothesized that anesthesiologists would apply greater pressure during intubations with MILS than without because MILS impairs glottic visualization. Nine anesthetized and pharmacologically paralyzed patients underwent 2 sequential laryngoscopies and intubations, 1 with MILS and 1 without in random order. A transducer array along a Macintosh 3 laryngoscope blade continuously measured the pressures applied, and the glottic view was characterized. Using MILS, glottic visualization was worse in 6 patients, and failure of intubation occurred in 2 of these patients. Maximum laryngoscope pressure at best glottic view was greater with MILS than without (717 T 339 vs 363 T 121 mm Hg, respectively, n = 8). Other measures of pressure application also indicated comparable increases with MILS. Pressures applied to airway tissues by the laryngoscope blade are transmitted secondarily to the cervical spine and lead to craniocervical motion. In the presence of cervical instability, impaired glottic visualization and secondary increases in pressure application with MILS can potentially increase pathologic craniocervical motion. COMMENTCurrent Advanced Trauma Life Support standards state that MILS should be used when direct laryngoscopy (DL) and tracheal intubation are urgently needed in patients with known or suspected cervical spine instability. Manual in-line stabilization is designed to externally restrict head and neck movement, presumably minimizing pathologic cervical spine motion that might otherwise occur at unstable segments. This potential benefit is, however, counterbalanced by the unwelcome fact that MILS impedes glottic visualization.The current well-designed study sought to enroll patients who would be easy to intubate with a Macintosh 3 blade. Exclusion criteria were focused on eliminating patients who might be at increased risk of intubation-related and/or other study-related complications. Faculty anesthesiologists performing the intubations had 19 T 10 years (mean T SD) of postresidency experience, the anesthetic protocol was standardized with patients being given equipotent doses of nondepolarizing neuromuscular blocking agents, and the patient's head and neck were placed in the neutral position just before DL was performed. During each DL and intubation, anesthesiologists were told to obtain the best possible glottic view using only the laryngoscope. Manual in-line stabilization was applied; manual head and neck movement and external laryngeal manipulation (cricoid pressure) were not allowed, the rationale being to ensure that all pressures applied to the airway could be quantitated. (Because the investigators measured pressure directed against the anterior surface of a Macintosh blade, the intubators could not use external posteriorly directed pressure.) Use of an endotracheal tube stylet was also not permitted. The results disclosed that DL with...

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