Sudden Tachycardia Due to Submucosal Migration of an Epinephrine-Soaked Swab During Nasal Intubation

Hoshi, Tsuyoshi; Suzuki, Takashi; Somei, Masayuki; Iijima, Takehiko; Kurihara, Yuka

doi:10.2344/anpr-66-01-02

Cited by 5 publications

(5 citation statements)

References 7 publications

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“…It has also been reported that the use of E for the prevention of nasal bleeding usually has a minimal effect on circulation in many patients [22,23]. However, sudden tachycardia was reported when E was used to prevent nasal bleeding [14]. In that study, it was assumed that severe tachycardia was triggered by submucosal migration of an epinephrine-soaked swab.…”

Section: Discussionmentioning

confidence: 98%

“…Considering their signi cant use in medical procedures for > 60 years, their e cacy and side effects are well known. Although arrhythmia has been reported in literature for nasal treatments performed with E [14], no previous reports compared the vasoconstriction effects and safety of these two vasoconstrictors during NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Epinephrine versus tramazoline to reduce nasal bleeding during nasotracheal intubation. A double-blind randomized trial

Sato

Sento

Kamimura

et al. 2021

Preprint

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BACKGROUNDː Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal cavity is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.METHODSː This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. Patients with a narrowed nasal cavity observed during preoperative CT test (n = 3), patients with hypertension (n = 3), patients undergoing antithrombotic therapy, and patients who did not give consent (n = 3) were excluded from the study. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal cavity was treated using either E or T. Next, NTI was performed via the right nostril. Primary outcome was the presence of nasal bleeding. If bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding. Secondary outcomes were the degree of bleeding (classified as none, mild, moderate, or severe), arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors.RESULTSː The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T).No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups.CONCLUSIONSː Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI.Trial RegistrationUMIN-CTR (Registration No. UMIN000037907)

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Epinephrine versus tramazoline to reduce nasal bleeding during nasotracheal intubation. A double-blind randomized trial

Sato

Sento

Kamimura

et al. 2021

Preprint

View full text Add to dashboard Cite

show abstract

“…42 Accordingly, in difficult airway scenarios, avoidance of nasal bleeding is warranted when the nasal route is chosen for tracheal intubation. Although thermosoftening of ETTs 43 and the use of topical vasoconstrictors 44 are effective measures to decrease the risk of epistaxis, the facts that both strategies are time-consuming and are not used without risk 45 render them impractical in emergency airway management. Our findings of lower risks of both severe epistaxis regardless of the tracheal intubation approach and difficult airway manipulation associated with PFT tube use may further support its application in difficult airway management.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and airway complications of Parker Flex-Tip tubes and standard endotracheal tubes during airway manipulation

Hung

Chen

Feng

et al. 2021

European Journal of Anaesthesiology

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BACKGROUND Despite reported superior intubation outcomes associated with Parker Flex-Tip (PFT) tubes compared with those associated with standard polyvinylchloride tubes, the efficacy and safety of PFT tubes remain uncertain. OBJECTIVES To compare the intubation outcomes between PFT and conventional standard polyvinylchloride tubes. DESIGN Meta-analysis of randomised controlled trials. DATA SOURCES Embase, Medline, Google Scholar, PubMed and the Cochrane controlled trials register from inception until 3 January 2021. ELIGIBILITY CRITERIA All randomised trials comparing intubation outcomes between PFT (PFT group) and standard polyvinylchloride (standard polyvinylchloride group) tubes. RESULTS Analysis of the 13 eligible trials showed no significant difference in successful first-attempt intubation rate [risk ratio (RR) 1.20, 95% confidence interval (CI) 0.99 to 1.44] (6 trials, 568 participants), trauma risk (RR 0.83, 95% CI 0.67 to 1.03) (5 trials, 501 participants) as well as the overall risks of epistaxis (RR 0.58, 95% CI 0.26 to 1.31) (3 trials, 262 participants), sore throat (RR 0.90, 95% CI 0.70 to 1.17) (4 trials, 451 participants) and hoarseness (RR 0.71, 95% CI 0.44 to 1.14) (4 trials, 451 participants) between the two groups. However, the intubation time was slightly shorter (weighted mean difference −4.2 s, 95% CI −7.4 to −1.0 s) (8 trials, 759 participants) and the risks of severe epistaxis (RR 0.15, 95% CI 0.03 to 0.84) (3 trials, 262 participants) and overall difficulty in airway manipulation (RR 0.48, 95% CI 0.29 to 0.80) (8 trials, 647 participants) were lower in the PFT group than those in the standard polyvinylchloride group. Trial sequential analysis conclusively confirmed a shorter intubation time with PFT tubes than with standard polyvinylchloride tubes, whereas other intubation outcomes were inconclusive. CONCLUSION The use of PFT tubes for airway manipulation was associated with a shorter intubation time compared with the standard polyvinylchloride tubes. The results of trial sequential analysis suggest the need for further trials and meta-analysis to compare other intubation outcomes associated with the two devices. TRIAL REGISTRATION PROSPERO CRD42020197670.

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“…It has also been reported that the use of E for the prevention of nasal bleeding usually has a minimal effect on circulation in many patients [ 25 , 26 ]. However, sudden tachycardia was reported when E was used to prevent nasal bleeding [ 16 ]. In that study, it was assumed that severe tachycardia was triggered by submucosal migration of an epinephrine-soaked swab.…”

Section: Discussionmentioning

confidence: 99%

“…Considering their significant use in medical procedures for >60 years, their efficacy and side effects are well known. Although arrhythmia and cardiac arrest have been reported in literature for nasal treatments performed with E and oxymetazoline [ 16 , 17 ] so far, no previous reports compared the vasoconstriction effects and safety of vasoconstrictors during NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.…”

Section: Introductionmentioning

confidence: 99%

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial

et al. 2021

View full text Add to dashboard Cite

Background Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI. Methods This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors. Results The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups. Conclusions Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI. Trial registration UMIN-CTR (Registration No. UMIN000037907). Registered (05/09/2019).

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Sudden Tachycardia Due to Submucosal Migration of an Epinephrine-Soaked Swab During Nasal Intubation

Cited by 5 publications

References 7 publications

Epinephrine versus tramazoline to reduce nasal bleeding during nasotracheal intubation. A double-blind randomized trial

Epinephrine versus tramazoline to reduce nasal bleeding during nasotracheal intubation. A double-blind randomized trial

Efficacy and airway complications of Parker Flex-Tip tubes and standard endotracheal tubes during airway manipulation

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial

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