BACKGROUND: Macintosh blade direct laryngoscopy is widely used for endotracheal intubation. It may, however, provide an incomplete view of the glottis in patients with challenging airway anatomy. Consequently, various video laryngoscopes have been developed to enhance the visualization of the glottis and facilitate intubation. Yet, the effectiveness of these video laryngoscopes for intubation using a double-lumen endotracheal tube (DLT), which is longer, larger, and more rigid and has a linear configuration as opposed to the naturally semicircular curvature of a single-lumen endotracheal tube, remains uncertain. We hypothesized that video laryngoscopes would be more efficient for DLT intubation compared to the Macintosh blade in an adult manikin.
METHODS: Ninety-four anesthesia providers, comprising 67 residents, 15 fellows, and 12 attendings, attempted to intubate an adult manikin with normal airway anatomy (Laerdal, Wappingers Falls, NY, USA) using a 37 Fr left-sided DLT. Three different intubation devices were used: the C-MAC® video laryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), the GlideScope® video laryngoscope (Verathon Inc., Bothell, WA), and the Macintosh blade direct laryngoscope-were used. Each participant intubated a manikin once with each of the three devices. Participants were randomized via a crossover design with the order of devices determined by using a Latin square design. Time to intubation and the number of failed intubations (esophageal intubation) were compared across the three different devices.
RESULTS: Mean times to intubation for the C-MAC®, GlideScope®, and Macintosh blades were 18.57 ± 0.77, 36.26 ± 2.69, and 20.76 ± 0.96 seconds, respectively. There was a statistically significant difference (P<0.001) between the GlideScope® and the other two laryngoscopes. The times for C-MAC® and Macintosh blades were not significantly different. There were two instances of first-attempt failed intubation with the Macintosh.
CONCLUSIONS: Both the C-MAC® and the Macintosh blades proved more efficient in terms of time to DLT intubation in the manikin with normal airway anatomy, when compared to the GlideScope®. Considering the occurrence of first-attempt failed intubation, the C-MAC® was the most effective device among the three laryngoscopes for timely successful DLT intubation in the adult manikin. Further studies are needed to confirm these results in human subjects.

UNASSIGNED: The visualization of the glottis may be inadequate in morbidly obese patients when a standard Macintosh blade laryngoscope (MCL) is used. The Vie Scope® (VS) is a novel type laryngoscope consisting of a straight, enclosed, illuminated tube that offers intubation via a bougie using the paraglossal technique. In this prospective, nonrandomized comparative study, we tested the research hypothesis that the VS may improve visualization of the glottic larynx in comparison to the MCL.
UNASSIGNED: After obtaining institutional ethics committee approval, 60 morbidly obese patients (BMI >40 kg/m2) undergoing elective non-head and neck surgery were included in the study. After induction of general anesthesia (GA), the glottic visualization was performed using the two laryngoscopes in succession, first MCL size 3 or 4 followed by the VS and was assessed using the modified Cormack-Lehane scale. Tracheal intubation was performed using the VS The first pass intubation success and the total success rate was recorded only for the VS Intubation time was not measured because of the paired study design.
UNASSIGNED: Mean demographic data included: age 41.9±8.2 years, height 171.2±10.2 cm, weight 129.9±21.6 kg, BMI 44.95±3.85 kg/m2. Using MCL, Cormack-Lehane grade 1 was observed in 36 (60%) cases; grade 2 in 7/60 (11.6%); grade 3 in 13/60 (21.7%); and grade 4 in 4/60 (6.7%). Poor laryngeal views represented by grades 3 and 4 were observed in 28.4% of patients with the MCL. Grades obtained with the VS were all grade 1 (100%). The first attempt intubation success was in 58/60 (96.7%) with the VS. No complications were observed.
UNASSIGNED: The Vie Scope® laryngoscope, using the paraglossal technique of tracheal intubation, significantly improves visualization of the vocal cords in morbidly obese patients compared to the standard Macintosh laryngoscope.

BACKGROUND: Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic.
UNASSIGNED: We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself.
CONCLUSIONS: This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC.

OBJECTIVE: Despite encouraging clinical, biomechanical and histological results, ACL reconstruction using the ITB was slowly abandoned. The hypothesis was that the current literature supports the use of ITB as the graft of choice for ACL reconstruction because of its good outcomes.
METHODS: A systematic search of the literature was performed in the PubMed, MEDLINE, Cochrane, and Ovid databases to identify published clinical studies relevant to ACL reconstruction with ITB autograft and studies comparing ITB autograft with bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts (none were found). The results of the eligible studies were analyzed in terms of graft failure, instrumented knee laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, Tegner activity score, return to sports rate, return to sports at pre-injury level and complications.
RESULTS: Nineteen clinical studies including 1,210 patients with ACL reconstruction met the inclusion criteria. Graft failure occurred after ITB autograft in 4.2% of patients. Postoperative mean side-to-side laxity was 1.41 mm with 21% of patients having greater than 3 mm side-to-side difference. Lachman test and pivot-shift test were negative (grade 0) in 57% and 85%, respectively, and were grade 0 or 1 in 95% and 97%, respectively. Functional outcomes were satisfactory in 84% of patients with good to excellent results (Lysholm score > 84). Mean postoperative Lysholm score was 93.3 and 84% of patients had an objective IKDC grade of A or B. Mean postoperative Tegner score was 6.8. The return to sports rate was 89% and 61% of patients returned to their pre-injury level. A comparison of 89 ITB versus 80 BPTB autografts revealed no significant differences in graft failure (n.s.), instrumented mean side-to-side knee laxity difference (n.s.) or Tegner score (n.s.).
CONCLUSIONS: The graft survival rate and clinical and functional outcomes for ITB autograft are satisfactory. By allowing ACL reconstruction and lateral tenodesis to be done with a single, continuous, pedicled graft through an outside-in femoral tunnel, this technique may become the preferred alternative for primary or secondary ACL surgery.
METHODS: Level IV.

UNASSIGNED: Double lumen tube (DLT) insertion for isolation of lung during thoracic surgery is challenging and is associated with considerable airway trauma. The advent of video laryngoscopy has revolutionized the management of difficult airway. Use of video laryngoscopy may reduce the time to intubate for DLTs even in patients with normal airway.
UNASSIGNED: A total of 87 ASA 1-3 adults, scheduled to undergo elective thoracotomy, requiring a DLT were randomly allocated to videolaryngoscope (CMAC) arm or Macintosh laryngoscope arm. It was on open label study, and only the patient was blinded. The primary objective of this study was to compare the mean time taken for DLT intubation with CMAC (Mac 3) and Macintosh laryngoscope blade and the secondary objectives included the hemodynamic response to intubation, the level of difficulty using the intubation difficulty scale (IDS), and complications associated with intubation. Data was analysed using the statistical software SPSS (version 18.0).
UNASSIGNED: The time taken for intubation was not significantly different (42.8 ± 14.8 s for CMAC and 42.5 ± 11.5 s for Macintosh laryngoscope P -0.908). The CMAC video laryngoscope was associated with an improved laryngoscopy grade (Grade I in 81.8% with CMAC and in 46.5% with Macintosh), less pressure applied on the tongue, and less external laryngeal pressure required. Hemodynamic responses to intubation were similar in both groups.
UNASSIGNED: Macintosh blade is as good as CMAC (mac 3) blade to facilitate DLT intubation in adult patients with no anticipated airway difficulty, however CMAC was superior as it offers better laryngoscopic view, needed less force, and fewer external laryngeal manipulations.

Hemodynamic responses during laryngoscopy can potentially precipitate ischemia in patients with coronary artery disease. There are conflicting reports regarding the hemodynamic stress responses between the conventional Macintosh and video laryngoscopes. There is a paucity of studies regarding the same in cardiac surgical patients.
A prospective, randomized control study to compare the hemodynamic responses and ease of intubation using Airtraq video laryngoscope and Macintosh laryngoscope in patients with ischemic heart disease.
Seventy patients were randomized into two groups. Baseline variables including age, weight, Mallampati score, and comorbidities were comparable between the two groups. There was statistically significant elevation in mean heart rate in the Macintosh group at 2nd-min (P = 0.02) and 3rd-min (P = 0.05) postintubation. Similarly, there was a significant increase in mean arterial pressure at 2nd (P = 0.06), 3rd (P = 0.03), and 4th (P = 0.03) in the Macintosh group. The time for laryngoscopy and Intubation Difficulty Scale was significantly better in the Airtraq group (P = 0.001 and 0.001). However, the median time to intubation was longer in the Airtraq group (13 s vs. 11 s, P = 0.05). Laryngoscopy view was better with Airtraq even in patients with Mallampati score 3 (ten patients). The incidence of trauma was same in both the groups.
Airtraq provides the better hemodynamic stability and ease of intubation and may be considered superior to conventional Macintosh laryngoscope for intubation in patients with ischemic heart disease.

UNASSIGNED: Airtraq® is a single-use video laryngoscope used to facilitate tracheal intubation in both expected and unexpected difficult airways.
UNASSIGNED: We hypothesized that Airtraq laryngoscope would facilitate better intubation criteria and lower stress response to laryngoscopy in comparison to the Macintosh laryngoscope.
UNASSIGNED: In this randomized, single-blinded, prospective study, 70 adult patients were randomly assigned to be intubated with either Airtraq (Group AT) or Macintosh (Group M) laryngoscope (35 patients in each). The primary outcomes involved intubation time, first-attempt success rate, time to best laryngoscopic view, and percentage of glottic opening (POGO) score. Other recorded parameters involved the hemodynamic and intraocular pressure (IOP) responses to laryngoscopy and intubation and complications during and after laryngoscopy and after extubation. Serum samples were collected before anesthesia induction and 2 min after intubation and analyzed for epinephrine, cortisol, and glucose.
UNASSIGNED: Group AT had significantly higher POGO score and significantly shorter intubation time and time to best laryngoscopic view than Group M (P < 0.001). The first-attempt success rate was 97.1% in Group AT and 94.3% in Group M (P = 0.55). Postoperatively, laryngospasm and sore throat were encountered in 2.9% of Group M patients compared to 0% in Group AT (P = 1.00). The heart rate, mean arterial pressure, IOP, serum epinephrine, and cortisol were significantly increased in Group M than Group AT.
UNASSIGNED: In comparison to the Macintosh laryngoscope, Airtraq conferred significantly better intubation criteria and lesser stress response to laryngoscopy and intubation.

OBJECTIVE: Truview evo2 has been found to improve the glottic view when compared with the Miller blade in pediatric population. However, there is limited literature comparing it with Macintosh laryngoscope in children. We thus aimed to assess and compare Truview evo2 with the Macintosh laryngoscope for orotracheal intubation in children with regards to time to intubate, laryngoscopic view, ease of intubation, and associated hemodynamic changes.
METHODS: Fifty ASA I-II children aged 2-8 years for elective surgery requiring general anesthesia with orotracheal intubation participated in this prospective randomized-controlled study. They were randomly allocated to two groups. In group-M (N = 25), laryngoscopy and intubation were performed using Macintosh laryngoscope, and in group-T (N = 25), Truview evo2 laryngoscope was used. Modified Cormack-Lehane grade, time to intubation, intubation difficulty score (IDS), and hemodynamic changes were compared between the groups. Data were analyzed using SPSS statistical software version 17 and P value <0.05 was considered statistically significant.
RESULTS: CL grade 1 was found in a larger number of patients of group-T (P = 0.003) and CL grades2a and 2b were found in a larger number of patients of group-M (P = 0.023 and P = 0.037, respectively). The mean time to intubation was significantly longer in group-T (19.0 ± 3.4 seconds) than in group-M (13.1 ± 2.1 seconds), P = 0.00. The over all IDS was lower in group-T than group M [i.e. median (IQR): 0 (0-0) vs 1 (0-2), respectively]. Heart rate, systolic and diastolic blood pressure, and oxygen saturation were comparable between the groups at all times.
CONCLUSIONS: Truview evo2 provides better laryngeal view and has a lesser IDS, but takes longer for intubation, when compared to the Macintosh laryngoscope in children.

BACKGROUND: This study was designed to compare the hemodynamic changes in response to direct laryngoscopy with using the McCoy or Macintosh blade.
METHODS: Seventy seven patients were randomly allocated into two groups. The induction of anesthesia was done with target controlled infusion of propofol (5 microgram/ml) and remifentanil (3 ng/ml) and vecuronium 0.1 mg/kg was also given. The vocal cords were visualized with either the McCoy or the Macintosh laryngoscope blade, and then tracheal intubation was performed. The heart rate and blood pressure were measured just before induction, at intubation and at 1, 3 and 5 minutes after intubation.
RESULTS: There were no significant differences in the blood pressure and heart rate responses to tracheal intubation with using the McCoy or Macintosh blade. But, in the Macintosh groups, the blood pressure at 1 and 3 minutes and the heart rate at 1 minute after intubation were increased significantly compared with the preintubation values. Also, in the McCoy groups, the blood pressure and heart rate at 1 minute after intubation were significantly higher than the preintubation values.
CONCLUSIONS: The McCoy and the Macintosh blade show similar changes in heart rate and blood pressure after tracheal intuba tion.

Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades.
Design: retrospective chart review.
hospital-based suburban ALS service with 20,000 annual calls.
prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated.
2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7).
Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success.