@2024 Afarand., IRAN

---

ISSN: 2252-0805    The Horizon of Medical Sciences 2018;24(3):203-213

Background
The Iranian educational system should be considered according to the needs of the community in order to develop skilled and capable human resources at all levels of medical sciences [1]. ... [2-6]. Ventilation skills, laryngoscopy, and tracheal intubation are of the most difficult and important techniques taught to anesthetic students and require careful and adequate care [7].
Previous Studies
In the studies carried out in the United Kingdom on the extent of training and skill of emergency physicians and the use of drugs and airway management, it has been concluded that physicians need at least 3 months of anesthesia training and ICU courses [8]. Statistical studies have shown that following the training of emergency physicians after 57 intubations, the success rate has reached 90%, and residents need help in only 18% of the cases; thus, they should always be prepared with good training courses to deal with many types of intubation cases [9, 10]. Another study in Turkey has shown that in intubation with rapid induction, the combination of propofol and remifentanil is used without the need for muscle relaxants in young and healthy people. In a number of studies, it has been concluded that in the absence of a drug, the most common complication, that is the hoarseness, is clearly increased [11].
Aim(s)
The aim of this study was to determine the level of awareness and utilization of tracheal intubation with medication by general practitioners and interns.
Research type
This research is a descriptive cross sectional study.
Research society, place and time
The research population consisted of physicians working in Shiraz Medical Education hospitals during 2015-2016, who intubated directly in the emergency department, or supervised the recovery team, as well as all interns and students, who were in charge of intubation.
Sampling method and number
The sample size was 178 based on the (n=z_1-a/2 P(1-P))/d^2 formula and previous studies that were selected from physicians and interns. The inclusion criteria included being interns or general practitioners. The exclusion criteria also included anesthetist students and resident, or medical students other than internship.
Used devices&materials
The data were collected by arranging and preparing a questionnaire. In this questionnaire, the knowledge and use of the subjects according to the expert's opinion in each case was scored from 0-10 (question 3-12); scores ≤3 are considered weak, 4-6 are considered moderate, 7-8 are considered good, and 9-10 are considered excellent. Also, the first question was to complete individual information and awareness of intubation by them, and in question 2, we reported the use of individuals. Age, gender, work experience, and educational level of the subjects were also questioned. According to the Dr. Samadi's estimate, the percentage of doctors using intubation is about 35%. The data were analyzed by SPSS 19, using descriptive statistics.
Findings by Text
In sum, 79 interns (88.77%) performed intubation in the emergency department. 21 participants (26.6%) performed less than 10 intubations and 58 participants (73.4%) h performed ad 10-50 intubations in the emergency department. In the case of using medications while intubations, 51.68% of the interns stated that they used only sedative medications and did not use muscle relaxants. The majority of general practitioners (56.2%) said they did not use any drug. The majority of general practitioners (77.5%) and most of the interns (73%) considered the use of medication in emergency intubation to be helpful. Most of the general practitioners (61.8%) and interns (61.8%) banned intubation by rapid induction while extensive trauma. For muscle relaxants in intubation by rapid induction, 83.2% of general practitioners and 58.4% of interns selected succinylcholine. 56.2% of general practitioners considered midazolam to be banned while intubation, and 71.9% of interns chose lidocaine, midazolam, and ketamine. 30.34% of the interns selected LMA as a good tool for rapid induction for intubation and 78.6% considered BVM and mask as appropriate tools. 48.3% of the interns and 33.6% of general practitioners used Etomidate-ketamine as an anesthetic for those with severe hemorrhage. 82% of interns and 39.3% of the general practitioners used ketamine-esculin for a randomized patient, of whom did not have a NPO status information and thought s/he might have a bleeding risk. 34.8% of the interns used ketamine-esculin to combine a drug for a severe neck trauma, and 34.8% selected no item. 33.7% of the general practitioners used ketamine-esculin to combine a drug for a patient with severe neck trauma. 41.6% of the interns and 50.6% of the general practitioners considered LMA as an option for the next option after failing to intubate due to anesthetic trauma. 33.7% and 55.1% of the interns chose tracheostomy and cricothyrotomy, respectively, if the intubation was performed in emergency and the ventilation was not possible. The awareness level of general practitioners was 27% as poor, 55% as moderate, and 18% as good. The awareness level of interns was 3.37% as poor, 78.65% as moderate, and 17.98% as good.
Main comparison to the similar studies
… [12]. Studies have shown that LMA performs better oxygenation than BVM with an airway, and by air way with LMA, permanent masking pores is not required [13]. … [14, 15]. Joo et al. reported that with the administration of 2 μg/kg remifentanil, after induction of sevoflurane gas without the need for muscle relaxant, 89% of the oral tracheal intubation could be performed [16]. Also, Durmus et al. have shown that the injection of 4 μg/kg of remifentanil before thiopental in 94% provides conditions for intubation in the trachea [17]. Regarding the comparison of remifentanil and alfentanil, Erhan et al. compared different doses of remifentanil with alfentanil after propofol administration and observed great status of oral tracheal intubation in 45% of patients, who received alfentanil at a dose 40 μg/kg, 75% of the patients, who received remifentanil at a dose of 3 μg/kg, and 95% of patients, who received 4 μg/kg remifentanil [18]. …. [19, 20]. Also, research has shown that hemodynamic changes following the concomitant administration of propofol and remifentanil are negligible compared with administration of each alone and, on the contrary, the effects on the respiratory system are exacerbated [21]. On the other hand, Trabold et al. have shown that in the case of injection of remifentanil after propofol (and not before), patients will have better hemodynamic and intubation conditions; this sequence was also observed in the injection of two drugs in the present study [22]. In this study, 24 interns (27.6%) use propofol without muscle relaxant to combine the drug for a disease with a severe neck trauma. … [23, 24]. In a Danish study of advanced airway prehospital management, we found a high degree of experience and training among EMS doctors, but their knowledge of the equipment was limited. Investigation, guidelines, standard operating procedures, and other quality control measures may be necessary [25]. …. [26]. In the present study, most of the participants were in moderate level and need more training for intubation in emergency department. In a study, success rates among the first to third year physician assistants were 84, 92, and 100, respectively. Quick induction of anesthesia is not dependent on the performer, provided that it is performed by the emergency resident [31-27]. In this study, the awareness level of interns was higher than that of general practitioners, and it is recommended to collaborate on intubation to have a better outcome.
Suggestions
Further studies with more cases and more accurate categorization can be helpful in clarifying the level of awareness and using tracheal intubation by general practitioners and interns.
Limitations
One of the limitations of this study was the fact that, due to the small number of participants, we did not succeed in categorizing them based on the duration of intubation training and the number of successful intubations on different patients.
Conclusions
Intubation in emergency department can be helpful by the interns and general practitioners, and it can be performed by both of them. To improve their performance, they can participate at workshops and training courses to update information.
Acknowledgments
We would like to express our gratitude to to Shahid Motahari Hospital of Shiraz University of Medical Sciences. The present article is a part of the dissertation of the Seyyed Ashkan Musaviopur.
Conflict of interest
There is no conflict of interest.
Ethical Permissions
This thesis was conducted with the support of the research deputy of the faculty of medicine from the research project under contract No. 95-7695 dated January 14th, 2017.
Funding Sources
Shiraz University of Medical Sciences has financially supported the present study.