113 APNOEIC OXYGENATION IN INTUBATION: PROLONGING THE TIME OF SAFE APNOEA. A SYSTEMATIC REVIEW AND META-ANALYSIS Miss. Andrea Marin 1, 2 , Arley Torres 1, 2 , Alberto Giraldo 1, 2, 3 . 1 Department of Anesthesiology of Universidad Del Valle, Cali, Colombia; 2 Department of Anesthesiology of Hospital Universitario del Valle, Cali, Colombia; 3 Universidad Javeriana, School of Epidemiology, Cali, Colombia The management of the airway is a fundamental part of the anesthetic act, multiple strategies have been proposed enhance safety during laryngos- copy to achieve a definitive approach of the airway, i.e., tracheal intuba- tion 1 . Apnoeic oxygenation is one of these strategies, that consists in administration of oxygen during laryngoscopy and intubation with the objective of extend tolerance to apnoea without desaturation beyond the time achieved with conventional preoxygenation 2 . This is done using high flow nasal or nasopharyngeal catheters and modified laryngoscopes. It is useful in patients with predicted difficult airway and difficult intubation 3 . We evaluated the effect of apnoeic oxygenation in the safe apnea time in patients older than 18 years scheduled for elective surgery with general anesthesia. The literature was systematically reviewed in the PubMed, SCOPUS and Medline databases with a deadline of October 30, 2018 for apnoeic oxygenation and safe apnea time. We also performed search with snowball strategy using the same terms and expanded the search with gray literature. We included randomized clinical trials (RCT), in patients older than 18 years, comparing time before desaturation with apnoea oxygenation and any other preoxygenation strategy, in patients who received general anesthesia for elective surgery. The main author extracted data from studies and we used Cochrane Collaboration’s Review Manager version 5.3. We submitted this research to the Universidad del Valle’s Ethics Committee for approval under the Animal (Scientific Procedures) Act (1986) with a low risk grade. Figura 1. Safe apnoea time (min)Ă We evaluated eight RCT that included a total of 308 patients. We found that Apnoeic oxygenation with nasal or nasolaryngeal cannulas extends safe apnoea time by 1.97 minutes (95% CI 1.38 - 2.55) in patients that receive general anaesthesia for elective surgery. It is a simple but effective inter- vention that provides an important benefit in terms of time without desaturation. However, this meta-analysis counted with a limited number of patients and considerable heterogeneity among studies (I2 93%). More RCT with more significant sample are needed to find more solid conclusions. References [1] Cook TM, Woodall N, Frerk C. Major complications of airway manage- ment in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaes- thesia. Br J Anaesth. 2011;106(5):617-31 [2] Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation: Physiologic Basis, Benefits, and Potential Risks. Anesth Analg. 2017;124(2):507-17. [3] Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesi- ology. 2005;103(1):33-9. 114 AWAKE FIBREOPTIC INTUBATION MADE EASY Islam Uddin 1 , Alaister Mulcahy 1 . 1 The Royal London Hospital, London, United Kingdom A Four step method to performing an awake fibreoptic intubation and simplifying a complex procedure so that it is easy to teach and remember. 37. Preparation: Equipment: 1. MADgic device 2. 2ml syringes 3. Nasal endotracheal tube size 6 4. Fibreoptic scope and screen 5. Lubricating gel 6. Oxygen catheter (nasal sponge) 7. TCI pump Drugs: 1. Co-phenylcaine 2. 4% Lidocaine 3. 10% Lidocaine spray 4. Glyco- pyrrolate 5 Choice of sedation and anaesthetic drugs Environment: 1. Ensure bed will go flat 2. Patient monitored 3. Trained personnel 1. Explanation & Sedation: Let the patient be in control. Explain why the procedure needs to be done. Explain how the procedure will be done. ‘I will stop if its uncomfortable’ ‘The local anaesthetic will be a disgusting taste and will make you cough’ ‘you will feel a lump in the back of your throat’‘ you will feel a lot of pressure when the tube passes through your nose’‘Once the tube is in the vocal cords you will not be able to talk to me’‘We will not hurt you’‘raise your hands if you want me to stop’‘ As soon as we have checked the tube is in the correct place we will put you to sleep’‘you will not be able to speak when the tube has been passed’ Sedation: Your choice of sedation e.g. 1. Midazolam 2mg + Fentanyl 50- 100mcg 2. Remifentanil TCI 2. Local Anaesthesia: 1. Prime the co-phenylcaine bottle with 3 sprays 2. Spray each nostril 3 times (takes 5 minutes to work effectively). 3. Curl MADgic device and pass into back of nose and spray with 2ml of 4% lidocaine, spraying small amounts at a time as progressing through to naso-pharynx. 4. 10% lidocaine (use new nozzle), spray into the mouth and the back of the nose. 3. Fibreoptic Intubation: Patient in the sitting position and standing in front of the patient. 1. Insert oxygen tubing to adjacent nostril if concerns of hypoxia. 2. Load preferred endotracheal tube. 3. Pass fibreoptic scope through preferred nostril. 4. 2ml syringe with 1ml of 4% lidocaine and 1ml of air e spray on vocal cords, once visible spray below cords. 5. Use lubricating gel on the nostril. 6. Warn patient of pressure as passing nasal tube. 7. Pass the tube past the cords (if unable to pass, pull the tube back and twist 90 degrees anticlockwise and advance again). 8. Pull back fibreoptic scope, ensuring end of tube in above the carina. 9. Confirm endotracheal tube in correct place with end-tidal monitoring. 10. Do not inflate endotracheal cuff until patient is asleep. 11. Anaesthetist the patient. 116 FLEXIBLE ENDOSCOPIC PLACEMENT OF DOUBLE LUMEN TUBE AS A PRIMARY TECHNIQUE. TIME-SAVING OR CONSUMING? Marcelo Ramos 1 , Guilherme Aquino 2 , Bruna Cabreira 2 , Ronaldo Antonio Silva 1 , Alex Madeira 1 . 1 Cancer center A. C. Camargo, S~ ao Paulo, Brazil; 2 Hospital Maternidade Cristov~ ao da Gama, Santo Andr e, Brazil Up to 2018 I usually did all my intubations with double lumen tubes (DLT) “by the book”, I mean, first (direct or video) laryngoscopy and placement of the DLT into the trachea, made the proper turn to try to blindly align the bronchial lumen with the left main bronchus and hope for the best. If all went well and that particular patient had no anatomic variation the left bronchus would be cannulated to the correct depth (without untoward intubation of any of its divisions) and the tracheal lumen would be func- tional to ventilate the right lung. After completing this step I always employed a flexible endoscope to check the right position of the tube. Sometimes I had some difficulty in diagnosing that accidentally the tube made an inverse selection and the right bronchus was intubated instead. Then at the beginning of 2018, I asked myself: Why am I repeating the cumbersome and irksome DLT intubation I learned back in the ’80s, and then checking if is it everything alright as I learned in 2000s? I began a “new” way to place the DLT, mainly because in my hospital the endoscope is supposed to be disinfected regardless of being used or not. Once in the room, even if untouched, the endoscope goes to disinfection to avoid clerical error and use of a “dirty” endoscope. So, from the beginning of 2018, instead of employing laryngoscopy (DL or VL) for intubation, I began to mount the DLT via the bronchial lumen onto the endoscope and navigate from the mouth to the division of superior and inferior left bronchus. Once with the tip of the endoscope placed in the Abstracts / Trends in Anaesthesia and Critical Care 30 (2020) e1ee192 e35