Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani

La destreza en la realización de procedimientos como la intubación orotraqueal es un elemento necesario en la formación de los médicos anestesiólogos. La laringoscopia directa es la técnica más usada de intubación traqueal, sin embargo, la secuencia de dispositivos a emplear al abordar la vía aérea...

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Autores:
Suarez Arias, Silvia Marcela
Tipo de recurso:
Fecha de publicación:
2023
Institución:
Universidad Autónoma de Bucaramanga - UNAB
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Repositorio UNAB
Idioma:
spa
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oai:repository.unab.edu.co:20.500.12749/23304
Acceso en línea:
http://hdl.handle.net/20.500.12749/23304
Palabra clave:
Anesthesiology
Medical sciences
Health sciences
Medicine
Laryngoscopy
Intubation
Shikani
Flexible fiberoptic bronchoscopy
Apparatus and instruments
Medical supplies
Endotracheal intubation
Anestesiología
Ciencias médicas
Medicina
Aparatos e instrumentos
Suministros médicos
Intubación endotraqueal
Ciencias de la salud
Laringoscopia
Intubación
Fibrobroncoscopia flexible
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License
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repository_id_str
dc.title.spa.fl_str_mv Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
dc.title.translated.spa.fl_str_mv Factors associated with the success of orotracheal intubation with the Shikani optical device
title Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
spellingShingle Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
Anesthesiology
Medical sciences
Health sciences
Medicine
Laryngoscopy
Intubation
Shikani
Flexible fiberoptic bronchoscopy
Apparatus and instruments
Medical supplies
Endotracheal intubation
Anestesiología
Ciencias médicas
Medicina
Aparatos e instrumentos
Suministros médicos
Intubación endotraqueal
Ciencias de la salud
Laringoscopia
Intubación
Fibrobroncoscopia flexible
title_short Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
title_full Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
title_fullStr Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
title_full_unstemmed Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
title_sort Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico Shikani
dc.creator.fl_str_mv Suarez Arias, Silvia Marcela
dc.contributor.advisor.none.fl_str_mv Gómez Garcés, Sonia Luz
Romero Rodríguez, Mario Fernando
dc.contributor.author.none.fl_str_mv Suarez Arias, Silvia Marcela
dc.contributor.cvlac.spa.fl_str_mv Suarez Arias, Silvia Marcela [0001755345]
Gómez Garcés, Sonia Luz [0001659600]
dc.contributor.apolounab.spa.fl_str_mv Romero Rodríguez, Mario Fernando [mario-fernando-romero-rodríguez]
dc.subject.keywords.spa.fl_str_mv Anesthesiology
Medical sciences
Health sciences
Medicine
Laryngoscopy
Intubation
Shikani
Flexible fiberoptic bronchoscopy
Apparatus and instruments
Medical supplies
Endotracheal intubation
topic Anesthesiology
Medical sciences
Health sciences
Medicine
Laryngoscopy
Intubation
Shikani
Flexible fiberoptic bronchoscopy
Apparatus and instruments
Medical supplies
Endotracheal intubation
Anestesiología
Ciencias médicas
Medicina
Aparatos e instrumentos
Suministros médicos
Intubación endotraqueal
Ciencias de la salud
Laringoscopia
Intubación
Fibrobroncoscopia flexible
dc.subject.lemb.spa.fl_str_mv Anestesiología
Ciencias médicas
Medicina
Aparatos e instrumentos
Suministros médicos
Intubación endotraqueal
dc.subject.proposal.spa.fl_str_mv Ciencias de la salud
Laringoscopia
Intubación
Fibrobroncoscopia flexible
description La destreza en la realización de procedimientos como la intubación orotraqueal es un elemento necesario en la formación de los médicos anestesiólogos. La laringoscopia directa es la técnica más usada de intubación traqueal, sin embargo, la secuencia de dispositivos a emplear al abordar la vía aérea en general no tiene un estándar, la elección dependerá de la predilección y la habilidad del laringoscopista. El Estilete óptico Shikani es un dispositivo de intubación con características que permiten abordar la tráquea sin requerir la alineación de los ejes en la laringoscopia, es económico, versátil y resistente; en la literatura ha mostrado buena tasa de éxito respecto a la laringoscopia convencional, la video laringoscopia y la fibrobroncoscopia flexible. Adicionalmente se ha planteado que tiene una curva de aprendizaje larga, sin embargo, no tenemos evidencia de su éxito cuando es utilizado por anestesiólogos o residentes, poblaciones con diferente grado de experiencia y desconocemos los factores asociados al procedimiento de intubación exitoso, por lo que se planteó el presente estudio.
publishDate 2023
dc.date.issued.none.fl_str_mv 2023
dc.date.accessioned.none.fl_str_mv 2024-01-26T20:28:51Z
dc.date.available.none.fl_str_mv 2024-01-26T20:28:51Z
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.local.spa.fl_str_mv Tesis
dc.type.hasversion.none.fl_str_mv info:eu-repo/semantics/acceptedVersion
dc.type.redcol.none.fl_str_mv http://purl.org/redcol/resource_type/TM
status_str acceptedVersion
dc.identifier.uri.none.fl_str_mv http://hdl.handle.net/20.500.12749/23304
dc.identifier.instname.spa.fl_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional UNAB
dc.identifier.repourl.spa.fl_str_mv repourl:https://repository.unab.edu.co
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identifier_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
reponame:Repositorio Institucional UNAB
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dc.language.iso.spa.fl_str_mv spa
language spa
dc.relation.references.spa.fl_str_mv Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.
Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Vol. 136, Anesthesiology. 2022. 31–81 p.
Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law JA, Pytka S, et al. Laryngoscopic Intubation: learning and performance. Anesthesiology. 2003;98(1):23–7.
Matek J, Kolek F, Klementova O, Michalek P, Vymazal T. Optical Devices in Tracheal Intubation-State of the Art in 2020. Diagnostics (Basel). 2021 Mar 22;11(3):575.
Falcetta S, Pecora L, Orsetti G, Gentili P, Rossi A, Gabbanelli V, Adrario E, Donati A, Pelaia P. The Bonfils fiberscope: a clinical evaluation of its learning curve and efficacy in difficult airway management. Minerva Anestesiol. 2012 Feb;78(2):176-84.
Greenland KB, Liu G, Tan H, Edwards M, Irwin MG. Comparison of the Levitan FPS ScopeTM and the single-use bougie for simulated difficult intubation in anaesthetised patients. Anaesthesia. 2007 May;62(5):509–15.
Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database of Systematic Reviews [Internet]. 2022 Apr 4 [cited 2023 Feb 27];2022(4).
Xu M, Li XX, Guo XY, Wang J. Shikani optical stylet versus macintosh laryngoscope for intubation in patients undergoing surgery for cervical spondylosis: A randomized controlled trial. Chin Med J (Engl). 2017;130(3):297–302.
Cheng T, Wang LK, Wu HY, Yang XD, Zhang X, Jiao L. Shikani Optical Stylet for Awake Nasal Intubation in Patients Undergoing Head and Neck Surgery. Laryngoscope. 2021 Feb 1;131(2):319–25.
Jhuang BJ, Luk HN, Qu JZ, Shikani A. Video-Twin Technique for Airway Management, Combining Video-Intubating Stylet with Videolaryngoscope: A Case Series Report and Review of the Literature. Healthcare (Switzerland). 2022;10(11).
Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth [Internet]. 2011;106(5):632–42.
Szarpak L. Laryngoscopes for difficult airway scenarios: a comparison of the available devices. Vol. 15, Expert Review of Medical Devices. Taylor and Francis Ltd; 2018. p. 631–43.
Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: A randomized controlled trial. Crit Care Med. 2015 Mar 4;43(3):636–41.
Yu T, Wang B, Jin XJ, Wu RR, Wu H, He JJ, et al. Predicting difficult airways: 3-3-2 rule or 3-3 rule? Ir J Med Sci. 2015 Sep 24;184(3):677–83.
López AM, Belda I, Bermejo S, Parra L, Áñez C, Borràs R, et al. Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert con. Revista Española de Anestesiología y Reanimación (English Edition). 2020;67(6):325–42.
Nørskov AK, Rosenstock C v., Wetterslev J, Lundstrøm LH. The effect of systematic use of an objective airway score vs. standard clinical airway assessment on the incidence of unanticipated difficult airway management. Design and rationale-The prediction of Difficult AIRway management trial: The DIFFICAIR Trial . Eur J Anaesthesiol. 2013;30:268–268.
Rai A, Sharma N, Jain SK, Varshney RK, Bhatnagar S. Predicting difficult intubation in apparently normal subjects. Int J Health Sci (Qassim). 2005;(2):5609–16.
Steven L. Ore Baughm, Paul E. Big e le ise n M. Atlas of Airway Management: Techniques and Tools 2nd Edition. 2012.
Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg. 2003 Feb;96(2):595-9.
Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106(4):1132–6.
Akhlaghi M, Abedinzadeh M, Ahmadi A, Heidari Z. Predicting difficult laryngoscopy and intubation with laryngoscopic exam test: A new method. Acta Med Iran. 2017;55(7):453– 8.
El-Ganzouri, Abdel Raouf MD; McCarthy, Robert J. PharmD; Tuman, Kenneth J. MD; Tanck, Erik N. MD; Ivankovich, Anthony D. MD. Preoperative Airway Assessment: Predictive Value of a Multivariate Risk Index. Anesthesia & Analgesia 82(6):p 1197-1204, June 1996.
Bicalho GP, Bessa RC Jr, Cruvinel MGC, Carneiro FS, Castilho JB, Castro CHV. A prospective validation and comparison of three multivariate models for prediction of difficult intubation in adult patients. Braz J Anesthesiol. 2023 Mar-Apr;73(2):153-158.
Langeron O, Cuvillon P, Ibanez-Esteve C, Lenfant F, Riou B, Le Manach Y. Prediction of difficult tracheal intubation: time for a paradigm change. Anesthesiology. 2012 Dec;117(6):1223-33.
Aghamohammadi H, Massoudi N, Fathi M, Jaffari A, Gharaei B, Moshki A. Intubation learning curve: comparison between video and direct laryngoscopy by inexperienced students. J Med Life. 2015;8(Spec Iss 4):150-153.
Singhal S, Kaur K, Yadav P. A study to evaluate the role of experience in acquisition of the skill of orotracheal intubation in adults. J Anaesthesiol Clin Pharmacol. 2021 Jul 1;37(3):469–74.
Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine. 2004;79(10 SUPPL.):70–81.
Hsiao YJ, Chen CY, Hung HT, Lee CH, Su YY, Ng CJ, et al. Comparison of the outcome of emergency endotracheal intubation in the general ward, intensivecare unit and emergency department. Biomed J. 2021 Dec 1;44(6):S110–8.
Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Vol. 34, Intensive Care Medicine. 2008. p. 222–8.
Zhu H, Liu J, Suo L, Zhou C, Sun Y, Jiang H. A randomized controlled comparison of non-channeled king vision, McGrath MAC video laryngoscope and Macintosh direct laryngoscope for nasotracheal intubation in patients with predicted difficult intubations. BMC Anesthesiol. 2019;19(1):1–9.
Jungbauer A, Schumann M, Brunkhorst V, Börgers A, Groeben H. Expected difficult tracheal intubation: A prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. Br J Anaesth. 2009;102(4):546–50.
G. Berci M, R. Katz M. Optical Stylet: An Aid to Intubation and Teaching. Annals of Otology, Rhinology & Laryngology. 1979;88(6):828–31.
Colt H. Using the Shikani Optical Stylet. Journal of Bronchology. 2003;10(1):61–3.
Guzmán J. Estilete con fibra óptica: bonfils. Rev Chil Anest. 2009;38:157–62.
Shikani AH. New “Seeing” Stylet-Scope and Method for the Management of the Difficult Airway. Otolaryngology–Head and Neck Surgery. 1999;113–6.
Phua DS, Mah CL, Wang CF. The Shikani optical stylet as an alternative to the GlideScope ® videolaryngoscope in simulated difficult intubations - A randomised controlled trial. Anaesthesia. 2012;67(4):402–6.
Liu L, Yue H, Li J. Comparison of three tracheal intubation techniques in thyroid tumor patients with a difficult airway: A randomized controlled trial. Medical Principles and Practice. 2014;23(5):448–52.
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dc.publisher.faculty.spa.fl_str_mv Facultad Ciencias de la Salud
dc.publisher.program.spa.fl_str_mv Especialización en Anestesiología
institution Universidad Autónoma de Bucaramanga - UNAB
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spelling Gómez Garcés, Sonia Luz4f3477c3-6604-43c6-b5f7-11dc8215d7cbRomero Rodríguez, Mario Fernando2b7093ac-195b-480c-9fe0-79cc3dea4da5Suarez Arias, Silvia Marcelaf86be82e-c820-4efe-9c0e-8339583e1cb6Suarez Arias, Silvia Marcela [0001755345]Gómez Garcés, Sonia Luz [0001659600]Romero Rodríguez, Mario Fernando [mario-fernando-romero-rodríguez]Bucaramanga (Santander, Colombia)2023UNAB Campus Bucaramanga2024-01-26T20:28:51Z2024-01-26T20:28:51Z2023http://hdl.handle.net/20.500.12749/23304instname:Universidad Autónoma de Bucaramanga - UNABreponame:Repositorio Institucional UNABrepourl:https://repository.unab.edu.coLa destreza en la realización de procedimientos como la intubación orotraqueal es un elemento necesario en la formación de los médicos anestesiólogos. La laringoscopia directa es la técnica más usada de intubación traqueal, sin embargo, la secuencia de dispositivos a emplear al abordar la vía aérea en general no tiene un estándar, la elección dependerá de la predilección y la habilidad del laringoscopista. El Estilete óptico Shikani es un dispositivo de intubación con características que permiten abordar la tráquea sin requerir la alineación de los ejes en la laringoscopia, es económico, versátil y resistente; en la literatura ha mostrado buena tasa de éxito respecto a la laringoscopia convencional, la video laringoscopia y la fibrobroncoscopia flexible. Adicionalmente se ha planteado que tiene una curva de aprendizaje larga, sin embargo, no tenemos evidencia de su éxito cuando es utilizado por anestesiólogos o residentes, poblaciones con diferente grado de experiencia y desconocemos los factores asociados al procedimiento de intubación exitoso, por lo que se planteó el presente estudio.Introducción Justificación científica Planteamiento del problema Marco teórico Estado del arte: Estilete óptico Shikani SOS Pregunta de investigación Objetivos Metodología Variables Base de datos y plan de análisis de datos Consideraciones éticas Resultados Discusión Conclusiones Bibliografía Anexos PresupuestoEspecializaciónSkill in performing procedures such as orotracheal intubation is a necessary element in the training of anesthesiologists. Direct laryngoscopy is the most used technique for tracheal intubation, however, the sequence of devices to be used when approaching the airway in general does not have a standard, the choice will depend on the predilection and skill of the laryngoscopist. The Shikani optical stylet is an intubation device with features that allow the trachea to be approached without requiring alignment of the axes in laryngoscopy. It is economical, versatile and resistant; In the literature it has shown a good success rate compared to conventional laryngoscopy, video laryngoscopy and flexible fiberoptic bronchoscopy. Additionally, it has been suggested that it has a long learning curve, however, we have no evidence of its success when used by anesthesiologists or residents, populations with different degrees of experience, and we do not know the factors associated with the successful intubation procedure, so it is proposed the present study.Modalidad Presencialapplication/pdfspahttp://creativecommons.org/licenses/by-nc-nd/2.5/co/Abierto (Texto Completo)Atribución-NoComercial-SinDerivadas 2.5 Colombiahttp://purl.org/coar/access_right/c_abf2Factores asociados al éxito de la intubación orotraqueal con el dispositivo óptico ShikaniFactors associated with the success of orotracheal intubation with the Shikani optical deviceEspecialista en AnestesiologíaUniversidad Autónoma de Bucaramanga UNABFacultad Ciencias de la SaludEspecialización en Anestesiologíainfo:eu-repo/semantics/masterThesisTesisinfo:eu-repo/semantics/acceptedVersionhttp://purl.org/redcol/resource_type/TMAnesthesiologyMedical sciencesHealth sciencesMedicineLaryngoscopyIntubationShikaniFlexible fiberoptic bronchoscopyApparatus and instrumentsMedical suppliesEndotracheal intubationAnestesiologíaCiencias médicasMedicinaAparatos e instrumentosSuministros médicosIntubación endotraquealCiencias de la saludLaringoscopiaIntubaciónFibrobroncoscopia flexibleFrerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Vol. 136, Anesthesiology. 2022. 31–81 p.Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law JA, Pytka S, et al. Laryngoscopic Intubation: learning and performance. Anesthesiology. 2003;98(1):23–7.Matek J, Kolek F, Klementova O, Michalek P, Vymazal T. Optical Devices in Tracheal Intubation-State of the Art in 2020. Diagnostics (Basel). 2021 Mar 22;11(3):575.Falcetta S, Pecora L, Orsetti G, Gentili P, Rossi A, Gabbanelli V, Adrario E, Donati A, Pelaia P. The Bonfils fiberscope: a clinical evaluation of its learning curve and efficacy in difficult airway management. Minerva Anestesiol. 2012 Feb;78(2):176-84.Greenland KB, Liu G, Tan H, Edwards M, Irwin MG. Comparison of the Levitan FPS ScopeTM and the single-use bougie for simulated difficult intubation in anaesthetised patients. Anaesthesia. 2007 May;62(5):509–15.Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database of Systematic Reviews [Internet]. 2022 Apr 4 [cited 2023 Feb 27];2022(4).Xu M, Li XX, Guo XY, Wang J. Shikani optical stylet versus macintosh laryngoscope for intubation in patients undergoing surgery for cervical spondylosis: A randomized controlled trial. Chin Med J (Engl). 2017;130(3):297–302.Cheng T, Wang LK, Wu HY, Yang XD, Zhang X, Jiao L. Shikani Optical Stylet for Awake Nasal Intubation in Patients Undergoing Head and Neck Surgery. Laryngoscope. 2021 Feb 1;131(2):319–25.Jhuang BJ, Luk HN, Qu JZ, Shikani A. Video-Twin Technique for Airway Management, Combining Video-Intubating Stylet with Videolaryngoscope: A Case Series Report and Review of the Literature. Healthcare (Switzerland). 2022;10(11).Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth [Internet]. 2011;106(5):632–42.Szarpak L. Laryngoscopes for difficult airway scenarios: a comparison of the available devices. Vol. 15, Expert Review of Medical Devices. Taylor and Francis Ltd; 2018. p. 631–43.Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: A randomized controlled trial. Crit Care Med. 2015 Mar 4;43(3):636–41.Yu T, Wang B, Jin XJ, Wu RR, Wu H, He JJ, et al. Predicting difficult airways: 3-3-2 rule or 3-3 rule? Ir J Med Sci. 2015 Sep 24;184(3):677–83.López AM, Belda I, Bermejo S, Parra L, Áñez C, Borràs R, et al. Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert con. Revista Española de Anestesiología y Reanimación (English Edition). 2020;67(6):325–42.Nørskov AK, Rosenstock C v., Wetterslev J, Lundstrøm LH. The effect of systematic use of an objective airway score vs. standard clinical airway assessment on the incidence of unanticipated difficult airway management. Design and rationale-The prediction of Difficult AIRway management trial: The DIFFICAIR Trial . Eur J Anaesthesiol. 2013;30:268–268.Rai A, Sharma N, Jain SK, Varshney RK, Bhatnagar S. Predicting difficult intubation in apparently normal subjects. Int J Health Sci (Qassim). 2005;(2):5609–16.Steven L. Ore Baughm, Paul E. Big e le ise n M. Atlas of Airway Management: Techniques and Tools 2nd Edition. 2012.Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg. 2003 Feb;96(2):595-9.Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106(4):1132–6.Akhlaghi M, Abedinzadeh M, Ahmadi A, Heidari Z. Predicting difficult laryngoscopy and intubation with laryngoscopic exam test: A new method. Acta Med Iran. 2017;55(7):453– 8.El-Ganzouri, Abdel Raouf MD; McCarthy, Robert J. PharmD; Tuman, Kenneth J. MD; Tanck, Erik N. MD; Ivankovich, Anthony D. MD. Preoperative Airway Assessment: Predictive Value of a Multivariate Risk Index. 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Medical Principles and Practice. 2014;23(5):448–52.https://apolo.unab.edu.co/en/persons/mario-fernando-romero-rodr%C3%ADguezORIGINAL2023_Tesis_Suarez_Arias_Silvia_Marcela.pdf2023_Tesis_Suarez_Arias_Silvia_Marcela.pdfTesisapplication/pdf2468034https://repository.unab.edu.co/bitstream/20.500.12749/23304/1/2023_Tesis_Suarez_Arias_Silvia_Marcela.pdf987086b417a6c01223ccb439ce1f5291MD51open access2023_Licencia_Suarez_Arias_Silvia_Marcela.pdf2023_Licencia_Suarez_Arias_Silvia_Marcela.pdfLicenciaapplication/pdf158695https://repository.unab.edu.co/bitstream/20.500.12749/23304/2/2023_Licencia_Suarez_Arias_Silvia_Marcela.pdf4e30e5d0a8f1bef943ce070257cad5dcMD52metadata only accessLICENSElicense.txtlicense.txttext/plain; charset=utf-8829https://repository.unab.edu.co/bitstream/20.500.12749/23304/3/license.txt3755c0cfdb77e29f2b9125d7a45dd316MD53open accessTHUMBNAIL2023_Tesis_Suarez_Arias_Silvia_Marcela.pdf.jpg2023_Tesis_Suarez_Arias_Silvia_Marcela.pdf.jpgIM Thumbnailimage/jpeg5745https://repository.unab.edu.co/bitstream/20.500.12749/23304/4/2023_Tesis_Suarez_Arias_Silvia_Marcela.pdf.jpgb2604cd53d41458206267954229fdb48MD54open access2023_Licencia_Suarez_Arias_Silvia_Marcela.pdf.jpg2023_Licencia_Suarez_Arias_Silvia_Marcela.pdf.jpgIM Thumbnailimage/jpeg12410https://repository.unab.edu.co/bitstream/20.500.12749/23304/5/2023_Licencia_Suarez_Arias_Silvia_Marcela.pdf.jpg570beccd9b49f2aeb8584769433b4b3eMD55metadata only access20.500.12749/23304oai:repository.unab.edu.co:20.500.12749/233042024-01-26 22:01:36.896open accessRepositorio Institucional | Universidad Autónoma de Bucaramanga - UNABrepositorio@unab.edu.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