Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review

Sugammadex and neuromuscular disease: a systematic review with assessment of reporting quality and content validity

BACKGROUND

Efficacy and safety of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) in patients with neuromuscular diseases remains unclear. We summarised the available evidence and evaluated the quality of data reporting and the validity of published reports.

METHODS

We searched for reports (any design) on the usage of sugammadex (any regimen) for the reversal of an NMBA in patients (any age) with any neuromuscular disease. We used a modified CARE checklist (maximum score 23) to assess the quality of data reporting and an original specific validity checklist (maximum score 41) that was developed through a Delphi process.

RESULTS

We retrieved 126 observational reports (386 patients). Most dealt with myasthenia gravis patients receiving rocuronium. The train-of-four ratio returned to ≥0.9 in 258 of 265 (97.4%) patients in whom neuromonitoring was used. Adverse events occurred in 14 of 332 (4.2%) patients in whom adverse events were reported as present or absent. In 90 case reports, the median score of the 23-point CARE checklist was 13.5 (inter-quartile range [IQR] 11-16). In all 126 reports, the median score of the 41-point validity checklist was 23 (IQR 20-27). Scores were positively correlated.

CONCLUSIONS

These uncontrolled observations (of mainly low to moderate quality and validity) do not allow confident assessment of the efficacy and safety of sugammadex for the reversal of NMBAs in patients with neuromuscular diseases. Reporting of observational data should follow established guidelines, include specific information to ensure validity, and emphasise what the new data add to current knowledge.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO 2019 (CRD42019119924).

Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system

Background: Neuromuscular blocking agents (NMBAs) are primarily used during surgical procedures to facilitate endotracheal intubation and optimize surgical conditions. This study aimed to explore the adverse event signals of NMBAs, providing reference for clinical safety. Methods: This study collected reports of atracurium, cisatracurium, rocuronium, and vecuronium as primary suspect drugs in The US Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2023. The adverse events (AEs) reported in the study were retrieved based on the Preferred Terms (PTs) of the Medical Dictionary for Regulatory Activities. In addition, we conducted disproportionality analysis on relevant reports using the reporting odds ratio (ROR) method and Bayesian confidence propagation neural network (BCPNN) method. A positive signal was generated when both algorithms show an association between the target drug and the AE. Results: A total of 11,518 NMBA-related AEs were reported in the FAERS database. The most AEs of rocuronium were collected. NMBA-related AEs involved 27 different system organs (SOCs), all of the four NMBAs had positive signals in "cardiac disorders," "immune system disorders," "respiratory, thoracic and mediastinal disorders" and "vascular disorders." At the PTs level, a total of 523 effective AEs signals were obtained for the four NMBAs. AEs labled in the instructions such as anaphylaxis (include anaphylactic reaction and anaphylactic shock), bronchospasm, respiratory arrest and hypotension were detected positive signals among all NMBAs. In addition, we also found some new AEs, such as ventricular fibrillation for the four NMBAs, hyperglycaemia for atracurium, kounis syndrome and stress cardiomyopathy for rocuronium, hepatocellular injury for cisatracurium, hyperkalaemia for vecuronium. To further investigated the AEs associated with serious clinical outcomes, we found that cardiac arrest and anaphylaxis were the important risk factors for death due to NMBAs. Conclusion: NMBA-related AEs have a significant potential to cause clinically severe consequences. Our study provides valuable references for the safety profile of NMBAs, and considering the limitations of the FAERS database, further clinical data are needed to validate the findings of this study.

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites

OBJECTIVE

The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made.

METHODS

We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models.

RESULTS

Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00).

CONCLUSIONS

This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

An educational intervention to reduce the incidence of postoperative residual curarisation: a cluster randomised crossover trial in patients undergoing general anaesthesia

BACKGROUND

The incidence of postoperative residual curarisation remains unacceptably high. We assessed whether an educational intervention on perioperative neuromuscular block management can reduce it.

METHODS

In this multicentre, cluster randomised crossover trial, centres were allocated to receive an educational intervention either in a first or a second period. The educational intervention consisted of a lecture about neuromuscular management key points, including quantitative neuromuscular monitoring and use of reversal agents. The lecture was streamed to allow repetition. Additionally, memory cards were distributed in each operating theatre. The primary outcome was postoperative residual curarisation in the PACU. Secondary outcomes were frequency of quantitative neuromuscular monitoring, use of reversal agents, and incidence of postoperative pulmonary complications during hospital stay. Measurements were performed before randomisation and after the first and the second period. The effect of the educational intervention was estimated using multivariable mixed effects logistic regression models.

RESULTS

We included 2314 subjects in 34 Spanish centres. Postoperative residual curarisation incidence was not affected by the educational intervention (odds ratio [OR] 0.90 [95% confidence interval {CI}: 0.51-1.58]; P=0.717 and 1.30 [0.73-2.30]; P=0.371] for first and second time-period interaction). The educational intervention increased the quantitative neuromuscular monitor usage (OR 2.04 [95% CI: 1.31-3.19]; P=0.002), the use of reversal agents was unchanged (OR 0.79 [95% CI: 0.50-1.26]; P=0.322), and the incidence of postoperative pulmonary complications decreased (OR 0.19 [95% CI: 0.10-0.35]; P<0.001).

CONCLUSIONS

An educational intervention on perioperative neuromuscular block management did not reduce the incidence of postoperative residual curarisation nor increase reversal, despite increased quantitative neuromuscular monitoring. Sugammadex reversal was associated with reduced postoperative residual curarisation. The educational intervention was associated with a decrease in postoperative pulmonary complications.

CLINICAL TRIAL REGISTRATION

NCT03128151.

Use of neuromuscular blockade for neck dissection and association with iatrogenic nerve injury

BACKGROUND

Cranial nerve injury is an uncommon but significant complication of neck dissection. We examined the association between the use of intraoperative neuromuscular blockade and iatrogenic cranial nerve injury during neck dissection.

METHODS

This was a single-center, retrospective, electronic health record review. Study inclusion criteria stipulated patients > 18 years who had ≥ 2 neck lymphatic levels dissected for malignancy under general anesthesia with a surgery date between 2008 - 2018. Use of neuromuscular blockade during neck dissection was the primary independent variable. This was defined as any use of rocuronium, cisatracurium, or vecuronium upon anesthesia induction without reversal with sugammadex prior to surgical incision. Univariate tests were used to compare variables between those patients with, and those without, iatrogenic cranial nerve injury. Multivariable logistic regression determined predictors of cranial nerve injury and was performed incorporating Firth's estimation given low prevalence of the primary outcome.

RESULTS

Our cohort consisted of 925 distinct neck dissections performed in 897 patients. Neuromuscular blockade was used during 285 (30.8%) neck dissections. Fourteen instances (1.5% of surgical cases) of nerve injury were identified. On univariate logistic regression, use of neuromuscular blockade was not associated with iatrogenic cranial nerve injury (OR: 1.73, 95% CI: 0.62 - 4.86, p = 0.30). There remained no significant association on multivariable logistic regression controlling for patient age, sex, weight, ASA class, paralytic dose, history of diabetes, stroke, coronary artery disease, carotid atherosclerosis, myocardial infarction, and cardiac arrythmia (OR: 1.87, 95% CI: 0.63 - 5.51, p = 0.26).

CONCLUSIONS

In this study, use of neuromuscular blockade intraoperatively during neck dissection was not associated with increased rates of iatrogenic cranial nerve injury. While this investigation provides early support for safe use of neuromuscular blockade during neck dissection, future investigation with greater power remains necessary.

Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial

BACKGROUND

Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0.

METHODS

One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg-1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions.

RESULTS

Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation.

CONCLUSIONS

The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions.

CLINICAL TRIAL NUMBER AND REGISTRY

URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.

General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances

Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.

Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm

Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.

Tracheal intubating conditions in elderly patients when train-of-four count is zero after rocuronium 0.6 or 0.9 mg/kg. A secondary analysis

PURPOSE

The neuromuscular blocking agent rocuronium can be administered to facilitate tracheal intubation. We hypothesized that rocuronium 0.9 mg/kg provided a larger proportion of patients with vocal cords in abducted position compared to rocuronium 0.6 mg/kg at train-of-four (TOF) 0.

METHODS

This secondary analysis was based on 52 elderly surgical patients of which 36 patients received rocuronium 0.6 mg/kg and 16 patients received rocuronium 0.9 mg/kg. Neuromuscular block was monitored with acceleromyography with TOF stimulation at the ulnar nerve. The primary outcome was the proportion of patients with vocal cords in abducted position at TOF 0. Secondary outcomes were intubating conditions evaluated by the Fuchs-Buder scale, the Intubating Difficulty Score (IDS), onset time, and duration of action of rocuronium.

RESULTS

At TOF 0, a significantly larger proportion of patients had vocal cords in abducted position in the rocuronium 0.9 mg/kg group (81%) compared with the rocuronium 0.6 mg/kg group (53%); difference (%) 28, 95% Cl 3-53, P = 0.05. Excellent intubating conditions (Fuchs-Buder) were more common in the rocuronium 0.9 mg/kg group (62.5%); difference (%) 32.5, 95% Cl 4-61), P = 0.03. No significant difference was found in IDS or onset time of rocuronium (difference 19 s, 95% Cl: -5-43). Duration of action was significantly longer (difference 29 min, 95% Cl: 10-47) in the 0.9 mg/kg group.

CONCLUSION

The proportion of patients with vocal cords in abducted position was significantly larger after rocuronium 0.9 mg/kg compared to rocuronium 0.6 mg/kg at TOF 0 monitored at the ulnar nerve.

Emergency airway management in a tertiary trauma centre (AIRMAN): a one-year prospective longitudinal study

PURPOSE

Emergency airway management can be associated with a range of complications including long-term neurologic injury and death. We studied the first-pass success rate with emergency airway management in a tertiary care trauma centre. Secondary outcomes were to identify factors associated with first-pass success and factors associated with adverse events peri-intubation.

METHODS

We performed a single-centre, prospective, observational study of patients ≥ 17 yr old who were intubated in the emergency department (ED), surgical intensive care unit (SICU), medical intensive care unit (MICU), and inpatient wards at our institution. Ethics approval was obtained from the local research ethics board.

RESULTS

In a seven-month period, there were 416 emergency intubations and a first-pass success rate of 73.1%. The first-pass success rates were 57.5% on the ward, 66.1% in the intensive care units (ICUs) and 84.3% in the ED. Equipment also varied by location; videolaryngoscopy use was 65.1% in the ED and only 10.6% on wards. A multivariate regression model using the least absolute shrinkage and selection algorithm (LASSO) showed that the odds ratios for factors associated with two or more intubation attempts were location (wards, 1.23; MICU, 1.24; SICU, 1.19; reference group, ED), physiologic instability (1.19), an anatomically difficult airway (1.05), hypoxemia (1.98), lack of neuromuscular blocker use (2.28), and intubator inexperience (1.41).

CONCLUSIONS

First-pass success rates varied widely between locations within the hospital and were less than those published from similar institutions, except for the ED. We are revamping ICU protocols to improve the first-pass success rate.

Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care

Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n  = 24 000) to the finally relevant clinical studies ( n  = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).

A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic

OBJECTIVE

Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes?

METHODS

A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days.

RESULTS

Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172).

CONCLUSION

A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial

IMPORTANCE

It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent.

OBJECTIVE

To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021.

INTERVENTIONS

Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic.

MAIN OUTCOMES AND MEASURES

The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%.

RESULTS

Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%).

CONCLUSIONS AND RELEVANCE

Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03960801.

Anesthetic management of a patient with subclinical myasthenia gravis who underwent a thymectomy: a case report

Background

Some individuals with subclinical myasthenia gravis (MG) are positive for serum anti-acetylcholine receptor antibodies, without neurological symptoms. There are no anesthetic management guidelines for subclinical MG. We report the anesthetic management of a patient with subclinical MG who underwent a thymectomy.

Case presentation

A 57-year-old female with subclinical MG was scheduled for an extended thymectomy. Anesthesia was induced and maintained with mainly propofol and remifentanil. We administrated the minimum amount of rocuronium with reference to train-of-four (TOF) monitoring when a neuromuscular relaxant is needed. Although the prolonged effect of rocuronium was observed, the TOF ratio had already recovered to 100% before the tracheal extubation. Postoperative analgesia was performed by a continuous epidural infusion of levobupivacaine.

Conclusion

We reported the anesthetic management of a patient with subclinical MG who underwent a thymectomy. Further research is necessary to clarify subclinical MG patients' sensitivity to rocuronium.

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China

The critical medicine residency training in China started in 2020, but no investigation on the practice of tracheal intubation in ICUs in China has been conducted. A survey was sent to the adult ICUs in public hospitals in Shenzhen (SZ) city and Xinjiang (XJ) province using a WeChat miniprogram to be completed by intensive care physicians. It included questions on training on intubation, intubation procedures, and changes in the use of personal protective equipment due to COVID-19. We analyzed 301 valid questionnaires which were from 72 hospitals. A total of 37% of respondents had completed training in RSI (SZ, 40% vs. XJ, 30%; $p=0.066$ ), and 50% had participated in a course on the emergency front of the neck airway (SZ, 47% vs. XJ, 54%; $p=0.256$ ). Video laryngoscopy was preferred by 75% of respondents. Manual ventilation (56%) and noninvasive positive pressure ventilation (34%) were the first-line options for preoxygenation. For patients with a high risk of aspiration, nasogastric decompression (47%) and cricoid pressure (37%) were administered. Propofol (82%) and midazolam (70%) were the most commonly used induction agents. Only 19% of respondents routinely used neuromuscular blocking agents. For patients with difficult airways, a flexible endoscope was the most commonly used device by 76% of respondents. Most participants (77%) believed that the COVID-19 pandemic had significantly increased their awareness of the need for personal protective equipment during tracheal intubation. Our survey demonstrated that the ICU doctors in these areas lack adequate training in airway management.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa

Introduction

Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success.

Methods

This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS.

Results

A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS.

Conclusion

This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00688-4.

Rocuronium 0.3 mg/kg or 0.9 mg/kg comparing onset time, duration of action and intubating conditions in patients 80 years and older. A randomized study

BACKGROUND

Limited data exist about the optimal dose of rocuronium for intubation in elderly patients. We hypothesized that rocuronium 0.9 mg kg^-1 would lead to a shorter onset time than 0.3 mg kg^-1 in patients above 80 years.

METHODS

Thirty-four patients were randomized to either rocuronium 0.3 mg kg^-1 or 0.9 mg kg^-1 . The primary outcome was onset time defined as time to train-of-four (TOF) count of 0. Other outcomes included duration of action (time to TOF ratio > 0.9), proportion of excellent intubating conditions using the Fuchs-Buder scale and tracheal intubating conditions using the Intubating Difficulty Scale (IDS).

RESULTS

Rocuronium 0.9 mg kg^-1 resulted in shorter onset time compared to rocuronium 0.3 mg kg^-1 ; 108 sec (SD 40) vs. 228 sec (SD 140) (difference: 119 seconds (95% CI: 41-196), P=0.005)), respectively. However, in 66% of the patients receiving rocuronium 0.3 mg kg^-1 a TOF count of 0 was not obtained. Duration of action was longer after rocuronium 0.9 mg kg^-1 : 118 minutes (SD 43) vs. 46 minutes (SD 13) (difference: 72 minutes (95% CI: 49-95) P<0.0001)), and a greater proportion of excellent intubating conditions (Fuchs-Buder) was obtained; 11/16 (69%) vs 4/18 (22%) (P=0.006). No difference was found regarding IDS score.

CONCLUSION

Rocuronium 0.9 mg kg^-1 resulted in a shorter onset time compared to rocuronium 0.3 mg kg^-1 in patients above 80 years of age. In 66% of the patients receiving rocuronium 0.3 mg kg^-1 a TOF count of 0 was not obtained.

Safe in the first attempt: teaching neonatal airway management

PURPOSE OF REVIEW

Quick and precise facemask ventilation and tracheal intubation are critical clinical skills in neonatal airway management. In addition, this vulnerable population requires a thorough understanding of developmental airway anatomy and respiratory physiology to manage and anticipate potential airway mishaps. Neonates have greater oxygen consumption, increased minute ventilation relative to functional residual capacity, and increased closing volumes compared to older children and adults. After a missed airway attempt, this combination can quickly lead to dire consequences, such as cardiac arrest. Keeping neonates safe throughout the first attempt of airway management is key.

RECENT FINDINGS

Several techniques and practices have evolved to improve neonatal airway management, including improvement in neonatal airway equipment, provision of passive oxygenation, and closer attention to the management of anesthetic depth. The role of nontechnical skills during airway management is receiving more recognition.

SUMMARY

Every neonatal intubation should be considered a critical event. Below we discuss some of the challenges in neonatal airway management, including anatomical and physiological principles which must be understood to approach the airway. We then follow with a description of current evidence for best practices and training.

Reasons behind failed prehospital intubation attempts while combining C-MAC videolaryngoscope and Frova introducer

BACKGROUND

High first-pass success rate is achieved with the routine use of C-MAC videolaryngoscope and Frova introducer. We aim to identify potential reasons and subgroups associated with failed intubation attempts, analyse actions taken after them and study possible complications.

METHODS

We conducted a retrospective observational study of adult intubated patients at a single helicopter emergency medical service unit in southern Finland between 2016 and 2018. We collected data on patient characteristics, reasons for failed attempts, complications and follow-up measures from a national helicopter emergency medical service database and from prehospital patient records.

RESULTS

1011 tracheal intubations were attempted. First attempt was successful in 994 cases (FPS 994/1011, 98.3%), 15 needed a second or third attempt and two a surgical airway (non-FPS 17/1011, 1.7%, 95% CI 1.0-2.7). The failed first attempt group had heterogenous characteristics. The most common cause for a failed first attempt was obstruction of the airway by vomit, food, mucus or blood (10/13, 76%). After the failed first attempt, there were six cases (6/14, 43%) of deviation from the protocol and the most frequent complications were five cases (5/17, 29%) of hypoxia and four cases (4/17, 24%) of hypotension.

CONCLUSIONS

When a protocol combining the C-MAC videolaryngoscope and Frova introducer is used, the most common reason for a failed first attempt is an airway blocked by gastric content, blood or mucus. These findings highlight the importance of effective airway decontamination methods and questions the appropriateness of anatomically focused pre-intubation assessment tools when such protocol is used.

A blinded randomized study comparing intubating conditions after either rocuronium 0.6 mg·kg-1 or remifentanil 2 µg·kg-1 in elderly patients

BACKGROUND

To facilitate tracheal intubation, either a neuromuscular blocking agent or a bolus dose of remifentanil can be administered. We hypothesized that rocuronium 0.6 mg·kg^-1 provided a larger proportion of excellent intubating conditions compared to remifentanil 2 µg·kg^-1 in patients above 80 years.

METHODS

A total of 78 patients were randomized to either rocuronium 0.6 mg·kg^-1 or remifentanil 2 µg·kg^-1 . General anaesthesia was initiated with fentanyl and propofol. Two minutes after the administration of either rocuronium or remifentanil, tracheal intubating conditions were evaluated using the Fuchs-Buder scale by a blinded investigator, and our primary outcome was the proportion of patients presenting intubating conditions deemed as excellent. Further outcomes included the Intubating Difficulty Scale (IDS), hoarseness or sore throat 24 h postoperatively, and intervention against hypotension.

RESULTS

No difference in the occurrence of excellent intubating conditions was found comparing the rocuronium group with the remifentanil group; 10 (28%) versus 15 (39%) (p = .29), respectively, relative risk = 0.72. Interventions against hypotension were used in 24 (67%) versus 28 (74%) (p = .51), respectively. Hoarseness and sore throat 24 h postoperatively were found in 37% versus 35% p = .86, and 14% versus 5% p = .20, respectively. The IDS score was 2 versus 2 p = .48.

CONCLUSION

No difference in intubating conditions was found 2 min after the administration of either rocuronium 0.6 mg·kg^-1 or remifentanil 2 µg·kg^-1 in patients aged above 80 years. Intubation conditions were less than optimal in a large proportion of this patient population.

CLINICAL TRIALS REGISTRATION

NCT04287426.

Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey

OBJECTIVE

To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units.

METHODS

An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade.

RESULTS

Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability.

CONCLUSION

The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

[Anesthesia for patients suffering from neuromuscular diseases]

Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic

Background

For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.

Research Question

For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?

Study Design and Methods

We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.

Results

One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).

Interpretation

Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

Impact of rocuronium on intraoperative neuromonitoring vagal amplitudes during thyroidectomy

PURPOSE

Neuromuscular blocking agents (NMBA) facilitate endotracheal intubation and reduce related laryngeal morbidity. However, NMBA interfere with intraoperative neuromonitoring amplitudes during thyroidectomy. The goal of this study was to evaluate the impact of rocuronium used for tracheal intubation on early intraoperative neuromonitoring vagal amplitudes observed during first thyroid lobe dissection.

METHODS

This is an observational pharmacoepidemiological study with prospective data collection and retrospective analysis. During the study period, all consecutive patients who underwent thyroid surgery with neuromonitoring were included. Patients underwent endotracheal intubation either using a single dose of rocuronium (NMBA group) or without NMBA (NMBA-free group) according to the anesthesiologist's preference.

RESULTS

Six hundred six patients were included (213 NMBA and 393 NMBA-free group patients). At V1, 39 patients (18%) in the NMBA group had an amplitude < 100 µV (need for curarization reversal in 30 patients) and 13 patients (3.3%) in the NMBA-free group (p < 0.001). In the remaining 554 patients, the mean V1 amplitude was significantly decreased in the NMBA group (544 versus 685 µV; p < 0.001). After exclusion of 25 patients with loss of signal types 1 and 2 during dissection, the difference between mean V1 and mean V2 was significantly lower in NMBA group patients (- 22 versus - 86 µV; p = 0.016).

CONCLUSION

This study provides new data showing how NMBA used for tracheal intubation significantly decrease V1 amplitude baseline and modify amplitude variations from V1 to V2 values during the first thyroid lobe dissection.

LEVEL OF EVIDENCE

Pharmacoepidemiological study.

A systematic review of meta-analyses comparing direct laryngoscopy with videolaryngoscopy

PURPOSE

In the preceding 20 years, many randomized-controlled trials and meta-analyses have compared direct Macintosh laryngoscopy with videolaryngoscopy. The videolaryngoscope blades have included both traditional Macintosh blades and hyperangulated blades. Macintosh and hyperangulated blades differ in their geometry and technique for tracheal intubation; certain patient populations may benefit from one blade type over another. The primary objective of this systematic review was to assess whether published meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy have accounted for the videolaryngoscope blade type. Secondary objectives evaluated heterogeneity among practitioner experience and specialty, clinical context, patient population, and original primary study outcomes.

SOURCE

A search was performed across Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar, and ANZCA discovery. A systematic review identified meta-analyses which compared direct Macintosh laryngoscopy to videolaryngoscopy. There were no patient age or clinical specialty restrictions. Exclusion criteria included non-English language, studies comparing non-Macintosh blade to videolaryngoscopy, and studies in awake patients.

PRINCIPAL FINDINGS

Twenty-one meta-analyses were identified that were published between 1 January 2000 and 7 May 2020. Macintosh and hyperangulated videolaryngoscope blades were combined in most studies (16/21; 76%). Heterogeneity was also present among practitioner experience (20/21; 95%), clinician specialty (15/21; 71%), and clinical locations (10/21; 48%). Adult and pediatric patients were combined or not defined in 5/21 studies (24%). The primary outcomes of the meta-analyses varied, with the most common (7/21; 33%) being first-pass tracheal intubation success.

CONCLUSIONS

Heterogeneity across important clinical variables is common in meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy. To better inform patient care, future videolaryngoscopy research should differentiate blade type, clinical context, and patient-related primary outcomes.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.

Management of Ambulatory Anesthesia in Older Adults

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Guidelines on muscle relaxants and reversal in anaesthesia

OBJECTIVES

To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded.

METHODS

The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system.

RESULTS

The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations.

CONCLUSION

Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

Urgent intubation without neuromuscular blocking agents and the risk of tracheostomy

Neuromuscular blocking agents play a significant role in improving the success rate for urgent intubation, although there is limited evidence about the effect on subsequent outcomes, such as the incidence of tracheostomy. In this retrospective cohort study, we aimed to examine the association between avoidance of neuromuscular blocking agents for urgent tracheal intubation and incidence of tracheostomy among patients in the intensive care unit (ICU). The setting of this study was an eight-bed ICU at a tertiary-care hospital in Okayama, Japan. We included patients who underwent urgent tracheal intubation at the emergency department or the ICU and were admitted to the ICU between April 2013 and November 2017. We extracted data on methods and medications of intubation, predictors for difficult intubation, Cormack-Lehane grade, patient demographics, primary diagnoses, reintubation. We estimated odds ratios and their 95% confidence intervals for elective tracheostomy during the ICU stay using logistic regression models. Of 411 patients, 46 patients underwent intubation without neuromuscular blocking agents and 61 patients underwent tracheostomy. After adjusting for potential confounders, patients who avoided neuromuscular blocking agents had more than double the odds of tracheostomy (odds ratio 2.59, 95% confidence interval 1.06-6.34, p value = 0.04). When stratifying the subjects by risk status for tracheostomy, the association was more pronounced in high-risk group, while we observed less significant association in the low-risk group. Avoidance of neuromuscular blocking agents for urgent intubation increases the risk of tracheostomy among emergency patients, especially those who have a higher risk for tracheostomy.

Drug Order in Rapid Sequence Intubation

BACKGROUND

The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.

OBJECTIVE

We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.

METHODS

We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model.

RESULTS

Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).

CONCLUSION

Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.

Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis

Background

Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy.

Methods

Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg^− 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement.

Results

Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg^− 1 and 0.28(0.17) mg.kg^− 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics.

Conclusions

Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy.

Trial registration

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Preparation for and Management of “Failed” Laryngoscopy and/or Intubation

An airway manager’s primary objective is to provide a path to oxygenation. This can be achieved by means of a facemask, a supraglottic airway, or a tracheal tube. If one method fails, an alternative approach may avert hypoxia. We cannot always predict the difficulties with each of the methods, but these difficulties may be overcome by an alternative technique. Each unsuccessful attempt to maintain oxygenation is time lost and may incrementally increase the risk of hypoxia, trauma, and airway obstruction necessitating a surgical airway. We should strive to optimize each effort. Differentiation between failed laryngoscopy and failed intubation is important because the solutions differ. Failed facemask ventilation may be easily managed with an supraglottic airway or alternatively tracheal intubation. When alveolar ventilation cannot be achieved by facemask, supraglottic airway, or tracheal intubation, every anesthesiologist should be prepared to perform an emergency surgical airway to avert disaster.