The videolaryngoscope as a first-line intubation device in women with hypertensive disease of pregnancy

Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis

PURPOSE

The incidence of difficult and failed intubation is higher in obstetrical patients than in the general population because of anatomic and physiologic changes in pregnancy. Videolaryngoscopy improves the success rate of intubation and reduces complications when compared with direct laryngoscopy in adults; however, it is not known whether this extends to obstetrical surgery. The aim of this study was to examine the efficacy, efficiency, and safety of videolaryngoscopy compared with direct laryngoscopy in obstetrics.

SOURCE

Central, CINAHL, Embase, MEDLINE and Web of Science databases were searched from inception to 27 May 2020 with no restrictions. Inclusion criteria included randomized-controlled trials (RCTs), observational studies, case series, and case reports that reported the application of videolaryngoscopy to intubate the trachea in pregnant patients having general anesthesia.

PRINCIPAL FINDINGS

Overall, four RCTs with 428 participants, nine observational studies, and 35 case reports/series with 100 participants were included. On meta-analysis of three trials, the co-primary outcomes of first-attempt success rate (risk ratio, 1.02; 95% confidence intervals [CI], 0.98 to 1.06; P = 0.29; I2 = 0%) and time to tracheal intubation (mean difference, 1.20 sec; 95% CI, -6.63 to 9.04; P = 0.76; I² = 95%) demonstrated no difference between videolaryngoscopy and direct laryngoscopy in parturients without difficult airways. Observational studies and case reports underline the role of videolaryngoscopy as a primary choice when difficulty with tracheal intubation is expected or as a rescue modality in difficult or failed intubations.

CONCLUSIONS

Evidence for the utility of videolaryngoscopy continues to evolve but supports its increased adoption in obstetrics where videolaryngoscopes should be immediately available for use as a first-line device.

TRIAL REGISTRATION

PROSPERO (CRD42020189521); registered 6 July 2020.

Pharmacological strategies to prevent haemodynamic changes after intubation in parturient women with hypertensive disorders of pregnancy: A network meta-analysis

Objective : This network meta-analysis (NMA) aimed to determine the relative efficacy and safety of pharmacological strategies used to mitigate haemodynamic instability by intubation for general anaesthesia in hypertensive parturient women undergoing caesarean section. Methods : We considered randomised controlled studies comparing the effects of pharmacological strategies used to alleviate haemodynamic instability during intubation in parturient women with hypertensive disorders of pregnancy. The primary endpoints were maximum blood pressure and heart rate after intubation, and secondary endpoints were the Apgar scores at 1 and 5 min. NMA allowed us to combine direct and indirect comparisons between strategies. Results : Twelve studies evaluating nine pharmacological strategies in 619 patients were included. According to the surface under the cumulative ranking curve, the maximal mean arterial pressure was lowest for high-dose remifentanil (99.4%) followed by nitroglycerin (73.6%) and labetalol (60.9%). The maximal heart rate was lowest for labetalol (99.9%) followed by high dose of remifentanil (81.2%) and fentanyl (61.6%). Apgar score at 1 min was higher with low-dose than with high-dose remifentanil (mean difference, 0.726; 95% confidence interval, 0.056 to 1.396; I2=0.0%). Conclusions : High-dose remifentanil produces minimum blood pressure changes, while labetalol is most effective in maintaining normal heart rate in parturient women with hypertensive disorders of pregnancy during caesarean section under general anaesthesia.