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Vested M, Kempff-Andersen S, Creutzburg A, Dalsten H, Wadland SS, Rosenkrantz O, Rosager CL, Rasmussen LS. Onset time, duration of action, and intubating conditions after mivacurium in elderly and younger patients. Acta Anaesthesiol Scand 2024; 68:898-905. [PMID: 38764184 DOI: 10.1111/aas.14440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The neuromuscular blocking agent mivacurium can be used during anesthesia to facilitate tracheal intubation. Data on onset time, duration of action, and effect on intubating conditions in patients 80 years and older are however limited. We hypothesized that onset time and duration of action of mivacurium would be longer in elderly patients than in younger adults. METHODS This prospective observational study included 35 elderly (≥80 years) and 35 younger (18-40 years) patients. Induction of anesthesia comprised fentanyl 1-3 μg kg-1 and propofol 1.5-2.5 mg kg-1 and propofol and remifentanil for maintenance. Acceleromyography was used for monitoring neuromuscular blockade. The primary outcome was onset time defined as time from injection of mivacurium 0.2 mg kg-1 to a train-of-four (TOF) count of zero. Other outcomes included duration of action (time to TOF ratio ≥0.9), intubating conditions using the Fuchs-Buder scale and the intubating difficulty scale (IDS), and occurrence of hoarseness and sore throat postoperatively. RESULTS No difference was found in onset time comparing elderly with younger patients; 219 s (SD 45) versus 203 s (SD 74) (difference: 16 s (95% CI: -45 to 14), p = .30). Duration of action was significantly longer in elderly patients compared with younger patients; 52 min (SD 17) versus 30 min (SD 8) (difference: 22 min [95% CI: 15 to 28], p < .001). No difference was found in the proportion of excellent intubating conditions (Fuchs-Buder); 31/35 (89%) versus 26/35 (74%) (p = .12) or IDS score (p = .13). A larger proportion of younger patients reported sore throat 24 h postoperatively; 34% versus 0%, p = .0002. No difference was found in hoarseness. CONCLUSION No difference in onset time of mivacurium 0.2 mg kg-1 was found comparing elderly and younger patients. However, elderly patients had significantly longer duration of action. No difference was found in intubating conditions.
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Affiliation(s)
- Matias Vested
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Kempff-Andersen
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Creutzburg
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Helene Dalsten
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sarah Sofie Wadland
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Oscar Rosenkrantz
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christine L Rosager
- Department of Anesthesia, Herlev Hospital, Herlev, Denmark
- Danish Cholinesterase Research Unit, Department of Anesthesia, Herlev Hospital, Herlev, Denmark
| | - Lars S Rasmussen
- Danish Ministry of Defence Personnel Agency, Copenhagen, Denmark
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Araújo B, Rivera A, Martins S, Abreu R, Cassa P, Silva M, Gallo de Moraes A. Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 2024; 28:1. [PMID: 38167459 PMCID: PMC10759602 DOI: 10.1186/s13054-023-04727-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain. METHODS We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models. RESULTS Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL. CONCLUSION VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.
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Affiliation(s)
- Beatriz Araújo
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - André Rivera
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Suzany Martins
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Renatha Abreu
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Paula Cassa
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Maicon Silva
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
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Kriege M, Rissel R, El Beyrouti H, Hotz E. Awake Tracheal Intubation Is Associated with Fewer Adverse Events in Critical Care Patients than Anaesthetised Tracheal Intubation. J Clin Med 2023; 12:6060. [PMID: 37763000 PMCID: PMC10531870 DOI: 10.3390/jcm12186060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Tracheal intubation in critical care is a high-risk procedure requiring significant expertise and airway strategy modification. We hypothesise that awake tracheal intubation is associated with a lower incidence of severe adverse events compared to standard tracheal intubation in critical care patients. METHODS Records were acquired for all tracheal intubations performed from 2020 to 2022 for critical care patients at a tertiary hospital. Each awake tracheal intubation case, using a videolaryngoscope with a hyperangulated blade (McGrath® MAC X-Blade), was propensity matched with two controls (1:2 ratio; standard intubation videolaryngoscopy (VL) and direct laryngoscopy (DL) undergoing general anaesthesia). The primary endpoint was the incidence of adverse events, defined as a mean arterial pressure of <55 mmHg (hypotension), SpO2 < 80% (desaturation) after sufficient preoxygenation, or peri-interventional cardiac arrest. RESULTS Of the 135 tracheal intubations included for analysis, 45 involved the use of an awake tracheal intubation. At least one adverse event occurred after tracheal intubation in 36/135 (27%) of patients, including awake 1/45 (2.2%; 1/1 hypotension), VL 10/45 (22%; 6/10 hypotension and 4/10 desaturation), and DL 25/45 (47%; 10/25 hypotension, 12/25 desaturation, and 3/25 cardiac arrest; p < 0.0001). CONCLUSIONS In this retrospective observational study of intubation practices in critical care patients, awake tracheal intubation was associated with a lower incidence of severe adverse events than anaesthetised tracheal intubation.
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Affiliation(s)
- Marc Kriege
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Rene Rissel
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Hazem El Beyrouti
- Department of Cardiac and Vascular Surgery, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Eric Hotz
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, 55131 Mainz, Germany
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4
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Saul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med 2023; 13:1327. [PMID: 37763095 PMCID: PMC10532647 DOI: 10.3390/jpm13091327] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.
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Affiliation(s)
- Sophie A. Saul
- St. John’s Hospital, Howden West Road, NHS Lothian, Livingston EH54 6PP, UK; (S.A.S.); (A.F.M.)
| | - Patrick A. Ward
- St. John’s Hospital, Howden West Road, NHS Lothian, Livingston EH54 6PP, UK; (S.A.S.); (A.F.M.)
| | - Alistair F. McNarry
- St. John’s Hospital, Howden West Road, NHS Lothian, Livingston EH54 6PP, UK; (S.A.S.); (A.F.M.)
- Western General Hospital, Crewe Road South, NHS Lothian, Edinburgh EH4 2XU, UK
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Nedunchezhian V, Nedunchezhian I, Van Zundert A. Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review. Healthcare (Basel) 2023; 11:2383. [PMID: 37685417 PMCID: PMC10487223 DOI: 10.3390/healthcare11172383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.
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Affiliation(s)
- Vikram Nedunchezhian
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD 4029, Australia;
| | - Ishvar Nedunchezhian
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD 4215, Australia;
| | - André Van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD 4029, Australia;
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6
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Ramesh K, Srinivasan G, Bidkar PU. Comparison of Tracheal Intubation Using King Vision (Non-channeled Blade) and Tuoren Video Laryngoscopes in Patients With Cervical Spine Immobilization by Manual In-Line Stabilization: A Randomized Clinical Trial. Cureus 2023; 15:e43471. [PMID: 37711910 PMCID: PMC10499184 DOI: 10.7759/cureus.43471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Glottic visualization on cervical immobilization with manual in-line stabilization (MILS) might be challenging in individuals with cervical spine injuries. We compared non-channeled King Vision video laryngoscope (VL) (Ambu GmbH, Bad Nauheim, Germany) with Tuoren video laryngoscope (Henan Tuoren Medical Device, Zhengzhou, China) for endotracheal intubation in patients with cervical spine immobilization. METHODS A total of 124 patients undergoing elective surgery under general anesthesia were included in this study. After induction of general anesthesia, patients were randomized into two groups (62 each): group K (non-channeled blade of King Vision video laryngoscope) and group T (Tuoren video laryngoscope). Cervical spine immobilization was achieved with manual in-line stabilization. The success of the first pass intubation, the time required to intubate, glottic visualization, and intubation difficulty score (IDS) were recorded. RESULTS The first-attempt success rate of intubation was 95.2% (59 out of 62 patients) in group K and 90.3% (56 out of 62 patients) in group T, which were comparable. The mean glottic visualization time was significantly less with group T (12.74 ± 6.32 seconds) compared to group K (17.92 ± 4.24 seconds). Intubation time was significantly faster with group K (18.79 ± 5.857 seconds) compared to group T (27.21 ± 8.514 seconds). Both video laryngoscopes provided good grades of glottic visualization. CONCLUSIONS We conclude that the performance of the Tuoren video laryngoscope is similar to the King Vision video laryngoscope in terms of first-attempt intubation success rate and glottic visualization score in patients with cervical spine immobilization by manual in-line stabilization. Although glottic visualization time was shorter with Tuoren VL, we could achieve faster intubation with King Vision VL.
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Affiliation(s)
- Killo Ramesh
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gnanasekaran Srinivasan
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Prasanna U Bidkar
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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7
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Kriege M, Noppens RR, Turkstra T, Payne S, Kunitz O, Tzanova I, Schmidtmann I. A multicentre randomised controlled trial of the McGrath Mac videolaryngoscope versus conventional laryngoscopy. Anaesthesia 2023; 78:722-729. [PMID: 36928625 DOI: 10.1111/anae.15985] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/18/2023]
Abstract
Before completion of this study, there was insufficient evidence demonstrating the superiority of videolaryngoscopy compared with direct laryngoscopy for elective tracheal intubation. We hypothesised that using videolaryngoscopy for routine tracheal intubation would result in higher first-pass tracheal intubation success compared with direct laryngoscopy. In this multicentre randomised trial, 2092 adult patients without predicted difficult airway requiring tracheal intubation for elective surgery were allocated randomly to either videolaryngoscopy with a Macintosh blade (McGrath) or direct laryngoscopy. First-pass tracheal intubation success was higher with the McGrath (987/1053, 94%), compared with direct laryngoscopy (848/1039, 82%); absolute risk reduction (95%CI) was 12.1% (10.9-13.6%). This resulted in a relative risk (95%CI) of unsuccessful tracheal intubation at first attempt of 0.34 (0.26-0.45; p < 0.001) for McGrath compared with direct laryngoscopy. Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (84/1039, 8%) compared with McGrath (8/1053, 0.7%; p < 0.001) No significant difference in tracheal intubation-associated adverse events was observed between groups. This study demonstrates that using McGrath videolaryngoscopy compared with direct laryngoscopy improves first-pass tracheal intubation success in patients having elective surgery. Practitioners may consider using this device as first choice for tracheal intubation.
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Affiliation(s)
- M Kriege
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - R R Noppens
- Department of Anesthesia and Peri-operative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, ON, London, Canada
| | - T Turkstra
- Department of Anesthesia and Peri-operative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, ON, London, Canada
| | - S Payne
- Department of Anaesthesia, Emergency and Intensive Care Medicine, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - O Kunitz
- Department of Anaesthesiology, Christophorus Hospital, Coesfeld, Germany
| | - I Tzanova
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Germany
| | - I Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Germany
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8
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Kriege M, Hilt JA, Dette F, Wittenmeier E, Meuser R, Staubitz JI, Musholt TJ. Impact of direct laryngoscopy vs. videolaryngoscopy on signal quality of recurrent laryngeal nerve monitoring in thyroid surgery: a randomised parallel group trial. Anaesthesia 2023; 78:55-63. [PMID: 36166515 DOI: 10.1111/anae.15865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
In thyroid surgery, intra-operative neuromonitoring signals of the recurrent laryngeal nerve can be detected by surface electrodes on a tracheal tube positioned at the vocal fold level. The incidence of difficult tracheal intubation in patients undergoing thyroidectomy for nodular goitre ranges from 5.3% to 20.5%. The aim of this study was to compare videolaryngoscopy with conventional direct laryngoscopy as methods for proper placement of the surface electrode to prevent insufficient intra-operative nerve signal quality. In this prospective randomised trial, adult patients requiring tracheal intubation during thyroid surgery were randomly allocated to two groups of C-MAC® (Macintosh style blade) videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. Primary outcome was the incidence of insufficient signal electromyogram amplitude level (< 500 μV) after successful tracheal intubation. A total of 260 (130 per group) participants were analysed. An insufficient signal was more frequent with direct laryngoscopy (35/130, 27%), compared with C-MAC (12/130, 9%, p < 0.001). First-pass tracheal intubation success rate was lower with direct laryngoscopy (86/130 (66%)) compared with the C-MAC (125/130 (96%)) (p < 0.0001). Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (16/130 (12%)), compared with the C-MAC (0/130, (0%)) (p < 0.0001). The results suggest that videolaryngoscopy has an impact on the quality of the initial intra-operative neuromonitoring signal in patients undergoing thyroid surgery, and this technique can provide optimised surface electrode positioning.
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Affiliation(s)
- M Kriege
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - J A Hilt
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - F Dette
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - E Wittenmeier
- Department of Anesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - R Meuser
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - J I Staubitz
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - T J Musholt
- Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Germany
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9
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Kang D, Bae HB, Choi YH, Bom JS, Kim J. A prospective randomized study of different height of operation table for tracheal intubation with videolaryngoscopy in ramped position. BMC Anesthesiol 2022; 22:378. [PMID: 36476332 PMCID: PMC9727988 DOI: 10.1186/s12871-022-01929-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Previous studies have reported that the ramped position provides a better laryngoscopic view, reduces tracheal intubation time, and increases the success rate of endotracheal intubation. However, the patient's head height changes while in the ramped position, which in turn changes the relative positions of the patient and intubator. Thus, making these changes may affect the efficiency of tracheal intubation; however, few studies have addressed this problem. This study analyzed intubation time and conditions during tracheal intubation using videolaryngoscope in the ramped position. METHODS This prospective study included 144 patients who were scheduled to receive general anesthesia for surgeries involving orotracheal intubation. The participants were randomly allocated to either the nipple or umbilical group according to the table height. Mask ventilation was assessed using the Warters grading scale. Tracheal intubation was performed using a McGrath MAC laryngoscope. The total intubation time, laryngoscopy time, tube insertion time, and difficulty of intubation (IDS score) were measured. RESULTS The umbilical group had a significantly shorter laryngoscopy time (10 ± 3 vs. 16 ± 4 s), tube insertion time (18 ± 4 vs. 24 ± 6 s), and total intubation time (28 ± 5 vs. 40 ± 7 s) compared to the nipple group. No significant difference in the difficulty of mask ventilation was observed between the two groups. The IDS score was higher in the nipple than umbilical group. CONCLUSION The lower (umbilical) table level reduced the intubation time and difficulty of videolaryngoscopy compared to the higher (nipple) table level. TRIAL REGISTRATION This study was registered at KCT0005987, 11/03/2021, Retrospectively registered.
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Affiliation(s)
- Dongho Kang
- grid.411602.00000 0004 0647 9534Department of Anesthesiology and Pain Medicine, Chonnam National University Hwasun Hospital, Hwasun, Chonnam, Korea
| | - Hong-Beom Bae
- grid.14005.300000 0001 0356 9399Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61469 Korea ,grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
| | - Yun Ha Choi
- grid.443803.80000 0001 0522 719XDepartment of Nursing, Honam University, Gwangju, Korea
| | - Joon-suk Bom
- grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
| | - Joungmin Kim
- grid.14005.300000 0001 0356 9399Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, 160, Baekseo-ro, Dong-gu, Gwangju, 61469 Korea ,grid.411597.f0000 0004 0647 2471Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Kwangju, Korea
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10
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Vested M, Kristensen CM, Pape P, Vang M, Hartoft M, Hjelmdal C, Rasmussen LS. Comparison of onset time, duration of action, and intubating conditions after cisatracurium 0.15 mg/kg in young and elderly patients. BMC Anesthesiol 2022; 22:339. [PMCID: PMC9639316 DOI: 10.1186/s12871-022-01881-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Introduction
Tracheal intubation during anesthesia can be facilitated by the neuromuscular blocking agent cisatracurium. However, limited data exists about onset time, duration of action and effect on intubating conditions in elderly patients above 80 years of age. We hypothesized that elderly patients would present a longer onset time and duration of action compared to younger adults.
Methods
This prospective observational study included 31 young (18–40 years) and 29 elderly (≥ 80 years) patients. Patients were given fentanyl 2 μg/kg and propofol 1.5–2.5 mg/kg for induction of anesthesia and maintained with remifentanil and propofol. Monitoring of neuromuscular function was performed with acceleromyography. Primary outcome was onset time defined as time from injection of cisatracurium 0.15 mg/kg (based on ideal body weight) to a train-of-four (TOF) count of 0. Other outcomes included duration of action (time to TOF ratio ≥ 0.9), intubation conditions using the Fuchs-Buder scale and the Intubating Difficulty Scale (IDS), and occurrence of hoarseness and sore throat postoperatively.
Results
Elderly patients had significantly longer onset time compared with younger patients; 297 seconds (SD 120) vs. 199 seconds (SD 59) (difference: 98 seconds (95% CI: 49–147), P < 0.001)). Duration of action was also significantly longer in elderly patients compared with younger patients; 89 minutes (SD 17) vs. 77 minutes (SD 14) (difference: 12 minutes (95% CI: 2.5–20.5) P = 0.01)). No difference was found in the proportion of excellent intubating conditions (Fuchs-Buder); 19/29 (66%) vs 21/31 (68%) (P = 0.86) or IDS score (P = 0.74). A larger proportion of elderly patients reported hoarseness 24 hours postoperatively; 62% vs 34% P = 0.04.
Conclusion
In elderly patients cisatracurium 0.15 mg/kg had significantly longer onset time and duration of action compared with younger patients. No difference was found in intubating conditions at a TOF count of 0.
Trial registration
Clinicaltrials.gov (NCT04921735, date of registration 10 June 2021).
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11
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The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility. Healthcare (Basel) 2022; 10:healthcare10091688. [PMID: 36141300 PMCID: PMC9498386 DOI: 10.3390/healthcare10091688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Among all the proposed predictors of difficult intubation defined by the intubation difficulty scale, head and neck movement (motility) stands out and plays as a crucial factor in determining the success rate and the degree of ease on endotracheal intubation. Aside from other airway tools (e.g., supraglottic airway devices), optical devices have been developed and applied for more than two decades and have shown their superiority to conventional direct laryngoscopes in many clinical scenarios and settings. Although awake/asleep flexible fiberoptic bronchoscopy is still the gold standard in patients with unstable cervical spines immobilized with a rigid cervical collar or a halo neck brace, videolaryngoscopy has been repeatedly demonstrated to be advantageous. In this brief report, for the first time, we present our clinical experience on the routine use of the Shikani video-assisted intubating stylet technique in patients with traumatic cervical spine injuries immobilized with a cervical stabilizer and in a patient with a stereotactic headframe for neurosurgery. Some trouble-shooting strategies for this technique are discussed. This paper demonstrates that the video-assisted intubating stylet technique is an acceptable alternative airway management method in patients with restricted or confined neck motility.
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Nalubola S, Jin E, Drugge ED, Weber G, Abramowicz AE. Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e29578. [PMID: 36312614 PMCID: PMC9595268 DOI: 10.7759/cureus.29578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/05/2022] Open
Abstract
Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees. Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice. Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students. Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.
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Affiliation(s)
| | - Evan Jin
- Anesthesiology, Westchester Medical Center, Valhalla, USA
| | - Elizabeth D Drugge
- Public Health, New York Medical College School of Health Sciences and Practice, Valhalla, USA
| | - Garret Weber
- Anesthesiology, Westchester Medical Center, Valhalla, USA
- Anesthesiology, New York Medical College, Valhalla, USA
| | - Apolonia E Abramowicz
- Anesthesiology, Westchester Medical Center, Valhalla, USA
- Anesthesiology, New York Medical College, Valhalla, USA
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13
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Vested M, Pape P, Kristensen CM, Dinesen F, Vang M, Christensen RE, Bjerring Lindahl C, Albrechtsen C, Rasmussen LS. 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. Acta Anaesthesiol Scand 2022; 66:811-817. [PMID: 35675032 PMCID: PMC9544287 DOI: 10.1111/aas.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/11/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Matias Vested
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Pernille Pape
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Camilla Meno Kristensen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Felicia Dinesen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Malene Vang
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | | | - Cecilie Bjerring Lindahl
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen
| | - Charlotte Albrechtsen
- Department of Anaesthesia, Juliane Marie Centret, Rigshospitalet, University of Copenhagen
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen.,Department of Clinical Medicine, University of Copenhagen
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Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev 2022; 4:CD011136. [PMID: 35373840 PMCID: PMC8978307 DOI: 10.1002/14651858.cd011136.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016. OBJECTIVES To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation. MAIN RESULTS We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit. We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%). AUTHORS' CONCLUSIONS VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.
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Affiliation(s)
| | - Andrew M Rogers
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Tim M Cook
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
- University of Bristol, Bristol, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
- Lancaster University, Lancaster, UK
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Çetin YS, Soyalp C. Comparison of three video-assisted intubation methods: Rigid telescopes, C-MAC, flexible fiberoptic bronchoscopy, for anticipated difficult airways. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Lee J, Cho Y, Kim W, Choi KS, Jang BH, Shin H, Ahn C, Kim JG, Na MK, Lim TH, Kim DW. Comparisons of Videolaryngoscopes for Intubation Undergoing General Anesthesia: Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. J Pers Med 2022; 12:363. [PMID: 35330362 PMCID: PMC8954588 DOI: 10.3390/jpm12030363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The efficacy and safety of videolaryngoscopes (VLs) for tracheal intubation is still conflicting and changeable according to airway circumstances. This study aimed to compare the efficacy and safety of several VLs in patients undergoing general anesthesia. METHODS Medline, EMBASE, and the Cochrane Library were searched until 13 January 2020. The following VLs were evaluated compared to the Macintosh laryngoscope (MCL) by network meta-analysis for randomized controlled trials (RCTs): Airtraq, Airwayscope, C-MAC, C-MAC D-blade (CMD), GlideScope, King Vision, and McGrath. Outcome measures were the success and time (speed) of intubation, glottic view, and sore throat (safety). RESULTS A total of 9315 patients in 96 RCTs were included. The highest-ranked VLs for first-pass intubation success were CMD (90.6 % in all airway; 92.7% in difficult airway) and King Vision (92% in normal airway). In the rank analysis for secondary outcomes, the following VLs showed the highest efficacy or safety: Airtraq (safety), Airwayscope (speed and view), C-MAC (speed), CMD (safety), and McGrath (view). These VLs, except McGrath, were more effective or safer than MCL in moderate evidence level, whereas there was low certainty of evidence in the intercomparisons of VLs. CONCLUSIONS CMD and King Vision could be relatively successful than MCL and other VLs for tracheal intubation under general anesthesia. The comparisons of intubation success between VLs and MCL showed moderate certainty of evidence level, whereas the intercomparisons of VLs showed low certainty evidence.
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Affiliation(s)
- Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (J.L.); (H.S.); (T.H.L.)
| | - Youngsuk Cho
- Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul 05355, Korea;
- Department of Biomedical Engineering, Hanyang University College of Medicine, Seoul 04763, Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Hallym University, Chuncheon 24253, Korea;
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul 04763, Korea; (K.-S.C.); (M.K.N.)
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul 02447, Korea;
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (J.L.); (H.S.); (T.H.L.)
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Korea;
| | - Jae Guk Kim
- Department of Emergency Medicine, Hallym University, Chuncheon 24253, Korea;
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul 04763, Korea; (K.-S.C.); (M.K.N.)
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (J.L.); (H.S.); (T.H.L.)
| | - Dong Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul 04763, Korea;
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17
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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18
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Vested M, Sørensen AM, Bjerring C, Christensen RE, Dinesen F, Vang M, Gilvanoff A, Hansen TE, Nielsen T, Rasmussen LS. A blinded randomized study comparing intubating conditions after either rocuronium 0.6 mg·kg -1 or remifentanil 2 µg·kg -1 in elderly patients. Acta Anaesthesiol Scand 2021; 65:1367-1373. [PMID: 34310692 DOI: 10.1111/aas.13957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/07/2021] [Accepted: 07/10/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Matias Vested
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Anne Marie Sørensen
- Department of Anaesthesiology, Pain and Respiratory Support Rigshospitalet Glostrup University of Copenhagen Copenhagen Denmark
| | - Cecilie Bjerring
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Rasmus E. Christensen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Felicia Dinesen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Malene Vang
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Alexander Gilvanoff
- Department of Anaesthesiology, Pain and Respiratory Support Rigshospitalet Glostrup University of Copenhagen Copenhagen Denmark
| | - Thea Ellehammer Hansen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Tatiana Nielsen
- Department of Anaesthesiology, Pain and Respiratory Support Rigshospitalet Glostrup University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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19
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Kriege M, Lang P, Lang C, Pirlich N, Griemert EV, Heid F, Wittenmeier E, Schmidtmann I, Schmidbauer W, Jänig C, Jungbecker J, Kunitz O, Strate M, Schmutz A. Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol. BMJ Open 2021; 11:e052977. [PMID: 34615684 PMCID: PMC8496391 DOI: 10.1136/bmjopen-2021-052977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration. METHODS AND ANALYSIS The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events. ETHICS AND DISSEMINATION The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION NCT04794764.
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Affiliation(s)
- Marc Kriege
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Philipp Lang
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christoph Lang
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Nina Pirlich
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Florian Heid
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Wittenmeier
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg Universitat Mainz, Mainz, Germany
| | - W Schmidbauer
- Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Germany
| | - Christoph Jänig
- Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Germany
| | - Johannes Jungbecker
- Department of Anaesthesia, Intensive Care Medicine and Emergency Medicine, Marienhaus Klinikum Hetzelstift Neustadt Weinstraße, Neustadt, Germany
| | - Oliver Kunitz
- Department of Anaesthesia, Emergency and Intensive Care Medicine, Klinikum Mutterhaus der Borromäerinnen gGmbH, Trier, Germany
| | - Maximilian Strate
- Department of Anaesthesiology and Critical Care, University of Freiburg, Freiburg im Breisgau, Germany
| | - Axel Schmutz
- Department of Anaesthesiology and Critical Care, University of Freiburg, Freiburg im Breisgau, Germany
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20
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Peyton J, Fiadjoe J, Stein ML, Park R, Staffa S, Zurakowski D, Kovatsis P. Comparing standard and non-standard videolaryngoscopes in children: methodological issues. Response to Br J Anaesth 2021; 127: e52-e4. Br J Anaesth 2021; 127:e172-e173. [PMID: 34511260 DOI: 10.1016/j.bja.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- James Peyton
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
| | - John Fiadjoe
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Mary L Stein
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Raymond Park
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Steven Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Pete Kovatsis
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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21
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Singleton BN, Morris FK, Yet B, Buggy DJ, Perkins ZB. Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Br J Anaesth 2021; 126:1055-1066. [PMID: 33610262 DOI: 10.1016/j.bja.2020.12.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cervical spine immobilisation increases the difficulty of tracheal intubation. Many intubation devices have been evaluated in this setting, but their relative performance remains uncertain. METHODS MEDLINE, EMBASE, and the Cochrane Library were searched to identify randomised trials comparing two or more intubation devices in adults with cervical spine immobilisation. After critical appraisal, a random-effects network meta-analysis was used to pool and compare device performance. The primary outcome was the probability of first-attempt intubation success (first-pass success). For relative performance, the Macintosh direct laryngoscopy blade was chosen as the reference device. RESULTS We included 80 trials (8039 subjects) comparing 26 devices. Compared with the Macintosh, McGrath™ (odds ratio [OR]=11.5; 95% credible interval [CrI] 3.19-46.20), C-MAC D Blade™ (OR=7.44; 95% CrI, 1.06-52.50), Airtraq™ (OR=5.43; 95% CrI, 2.15-14.2), King Vision™ (OR=4.54; 95% CrI, 1.28-16.30), and C-MAC™ (OR=4.20; 95% CrI=1.28-15.10) had a greater probability of first-pass success. This was also true for the GlideScope™ when a tube guide was used (OR=3.54; 95% CrI, 1.05-12.50). Only the Airway Scope™ had a better probability of first-pass success compared with the Macintosh when manual-in-line stabilisation (MILS) was used as the immobilisation technique (OR=7.98; 95% CrI, 1.06-73.00). CONCLUSIONS For intubation performed with cervical immobilisation, seven devices had a better probability of first-pass success compared with the Macintosh. However, more studies using MILS (rather than a cervical collar or other alternative) are needed, which more accurately represent clinical practice. CLINICAL TRIAL REGISTRATION PROSPERO 2019 CRD42019158067 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=158067).
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Affiliation(s)
- Barry N Singleton
- Department of Anaesthesiology and Critical Care Medicine, Our Lady's Children's Hospital Crumlin, Dublin, Ireland.
| | - Fiachra K Morris
- Department of Anaesthesiology and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Barbaros Yet
- Graduate School of Informatics, Middle East Technical University, Ankara, Turkey
| | - Donal J Buggy
- Department of Anaesthesiology and Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | - Zane B Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
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22
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. 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 was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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23
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Theiler L, Greif R, Bütikofer L, Arheart K, Kleine-Brueggeney M. The skill of tracheal intubation with rigid scopes - a randomised controlled trial comparing learning curves in 740 intubations. BMC Anesthesiol 2020; 20:263. [PMID: 33066735 PMCID: PMC7565755 DOI: 10.1186/s12871-020-01181-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background Rigid scopes are successfully used for management of difficult airways, but learning curves have not been established. Methods This randomised controlled trial was performed at the University Hospital Bern in Switzerland to establish learning curves for the rigid scopes Bonfils and SensaScope and to assess their performance. Fifteen consultant anaesthetists and 15 anaesthesia registrars performed a total of 740 intubations (10 to 20 intubations with each device per physician) in adult patients without predictors of a difficult airway under general anaesthesia. According to randomisation, physicians intubated the patient’s trachea with either the Bonfils or the SensaScope. A maximum of three intubation attempts was allowed. Primary outcome was overall time to successful intubation. Secondary outcome parameters included first attempt success, first attempt success within 60 s, failures and adverse events. Results A clear learning effect was demonstrated: Over 20 trials, intubations became 2.5-times quicker and first attempt intubation success probability increased by 21–28 percentage points. Fourteen and 20 trials were needed with the Bonfils and the SensaScope, respectively, to reach a 90% first attempt success probability. Intubation times were 23% longer (geometric mean ratio 1.23, 95% confidence interval 1.12–1.36, p < 0.001) and first attempt success was less likely (odds ratio 0.64, 95% confidence interval 0.45–0.92, p = 0.016) with the SensaScope. Consultants showed a tendency for a better first attempt success compared to registrars. Overall, 23 intubations (10 Bonfils, 13 SensaScope) failed. Adverse events were rare and did not differ between devices. Conclusions A clear learning effect was demonstrated for both rigid scopes. Fourteen intubations with the Bonfils and 20 intubations with the SensaScope were required to reach a 90% first attempt success probability. Learning of the technique seemed more complex with the SensaScope compared to the Bonfils. Trial registration Current Controlled Trials, ISRCTN14429285. Registered 28 September 2011, retrospectively registered.
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Affiliation(s)
- Lorenz Theiler
- Department of Anaesthesia, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | | | - Kristopher Arheart
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maren Kleine-Brueggeney
- Department of Anaesthesia, University Children's Hospital Zurich - Eleonore Foundation and University of Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
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24
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López AM, Belda I, Bermejo S, Parra L, Áñez C, Borràs R, Sabaté S, Carbonell N, Marco G, Pérez J, Massó E, Soto JM, Boza E, Gil JM, Serra M, Tejedor V, Tejedor A, Roza J, Plaza A, Tena B, Valero R. 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 consensus. ACTA ACUST UNITED AC 2020; 67:325-342. [PMID: 32471791 DOI: 10.1016/j.redar.2019.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 11/27/2022]
Abstract
The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.
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Affiliation(s)
- A M López
- Hospital Clínic de Barcelona, Barcelona, España
| | - I Belda
- Hospital Clínic de Barcelona, Barcelona, España
| | - S Bermejo
- Consorci Mar Parc de Salut de Barcelona, Barcelona, España
| | - L Parra
- Consorci Sanitari Integral, L'Hospitalet de Llobregat, España
| | - C Áñez
- Hospital Universitari de Tarragona Joan XXIII, Tarragona, España
| | - R Borràs
- Hospital Universitari Dexeus, Barcelona, España
| | - S Sabaté
- Fundació Puigvert (IUNA), Barcelona, España
| | - N Carbonell
- Hospital Universitari Dexeus, Barcelona, España
| | - G Marco
- Hospital Universitari Santa Maria de Lleida, Lleida, España
| | - J Pérez
- Hospital Universitari Parc Taulí, Sabadell, España
| | - E Massó
- Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - J Mª Soto
- Hospital d' Igualada, SEM, Igualada, España
| | - E Boza
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - J M Gil
- Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M Serra
- Consorci Sanitari Integral, L'Hospitalet de Llobregat, España
| | - V Tejedor
- Consorci Sanitari Integral, L'Hospitalet de Llobregat, España
| | - A Tejedor
- Consorci Sanitari Integral, L'Hospitalet de Llobregat, España
| | - J Roza
- Hospital Universitari de Vic, Vic, España
| | - A Plaza
- Hospital Clínic de Barcelona, Barcelona, España
| | - B Tena
- Hospital Clínic de Barcelona, Barcelona, España
| | - R Valero
- Hospital Clínic de Barcelona, Barcelona, España.
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25
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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; 19:166. [PMID: 31470814 PMCID: PMC6717380 DOI: 10.1186/s12871-019-0838-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND King Vision and McGrath MAC video laryngoscopes (VLs) are increasingly used. The purpose of this study was to evaluate the performance of nasotracheal intubation in patients with predicted difficult intubations using non-channeled King Vision VL, McGrath MAC VL or Macintosh laryngoscope by experienced intubators. METHODS Ninety nine ASA I or II adult patients, scheduled for oral maxillofacial surgeries with El-Ganzouri risk index 1-7 were enrolled. Patients were randomly allocated to intubate with one of three laryngoscopes (non-channeled King Vision, McGrath MAC and Macintosh). The intubators were experienced with more than 100 successful nasotracheal intubations using each device. The primary outcome was intubation time. The secondary outcomes included first success rate, time required for viewing the glottis, Cormack-Lehane grade of glottis view, the number of assist maneuvers, hemodynamic responses, the subjective evaluating of sensations of performances and associated complications. RESULTS The intubation time of King Vision and McGrath group was comparable (37.6 ± 7.3 s vs. 35.4 ± 8.8 s) and both were shorter than Macintosh group (46.8 ± 10.4 s, p < 0.001). Both King Vision and McGrath groups had a 100% first attempt success rate, significantly higher than Macintosh group (85%, p < 0.05). The laryngoscopy time was comparable between King Vision and McGrath group (16.7 ± 5.5 s vs. 15.6 ± 6.3 s) and was shorter than Macintosh group (22.8 ± 7.2 s, p < 0.05) also. Compared with Macintosh laryngoscope, Glottis view was obviously improved when exposed with either non-channeled King Vision or McGrath MAC VL (p < 0.001), and assist maneuvers required were reduced (p < 0.001). The maximum fluctuations of MAP were significantly attenuated in VL groups (47.7 ± 12.5 mmHg and 45.1 ± 10.3 mmHg vs. 54.9 ± 10.2 mmHg, p < 0.05 and p < 0.01). Most device insertions were graded as excellent in McGrath group, followed by Macintosh and King Vision group (p = 0.0014). The tube advancements were easier in VLs compared with the Macintosh laryngoscope (p < 0.001). Sore throat was found more frequent in Macintosh group compared with King Vision group (p < 0.05). CONCLUSIONS Non-channeled King Vision and McGrath MAC VLs were comparable and both devices facilitated nasotracheal intubation in managing predicted difficult intubations compared with Macintosh laryngoscope. TRIAL REGISTRATION ClinicalTrials registration number NCT03126344 . Registered on April 24, 2017.
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Affiliation(s)
- Haozhen Zhu
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Jinxing Liu
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Lulu Suo
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Chi Zhou
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yu Sun
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
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Oshika H, Koyama Y, Taguri M, Maruyama K, Hirabayashi G, Yamada SM, Kohno M, Andoh T. Supraglottic airway device versus a channeled or non-channeled blade-type videolaryngoscope for accidental extubation in the prone position: A randomized crossover manikin study. Medicine (Baltimore) 2018; 97:e11190. [PMID: 29924038 PMCID: PMC6023683 DOI: 10.1097/md.0000000000011190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND It is very rare but challenging to perform emergency airway management for accidental extubation in a patient whose head and neck are fixed in the prone position when urgently turning the patient to the supine position would be unsafe. The authors hypothesized that tracheal intubation with a videolaryngoscope would allow effective airway rescue in this situation compared with a supraglottic airway device and designed a randomized crossover manikin study to test this hypothesis. METHODS The authors compared airway rescue performances of the 3 devices-the ProSeal laryngeal mask airway (PLMA; Teleflex Medical, Westmeath, Ireland) as a reference; the Pentax AWS (AWS; Nihon Kohden, Tokyo, Japan) as a channeled blade-type videolaryngoscope; and the McGRATH videolaryngoscope (McGRATH; Medtronic, Minneapolis, MN) as a nonchanneled blade type in a manikin fixed to the operating table in the prone position. Twenty-one anesthesiologists performed airway management on the prone manikin with the 3 devices, and the time required for intubation/ventilation and the success rates were recorded. RESULTS The median (range) intubation/ventilation times with the PLMA, AWS, and McGRATH were 24.5 (13.5-89.5) s, 29.9 (17.1-79.8) s, and 46.7 (21.9-211.7) s, respectively. There was no significant difference in intubation/ventilation times between the PLMA and AWS. The AWS permitted significantly faster tracheal intubation than did the McGRATH (P = 0.006). The success rates with the PLMA (100%) and AWS (100%) were significantly greater than that with the McGRATH (71.4%). Airway management performance of the PLMA and AWS was comparable between devices and better than that of the McGRATH in the prone position. CONCLUSIONS Considering that tracheal intubation can provide a more secure airway and more stable ventilation than the PLMA, re-intubation with a channeled blade-type videolaryngoscope such as the AWS may be a useful method of airway rescue for accidental extubation in patients in the prone position.
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Affiliation(s)
- Hiroyuki Oshika
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
| | - Yukihide Koyama
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
| | - Masataka Taguri
- Department of Biostatics, Yokohama City University Graduate School of Medicine, Yokohama
| | - Koichi Maruyama
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
| | - Go Hirabayashi
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
| | - Shoko Merrit Yamada
- Department of Neurosurgery, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
| | - Masashi Kohno
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
- Department of Anesthesia, Tomei Atsugi Hospital, Atsugi, Japan
| | - Tomio Andoh
- Department of Anesthesiology, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki
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28
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Mendonca C, Ungureanu N, Nowicka A, Kumar P. A randomised clinical trial comparing the ‘sniffing’ and neutral position using channelled (KingVision®
) and non-channelled (C-MAC®
) videolaryngoscopes. Anaesthesia 2018; 73:847-855. [DOI: 10.1111/anae.14289] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 12/29/2022]
Affiliation(s)
- C. Mendonca
- University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - N. Ungureanu
- Burton Hospitals NHS Foundation Trust; Burton-on-Trent UK
| | - A. Nowicka
- University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| | - P. Kumar
- University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
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Nabecker S, Koennecke X, Theiler L, Riggenbach C, Greif R, Kleine-Brueggeney M. Effect of the tube-guiding channel on intubation success with videolaryngoscopes. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Letter to the Editor concerning "Spinal movement and dural sac compression during airway management in a cadaveric model with atlanto-occipital instability" by Liao S, Schneider NRE, Weilbacher F, et al. (2017) Eur Spine J; doi:10.1007/s00586-017-5416-9. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:913-914. [PMID: 29335901 DOI: 10.1007/s00586-018-5468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/06/2018] [Indexed: 10/18/2022]
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McNarry A, Patel A. The evolution of airway management – new concepts and conflicts with traditional practice. Br J Anaesth 2017; 119:i154-i166. [DOI: 10.1093/bja/aex385] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:288. [PMID: 29178953 PMCID: PMC5702235 DOI: 10.1186/s13054-017-1885-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/06/2017] [Indexed: 01/12/2023]
Abstract
Background There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients. Methods We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes. Results Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I2 = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy. Conclusions On the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1885-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Danxu Ma
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, affiliated with Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, 100010, China
| | - Yun Yue
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Fushan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China.
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Jenkins BJ. The view from the top. Is it worth recording for posterity? Anaesthesia 2017; 73:151-154. [DOI: 10.1111/anae.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
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Sorbello M, Di Giacinto I, Zdravkovic I. Nessie and airway management: Do we need to see to believe? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Aleksandrowicz D, Gaszyński T. Airway management with simultaneous cervical spine immobilisation: A comparison between the Macintosh laryngoscope and the Airtraq ® optical laryngoscope used by experienced paramedics – A manikin study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dabrowski M, Dabrowska A, Sip M. Videolaryngoscopy for trauma patient intubation. Am J Emerg Med 2017; 35:1564-1565. [PMID: 28413124 DOI: 10.1016/j.ajem.2017.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Marek Dabrowski
- Department of Rescue and Disaster Medicine, Poznan University of Medical Sciences, Poland; Polish Society of Simulation Medicine, Poland.
| | - Agata Dabrowska
- Department of Rescue and Disaster Medicine, Poznan University of Medical Sciences, Poland; Polish Society of Simulation Medicine, Poland
| | - Maciej Sip
- Department of Rescue and Disaster Medicine, Poznan University of Medical Sciences, Poland; Polish Society of Simulation Medicine, Poland
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