Difficult Airway Society Guidelines for the management of tracheal extubation

Lateral versus supine position for tracheal extubation among infants after intraabdominal surgery: A randomised controlled trial

In this prospective randomised controlled trial, we compared the impact of the lateral versus supine position for tracheal extubation among infants aged two months to two years after intraabdominal surgery on the incidence of respiratory adverse events that may occur after extubation. The anaesthesia protocol was standardised. Among the 120 infants included (60 in each group), the demographic and perioperative data were comparable between both groups. The incidence of perioperative respiratory adverse events after tracheal extubation was 21.6% and 5% in the supine and lateral position groups, respectively, with p = 0.007 and odds ratio = 3.87; 95% confidence interval: 1.18-12.6. Lateral position also reduced the incidence of airway obstruction with p = 0.004 and odds ratio = 11.8; 95% confidence interval: 1.46-95.3 and oxygen desaturation below 92% with p = 0.008 and odds ratio = 11.8; 95% confidence interval: 1.46-95. The lateral position seems to be practical and beneficial for tracheal extubation among infants.

The effects of laryngeal mask versus endotracheal tube on atelectasis after general anesthesia induction assessed by lung ultrasound: A randomized controlled trial

STUDY OBJECTIVE

This study aims to evaluate the impact of Supreme™ laryngeal masks versus endotracheal tubes on atelectasis during general anesthesia using lung ultrasound (LUS), and provide evidence for respiratory management.

DESIGN

A single-center, double-blind, randomized controlled trial was conducted.

SETTING

The study was conducted in both the operating room and the post-anesthesia care unit, with follow-up assessments performed in the ward.

PATIENTS

Enrollment included 180 cases undergoing non-laparoscopic surgeries in gynecology, urology, and orthopedic limb surgeries.

INTERVENTIONS

Patients were randomly assigned 1:1 to the endotracheal intubation or laryngeal mask group.

MEASUREMENTS

LUS scores were recorded across 12 lung regions at baseline, 15 min after airway establishment, at the end of surgery, and 30 min following airway removal. Outcome measures encompassed the oxygenation index, dynamic lung compliance, incidence of postoperative pulmonary complications, throat pain, and other postoperative complications assessed at 24 and 48 h postoperatively. The primary outcome focused on the LUS score in all 12 lung regions at 15 min after airway establishment.

MAIN RESULTS

Intention-to-treat analysis of 177 subjects revealed endotracheal intubation led to significantly higher LUS scores at 15 min {P < 0.001, mean difference 4.15 ± 0.60, 95% CI [2.97, 5.33]}, end of surgery (P < 0.001, mean difference 3.37 ± 0.68, 95% CI [2.02, 4.72]), and 30 min post-removal (P < 0.001, mean difference 2.63 ± 0.48, 95% CI [1.68, 3.58]). No major complications occurred in the two groups.

CONCLUSIONS

Compared to endotracheal intubation, laryngeal masks effectively reduce atelectasis formation and progression in gynecological, urological non-laparoscopic, and orthopedic limb surgeries. However, caution is warranted when generalizing these findings to surgeries with a higher risk of laryngeal mask leakage or obese patients. Additionally, the efficacy of laryngeal masks in reducing postoperative atelectasis remains uncertain when comprehensive monitoring of muscle relaxation and reversal therapy is employed.

Hypotension prediction index for prevention of intraoperative hypotension in patients undergoing general anesthesia: a randomized controlled trial

BACKGROUND

Intraoperative hypotension is a common side effect of general anesthesia. Here we examined whether the Hypotension Prediction Index (HPI), a novel warning system, reduces the severity and duration of intraoperative hypotension during general anesthesia.

METHODS

This randomized controlled trial was conducted in a tertiary referral hospital. We enrolled patients undergoing general anesthesia with invasive arterial monitoring. Patients were randomized 1:1 either to receive hemodynamic management with HPI guidance (intervention) or standard of care (control) treatment. Intraoperative hypotension treatment was initiated at HPI > 85 (intervention) or mean arterial pressure (MAP) < 65 mmHg (control). The primary outcome was hypotension severity, defined as a time-weighted average (TWA) MAP < 65 mmHg. Secondary outcomes were TWA MAP < 60 and < 55 mmHg.

RESULTS

Of the 60 patients who completed the study, 30 were in the intervention group and 30 in the control group. The patients' median age was 62 years, and 48 of them were male. The median duration of surgery was 490 min. The median MAP before surgery presented no significant difference between the two groups. The intervention group showed significantly lower median TWA MAP < 65 mmHg than the control group (0.02 [0.003, 0.08] vs. 0.37 [0.20, 0.58], P < 0.001). Findings were similar for TWA MAP < 60 mmHg and < 55 mmHg. The median MAP during surgery was significantly higher in the intervention group than that in the control group (87.54 mmHg vs. 77.92 mmHg, P < 0.001).

CONCLUSIONS

HPI guidance appears to be effective in preventing intraoperative hypotension during general anesthesia. Further investigation is needed to assess the impact of HPI on patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04966364); 202105065RINA; Date of registration: July 19, 2021; The recruitment date of the first patient: July 22, 2021.

Risk factors for postoperative adverse airway events in patients with primary oral cancer undergoing reconstruction without prophylactic tracheostomy

OBJECTIVE

To identify risk factors associated with adverse airway events (AAEs) in primary oral cancer patients undergoing tumor ablation followed by free tissue transfer without prophylactic tracheostomy.

METHODS

We retrospectively collected primary oral cancer patients who underwent tumor ablation surgery following free-tissue transfer without prophylactic tracheostomy during February 2017 to June 2019 in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. 379 patients were included. Data were analysed from 2020 to 2021. Demographics, comorbidities, intraoperative variables and postoperative respiration profile were obtained from the medical record. Main outcome was postoperative AAEs, including requirement of endotracheal intubation after extubation and tracheostomy after prolonged intubation.

RESULTS

Of the 379 patients, postoperative AAEs happened in 29 patients (7.6 %). In reintubation group, patients were older with more diabetes mellitus, hypertension and cerebrovascular disease. These patients had lower preoperative hemoglobin, creatinine, and albumin level with more intraoperative blood transfusion. In postoperative respiration profile, rapid shallow breathing index (RSBI) and PaO2/FiO2 (PF) ratio were poorer. On multivariate analysis, patient's age, tumor location, and cross-midline segmental mandibulectomy and a lower PF ratio were independent risk factors for postoperative AAEs.

CONCLUSIONS

In head and neck cancer patients that underwent tumor ablation followed by free tissue transfer without prophylactic tracheostomy, patient's age, tumor location, cross-midline segmental mandibulectomy and P/F ratio are associated with postoperative AAEs.

Placement of bronchial occluder outside the tracheal tube in a patient combined with airway compression undergoing mediastinal tumors resection: a case report

BACKGROUND

Mediastinal tumors pose a challenging respiratory and circulatory management during anesthesia procedures, there is a risk of circulatory collapse or complete airway obstruction, which in severe cases can lead to cardiac arrest. We reported a case of anesthetic management using a bronchial blocker placed outside the tracheal tube. In this case report, the patient's trachea was so severely compressed that the airway was extremely narrow, only 4 mm at its narrowest point. By reporting the anesthetic management of this patient, we intend to provide an unusual approach for airway management.

CASE PRESENTATION

A 52-year-old male patient was admitted to the hospital due to cough and expectoration for one year. Additionally, the patient experienced chest tightness and asthma after physical activity. The enhanced computed tomography revealed there existed an irregular soft tissue mass in the right upper mediastinum, which significantly compressed the trachea and esophagus. The results of the mediastinal puncture pathology showed the presence of mesenchymal tumors. According to the results above, the patient was diagnosed with a mediastinal tumor and scheduled to undergo tumor resection under general anesthesia. We used a bronchial occluder outside the tracheal tube for general anesthesia. After surgery, the patient received thorough treatment and was subsequently discharged from the hospital.

CONCLUSION

In patients with severe airway compression from a mediastinal tumor airway compression, positioning a bronchial occluder externally to the tracheal tube is an effective method of airway management. However, we still need more clinical practice to help the process become more standardized.

Difficult intubation in ENT patient: Simultaneous videolaryngoscopy with flexible bronchoscopy. A combined approach. Case report

INTRODUCTION

Difficult intubation is the situation when a skilled anesthetist has difficulties to manage airway using face mask, laryngoscopy, supraglottic device, tracheal intubation, surgery. Videolaryngoscope and flexible fibroscope (FFS) represent valid alternatives for difficult airway management, with some limitations. However, literature lacks of studies about the efficacy of the combined use of videolaryngoscope and FFS.

CASE REPORT

We report a case of a man, with glottic lesion, who needs surgery under general anesthesia. Anesthesiologic pre-operative evaluation revealed that he's a difficult intubation case. So, in a supine position, intubation was performed on first attempt by videolaryngoscope combined with FFS. On post-op, no signs of injuries due to intubation have been found.

DISCUSSION

In 2022, the American Society of Anesthesiologists defined the guidelines to manage difficult intubation: based on patient' anatomical and clinical feature and anesthetist' skills, several intubation procedures could be used. Each procedure has pros and cons.

CONCLUSION

It's the first case of anticipated difficult intubation in adult man that was intubated under general anesthesia by using videolaryngoscope combined with FFS. We demonstrated that this procedure is safe and useful in case of difficult airway and recommended in case of laryngeal lesions that hinder the visualization of glottic plane.

Management of the Difficult Airway: An Appraisal of Clinical Practice Guidelines

OBJECTIVE

Management of the difficult airway can be a challenging process, which necessitates actionable recommendations from well-established guidelines. Herein, clinical practice guideline (CPG) quality is evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

STUDY DESIGN

A systematic literature search was performed using Scopus, EMBASE, and MEDLINE via PubMed.

SETTING

Literature database.

METHODS

Data were abstracted from relevant guidelines and appraised by 4 expert reviewers in the 6 domains of quality defined by AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to quantify interrater reliability.

RESULTS

Twelve guidelines met the inclusion criteria. With a mean quality score of 83.1%, the highest quality guideline was authored by the American Society of Anesthesiologists (ASA). Low-quality content was observed in CPGs authored by the Japanese Society of Anesthesiologists (JSA) and the Chinese Collaboration Group for Emergency Airway Management (CCGEAM). Overall, deficits were most pronounced in domains describing the involvement of stakeholders, developmental rigor, and editorial independence. These findings were consistent among the panel of independent reviewers, with high ICC inter-rater reliability scores of 58.0% to 70.0% for the referenced domains.

CONCLUSION

By providing a comprehensive appraisal of guidelines, this report may serve as a reference for clinicians seeking to understand and improve upon the developmental quality of difficult airway management resources. According to AGREE II criteria for the quality of the guideline creation process, the 2022 ASA guideline outperforms its predecessors.

Anesthetic management with remimazolam for a patient with hereditary angioedema:a case report

BACKGROUND

Hereditary angioedema (HAE), a genetic disorder caused by C1-inhibitor deficiency or dysfunction, may cause mucosal edema in the upper airway during tracheal intubation and extubation.

CASE REPORT

A 57-year-old man with HAE and a history of laryngeal edema, scheduled to undergo cervical laminoplasty under general anesthesia. General anesthesia was induced by continuous injection of remimazolam and remifentanil, during which manual mask ventilation and intubation were performed without difficulty. The patient was extubated under deep anesthesia. After emergence from general anesthesia, he had no significant upper airway edema and was treated with a C1-inhibitor seven hours post-surgery because of slight tongue swelling. No additional airway edema was observed, and the patient was discharged from the intensive care unit the following day.

CONCLUSIONS

Deep anesthesia tracheal extubation with remimazolam may be effective in preventing upper airway edema during anesthetic management in patients with HAE. J. Med. Invest. 71 : 184-186, February, 2024.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults

Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available.

Awake tracheal extubation, can be anticipated? case reports

Perioperative airway management is a crucial task for anesthesiologists. Several perioperatively techniques make it difficult to predict the appropriate time for tracheal extubation. The aim of this article is to report the successful anticipation of an appropriate time for awake tracheal extubation. Three cases were observed related to smooth recovery without airway complication following intentionally removing airway devices after specific time. These reports demonstrate the relationship between awake status and return of spontaneous breathing which may demonstrate a good recovery of different sites of central nervous system from anesthesia effects. Theoretically, the appropriate time for awake tracheal extubation can be anticipated.

A novel nomogram for predicting the decision to delayed extubation after thoracoscopic lung cancer surgery

OBJECTIVE

Delayed extubation was commonly associated with increased adverse outcomes. This study aimed to explore the incidence and predictors and to construct a nomogram for delayed extubation after thoracoscopic lung cancer surgery.

METHODS

We reviewed medical records of 8716 consecutive patients undergoing this surgical treatment from January 2016 to December 2017. Using potential predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal validation. For external validation, we additionally pooled 3676 consecutive patients who underwent this procedure between January 2018 and June 2018. Extubation performed outside the operating room was defined as delayed extubation.

RESULTS

The rate of delayed extubation was 1.60%. Multivariate analysis identified age, BMI, FEV₁/FVC, lymph nodes calcification, thoracic paravertebral blockade (TPVB) usage, intraoperative transfusion, operative time and operation later than 6 p.m. as independent predictors for delayed extubation. Using these eight candidates to develop a nomogram, with a concordance statistic (C-statistic) value of 0.798 and good calibration. After internal validation, similarly good calibration and discrimination (C-statistic, 0.789; 95%CI, 0.748 to 0.830) were observed. The decision curve analysis (DCA) indicated the positive net benefit with the threshold risk range of 0 to 30%. Goodness-of-fit test and discrimination in the external validation were 0.113 and 0.785, respectively.

CONCLUSION

The proposed nomogram can reliably identify patients at high risk for the decision to delayed extubation after thoracoscopic lung cancer surgery. Optimizing four modifiable factors including BMI, FEV₁/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.Key Messages:This study identified eight independent predictors for delayed extubation, among which lymph node calcification and anaesthesia type were not commonly reported.Using these eight candidates to develop a nomogram, we could reliably identify high-risk patients for the decision to delayed extubation.Optimizing four modifiable factors, including BMI, FEV₁/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.

Anesthetic challenges of pregnant obesity women

Obesity causes significant morbidity and increases the mortality risk for both mother and fetus. With an increasing projected prevalence, it is vital that the obstetric anesthetist is equipped with the knowledge and tools to manage these women. A multi-disciplinary team approach and early planning is required. Neuraxial analgesia for labor helps to negate the need for general anesthesia, which is associated with increased risk in this subset of women. Catheter techniques for neuraxial anesthesia allow for titration, manipulation, and prolongation of the anesthetic block to reduce the risk of conversion to general anesthesia.

A comprehensive review of difficult airway management strategies for patient safety

Difficult airway management is critical to ensuring patient safety. It involves addressing the challenges and failures that can occur, even with skilled healthcare providers, during face mask ventilation, intubation, supraglottic airway placement, invasive airway procedures, or extubation. Although the incidence of the most critical situation in airway management, "cannot intubate, cannot oxygenate," is low at 0.0019-0.04%, its occurrence can have severe consequences, including dental injury, airway injury, hypoxic brain damage, and even death. This study aimed to offer healthcare providers a comprehensive and evidence-based approach for difficult airway management by reviewing recent guidelines and incorporating the latest evidence-based practices to improve their preparedness and competence in difficult airway management, and thus ultimately contribute to improved patient safety.

Anesthesia Risk Alert Program: A Proactive Safety Initiative

BACKGROUND

Analyzing adverse events data collected over a three-year period on all anesthetic cases, North American Partners in Anesthesia (NAPA), a nationwide anesthesia practice, found a correlation between certain high-risk clinical factors and a number of critical events. Seeking to reduce the incidence of critical adverse events associated with these high-risk factors, the quality team of the NAPA Anesthesia Patient Safety Institute (NAPSI) developed the Anesthesia Risk Alert (ARA) program, which guides clinicians in proactively applying targeted risk mitigation interventions in five specific clinical scenarios. NAPSI is NAPA's Patient Safety Organization (PSO).

METHODS

ARA promotes a proactive (Safety II) approach to patient safety. The protocol incorporates innovative collaboration techniques to improve clinical decision-making, along with recommendations by professional medical societies. ARA risk mitigation strategies also adapt decision tools from other industries, such as red team/blue team methodology. Following implementation training to approximately 6,000 NAPA clinicians, ongoing compliance is tracked for the program's two components: screening patients for the five high-risk clinical scenarios and performing the associated mitigation strategy when one or more risk factor is identified.

RESULTS

Since launching the ARA program in 2019, clinician compliance consistently exceeds 95%. Simultaneously, available data indicate that the incidence of selected adverse events has decreased.

CONCLUSION

ARA, developed as a process improvement initiative to reduce patient harm in several vulnerable perioperative patient populations, demonstrates how proactive safety strategies can improve clinical outcomes and create better perioperative cultures. At various sites, NAPA anesthesia clinicians reported that ARA's collaboration strategies were transformative behaviors that extended beyond the operating room. Other health care providers may customize the lessons learned from ARA with a Safety II approach.

A prospective observational study of recall of discomfort on tracheal extubation after general anaesthesia

Background

Tracheal extubation is a critical stage in the management of general anaesthesia during which serious complications may occur. Immediately before extubation, patients often exhibit signs that suggest that they are awake and experiencing discomfort. There is concern that patients may retain such memories of the extubation process. However, previous studies have not examined patient recall of extubation in detail. We therefore investigated the frequency of recall of discomfort during extubation, as well as first orientation to place, and other recollections upon emerging from general anaesthesia.

Methods

In a prospective observational study, 818 patients were interviewed during routine post-anaesthesia rounds on the day after general anaesthesia. The primary outcome was the proportion of patients recalling discomfort during extubation. The secondary outcome was the location of orientation to place upon emerging from general anaesthesia.

Results

Recall of discomfort during extubation was uncommon, at 1.1% (n=9; 95% confidence interval [CI]: 0.5-2.1%). Only 3.1% of patients recalled the extubation process at all (n=25; 95% CI: 2.0-4.5%). The first orientation to place was most commonly in transit to a ward, in 41% of cases (n=337; 95% CI: 38-45%).

Conclusions

Recall of discomfort during extubation appears to be rare, and the great majority of patients may not retain any memory of the extubation process. This information may be used to reassure patients and guide extubation practices for anaesthetists.

Clinical trial registration

UMIN Clinical Trials Registry (UMIN000046136).

Efficacy and safety of Cook staged Extubation Set in patients with difficult airway: a systematic review and meta-analysis

BACKGROUND

Cook Stage extubation is a tool developed by Cook Medical for patients with difficult airways. Multiple clinical studies demonstrated the effectiveness and safety of Cook Stage extubation Set (CSES). Currently, no systematic review evidence has been published in this field. Therefore, this study aimed to review the clinical success rate, safety, and tolerability of CSES in patients with difficult airways.

METHOD

The inclusion criteria were based on the population, intervention, comparator, outcomes, and study designs. An electronic search was conducted, and the following databases were used: PubMed, EMBASE, Cochrane Library, and Web of Science. Search keywords included difficult airway and CSES. The primary outcome was the CSES clinical success rate.The Joanna Briggs Institute Critical Appraisal tools for Case Series were used to assess the risk of bias in the included studies. R studio, version 4.2.2. was used to perform the statistical analysis. The Cochrane Q and I2 statistics were used to test the heterogeneity among all studies. Details of the included case reports were summarized in the systematic review part.

RESULTS

Five studies were eligible for meta-analysis, and 7 case reports were included for systematic review. The pooled overall CSES clinical success rate was 93% (95% CI: 85%, 97%). The CSES intolerable and complication incidence rates were 9% (95% CI: 5%, 18%) and 5% (95% CI: 2%, 12%), respectively. CSES clinical success rate was influenced by the study center and study design. The success rate of CSES was higher in multicenter and prospective design studies. Seven case reports have documented the successful operation of CSES intubation in obese, tall, oncologist, and pediatric patients.

DISCUSSION

This meta-analysis suggested that CSES have achieved a high clinical success rate in adult and pediatric patients with different physical conditions and types of surgery. The results of all original studies and meta-analysis confirmed a remarkably high tolerance rate and low overall complication rate. However, regardless of the tools chosen, a personalized, safe intubation strategy and a highly qualified anesthesiologist should be considered as the fundamental guarantee of a high clinical success rate. Future studies should also focus on the success rate of reintubation using CSES in patients with airway difficulties.

A robust approach for endotracheal tube localization in chest radiographs

Precise detection and localization of the Endotracheal tube (ETT) is essential for patients receiving chest radiographs. A robust deep learning model based on U-Net++ architecture is presented for accurate segmentation and localization of the ETT. Different types of loss functions related to distribution and region-based loss functions are evaluated in this paper. Then, various integrations of distribution and region-based loss functions (compound loss function) have been applied to obtain the best intersection over union (IOU) for ETT segmentation. The main purpose of the presented study is to maximize IOU for ETT segmentation, and also minimize the error range that needs to be considered during calculation of distance between the real and predicted ETT by obtaining the best integration of the distribution and region loss functions (compound loss function) for training the U-Net++ model. We analyzed the performance of our model using chest radiograph from the Dalin Tzu Chi Hospital in Taiwan. The results of applying the integration of distribution-based and region-based loss functions on the Dalin Tzu Chi Hospital dataset show enhanced segmentation performance compared to other single loss functions. Moreover, according to the obtained results, the combination of Matthews Correlation Coefficient (MCC) and Tversky loss functions, which is a hybrid loss function, has shown the best performance on ETT segmentation based on its ground truth with an IOU value of 0.8683.

Management of unanticipated difficult airway in a patient with well-visualized vocal cords using video laryngoscopy - A case report

BACKGROUND

Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube.

CASE

We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS).

CONCLUSIONS

Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.

Patient and Operative Factors Predict Risk of Discretionary Prolonged Postoperative Mechanical Ventilation in a Broad Surgical Cohort

BACKGROUND

Patients undergoing surgery with general anesthesia and endotracheal intubation are ideally extubated upon case completion, as prolonged postoperative mechanical ventilation (PPMV) has been associated with poor outcomes. However, some patients require PPMV for surgical reasons, such as airway compromise, while others remain intubated at the discretion of the anesthesia provider. Incidence and risk factors for discretionary PPMV (DPPMV) have been described in individual surgical subspecialties and intensive care unit (ICU) populations, but are relatively understudied in a broad surgical cohort. The present study seeks to fill this gap and identify the perioperative risk factors that predict DPPMV.

METHODS

After obtaining institutional review board (IRB) exemption, existing electronic health record databases at our large referral center were retrospectively queried for adult surgeries performed between January 2018 and December 2020 with general anesthesia, endotracheal intubation, and by surgical services that do not routinely leave patients intubated for surgical reasons. Patients who arrived to the ICU intubated after surgery were identified as experiencing DPPMV. Selection of candidate risk factors was performed with LASSO-regularized logistic regression, and surviving variables were used to generate a multivariable logistic regression model of DPPMV risk.

RESULTS

A total of 32,915 cases met inclusion criteria, of which 415 (1.26%) experienced DPPMV. Compared to extubated patients, those with DPPMV were more likely to have undergone emergency surgery (42.9% versus 3.4%; P < .001), surgery during an existing ICU stay (30.8% versus 2.8%; P < 0.001), and have 20 of the 31 elixhauser comorbidities ( P < .05 for each comparison), among other differences. A risk model with 12 variables, including American Society of Anesthesiologists (ASA) physical classification status, emergency surgery designation, four Elixhauser comorbidities, surgery during an existing ICU stay, surgery duration, estimated number of intraoperative handoffs, and vasopressor, sodium bicarbonate, and albuterol administration, yielded an area under the receiver operating characteristic curve of 0.97 (95% confidence interval, 0.96-0.97) for prediction of DPPMV.

CONCLUSIONS

DPPMV was uncommon in this broad surgical cohort but could be accurately predicted using readily available patient-specific and operative factors. These results may be useful for preoperative risk stratification, postoperative resource allocation, and clinical trial planning.

Clinical significance of postoperative subcutaneous emphysema after video-assisted thoracoscopic surgery for esophageal cancer

BACKGROUND

Postoperative subcutaneous emphysema (SE) is a possible complication of thoracoscopic or laparoscopic surgery. This study investigated the risk factors and clinical significance of SE after video-assisted thoracoscopic surgery for esophageal cancer (VATS-e).

METHODS

This study included 135 patients who underwent VATS-e with artificial CO₂ pneumothorax. Based on the X-ray images on the first postoperative day, patients were divided into two groups: N/L group (no SE or SE localized at the thoracic area, n = 65) and SE group (SE extended to the cervical area, n = 70). We compared clinicopathological features, surgical findings, and short-term outcomes between the two groups.

RESULTS

In SE group, there were more patients who received neoadjuvant chemotherapy compared to N/L group. SE group had significantly lower preoperative body mass index. SE group had more frequently two-lung ventilation than N/L group. Multivariate analysis demonstrated that low BMI, NAC, and two-lung ventilation were independent risk factors for SE extended to the cervical area. Although pulmonary complication was relatively frequent in SE group, there were no significant differences in surgical outcomes between two groups, and all patients had SE disappeared within 21 days without serious complications.

CONCLUSIONS

Despite extension to the cervical area, SE had a modest impact on the short-term result of VATS-e with artificial CO₂ pneumothorax.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Development of a Machine-Learning Model for Prediction of Extubation Failure in Patients with Difficult Airways after General Anesthesia of Head, Neck, and Maxillofacial Surgeries

(1) Background: Extubation failure after general anesthesia is significantly associated with morbidity and mortality. The risk of a difficult airway after the general anesthesia of head, neck, and maxillofacial surgeries is significantly higher than that after general surgery, increasing the incidence of extubation failure. This study aimed to develop a multivariable prediction model based on a supervised machine-learning algorithm to predict extubation failure in adult patients after head, neck, and maxillofacial surgeries. (2) Methods: A single-center retrospective study was conducted in adult patients who underwent head, neck, and maxillofacial general anesthesia between July 2015 and July 2022 at the Shanghai Ninth People's Hospital. The primary outcome was extubation failure after general anesthesia. The dataset was divided into training (70%) and final test sets (30%). A five-fold cross-validation was conducted in the training set to reduce bias caused by the randomly divided dataset. Clinical data related to extubation failure were collected and a stepwise logistic regression was performed to screen out the key features. Six machine-learning methods were introduced for modeling, including random forest (RF), k-nearest neighbor (KNN), logistic regression (LOG), support vector machine (SVM), extreme gradient boosting (XGB), and optical gradient boosting machine (GBM). The best performance model in the first cross-validation dataset was further optimized and the final performance was assessed using the final test set. (3) Results: In total, 89,279 patients over seven years were reviewed. Extubation failure occurred in 77 patients. Next, 186 patients with a successful extubation were screened as the control group according to the surgery type for patients with extubation failure. Based on the stepwise regression, seven variables were screened for subsequent analysis. After training, SVM and LOG models showed better prediction ability. In the k-fold dataset, the area under the curve using SVM and LOG were 0.74 (95% confidence interval, 0.55-0.93) and 0.71 (95% confidence interval, 0.59-0.82), respectively, in the k-fold dataset. (4) Conclusion: Applying our machine-learning model to predict extubation failure after general anesthesia in clinical practice might help to reduce morbidity and mortality of patients with difficult airways after head, neck, and maxillofacial surgeries.

Laryngeal mask airway facilitates a safe and smooth emergence from anesthesia in patients undergoing craniotomy: a prospective randomized controlled study

BACKGROUND

Endotracheal extubation under deep anesthesia (deep extubation) has been proved to present stable hemodynamics and steady intracranial pressure during emergence from anesthesia in patients undergoing craniotomy. This study aims to examine, in comparison with deep extubation, if a laryngeal mask airway (LMA) could provide a safer and smoother emergence from anesthesia in patients undergoing craniotomy.

METHODS

This prospective randomized controlled study was conducted on patients undergoing elective craniotomy for brain tumors. After the complement of the surgical procedure, the patients had anesthesia maintained with end-tidal sevoflurane concentration 2.5% and also fully regained muscle power (Time Zero), they were randomly assigned to ETT Group (n = 29) for deep extubation or to LMA Group (n = 29), where the endotracheal tube was replaced by a laryngeal mask airway. The primary outcomes were respiratory complications, airway interventions and hemodynamic changes through emergence from anesthesia till 30 min following Time Zero. The secondary outcomes were re-operation incidence in 24 h, stay time in the intensive care unit and postoperative hospital days.

RESULTS

At 5 min before Time Zero either oxygen partial pressures (PaO₂) or carbon dioxide partial pressures (PaCO₂) between the two groups were comparable. No significant PaCO₂ change was noted in both groups in 5 min after Time Zero, yet there was a remarkably lower PaO₂ in ETT Group at that time point, 188.9 (± 71.1) in ETT Group vs 264.4 (± 85.4) in LMA Group. In ETT Group, coughs and snores were considerably more frequent, and thus more interventions were needed to maintain adequate respiration. From Time Zero on, blood pressures (systolic, diastolic and mean) and heart rates in ETT Group were generally higher than those in LMA Group, but the differences were insignificant at all time points except heart rate at 10 min after Time Zero. The secondary outcomes between the two groups were similar.

CONCLUSIONS

Compared with deep extubation, a LMA, as a temporary airway replacement, facilitates a safer and smoother emergence from anesthesia for patients undergoing craniotomy, in terms of better oxygen saturation, fewer respiratory complications and fewer airway interventions.

TRIAL REGISTRATION

The study was conducted after receiving approval from Institutional Review Board of Chang Gung Memorial Hospital, Linkou Branch, Taiwan (registration number 202102115A3; January 27, 2022), and the clinicaltrials.gov (NCT05253404) on 23 February 2022.

REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study)

Background: Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. Methods: We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. Results: From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value < 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Conclusions: Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.

Oxford guidelines for adult day-case tonsillectomy

Oxford guidelines were developed after critically reviewing the existing literature and aim to assist anaesthetists, surgeons and allied healthcare staff in providing optimal care for patients undergoing tonsillectomy as a day-case procedure. Appropriate patient selection, provision of robust analgesia, antiemesis, perioperative warming and hydration are key factors to ensure patient comfort and allow same-day discharge. Patients can be discharged home after a minimum observation of 6h as this is the period with the greatest risk of primary haemorrhage. All patients must have a clear and safe understanding of which complications may occur and know how to seek help. A team effort and close collaboration between the anaesthetic, surgical, theatre and ward teams are essential to achieve optimum outcomes and reduce the rate of failed discharges.

Unexpected delayed reversal of rocuronium-induced neuromuscular blockade by sugammadex: A case report and review of literature

BACKGROUND

Rocuronium, a nondepolarizing muscle relaxant, is usually administered during general anesthesia to facilitate endotracheal intubation and keep patients immobile during the surgery. Sugammadex, the selective reversal agent of rocuronium, fully reverses the neuromuscular blockade (NMB) at the end of surgery. Most reports show that sugammadex rapidly achieves a ratio of train-of-four (TOF), a quantitative method of neuromuscular monitoring, of 0.9 which ensures adequate recovery for safe extubation. However, very rare patients with neuromuscular diseases may respond poorly to sugammadex.

CASE SUMMARY

A 69-year-old female presented with abdominal fullness and nausea, and was diagnosed with gastroparesis. She underwent gastric peroral endoscopic myotomy under general anesthesia with rocuronium (0.7 mg/kg). At the end of surgery, sugammadex 3.6 mg/kg was administered when TOF showed 2 counts. Afterward, the TOF ratio recovered to 0.65 in 30 min. She was awake but could not fully open her eyelids. The tidal volume during spontaneous breathing was low. After additional doses of sugammadex (up to 7.3 mg/kg) in the following 3 h, the TOF ratio was 0.9, and the endotracheal tube was smoothly removed. After excluding possible mechanisms underlying the prolonged recovery course, we speculated our patient may have had an undiagnosed neuromuscular disease, hinted by her involuntary movement of the tongue and mouth. Furthermore, her poor renal function and history of delayed recovery from general anesthesia may be related to the long duration of rocuronium.

CONCLUSION

In our case, both prolonged rocuronium-induced NMB and poor response to sugammadex were noted. To optimize the dose of rocuronium, perioperative TOF combined with other neuromuscular monitoring is suggested.

Trismus during tracheal extubation as a complication of general anaesthesia – A case report

Tracheal extubation is a risky phase of anaesthesia. Most complications that occur when an endotracheal tube is removed are of minor nature, but those that require critical action can end in serious complications or even death. Patient – A 55-year-old woman was admitted for elective transabdominal hysterectomy and adnexal procedures. Anaesthesia – Standard monitoring. For induction, we used fentanyl, propofol, and rocuronium. The maintenance phase of anaesthesia was without complications. After extubation, the patient presented with severe trismus and mask ventilation was unsuccessful (cannot ventilate) – It was not until 200 mg of succinylcholine was administered that the masseter muscle spasm subsided.

Extubation is a process that must always be planned. A routine approach and lack of a contingency plan is responsible for a number of complications related to the period of patient awakening and associated with the removal of the endotracheal tube. Trismus, in response to extubation, is a phenomenon not described in the literature in non-high risk patients.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

Recall of extubation after remimazolam anesthesia with flumazenil antagonism during emergence: a retrospective clinical study

PURPOSE

This study was performed to examine and compare the incidence of extubation recall in surgical patients who underwent remimazolam anesthesia with flumazenil antagonism during emergence and in those who underwent propofol anesthesia.

METHODS

One hundred sixty-three patients who underwent surgery using general endotracheal or supraglottic airway anesthesia with propofol (n = 97) or remimazolam (n = 66) were retrospectively analyzed. Remimazolam was antagonized by flumazenil after discontinuation of remimazolam at the end of surgery. The endotracheal tube or supraglottic airway was removed after surgery was complete, and consciousness and adequate spontaneous breathing were confirmed. The incidence of extubation recall was compared between the remimazolam and propofol anesthesia groups using propensity score matching.

RESULTS

Extubation recall was observed in 28 patients (17%). After propensity score matching, the incidence of extubation recall did not significantly differ between the remimazolam and propofol anesthesia groups (15.6% vs. 18.8%; p = 1.000).

CONCLUSION

The incidence of extubation recall after remimazolam anesthesia with flumazenil antagonism during emergence did not significantly differ from that after propofol anesthesia.

Gargle test for successful extubation in critically ill patients underwent head and neck surgeries: A new test

Background

Improvement of predictive tools for recognition of airway edema is crucial for safe extubation and patient safety. This study aimed to evaluate the diagnostic accuracy of the Gargle test (GT) as a new test for assessing airway edema and predicting successful extubation in patients admitted to the intensive care unit (ICU).

Method

In this prospective observational study, patients underwent head and neck surgeries and admitted to ICU included. All the patients were weaned based on the same protocol.Quantitative Cuff Leak Test (CLT) and qualitative CLTwere first applied followed by GT with normal saline 0.9%. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated.

Results

One hundred and eighteen (male 67, female 51) participated in this study. The agreement between GT and CLT was low (Kappa: quantitative CLT 0.07, qualitative CLT 0.21). The GT compared to CLT had higher sensitivity (33.3% vs 16.6%), specificity (96.3% vs qualitative CLT 92.8%, quantitative CLT 79.4%), PPV (33.3% vs qualitative CLT 11.11%, quantitative CLT 4.0%), NPV (96.3% vs qualitative CLT 95.4%, quantitative CLT 94.6%), and accuracy (92.92% vs qualitative CLT 88.98%, quantitative CLT 76.27%. The cut-off value for GT was estimated 16.5% (sensitivity 74.1% and specificity 60%).

Conclusion

The GT is a simple accurate test and can be used as a new test in the ICU for recognition of airway edema and prediction of safe extubation in patients with head and neck surgeries.

•

This study aimed to introduce the new gargle test for predicting successful extubation in patients admitted to the ICU.

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The gargle test is simple, easy to apply and interpret test with sound diagnostic accuracy.

•

The gargle test is a useful test for predicting extubation failure in patients with head and neck surgery.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database

Background

Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events.

Methods

An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated.

Results

One hundred two events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient’s demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence.

Conclusions

Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.

Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.

Body Map of Droplet Distributions During Oropharyngeal Suction to Protect Health Care Workers From Airborne Diseases

PURPOSE

Health care workers (HCWs), and in particular anesthesia providers, often must perform aerosol-generating medical procedures (AGMPs). However, no studies have analyzed droplet distributions on the bodies of HCWs during AGMPs. Therefore, the purpose of this study was to assess and analyze droplet distributions on the bodies of HCWs during suction of oral cavities with and without oral airways and during extubations.

DESIGN

Using a quasi-experiemental design, we assumed the HCWs perform suction and extubation on intubated patients, and we prepared an intubated mannequin mimicking a patient. This study performed the oral suction and extubation on the intubated mannequin (with or without oral airways in place) and analyzed the droplet distributions.

METHODS

We prepared a mannequin intubated with an 8.0 mm endotracheal tube, assuming the situation of general anesthesia. We designed the body mapping gown, and divided it into 10 areas including the head, neck, chest, abdomen, upper arms, forearms, and hands. We classified experiments into group O when suctions were performed on the mannequin with an oral airway, and into group X when the suctions were performed on the mannequin without an oral airway. An experienced board-certified anesthesiologist performed 10 oral suctions on each mannequin, and 10 extubations. We counted the droplets on the anesthesiologist's gown according to the divided areas after each procedure.

FINDINGS

The mean droplet count after suction was 6.20 ± 2.201 in group O and 13.6 ± 4.300 in group X, with a significant difference between the two groups (P < .001). The right and left hands were the most contaminated areas in group O (2.8 ± 1.033 droplets and 2.0 ± 0.943 droplets, respectively). The abdomen, right hand, left forearm, and left hand showed many droplets in group X. (1.3 ± 1.337 droplets, 3.1 ± 1.792 droplets, 3.2 ± 3.910 droplets, and 4.3 ± 2.214 droplets, respectively). The chest, abdomen, and left hand presented significantly more droplets in group X than in group O. The trunk area (chest and abdomen) was exposed to more droplets during extubations than during suctions.

CONCLUSIONS

During suctions, more droplets are splattered from mannequins without oral airways than from those with oral airways. The right and left hands were the most contaminated areas in group O. Moreover, the abdomen, right hand, left forearm, and left hand presented a lot of droplets in group X. In addition, extubations contaminate wider areas (the head, neck, chest and abdomen) of an HCW than suctions.

A Study to Evaluate Changes in Modified Mallampati Class in Patients Undergoing Spine Surgery in Prone Position

Background: Perioperative airway changes due to anesthesia and surgery could change a normal airway at induction to a risky airway at extubation.

Objectives: The objective is to evaluate primarily the degree of airway changes, as quantified by the modified Mallampati (MMP) class, after spine surgery in the prone position. Secondary to assess the time required for these changes to revert back to the preoperative state and their correlation with other demographic and surgical variables.

Methods: The present prospective observational study was conducted in a tertiary care hospital after ethical approval and trial registration. Fifty ASA I and II patients aged 18-65 years of both sex and undergoing spine surgery in prone positions were included. Supine MMP grade was observed preoperatively and at one, two, four, 24, and 48 hours postoperatively.

Statistical analysis: IBM SPSS version 22 (IBM Corp, Armonk, NY) was used.Mean values were compared using paired t-tests and medians by the Wilcoxon test. The Spearman correlation was used to assess a relationship. The time for recovery was analyzed by Kaplan-Meir analysis.

Results: An increase in MMP grade was observed at one hour postoperatively in 46 (92%) patients. Changes reverted back in 45 (98%) patients by 24 hours postoperatively. A weak positive correlation with age, weight, body mass index, duration of surgery, perioperative drop in hemoglobin, and a moderate positive correlation with fluid administered and estimated blood loss was recorded.

Conclusions: An increase in postoperative MMP occurs in the majority of patients undergoing prone position spine surgery which may persist up to 48 hours. So, more vigilance and caution are warranted should reintubation be needed postoperatively.

Safety and Comfort of Wearing Medical Masks in Adult Surgical Patients After General Anesthesia During the COVID-19 Epidemic: A Retrospective, Observational Cohort Study

OBJECTIVE

This study assessed oxygen saturation variation and comfort in adult surgical patients wearing masks in PACU during the COVID-19 epidemic.

DESIGN

Retrospective observation was applied in this study.

METHODS

One hundred thirty-seven patients wearing no medical masks (Group A, aged from 20 to 87) and 136 patients wearing medical masks (Group B, aged from 18 to 91) were selected in this retrospective study after extubation in PACU. After extubation their pulse oxygen saturation, noninvasive mean blood pressure and heart rate were recorded at two different time points (treated with 40% O₂ oxygen therapy for 10 minutes and breathing room air for 10 minutes). The comfort, arterial blood gas data, complications and duration of patients were also reviewed in PACU.

FINDINGS

There were no significant differences in the pulse oxygen saturation between the two groups after inhaling 40% O₂ or air. Compared with Group A, patients in Group B have lower comfort (6 [4-7] vs 7 [6-8]; P < .001), with shortened duration after extubation in PACU (50 [45-55] vs 56 [48-60]; P < .001). No significant differences were found in heart rate, noninvasive mean blood pressure, arterial blood gas data and complications. And no hypoxemia and respiratory adverse events happened in two groups.

CONCLUSIONS

Wearing medical masks does not reduce oxygen saturation in adult surgical patients during recovery from general anesthesia. The discomfort caused by masks is the concern in PACU.

Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team-focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

Extubation of the potentially difficult airway in the intensive care unit

PURPOSE OF REVIEW

Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE).

RECENT FINDINGS

Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE.

SUMMARY

Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.

Safeguarding the patient: a grounded theory study of registered nurse anesthetists' main concerns in the process of extubation in the anesthesia setting

Background

The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist.

Aim

To obtain a deeper understanding of Registered Nurse Anesthetists’ main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia.

Participants

A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II).

Method

A classic grounded theory approach with a qualitative design was used for this study.

Findings

The RNAs’ main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: ‘Having a back-up plan’, ‘Getting into the right frame of mind’, ‘Evaluating the patient’s reactions’, ‘Using one’s own experience’, ‘Dealing with uncertainty’, ‘Pressure from others’, and ‘Being interrupted’. The theory, Safeguarding the patient in the process of extubation, emerged.

Conclusion

To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

Lymph Node Dissection Is a Risk Factor for Short-Term Cough after Pulmonary Resection

Cough is a common complication after pulmonary resection. However, the factors associated with cough that develop after pulmonary resection are still controversial. In this study, we used the Simplified Cough Score (SCS) and the Leicester Cough Questionnaire (LCQ) score to investigate potential risk factors for postoperative cough. Between January 2017 and June 2021, we collected the clinical data of 517 patients, the SCS at three days after surgery and the LCQ at two weeks and six weeks after surgery. Then, univariate and multivariate analyses were used to identify the independent risk factors for postoperative cough. The clinical baseline data of the cough group and the non-cough group were similar. However, the cough group had longer operation time and more blood loss. The patients who underwent lobectomy were more likely to develop postoperative cough than the patients who underwent segmentectomy and wedge resection, while the patients who underwent systematic lymph node dissection were more likely to develop postoperative cough than the patients who underwent lymph node sampling and those who did not undergo lymph node resection. When the same lymph node management method was applied, there was no difference in the LCQ scores between the patients who underwent wedge resection, lobectomy and segmentectomy. The lymph node resection method was an independent risk factor for postoperative cough (p < 0.001). Conclusions: Lymph node resection is an independent risk factor for short-term cough after pulmonary resection with video-assisted thoracoscopic surgery, and damage to the vagus nerve and its branches (particularly the pulmonary branches) is a possible cause of short-term cough. The mechanism of postoperative cough remains to be further studied.

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.