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De Luis-Cabezón N, Ly-Liu D, Renedo-Corcostegui P, Santaolalla-Montoya F, Zabala-Lopez de Maturana A, Herrero-Herrero JC, Martínez-Hurtado E, De Frutos-Parra R, Bilbao-Gonzalez A, Fernandez-Vaquero MA. A new score for airway assessment using clinical and ultrasound parameters. Front Med (Lausanne) 2024; 11:1334595. [PMID: 38420361 PMCID: PMC10899447 DOI: 10.3389/fmed.2024.1334595] [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: 11/07/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
Background Over the last few years, ultrasonography has been introduced as the fifth pillar to patient's bedside physical examination. Clinical assessments aim to screen and look for airway difficulties to predict difficult intubations, but none have demonstrated a significant predictive capacity. Recent systematic reviews have established a correlation between ultrasound imaging and difficult direct laryngoscopy. The primary objective of this study was to determine whether the utilization of ultrasonography to examine the upper airway could accurately predict difficult direct laryngoscopy. Methods This is a prospective observational study including 102 adult patients that required general anesthesia for elective surgery. Preoperatively, clinical airway assessments were performed. Data such as Mallampati-Samsoon grade (MS), upper lip bite test (ULBT), thyromental (TMD) and sternomental distance (SMD), cervical circumference (CC) and the Arné risk index were collected. Ultrasound evaluation was taken at five different levels in two planes, parasagittal and transverse. Therefore, the following measurements were registered: distance from skin to hyoid bone (DSHB), distance from skin to thyrohyoid membrane (DSTHM), distance from skin to epiglottis (DSE), distance from skin to thyroid cartilage (DSTC) and distance from hyoid bone and thyroid cartilage (DHBTC). Patients were divided into two groups based on the difficulty to perform direct laryngoscopy, according to Cormack-Lehane (C-L) classification. Grades I and II were classified as easy laryngoscopy and grades III or IV as difficult. Logistic regression models and the Receiver Operating Characteristic (ROC) curve was employed to determine the diagnostic precision of ultrasound measurements to distinguish difficult laryngoscopy (DL). Results The following risk score for DL was obtained, DSTHM ≥ 1.60 cm (2 points), DSTC ≥ 0.78 cm (3 points) and gender (2 points for males). The score can range from 0 to 7 points, and showed and AUC (95% CI) of 0.84 (0.74-0.95). A score of 5 points or higher indicates a 34-fold increase in the risk of finding DL (p = 0.0010), sensitivity of 91.67, specificity of 75.56, positive predictive value of 33.33, and negative predictive value of 98.55. Conclusion The use of ultrasonography combined with classic clinical screening tests are useful tools to predict difficult direct laryngoscopy.
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Affiliation(s)
- Nekari De Luis-Cabezón
- Department of Anesthesiology, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Instituto IIS Biobizkaia, Barakaldo, Spain
| | - Diana Ly-Liu
- Department of Anesthesiology, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
| | - Pablo Renedo-Corcostegui
- Department of Anesthesiology, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
| | | | | | | | | | - Raúl De Frutos-Parra
- Department of Anesthesiology, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
| | - Amaia Bilbao-Gonzalez
- Unidad de Investigación e Innovación, RICAPPS, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
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Non-invasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2022; 22:306. [PMID: 36180822 PMCID: PMC9524013 DOI: 10.1186/s12871-022-01842-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background and objectives Preoxygenation is crucial for providing sufficient oxygen reservoir to a patient before intubation and enables the extension of the period between breathing termination and critical desaturation (safe apnoea time). Conventionally, face mask ventilation is used for preoxygenation. Non-invasive ventilation is a new preoxygenation method. The study objective was to compare the outcomes of non-invasive ventilation and face mask ventilation for preoxygenation. Method PubMed, Embase, Cochrane Library, and the ClinicalTrials.gov registry were searched for eligible studies published from database inception to September 2021. Individual effect sizes were standardized, and a meta-analysis was conducted using random effects models to calculate the pooled effect size. Inclusion criteria were randomised controlled trials of comparing the outcomes of non-invasive ventilation or face mask ventilation for preoxygenation in patients scheduled for surgeries. The primary outcome was safe apnea time, and the secondary outcomes were post-operative complications, number of patients who achieved the expired O2 fraction (FeO2) after 3 min of preoxygenation, minimal SpO2 during tracheal intubation, partial pressure of oxygen in the arterial blood (PaO2) and partial pressure of carbon dioxide (PaCO2) after preoxygenation, and PaO2 and PaCO2 after tracheal intubation. Results 13 trials were eligible for inclusion in this study. Significant differences were observed in safe apnoea time, number of patients who achieved FeO2 90% after preoxygenation for 3 min, and PaO2 and PaCO2 after preoxygenation and tracheal intubation. Only in the non-obese subgroup, no significant difference was observed in safe apnoea time (mean difference: 125.38, 95% confidence interval: − 12.26 to 263.03). Conclusion Non-invasive ventilation appeared to be more effective than conventional methods for preoxygenation. We recommend non-invasive ventilation based on our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01842-y.
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Lundstrøm LH, Rosenstock CV, Wetterslev J, Nørskov AK. The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients. Anaesthesia 2019; 74:1267-1276. [PMID: 31106851 DOI: 10.1111/anae.14701] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 12/01/2022]
Abstract
Facemask ventilation is an essential part of airway management. Correctly predicting difficulties in facemask ventilation may reduce the risk of morbidity and mortality among patients at risk. We aimed to develop and evaluate a weighted risk score for predicting difficult facemask ventilation during anaesthesia. We analysed a cohort of 46,804 adult patients who were assessed pre-operatively airway for 13 predictors of difficult airway management and subsequently underwent facemask ventilation during general anaesthesia. We developed the Difficult Facemask (DIFFMASK) score in two consecutive steps: first, a multivariate regression analysis was performed; and second, the regression coefficients of the adjusted regression model were converted into a clinically applicable weighted point score. The predictive accuracy of the DIFFMASK score was evaluated by assessment of receiver operating characteristic curves. The prevalence of difficult facemask ventilation was 1.06% (95%CI 0.97-1.16). Following conversion of regression coefficients into 0, 1, 2 or 3 points, the cumulated DIFFMASK score ranged from 0 to 18 points and the area under the receiver operating characteristic curve was 0.82. The Youden index indicated a sum score ≥ 5 as an optimal cut-off value for prediction of difficult facemask ventilation giving a sensitivity of 85% and specificity of 59%. The DIFFMASK score indicated that a score of 6-10 points represents a population of patients who may require heightened attention when facemask ventilation is planned, compared with those patients who are obviously at a high- or low risk of difficulties. The DIFFMASK score may be useful in a clinical context but external, prospective validation is needed.
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Affiliation(s)
- L H Lundstrøm
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerød, Denmark
| | - C V Rosenstock
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerød, Denmark
| | - J Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - A K Nørskov
- Department of Anaesthesiology and Intensive care, Nordsjaellands Hospital, Hillerød, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Anaesthetic Considerations in a Patient with Pycnodysostosis undergoing Caesarean Delivery. Case Rep Anesthesiol 2018; 2018:5675637. [PMID: 30538866 PMCID: PMC6260546 DOI: 10.1155/2018/5675637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/01/2018] [Indexed: 11/20/2022] Open
Abstract
Pycnodysostosis is a rare congenital disorder with several implications, which might complicate anesthesia. Patients are more prone to fractures and have an anticipated difficult airway. We report a case of a 34-year-old woman with pycnodysostosis who underwent elective caesarean delivery under epidural blockade.
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Cook TM. Strategies for the prevention of airway complications - a narrative review. Anaesthesia 2017; 73:93-111. [DOI: 10.1111/anae.14123] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 12/17/2022]
Affiliation(s)
- T. M. Cook
- Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
- School of Clinical Sciences; Bristol University; Bristol UK
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Nørskov AK, Wetterslev J, Rosenstock CV, Afshari A, Astrup G, Jakobsen JC, Thomsen JL, Lundstrøm LH. Prediction of difficult mask ventilation using a systematic assessment of risk factors vs. existing practice - a cluster randomised clinical trial in 94,006 patients. Anaesthesia 2016; 72:296-308. [DOI: 10.1111/anae.13701] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2016] [Indexed: 12/28/2022]
Affiliation(s)
- A. K. Nørskov
- Department of Anaesthesiology; Nordsjaellands Hospital; Hillerød Denmark
- Copenhagen Trial Unit; Rigshospitalet; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Rigshospitalet; Copenhagen Denmark
| | - C. V. Rosenstock
- Department of Anaesthesiology; Nordsjaellands Hospital; Hillerød Denmark
| | - A. Afshari
- Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
| | - G. Astrup
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
| | - J. C. Jakobsen
- Copenhagen Trial Unit; Rigshospitalet; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - J. L. Thomsen
- Department of Anaesthesiology; Herlev Hospital; Herlev Denmark
| | - L. H. Lundstrøm
- Department of Anaesthesiology; Nordsjaellands Hospital; Hillerød Denmark
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Wiesner G, Tassani-Prell P, Mayr NP. Comment to: De Waha S, Seeburger J et al. (2016): Deep sedation versus general anaesthesia in percutaneous edge-to edge mitral valve reconstruction using the MitraClip system. Clin Res Cardiol 105(6):535-43. Clin Res Cardiol 2016; 106:160-161. [PMID: 27815637 DOI: 10.1007/s00392-016-1046-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Lazarettstr. 36, 80636, Munich, Germany.
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - N Patrick Mayr
- Institute of Anaesthesiology, German Heart Centre Munich, Lazarettstr. 36, 80636, Munich, Germany
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Abstract
Aim of database The aim of the Danish Anaesthesia Database (DAD) is the nationwide collection of data on all patients undergoing anesthesia. Collected data are used for quality assurance, quality development, and serve as a basis for research projects. Study population The DAD was founded in 2004 as a part of Danish Clinical Registries (Regionernes Kliniske Kvalitetsudviklings Program [RKKP]). Patients undergoing general anesthesia, regional anesthesia with or without combined general anesthesia as well as patients under sedation are registered. Data are retrieved from public and private anesthesia clinics, single-centers as well as multihospital corporations across Denmark. In 2014 a total of 278,679 unique entries representing a national coverage of ~70% were recorded, data completeness is steadily increasing. Main variable Records are aggregated for determining 13 defined quality indicators and eleven defined complications all covering the anesthetic process from the preoperative assessment through anesthesia and surgery until the end of the postoperative recovery period. Descriptive data Registered variables include patients’ individual social security number (assigned to all Danes) and both direct patient-related lifestyle factors enabling a quantification of patients’ comorbidity as well as variables that are strictly related to the type, duration, and safety of the anesthesia. Data and specific data combinations can be extracted within each department in order to monitor patient treatment. In addition, an annual DAD report is a benchmark for departments nationwide. Conclusion The DAD is covering the anesthetic process for the majority of patients undergoing anesthesia in Denmark. Data in the DAD are increasingly used for both quality and research projects.
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Affiliation(s)
- Kristian Antonsen
- Board of Directors, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Capital Region of Denmark, Denmark
| | - Charlotte Vallentin Rosenstock
- Department of Anesthesiology, Copenhagen University Hospital, Nordsjællands Hospital-Hillerød, Capital Region of Denmark, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anesthesiology, Copenhagen University Hospital, Nordsjællands Hospital-Hillerød, Capital Region of Denmark, Denmark
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Hansen MS, Petersen EE, Dahl JB, Wetterslev J. Post-operative serious adverse events in a mixed surgical population - a retrospective register study. Acta Anaesthesiol Scand 2016; 60:1209-21. [PMID: 27417678 DOI: 10.1111/aas.12762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation. METHODS Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013. RESULTS A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively. CONCLUSION We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.
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Affiliation(s)
- M. S. Hansen
- Department of Anaesthesiology; Dep. 4231; Centre of Head and Orthopaedics; Rigshospitalet; Copenhagen Denmark
| | - E. E. Petersen
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
| | - J. B. Dahl
- Department of Anaesthesiology; Dep. Z; Bispebjerg Hospital; København Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Dep. 7812; Copenhagen Denmark
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Nørskov A, Wetterslev J, Rosenstock C, Afshari A, Astrup G, Jakobsen J, Thomsen J, Bøttger M, Ellekvist M, Schousboe B, Horn A, Jørgensen B, Lorentzen K, Madsen M, Knudsen J, Thisted B, Estrup S, Mieritz H, Klesse T, Martinussen H, Vedel A, Maaløe R, Bøsling K, Kirkegaard P, Ibáñez C, Aleksandraviciute G, Hansen L, Mantoni T, Lundstrøm L. Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation - a cluster randomized trial with 64,273 participants. Br J Anaesth 2016; 116:680-9. [DOI: 10.1093/bja/aew057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2016] [Indexed: 11/14/2022] Open
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Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia 2014; 70:272-81. [DOI: 10.1111/anae.12955] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 11/28/2022]
Affiliation(s)
- A. K. Nørskov
- Department of Anaesthesiology; Copenhagen University Hospital; Nordsjaellands Hospital; Hillerød Denmark
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - C. V. Rosenstock
- Department of Anaesthesiology; Copenhagen University Hospital; Nordsjaellands Hospital; Hillerød Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - G. Astrup
- Department of Anaesthesiology; Aarhus University Hospital; Aarhus C Denmark
| | - A. Afshari
- Department of Anaesthesiology; Juliane Marie Centre; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - L. H. Lundstrøm
- Department of Anaesthesiology; Copenhagen University Hospital; Nordsjaellands Hospital; Hillerød Denmark
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Nørskov AK, Lundstrøm LH, Rosenstock CV, Wetterslev J. Detailed statistical analysis plan for the difficult airway management (DIFFICAIR) trial. Trials 2014; 15:173. [PMID: 24885548 PMCID: PMC4030275 DOI: 10.1186/1745-6215-15-173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 05/08/2014] [Indexed: 02/08/2023] Open
Abstract
Background Preoperative airway assessment in Denmark is based on a non-specific clinical assessment left to the discretion of the responsible anesthesiologist. The DIFFICAIR trial compares the effect of using a systematic and consistent airway assessment versus a non-specific clinical assessment on the frequency of unanticipated difficult airway management. To prevent outcome bias and selective reporting, we hereby present a detailed statistical analysis plan as an amendment (update) to the previously published protocol for the DIFFICAIR trial. Method/Design The DIFFICAIR trial is a stratified, parallel group, cluster (cluster = department) randomized multicenter trial involving 28 departments of anesthesia in Denmark randomized to airway assessment either by the Simplified Airway Risk Index (SARI) or by a usual non-specific assessment. Data from patients’ preoperative airway assessment are registered in the Danish Anesthesia Database. An objective score for intubation grading the severity, that is the severity of the intubations, as well as the frequency of unanticipated difficult intubation, is measured for each group. Primary outcome measures are the fraction of unanticipated difficult and easy intubations. The database is programmed so that the registration of the SARI is mandatory for the intervention group but invisible to controls. Data recruitment was commenced in October 2012 and ended in ultimo December 2013. Conclusion We intend to increase the transparency of the data analyses regarding the DIFFICAIR trial by an a priori publication of a statistical analysis plan. Trial registration ClinicalTrials.gov: NCT01718561.
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Affiliation(s)
- Anders Kehlet Nørskov
- Department of Anaesthesiology, Nordsjællands Hospital, Copenhagen University Hospital, Hillerød, Capital region of Denmark 3400, Denmark.
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