Is it safe to use telephone for anaesthesia consultation in high-risk patients before non-invasive surgery? A pilot study in ophthalmology.

BACKGROUND: Although telemedicine with video support for preoperative evaluation has been found effective, there is limited research on anaesthesia consultation by phone without video support, particularly among high-risk patients. To evaluate the effectiveness, safety and potential benefits of performing pre-anaesthesia evaluation by phone before eye surgery in patients having non-invasive surgery, we performed an observational study in a French teaching hospital. METHOD: All elective patients having elective ophthalmic surgery were included to have a consultation by phone instead of an in-person consultation, regardless of the type of anaesthesia or ASA score. The incidence of day-of-surgery cancellations, patient satisfaction and time/distance saved through phone consultations were assessed. RESULTS: From February to October 2022, data of 3480 patients were analyzed, including 370 (11%) high-risk patients (ASA 3-4). Anaesthesia-related day-of-surgery cancellation rate was 0.5% (n = 20) due to non-compliance with pre-operative instructions. No cancellation was due to inadequate pre-operative evaluation. No difference in cancellation rate was observed between low-risk patients and high-risk patients. Telephone consultations saved patients a mean of 126 min and 86 km. A younger age, an active status and living far from the hospital were associated with phone consultation preference. CONCLUSION: Phone anaesthesia consultation seems to be effective and safe before ophthalmic surgery, regardless of patient's perioperative risk. In addition, phone consultation provides significant time and distance savings. Our results must be confirmed through a multicentric randomised study comparing phone and traditional consultation in ophthalmology as well as in other non-invasive surgical procedures in a high-risk patients population.

How anesthesiology can deal with innovation and new technologies?

Innovation and new technologies have always impacted significantly the anesthesiology practice all along the perioperative course, as it is recognized as one of the most transformative medical specialties specifically regarding patient's safety. Beside a number of major changes in procedures, equipment, training, and organization that aggregated to establish a strong safety culture with effective practices, anesthesiology is also a stakeholder in disruptive innovation. The present review is not exhaustive and aims to provide an overview on how innovation could change and improve anesthesiology practices through some examples as telemedicine (TM), machine learning and artificial intelligence (AI). For example, postoperative complications can be accurately predicted by AI from automated real-time electronic health record data, matching physicians' predictive accuracy. Clinical workflow could be facilitated and accelerated with mobile devices and applications, assuming that these tools should remain at the service of patients and care providers. Care providers and patients connections have improved, thanks to these digital and innovative transformations, without replacing existing relationships between them. It also should give time back to physicians and nurses to better spend it in the perioperative care, and to provide "personalized" medicine keeping a high level of standard of care.

Construction of reference criteria to admit patients to intermediate care units in France: a Delphi survey of intensivists, anaesthesiologists and emergency medicine practitioners (first part of the UNISURC project).

OBJECTIVES: No consensus criteria describe the medical eligibility of the patients to intermediate care units (IMCUs). In this first part of the UNISURC project, we aimed to develop criteria based on a consensus of physicians from the main specialties involved in IMCU admission decisions. DESIGN: We selected criteria from IMCU literature, scoring systems and intensive care unit nursing workload. We submitted these criteria to a panel of experts in a Delphi survey. We used a two-round Delphi survey procedure to assess the validity and feasibility of each criterion. SETTING: Medical practitioners in either public or private French institutions and proposed by the national scientific societies of anaesthesiology, emergency medicine and intensive care. The Delphi rounds took place in 2015-2016. OUTCOME MEASURES: Validity and feasibility of the proposed criteria; uniformity of the judgement across the primary specialty and the hospital category of the responders. RESULTS: The criteria submitted to vote were classified as one of: chronic factor (CF); acute factor (AF); specific pathway (SP); nursing activity (NA) and hospital environment (HE). Of 189 experts invited, 81 (41%) responded to the first round and 62 of them (76%) responded to the second round. A definite selection of 63 items was made, distributed across 6 CF, 18 AF, 31 SP, 3 NA and 5 HE. Validity and feasibility were influenced by the specialty or the public/private status of the institution of the responders for a few items. CONCLUSION: We created a set of 63 consensus criteria with acceptable validity and feasibility to assess the medical eligibility of the patients to IMCUs. The second part of the UNISURC project will assess the distribution of each criterion in a prospective multicentre national cohort. TRIAL REGISTRATION NUMBER: NCT02590172.

Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study.

INTRODUCTION: For thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. PATIENTS AND METHODS: In this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg-1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 µV. If not, sugammadex (2 mg.kg-1) was administered. The dissection began when the signal was positive. RESULTS: From January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/- 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DISCUSSION: This prospective study shows that the use of 0.5 mg.kg-1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.

Investigating pupillometry to detect preoperative anxiety: a pilot study.

Guidelines from the European Society of Anesthesia (ESA) insist on the importance of preoperative anxiety management. However, its assessment currently relies on questionnaires that are long to submit and sometimes difficult to interpret. Exploring the balance between sympathetic and parasympathetic neural systems through the use of pupillometry is a promising path to identify anxiety and thus provides an objective and reproducible assessment tool. A single-center prospective observational study was conducted in a population of ambulatory ophthalmological surgery patients. Preoperative anxiety was assessed using the Surgical Fear Questionnaire (SFQ). Measurements were taken using an Algiscan® (IDMed) type pupillometer before, during, and after insertion of the peripheral IV catheter. A statistical correlation test was carried out between the different evaluations of anxiety and the coefficient of variation of the pupillary diameter (VCPD). A total of 71 patients were included in the study between July 2020 and February 2021, with a median SFQ score of 23 [IQR 11-34]. No significant statistical correlation was found between the baseline pupillary diameter, or VCPD, and preoperative anxiety levels. Similarly, the pupillometric variables did not differ significantly when adjusting for the level of anxiety during and after painful stimulation due to canulation. More studies are necessary to explore the potential correlation between preoperative anxiety and pupillometry.

Sample size considerations for studies comparing intubating conditions using quantitative monitoring versus a fixed interval during onset of neuromuscular blockade.

INTRODUCTION: Data in the literature are still scarce to establish any recommendations on the use of quantitative monitoring during tracheal intubation. PATIENTS AND METHODS: In this monocentric study, non-morbidly obese adult female patients without risk factors for difficult tracheal intubation were prospectively included. After 0.5 mg.kg-1 atracurium during propofol-sufentanil anaesthesia, intubation conditions were evaluated using the Copenhague and Cormack-Lehane classification at the complete twitch suppression at the TOF to the AP (monitor group) or after a fixed 3 min waiting time after atracurium injection (3-min group). We also examined sample size for future studies. RESULTS: We included 102 (monitor group) and 97 (3-min group) adult non-obese female patients without different characteristics. Intubation conditions were acceptable in 96/102 (94%) in the monitor group vs. 84/97 (87%) in the 3-min group, p = 0.07. The presence of a Cormack and Lehane view of 1 was marginally better in the monitor group as compared to the 3-min group, p = 0.041. We propose two possibility of sample size based on a difference of observed events based on acceptable intubation conditions, n = 602, or on excellent intubation conditions, n = 550. DISCUSSION: This observational study shows that the use of a neuromuscular TOF monitoring of the ulnar nerve as compared to a fixed 3-min waiting time after atracurium injection could improve laryngoscopic view and show a tendency to better intubation conditions without conclusive statistical significance. We suggest that researchers consider our recommendations in terms of the sample size to include in their future research, keeping in mind the limitations of our study.

The StarvAnx Study-Comparison Between the Effects of Non-fasting Vs. Fasting Strategy on Surgical Outcomes, Anxiety and Pain in Patients Undergoing Cataract Surgery Under Topical Anesthesia: A Randomized, Crossover, Controlled Trial.

Background: Fasting is usually recommended in patients undergoing cataract surgery under topical anesthesia. However, starving before surgery may increase preoperative anxiety and affect surgical outcomes. It is not known which fasting or non-fasting strategy is best for cataract surgery. The aim of this study was to compare non-fasting and fasting strategy in patients undergoing cataract surgery under topical anesthesia with regard to surgical outcomes, anxiety and pain. Methods: This randomized, crossover, controlled trial enrolled patients undergoing surgery for bilateral cataract under topical anesthesia at Cochin Hospital (Paris, France), from February to May 2021. Patients were randomly assigned to the non-fasting or fasting group for the first eye surgery and were switched to the other group for the second eye surgery. The primary endpoint was to compare the rate of anesthetist's interventions during surgery. The secondary endpoints included intra-operative complications, duration of surgery, surgeon perception of surgical difficulty, anesthesia-related complications and anxiety and pain level. Results: one hundred and nine consecutive patients were included, with 60 of them being fasted first and non-fasted for the second eye surgery, while the other 59 were non-fasted first and fasted for the next surgery. The number of patients requiring sedation was significantly lower in the non-fasting group compared with the fasting group [1%; 95%IC (0-3.2) vs. 6%; 95%IC (2.9-8.9), P = 0.04]. No anesthesia-related complications were observed. There was no difference in the number of intra-operative complications between the non-fasting and the fasting groups (,respectively, 0 and 1; P = 1). Anxiety level and surgical pain were significantly lower in the non-fasting group compared to the fasting group (,respectively, 2.3 ± 2.0 vs. 4.1 ± 2.4, P = 0.01 and 0.6 ± 0.6 vs. 2.6 ± 3.4, P = 0.003). The mean duration of surgery was significantly shorter in the non-fasting group compared with the fasting group (,respectively, 16.0 ± 5.9 vs. 22.3 ± 6.1 min; P = 0.03). Conclusion: In conclusion pre-operatory non-fasting strategy provides a better patient experience with regards to preoperative anxiety and surgical pain. It allows to reduce operating times and is safe and well-tolerated as regards the anesthetic intervention.

Perioperative outcomes of pheochromocytoma/paraganglioma surgery preceded by Takotsubo-like cardiomyopathy.

BACKGROUND: Pheochromocytomas and paragangliomas can induce severe cardiovascular manifestations such as Takotsubo-like cardiomyopathy. What the perioperative outcomes are of patients presenting with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy remains an unresolved question. METHODS: From 2006 to 2019, all patients who underwent surgery for pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy were included from 3 high-volume centers, with specific attention to perioperative hemodynamic instability and postoperative outcomes. RESULTS: Overall, 37 patients were included, with a median age of 45 years. Patients were operated on 2 months (1-4) after a Takotsubo-like cardiomyopathy episode; 33 (89%) had a laparoscopic approach. All those who underwent surgery presented in a hemodynamically stable situation. All except 1 of the pheochromocytomas/paragangliomas patients had at least 1 antihypertensive treatment at the time of surgery. The median preoperative systolic blood pressure in the Takotsubo-like cardiomyopathy group was 120 mm Hg (95-132). Overall, 27/34 (79%) of patients required vasoactive drugs during surgery with nicardipine (n = 22), esmolol (n = 12), and/or norepinephrine (n = 8). No patient presented a catecholamine-induced life-threatening complication such as hypertensive crisis, cardiac arrhythmias, pulmonary edema, cardiac ischemia, or Takotsubo-like cardiomyopathy in the perioperative period. Severe morbi-mortality was nil. The systematic review identified 5 studies including 38 pheochromocytomas/paragangliomas patients with at least 1 episode of acute heart failure considered as Takotsubo-like cardiomyopathy before surgery, of which 28 patients had delayed surgery with 1 postoperative death. CONCLUSION: Hemodynamically stabilized patients with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy can be safely scheduled for an elective pheochromocytomas/paragangliomas surgery, with similar intra and postoperative outcomes as those without Takotsubo-like cardiomyopathy.

Enhanced Recovery Pathway in Lung Resection Surgery: Program Establishment and Results of a Cohort Study Encompassing 1243 Consecutive Patients.

INTRODUCTION: In spite of increasing diffusion, Enhanced Recovery Pathways (ERP) have been scarcely assessed in large scale programs of lung cancer surgery. The aim of this study was auditing our practice. METHODS: A two-step audit program was established: the first dealing with our initial ERP experience in patients undergoing non-extended anatomical segmentectomies and lobectomies, the second including all consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components are associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. RESULTS: Over a one-year period, 166 patients were included. The median number of ERP procedures per patient was three (IQR 3-4). No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2 (OR = 0.21, 95% CI (0.10-0.46)). The 1-, 3-, and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included in our ERP; 11 patients died during the postoperative period or within 30 days of operation (1.02%). The overall postoperative adverse event rate was 30.3%, major complication occurring in 134 (12.4%), and minor ones in 192 (17.8%). Respiratory complications occurred in 64 (5.9%). Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). CONCLUSIONS: Compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. In a large setting scale, ERP can be applied with satisfactory results in terms of mortality and morbidity. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.

Extended antibiotic prophylaxis after pancreatoduodenectomy reduces postoperative abdominal infection in high-risk patients: Results from a retrospective cohort study.

BACKGROUND: Preoperative biliary stenting before pancreatoduodenectomy is associated with a greater risk of bacteribilia and thus could lead to more frequent and severe surgical site infections. We hypothesized that an extended antibiotic prophylaxis could reduce the risk of surgical site infections for these high-risk patients compared with standard antibiotic prophylaxis. METHODS: All consecutive patients who underwent pancreatoduodenectomy between January 1, 2010 and December 31, 2016 were included in a tricentric retrospective cohort and classified according to the risk of surgical site infections (high or low) and the type of antibiotic prophylaxis (standard or extended). Extended antibiotic prophylaxis was defined by the use of high-rank ß-lactams >2 days after surgery. Standard antibiotic prophylaxis concerned all single dose of low-rank ß-lactams antibiotic prophylaxis. The primary outcome was postoperative surgical site infections. RESULTS: Three hundred and eight patients were included; 146 (47%) were high-risk patients, and 81 (55%) received extended antibiotic prophylaxis, mostly composed of piperacilline-tazobactam and gentamicin. There were significantly fewer surgical site infections in high-risk patients receiving extended antibiotic prophylaxis versus standard antibiotic prophylaxis (odds ratio = 0.4; 95% confidence interval, 0.2-0.8; P = .011), even after adjusting on age, sex, and duration of the surgical procedure (adjusted odds ratio = 0.3; 95% confidence interval, 0.1-0.7; P = .0071). There was no statistical difference in 28-day mortality (P = .32) or 90-day mortality (P = .13). Microorganisms identified in bile culture were more often sensitive to antibiotic prophylaxis in high-risk extended antibiotic prophylaxis group than in high-risk standard antibiotic prophylaxis group (64% versus 38%; P = .01). CONCLUSION: Extended antibiotic prophylaxis is associated with a reduced risk of surgical site infections for high-risk patients with no significant reduction on 28-day mortality. Additional studies are required to determine the optimal duration of extended antibiotic prophylaxis for these patients.

Assessing Preoperative Anxiety: Nurses Versus Health Care Assistants.

PURPOSE: Our objective was to compare the difference in anxiety levels self-reported by patients and those estimated by health care assistants and nurses in two ambulatory surgery settings. DESIGN: We performed a prospective study. METHODS: Patients' preoperative anxiety was graded using a visual analog scale. FINDINGS: Between September 1 and November 31, 2019, a total of fifteen health care assistants and fourteen nurses assessed anxiety scores of 170 patients, including 92 women and 78 men. At admission, the mean visual analog scale anxiety score declared to health care assistants and nurses was 5.3 (SD = 2.9) and 4.2 (SD = 3.1), respectively (P = .02). The correlation between health care assistants' assessment of the patients' anxiety and the declared level of anxiety was significantly higher than nurses' assessment (r = 0.83 vs r = 0.12; P < .001). CONCLUSIONS: Nurse assistants estimate patients' preoperative anxiety with more accuracy than nurses in our hospital. Nursing education curriculum should continue to include addressing preoperative patient anxiety.

Efficacy of a Web App-Based Music Intervention During Cataract Surgery: A Randomized Clinical Trial.

IMPORTANCE: Hypertensive events during cataract surgery may induce complications. Information and communication technologies applied to health are popular, but clinical evidence of its usefulness is rare and limited to treating anxiety without specific analysis. Recent publications have described the potential effects of personalized music choices as mobile-based intervention on pain but not on anxiety. OBJECTIVE: To demonstrate the effects of a web app-based music intervention on the incidence of hypertension in participants during cataract surgery performed under local anesthesia. DESIGN, SETTING, AND PARTICIPANTS: This randomized, single masked, controlled clinical trial was composed of 2 arms and took place at a single center at Cochin Hospital in Paris, France. A total of 313 participants were screened between February 2017 and July 2018. Among these, 311 participants undergoing a phacoemulsification procedure for elective surgery for their first eye cataract under local anesthesia were enrolled. Analysis was intention to treat and began in September 2018 and ended November 2018. INTERVENTIONS: Participants requiring cataract surgery were assigned randomly to either the experimental arm (web app-based music listening intervention delivered via headphones) or control arm (noise-canceling headphones without music) for 20 minutes before surgery. MAIN OUTCOMES AND MEASURES: The occurrence of at least 1 hypertensive event during surgery. RESULTS: A total of 310 participants were randomized in the study (155 to each arm) and 309 were analyzed (1 participant in the music arm had already undergone cataract surgery to the other eye). The mean (SD) age of the participants was 68.9 (10.8) years, and there were 176 female individuals (57%). On the primary end point, the incidence of hypertension was significantly lower in the music arm (21 [13.6%]) than in the control arm (82 [52.9%]), with a difference between the 2 arms of 39.3% (95% CI, 21.4%-48.9%; P < .001). Regarding the secondary end points, the mean (SD) visual measure of anxiety was lower in the music arm (1.4 [2.0]) than in the control arm (3.1 [2.4]), with a difference of 1.5 (95% CI, 1.0-2.1; P = .005). The mean (SD) number of sedative drug injections required during surgery was 0.04 (0.24) vs 0.54 (0.74) in the music vs control arms, respectively, with a difference of 0.50 (95% CI, 0.43-0.57; P < .001). CONCLUSIONS AND RELEVANCE: For participants similar to those enrolled in this study, the trial suggests that a web app-based personalized music intervention before cataract surgery may be considered to lower anxiety levels and hypertension or reduce the need for sedative medication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02892825.

Multivariate Analysis of the Failure Risk of First Tracheal Intubation Attempt in a Population of Patients Scheduled for Bariatric Surgery.

BACKGROUND: Airway management during the administration of anesthesia to patients undergoing bariatric surgery is challenging. The goal is to avoid multiple intubation attempts because the risk of complications increases with the number of attempts. The objective of this study was to determine the failed first intubation attempt rate, as well as variables associated with this failure, in patients undergoing bariatric surgery. METHODS: We enrolled patients scheduled for bariatric surgery in this prospective, observational, single-center study. We determined predictive criteria for difficult intubation at the preoperative anesthesia consultation. All patients were evaluated for obstructive sleep apnea by polygraphy. The primary study endpoint was a failed first intubation attempt. RESULTS: We enrolled 519 patients between December 2012 and January 2015. The cohort consisted of 425 women (82%), with a median (interquartile range [IQR]) age of 39 (30-50) years and a body mass index of 42 (39-46) kg/m2. The first intubation attempt failed in 60 patients, with an incidence rate of 11.5% (95% confidence interval [CI], 8.8-14.2%). We included nine variables in the final multivariate model. Two variables were associated with failed first intubation attempt: male sex (odds ratio [OR] [95% CI], 6.9% [2.5-18.7%]) and Mallampati score 3-4 (OR [95% CI], 2.2% [1.0-4.7%]). CONCLUSIONS: In this morbidly obese population, the first intubation attempt failed in 11.5% of patients, and the risk factors for failure were male sex and a high Mallampati score.

Preoperative assessment of patient comorbidities before left colectomy: Comparison between ASA performance status scale and a new computed tomography physical status score.

PURPOSE: To compare a newly developed preoperative computed tomography physical status (CT-PS) score with the American Society of Anesthesiology performance status (ASA-PS) scale in the assessment of patient preoperative health status and stratification of perioperative risk before left colectomy. MATERIALS AND METHODS: Preoperative chest-abdomen-pelvis CT examinations of patients who were scheduled to undergo elective laparoscopic left colonic resection for cancer in two centers were reviewed by two radiologists blinded to clinical data for the presence of several key imaging features in order to assess general, cardiac, pulmonary, abdominal, renal, vascular and musculoskeletal status. CT examinations of patients from center 1 were used to build a CT-PS score to predict ASA-PS≥III. CT-PS score was further validated using an external cohort of patients from center 2. RESULTS: During a 2-year period, 117 consecutive patients (63 men, 54 women; mean age, 65±13 [SD] years; age range: 53-90 years) who underwent laparoscopic left colectomy for cancer in center 1 (66 patients, building cohort) and center 2 (51 patients, validation cohort) were retrospectively included. Ninety-one percent of patients were ASA-PS 1-2. Overall postoperative morbidity was 23% and severe morbidity 12%. The area under the receiver operating characteristic curve of CT-PS score was 0.968 (95% CI: 0.901-1.000) in the building cohort and 0.828 (95% CI: 0.693-0.963) in the validation cohort. The optimal thresholds yielded 87% (95% CI: 83-91%) sensitivity and 100% (95% CI: 91-100%) specificity in the building cohort and 75% (95% CI: 69-81%) sensitivity and 83% (95% CI: 77-88%) specificity in the validation cohort for the prediction of ASA-PS. CONCLUSION: Preoperative chest-abdomen-pelvis CT thoroughly and wisely read is highly accurate to differentiate patients with ASA-PS I/II from those with ASA-PS III/IV before left colectomy.

Incidence and risk factors for maternal hypoxaemia during induction of general anaesthesia for non-elective Caesarean section: a prospective multicentre study.

BACKGROUND: Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting. METHODS: Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpO2 ≤95%. The secondary endpoint was the incidence of difficult intubation defined as more than two attempts or failed intubation. RESULTS: During the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17-22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6-42.7], P<0.0001) and BMI >35 kg m-2 (aOR=0.53 [0.28-0.998], P=0.0495). Intubation was difficult in 40 women (4.5%; CI, 3.3-6%) and failed intubation occurred in five women (0.56%; CI, 0.1-1%). In the multivariate analysis, use of a hypnotic drug other than propofol was associated with difficult or failed intubation (aOR=25 [2-391], P=0.02). A propensity score confirmed that propofol was associated with a significant decreased risk of difficulty or failure to intubate (P<0.001). CONCLUSIONS: Hypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.

Guidelines on muscle relaxants and reversal in anaesthesia.

OBJECTIVES: To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.