Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis.

BACKGROUND: The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA). METHODS: Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI. RESULTS: Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001). CONCLUSIONS: Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.

Preoperative communication between anaesthetists and patients with obesity regarding perioperative risks and weight management: a structured narrative review.

BACKGROUND: Individuals with obesity frequently present for anaesthesia and surgery. Good communication during the preoperative consultation can optimise the provision of relevant health information and guide improvement of health status preoperatively. METHODS: We planned a systematic literature review to assess existing guidelines and evidence of effectiveness for how anaesthetists should communicate with patients who have obesity in the preoperative period about perioperative risks and weight management. Database searches used keywords related to perioperative weight loss conversations. We found no papers that directly addressed our aim. The literature identified as most relevant was analysed in the form of a narrative review. RESULTS: The majority of suggestions for weight loss conversations came from primary care. Four primary themes potentially relevant to anaesthetists were identified: barriers to such conversations, communication tools, language and communication and specific recommendations. Identified barriers included lack of skills, training, poor remuneration, pessimism and time constraints for clinicians. Established discussion tools including the '5A's' approach (Assess, Advise, Agree, Assist, Arrange) and motivational interviewing may hold promise to improve preoperative conversations. The papers highlighted a need for empathetic language, including use of patient-specific language where possible. CONCLUSIONS: There are currently no published guidelines for how anaesthetists could most effectively discuss weight in the perioperative period with patients who have obesity. Much of the literature for obesity communication is based on the primary care setting. The perioperative period may represent an increased time of receptiveness for patients. Guidelines for discussions about weight management and associated perioperative risk are suggested.

Cricoid pressure during intubation: A systematic review and meta-analysis of randomised controlled trials.

PURPOSE: This systematic review and meta-analysis aimed to determine whether cricoid pressure protects against aspiration and whether this technique adversely affects intubating conditions in adult patients. METHODS: A systematic review of five databases was performed for randomised controlled trials comparing cricoid pressure to no cricoid or sham cricoid during intubation. The primary outcome was incidence of aspiration and the secondary outcomes included first attempt intubation success, time to intubation, Cormack and Lehane Grade 3 or 4 and difficult intubation. RESULTS: The search identified twelve high quality RCTs with 4,862 patients for inclusion. Among four studies reporting the primary outcome, there was no difference (RR=1.18; 95%CI=0.71 to 1.96; I2=0%; p=0.51). Only 3 studies were in patients at high risk of aspiration. There was significantly worse first attempt success (RR= 0.94; 95%CI= 0.89 to 0.99; I2=66%; p=0.02), time to intubation (WMD= 6.77seconds; 95%CI=4.40 to 9.14seconds; I2=97%) and laryngoscopy views (RR=1.69; 95%CI=1.41 to 2.02;I2=1%; p<0.00001) with cricoid pressure. CONCLUSIONS: Cricoid pressure failed to show any increase in protection from aspiration and may increase difficulty of intubation. Further studies in high-risk patients, such as intensive care patients, are required.