Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.

BACKGROUND: Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. METHODS: This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. RESULTS: Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. CONCLUSIONS: Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.

Carbon dioxide and cardiac output as major contributors to cerebral oxygenation during apnoeic oxygenation.

Apnoeic oxygenation has experienced a resurgence in interest in critical care and perioperative medicine. However, its effect on cerebral oxygenation and factors influencing it, have not yet been investigated in detail. By using near-infrared spectroscopy, we intended to provide further evidence for the safety of apnoeic oxygenation and to increase our understanding of the association between cerebral perfusion, haemodynamic, respiratory and demographic factors. In this secondary analysis of a prospective randomized controlled noninferiority trial, we recruited 125 patients, who underwent surgery under general anaesthesia with neuromuscular blockade. Arterial blood samples were taken every 2 min for a total of 15 min under apnoeic oxygenation with 100% oxygen. Near-infrared spectroscopy and cardiac output were continuously measured. Statistical analysis was performed using uni- and multivariable statistics. Ninety-one complete data sets were analysed. In six patients the SpO2 fell below 92% (predefined study termination criterion). The significant average increase of cerebral oxygenation was 0.5%/min and 2.1 mmHg/min for the arterial pressure of carbon dioxide (paCO2). The median cardiac output increased significantly from 5.0 l/min (IQR 4.5-6.0) to 6.5 l/min (IQR 5.7-7.5). The most significant effect on cerebral oxygenation was exhibited by the variable paCO2 and non-specific patient factors, followed by cardiac output and paO2. Apnoeic oxygenation proves to have a high safety profile while significantly increasing cerebral oxygenation, paCO2 and cardiac output. In reverse, NIRS might act as a reliable clinical surrogate of paCO2 and cardiac output during stable arterial oxygenation.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials.

INTRODUCTION: The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS: Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour). ETHICS AND DISSEMINATION: Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER: CRD42018090261.

The influence of the COVID-19 pandemic on videolaryngoscopy: a cross-sectional before-and-after survey.

BACKGROUND: Guidelines and consensus statements recommend the use of videola-ryngoscopes (VLs) in airway management of patients with COVID-19. However, there is a lack of knowledge about which types of videolaryngoscopes are used, differences of use between countries, and how the COVID-19 pandemic influenced their use. The primary aim of this before-and-after cross-sectional survey study was to assess the frequency of the use of videolaryngoscopy in the operation theatres in different countries. Also, the preferred characteristics of videolaryngoscopes were assessed. METHODS: With Ethics Committee approval, a questionnaire was distributed among anaes-thesiologists through the European Airway Management Society's network in 2019 before and in 2021 during the COVID-19 pandemic. Responses to the questions were analysed and presented as descriptive statistics. RESULTS: We reached out to 791 anaesthesiologists; 155 (19.5%) returned the first questionnaire, and 91 (11.5%) returned the second survey. Videolaryngoscopes were used in 24.1% of cases before COVID-19 and in 43.1% after the pandemic ( P < 0.001). We revealed that the availability of videolaryngoscopes increased to 100% in all centres during the pandemic. Routine use of videolaryngoscopes in all cases increased from 12.5% to 38.9%. The type of videolaryngoscope and the blade preference did not change during this period ( P = 1.000). CONCLUSIONS: This survey reflects that the COVID-19 pandemic significantly increased the availability and use of videolaryngoscopes in operating theatres, and that more anaesthesiologists now use them routinely in all cases. The preferred type of VL or blade did not change during the pandemic.

Characteristics and neurological survival following intraoperative cardiac arrest in a Swiss University Hospital: a 7-year retrospective observational cohort study.

Introduction: Little is known about intraoperative cardiac arrest during anesthesia care. In particular, data on characteristics of cardiac arrest and neurological survival are scarce. Methods: We conducted a single-center retrospective observational study evaluating anesthetic procedures from January 2015 until December 2021. We included patients with an intraoperative cardiac arrest and excluded cardiac arrest outside of the operating room. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes were sustained ROSC over 20 min, 30-day survival, and favorable neurological outcome according to Clinical Performance Category (CPC) 1 and 2. Results: We screened 228,712 anesthetic procedures, 195 of which met inclusion criteria and were analyzed. The incidence of intraoperative cardiac arrest was 90 (CI 95% 78-103) in 100,000 procedures. The median age was 70.5 [60.0; 79.4] years, and two-thirds of patients (n = 135; 69.2%) were male. Most of these patients with cardiac arrest had ASA physical status IV (n = 83; 42.6%) or V (n = 47; 24.1%). Cardiac arrest occurred more frequently (n = 104; 53.1%) during emergency procedures than elective ones (n = 92; 46.9%). Initial rhythm was pre-dominantly non-shockable with pulseless electrical activity mostly. Most patients (n = 163/195, 83.6%; CI 95 77.6-88.5%) had at least one instance of ROSC. Sustained ROSC over 20 min was achieved in most patients with ROSC (n = 147/163; 90.2%). Of the 163 patients with ROSC, 111 (68.1%, CI 95 60.4-75.2%) remained alive after 30 days, and most (n = 90/111; 84.9%) had favorable neurological survival (CPC 1 and 2). Conclusion: Intraoperative cardiac arrest is rare but is more likely in older patients, patients with ASA physical status ≥IV, cardiac and vascular surgery, and emergency procedures. Patients often present with pulseless electrical activity as the initial rhythm. ROSC can be achieved in most patients. Over half of the patients are alive after 30 days, most with favorable neurological outcomes, if treated immediately.

Limitations of transcutaneous carbon dioxide monitoring in apneic oxygenation.

BACKGROUND: High-flow nasal oxygenation is increasingly used during sedation procedures and general anesthesia in apneic patients. Transcutaneous CO2 (ptcCO2)-monitoring is used to monitor hypercapnia. This study investigated ptcCO2-monitoring during apneic oxygenation. METHODS: We included 100 patients scheduled for elective surgery under general anesthesia in this secondary analysis of a randomized controlled trial. Before surgery, we collected ptcCO2 measured by TCM4 and TCM5 monitors and arterial blood gas (ABG) measurements every two minutes during 15 minutes of apnea. Bland-Altman plots analyzed agreement between measurement slopes; linear mixed models estimated the different measuring method effect, and outlined differences in slope and offset between transcutaneous and arterial CO2 partial pressures. RESULTS: Bland-Altman plots showed a bias in slope (95% confidence intervals) between ABG and TCM4-measurements of 0.05mmHg/min (-0.05 to 0.15), and limits of agreement were -0.88mmHg/min (-1.06 to -0.70) and 0.98mmHg/min (0.81 to 1.16). Bias between ABG and TCM5 was -0.14mmHg/min (-0.23 to -0.04), and limits of agreement were -0.98mmHg/min (-1.14 to -0.83) and 0.71mmHg/min (0.55 to 0.87). A linear mixed model (predicting the CO2-values) showed an offset between arterial and transcutaneous measurements of TCM4 (-15.2mmHg, 95%CI: -16.3 to -14.2) and TCM5 (-19.1mmHg, -20.1 to -18.0). Differences between the two transcutaneous measurements were statistically significant. CONCLUSIONS: Substantial differences were found between the two transcutaneous measurement systems, and between them and ABG. Transcutaneous CO2 monitoring cannot replace arterial CO2-monitoring during apneic oxygenation. In clinical settings with rapidly changing CO2-values, arterial blood gas measurements are needed to reliably assess the CO2-partial pressure in blood. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03478774).

Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study.

BACKGROUND: Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated. METHODS: This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy. RESULTS: Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02). CONCLUSIONS: In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events. CLINICAL TRIAL REGISTRATION: NCT03616054.

Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial.

BACKGROUND: Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. METHODS: We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. FINDINGS: Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. INTERPRETATION: Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. FUNDING: Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.

Preoperative airway ultrasound assessment in the sniffing position: a prospective observational study.

BACKGROUND: Clinical airway screening tests intend to predict difficult airways, but none have a high predictive value. Recent systematic reviews correlate ultrasound with difficult laryngoscopy. This study aimed primarily to correlate ultrasound measurements of anatomical upper airway structures in the sniffing position with difficult direct laryngoscopy. The secondary aim was to observe gender-based differences. METHODS: This prospective, cross-sectional, single-center observational study included 209 patients requiring general anesthesia for elective surgery. Preoperatively, we performed six clinical airway assessments and three ultrasound measurements, which were the Distance from Skin to the Hyoid Bone (DSHB), to the Epiglottis (DSE), and to the anterior commissure of the vocal cords (DSAC) in a sniffing position. Benumof's criteria for the "best view at the first attempt" for direct laryngoscopy assessed the difficulty of laryngoscopy. RESULTS: The distance from skin to the epiglottis was the best predictor of direct difficult laryngoscopy (defined as Cormack-Lehane grade ≥ 2b) with a minimum thickness cut-off at 2.70 ± 0.19 cm (sensitivity 91.3%; specificity 96.9%). The skin to the hyoid bone distance cut-off was 1.41 ± 0.30 cm with moderate correlation (sensitivity 80.4%; specificity 60.1%). No correlation was found for the distance to the anterior commissure of the vocal cords. In women compared to men, the skin to the epiglottis distance was more sensitive (92.3% vs. 90.9%) and specific (98.8% vs. 95.2%). CONCLUSIONS: DSE in the sniffing position is the most reliable parameter for preoperative airway ultrasound assessment in the Caucasian population, with higher sensitivity and specificity in women, and might be considered as an independent predictor for direct difficult laryngoscopy.

Preoperative airway ultrasound assessment in the sniffing position: a prospective observational study

Abstract Background: Clinical airway screening tests intend to predict difficult airways, but none have a high predictive value. Recent systematic reviews correlate ultrasound with difficult laryngoscopy. This study aimed primarily to correlate ultrasound measurements of anatomical upper airway structures in the sniffing position with difficult direct laryngoscopy. The secondary aim was to observe gender-based differences. Methods: This prospective, cross-sectional, single-center observational study included 209 patients requiring general anesthesia for elective surgery. Preoperatively, we performed six clinical airway assessments and three ultrasound measurements, which were the Distance from Skin to the Hyoid Bone (DSHB), to the Epiglottis (DSE), and to the anterior commissure of the vocal cords (DSAC) in a sniffing position. Benumof's criteria for the "best view at the first attempt" for direct laryngoscopy assessed the difficulty of laryngoscopy. Results: The distance from skin to the epiglottis was the best predictor of direct difficult laryngoscopy (defined as Cormack-Lehane grade > 2b) with a minimum thickness cut-off at 2.70 ± 0.19 cm (sensitivity 91.3%; specificity 96.9%). The skin to the hyoid bone distance cut-off was 1.41 ± 0.30 cm with moderate correlation (sensitivity 80.4%; specificity 60.1%). No correlation was found for the distance to the anterior commissure of the vocal cords. In women compared to men, the skin to the epiglottis distance was more sensitive (92.3% vs. 90.9%) and specific (98.8% vs. 95.2%). Conclusions: DSE in the sniffing position is the most reliable parameter for preoperative airway ultrasound assessment in the Caucasian population, with higher sensitivity and specificity in women, and might be considered as an independent predictor for direct difficult laryngoscopy.

A view on pediatric airway management: a cross sectional survey study.

BACKGROUND: This survey aimed to investigate routine practices and approaches of clinicians on pediatric airway in anesthesia and intensive care medicine. METHODS: A 20-question multiple-choice questionnaire with the possibility to provide open text answers was developed and sent. The survey was sent to the members of European Airway Management Society via a web-based platform. Responses were analyzed thematically. Only the answers from one representative of the pediatric service of each hospital was included into the analysis. RESULTS: Among the members, 143 physicians responded the survey, being anesthesiologists (83.2%), intensivists (11.9%), emergency medicine physicians (2.1%), and (2.8%) pain medicine practitioners. A straight blade was preferred by 115 participants (80.4%) in newborns, whereas in infants 86 (60.1%) indicated a curved blade and 55 (38.5%) a straight blade. Uncuffed tracheal tube were preferred by 115 participants (80.4%) in newborns, whereas 24 (16.8%) used cuffed tubes. Approximately 2/3 of the participants (89, 62.2%) reported not to use routinely a cuff manometer in their clinical practice, whereas 54 participants (37.8%) use it routinely in pediatric patients. Direct laryngoscopy for routine pediatric tracheal intubation was reported by 127 participants (88.8%), while 16 (11.2%) reported using videolaryngoscopes routinely. Interestingly, 39 (27.3%) had never performed neither videolaryngoscopy nor flexible bronchoscopy in children. These results were significantly less in hospitals with a dedicated pediatric anesthesiologist. CONCLUSIONS: This survey on airway management in pediatric anesthesia revealed that the use of cuffed tubes and the routine monitoring of cuff pressure are rare. In addition, the rate of videolaryngoscopy or flexible optical intubation was low for expected difficult intubation. Our survey highlights the need for properly trained pediatric anesthesiologists working in-line with updated scientific evidence.

Evaluation of atelectasis using electrical impedance tomography during procedural deep sedation for MRI in small children: A prospective observational trial.

STUDY OBJECTIVE: To investigate the variation of poorly ventilated lung units (i.e., silent spaces) in children undergoing procedural sedation in a day-hospital setting, until discharge home from the Post-Anesthesia Care Unit (PACU). DESIGN: Prospective, single-center, observational cohort trial. SETTING: This study was conducted at the radiology department and in PACU at Bern University Hospital (Switzerland), a tertiary care hospital. PATIENTS: We included 25 children (1-6 years, ASA I-III) scheduled for cerebral magnetic resonance imaging scan, spontaneously breathing under deep sedation. Children planned for tracheal intubation, supraglottic airway insertion, or with contraindication for propofol were excluded. INTERVENTION: After intravenous or inhaled induction, deep sedation was performed with 10 mg/kg/h Propofol. All children received nasal oxygen 0.3 ml/kg/min. MEASUREMENTS: The proportion of silent spaces and the global inhomogeneity index were determined at each of five procedural points, using electrical impedance tomography: before induction (T1); before (T2) and after (T3) magnetic resonance imaging; at the end of sedation before transport to the PACU (T4); and before hospital discharge (T5). MAIN RESULTS: The median [interquartile range (IQR)] proportion of silent spaces at the five analysis points were: T1, 5% [2%-14%]; T2, 10% [7%-14%]; T3, 12% [5%-23%]; T4, 12% [7%-24%]; and T5, 3% [2%-11%]. These defined significant changes in silent spaces over the course of sedation (p = 0.009), but no differences in silent spaces from before induction to before discharge from the PACU (T1 vs. T5; p = 0.29). Median [IQR] global inhomogeneity indices were 0.57 [0.55-0.58], 0.56 [0.53-0.59], 0.56 [0.54-0.59], 0.57 [0.54-0.60] and 0.56 [0.54-0.57], respectively (p = 0.93). None of the children reported anesthesia-related complications. CONCLUSION: Deep sedation results in significantly increased poorly ventilated lung units during sedation. However, this does not significantly affect ventilation homogeneity, which was fully resolved at discharge from the PACU. TRIAL REGISTRATION: clinicaltrials.gov, identifier NCT04507581.

Refreshing medical students' intravenous-cannulation skills: a blinded observer three-arm randomised comparison of mental imagery, part-task trainer simulation and written instructions.

INTRODUCTION: Intravenous cannulation is a core competence in medicine, but is considered challenging to learn. This study investigates the effectiveness of three educational strategies used to refresh the intravenous cannulation skills of first-year medical students: mental imagery, part-task trainer simulation and written instructions. MATERIALS AND METHODS: In this single-centre randomised controlled trial, first-year medical students were assigned to one of three different refresher tutorials on intravenous cannulation. Six months after their compulsory 4 hour instructor-led intravenous-cannulation course, each student was randomised to a 6 min self-learning tutorial: a mental imagery audioguide session, hands-on intravenous cannulation on a part-task trainer or reading written instructions.Immediately after the refresher tutorials, trained evaluators who were blinded to the randomised group assessed the students' performance. Each evaluator completed a 15-item standardised checklist in an Objective Structured Clinical Examination (OSCE) station for intravenous cannulation. We performed a descriptive analysis of the data and a one-way analysis of variance. Additionally, we investigated the influence of previous intravenous cannulation experience on the total OSCE score. RESULTS AND DISCUSSION: On analysing the 309 students' results, we did not find differences in the total rating of the performance (in percentage) between the three groups at the OSCE station (mental imagery group: 72.0%±17.9%; part-task trainer group: 74.4%±15.6%; written instructions group: 69.9%±16.6%, p=0.158). Multiple linear regression showed a small but statistically significant effect of students' previous intravenous cannulation experience on OSCE performance. With the same outcome, written instructions and mental imagery had a better return on effort, compared with resource-intensive hands-on training with part-task trainers. CONCLUSION: A single, short refresher seems to have a limited effect on intravenous-cannulation skills in first-year medical students. Less resource-intensive interventions, such as written instructions or mental imagery, are effective compared with hands-on part-task trainer simulation for refreshing this simple but important skill. TRIAL REGISTRATION NUMBER: AEARCTR-0008043.

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries.

Importance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. Exposures: Tracheal intubation. Main Outcomes and Measures: The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. Results: Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. Conclusions and Relevance: In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

Prospective observational study evaluating the C-MAC Video Stylet for awake tracheal intubation: a single-center study.

BACKGROUND: The gold standard for management of known or predicted difficult airways is awake tracheal intubation. The newly developed C-MAC Video Stylet promises to combine the advantages of rigid stylets and flexible optical scopes. We therefore evaluated the feasibility of awake orotracheal intubations with this device. METHODS: In this prospective observational study, three anesthesiologists experienced in advanced airway management performed each 12 awake oral intubations with this device on adult patients with known or predicted intubation difficulties. The primary outcome was overall intubation success. Secondary outcomes were total attempts, successful time, first postoperative day sequelae, and subjective intubation difficulty rated on a visual analogue scale (1, very easy; 10, extremely difficult). RESULTS: Thirty-six patients (10 females), aged 64±13 years, with BMI 26±5 kg/m2, were enrolled in the study. ASA status II, III, IV were eight (22%), 23 (64%), and five (14%), respectively. Indications for awake oral intubation were: oropharyngeal tumor 20 (56%), cervical-spine fracture eight (22%), previously known difficult airway four (11%), spinal canal stenosis three (8%), and bilateral peritonsillar abscess one (3%). Overall, 97% were successfully intubated in 45 s (31-88). First-attempt success rate was 80% in 37 s (29-54); 92% of patients would choose the same procedure again. On the first postoperative day, 11 (31%) patients complained of sore throat; five (14%) had minor injuries. Ease of intubation was rated as median VAS 3 (IQR: 1-7). CONCLUSIONS: The new C-MAC Video Stylet has the potential to serve as a suitable device for visualized oral awake intubation in difficult airway situations.

Pre-induction checklists and discomfort in patients. An observational study.

BACKGROUND: Since the WHO release of the Safe Surgery Saves Lives Program in 2008, peri-operative checklists minimise errors and improve patient safety worldwide. Anaesthesia professionals are often reluctant to use these checklists in front of patients because they fear causing patients' discomfort before anaesthesia and surgery. OBJECTIVE: To assess and compare the subjective level of patient discomfort caused by the use of pre-induction checklists with the patient discomfort estimated by anaesthesia providers. DESIGN: Prospective observational study. SETTING: The current single-centre trial included 110 anaesthesia providers and 125 nonpremedicated ear, nose and throat or maxillofacial surgery patients in Switzerland from June to August 2016. Inclusion criterion: signed general research consent. EXCLUSION CRITERIA: received premedication, less than 18 years old, day-care patients, dementia or other mental illnesses. INTERVENTIONS: Anaesthesia healthcare providers and patients before surgery and on the first postoperative day were asked to rate three statements: MAIN OUTCOME MEASURES: All statements were rated on a 100-mm visual analogue scale, where 0 meant no agreement and 100 meant total agreement. RESULTS: Patients overwhelmingly agreed that anaesthesia providers should use checklists in front of them. Anaesthesia providers rated the patient discomfort much higher than actually perceived by patients. Both, patients and anaesthesia providers rated the possibility of reducing the risk of errors high. CONCLUSION: Patients experience far less discomfort observing the use of pre-induction checklists than anaesthesia providers expect. Patients value the potential safety benefit significantly higher than anaesthesia providers. These results further support the implementation of peri-operative checklists in the operating room environment. TRIAL REGISTRATION: The current observational study had no intervention, therefore, was not registered.

Apnoeic oxygenation with nasal cannula oxygen at different flow rates in anaesthetised patients: a study protocol for a non-inferiority randomised controlled trial.

INTRODUCTION: Apnoeic oxygenation using nasal high-flow oxygen delivery systems with heated and humidified oxygen has recently gained popularity in the anaesthesia community. It has been shown to allow a prolonged apnoea time of up to 65 min as CO2 increase was far slower compared with previously reported data from CO2 increase during apnoea. A ventilatory exchange due to the high nasal oxygen flow was proposed explaining that phenomenon. However, recent studies in children did not show any difference in CO2 clearance comparing high-flow with low-flow oxygen. To investigate this ventilatory exchange in adults, we plan this study comparing different oxygen flow rates and the increase of CO2 during apnoea. We hypothesise that CO2 clearance is non-inferior when applying low oxygen flow rates. METHODS AND ANALYSIS: In this single-centre, single-blinded, randomised controlled trial, we randomly assign 100 patients planned for elective surgery to either control (oxygen 70 L/min, airway opened by laryngoscopy) or one of three intervention groups: oxygen 70, or 10, or 2 L/min, all with jaw thrust to secure airway patency. After anaesthesia induction and neuromuscular blockage, either one of the interventions or the control will be applied according to randomisation. Throughout the apnoea period, we will measure the increase of transcutaneous pCO2 (tcpCO2) until any one of the following criteria is met: time=15 min, SpO2 <92%, tcpCO2 >10.67 kPa, art. pH <7.1, K+ >6.0 mmol/L. Primary outcome is the mean tcpCO2 increase in kPa/min. ETHICS AND DISSEMINATION: After Cantonal Ethic Committee of Bern approval (ID 2018-00293, 22.03.2018), all study participants will provide written informed consent. Patients vulnerable towards hypoxia or hypercarbia are excluded. Study results will be published in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER: This study was registered on www.clinicaltrials.gov (NCT03478774,Pre-results) and the Swiss Trial Registry KOFAM (SNCTP000002861).

Pediatric supraglottic airway devices in clinical practice: A prospective observational study.

BACKGROUND: Supraglottic airway devices (SGA) are commonly used in pediatric anesthesia and serve as primary or back-up devices for difficult airway management. Most SGA are marketed without proper clinical evaluation. The purpose of this study was to evaluate the performance of the pediatric LMA Supreme™, Air-Q® and Ambu® Aura-i™. METHODS: This prospective observational study was performed at Bern University Hospital, Switzerland. With ethics committee approval and a waiver for written informed consent 240 children undergoing elective surgery with an ASA class I-III and a weight of 5-30 kg were included. Three different pediatric supraglottic airway devices were assessed: The LMA Supreme™, Air-Q® and Ambu® Aura-i™. Primary outcome parameter was airway leak pressure. Secondary outcome parameters included first attempt and overall success rate, insertion time, fiberoptic view through the SGA, and adverse events. The primary hypothesis was that the mean airway leak pressure of each tested SGA was 20 cmH2O ± 10%. RESULTS: None of the SGA showed a mean airway leak pressure of 20 cmH2O ± 10%, but mean airway leak pressures differed significantly between devices [LMA Supreme™ 18.0 (3.4) cmH2O, Air-Q® 15.9 (3.2) cmH2O, Ambu® Aura-i™ 17.3 (3.7) cmH2O, p < 0.001]. First attempt success rates (LMA Supreme™ 100%, Air-Q® 90%, Ambu® Aura-i™ 91%, p = 0.02) and overall success rates (LMA Supreme™ 100%, Air-Q® 91%, Ambu® Aura-i™ 95%, p = 0.02) also differed significantly. Insertion times ranged from 20 (7) seconds (Air-Q®) to 24 (6) seconds (LMA Supreme™,