Intraoperative individualization of positive-end-expiratory pressure through electrical impedance tomography or esophageal pressure assessment: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: This systematic review of randomized-controlled trials (RCTs) with meta-analyses aimed to compare the effects on intraoperative arterial oxygen tension to inspired oxygen fraction ratio (PaO2/FiO2), exerted by positive end-expiratory pressure (PEEP) individualized trough electrical impedance tomography (EIT) or esophageal pressure (Pes) assessment (intervention) vs. PEEP not tailored on EIT or Pes (control), in patients undergoing abdominal or pelvic surgery with an open or laparoscopic/robotic approach. METHODS: PUBMED®, EMBASE®, and Cochrane Controlled Clinical trials register were searched for observational studies and RCTs from inception to the end of August 2022. Inclusion criteria were: RCTs comparing PEEP titrated on EIT/Pes assessment vs. PEEP not individualized on EIT/Pes and reporting intraoperative PaO2/FiO2. Two authors independently extracted data from the enrolled investigations. Data are reported as mean difference and 95% confidence interval (CI). RESULTS: Six RCTs were included for a total of 240 patients undergoing general anesthesia for surgery, of whom 117 subjects in the intervention group and 123 subjects in the control group. The intraoperative mean PaO2/FiO2 was 69.6 (95%CI 32.-106.4 ) mmHg higher in the intervention group as compared with the control group with 81.4% between-study heterogeneity (p < 0.01). However, at meta-regression, the between-study heterogeneity diminished to 44.96% when data were moderated for body mass index (estimate 3.45, 95%CI 0.78-6.11, p = 0.011). CONCLUSIONS: In patients undergoing abdominal or pelvic surgery with an open or laparoscopic/robotic approach, PEEP personalized by EIT or Pes allowed the achievement of a better intraoperative oxygenation compared to PEEP not individualized through EIT or Pes. PROSPERO REGISTRATION NUMBER: CRD 42021218306, 30/01/2023.

Lumbar skeletal muscle index derived from routine computed tomography exams predict adverse post-extubation outcomes in critically ill patients.

PURPOSE: To evaluate the effect of a skeletal muscle index derived from a routine CT image at the level of vertebral body L3 (L3SMI) on outcomes of extubated patients in the surgical intensive care unit. MATERIALS AND METHODS: 231 patients of a prospective observational trial (NCT01967056) who had undergone CT within 5days of extubation were included. L3SMI was computed using semi-automated segmentation. Primary outcomes were pneumonia within 30days of extubation, adverse discharge disposition and 30-day mortality. Secondary outcomes included re-intubation within 72h, total hospital costs, ICU length of stay (LOS), post-extubation LOS and total hospital LOS. Outcomes were analyzed using multivariable regression models with a priori-defined covariates height, gender, age, APACHE II score and Charlson Comorbidity Index. RESULTS: L3SMI was an independent predictor of pneumonia (aOR 0.96; 95% CI 0.941-0.986; P=0.002), adverse discharge disposition (aOR 0.98; 95% CI 0.957-0.999; P=0.044) and 30-day mortality (aOR 0.94; 95% CI 0.890-0.995; P=0.033). L3SMI was significantly lower in re-intubated patients (P=0.024). Secondary analyses suggest that L3SMI is associated with total hospital costs (P=0.043) and LOS post-extubation (P=0.048). CONCLUSION: The lumbar skeletal muscle index, derived from routine abdominal CT, is an objective prognostic tool at the time of extubation.

Difficult intubation in the adult patients undergoing oropharygolaryngeal, neck, and maxillofacial procedures: Thai Anesthesia Incident Monitoring Study (Thai AIMS).

BACKGROUND: Difficult intubation is one of the common anesthetic related complications during the perioperative period. In the patients with pathology or disease involving the oropharyngolarynx, neck, or maxillo-facial region, they might have a potentially higher risk than the general population. OBJECTIVE: To determine the characteristics and the contributing factors of difficult intubation in the adult patients undergoing oropharyngolaryngeal, neck, and maxillofacial procedures, and the factors minimizing this incidence and the suggested corrective strategies. MATERIAL AND METHOD: All incident reports of difficult intubation in the adult patients who received general anesthesia for the procedure involving the oropharyngolarynx, neck, and maxillofacial region from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database were identified. The details of the reports, the contributing factors, the factors those minimizing the incident, and the suggestive corrective strategies were studied. RESULTS: There were 26 (1.3%) incident reports of difficult intubation from the database. This occurred in 35%, 58%, and 15% of the patients with Mallampati class 1-2, thyromental distance equal or more than 5 cm or 3 fingerbreadths, and combined both parameters, respectively. Forty two percent of cases were judged as an unplanned difficult intubation. Twenty-seven, 23, and 19 percent of the patients had tumor or carcinoma at the oropharyngolarynx, deep neck infection, and maxillofacial fracture, respectively. Nearly half of the adverse events accompanied with difficult intubation were desaturation. No immediate fatally and late outcome was reported. Patients' disease/anatomy was the major contributing factor that might relate to the incidence. Previous experience, experienced assistance, and high vigilance were the factors minimizing incidence. Suggestive corrective strategies were guideline practices, additional training, and improved supervision. CONCLUSION: Carefully preoperative airway assessment and additional attention focused on the pathology or disease were the principle tasks. Algorithms for both anticipated and unanticipated difficult airway as well as alternative airway equipments should be implemented.