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.

BACKGROUND: Unanticipated difficult intubation remains a challenge in anaesthesia. The Simplified Airway Risk Index (SARI) is a multivariable risk model consisting of seven independent risk factors for difficult intubation. Our aim was to compare preoperative airway assessment based on the SARI with usual airway assessment. METHODS: From 01.10.2012 to 31.12.2013, 28 departments were cluster-randomized to apply the SARI model or usual airway assessment. The SARI group implemented the SARI model. The Non-SARI group continued usual airway assessment, thus reflecting a group of anaesthetists' heterogeneous individual airway assessments. Preoperative prediction of difficult intubation and actual intubation difficulties were registered in the Danish Anaesthesia Database for both groups. Patients who were preoperatively scheduled for intubation by advanced techniques (e.g. video laryngoscopy; flexible optic scope) were excluded from the primary analysis. Primary outcomes were the proportions of unanticipated difficult and unanticipated easy intubation. RESULTS: A total of 26 departments (15 SARI and 11 Non-SARI) and 64 273 participants were included. In the primary analyses 29 209 SARI and 30 305 Non-SARI participants were included.In SARI departments 2.4% (696) of the participants had an unanticipated difficult intubation vs 2.4% (723) in Non-SARI departments. Odds ratio (OR) adjusted for design variables was 1.03 (95% CI: 0.77-1.38). The proportion of unanticipated easy intubation was 1.42% (415) in SARI departments vs 1.00% (302) in Non-SARI departments. Adjusted OR was 1.26 (0.68-2.34). CONCLUSIONS: Using the SARI compared with usual airway assessment we detected no statistical significant changes in unanticipated difficult- or easy intubations. CLINICAL TRIAL REGISTRATION: NCT01718561.

Transplantation of a lobe of lung from mother to child following previous transplantation with maternal bone marrow.

A left lower lobe of the lung was transplanted from a mother to her child, who had previously received a maternal bone marrow transplant for an immune defect. Following the bone marrow transplantation, the child had developed severe pulmonary fibrosis. Surgery and the early postoperative course have been uncomplicated. Immunosuppression with corticosteroids was administered for a short period, after which all immunosuppressive treatment was discontinued. The operation and the outcome are described both in the donor and recipient. Rehabilitation was slow, but one year later the patient is doing well.

[Transplantation of lung lobe from a mother to a child previously transplanted with her bone marrow]. / Transplantation af lungelap fra mor til barn som tidligere var blevet transplanteret med knoglemarv fra moderen.

The lower lobe of the left lung was transplanted from a mother to her child, who previously had received a bone marrow transplant from the mother because of an immune defect. After the bone marrow transplant the child had developed progressive pulmonary fibrosis (obliterative bronchiolitis). The surgical procedure and the early postoperative period has been uncomplicated. Immunosuppression with corticosteroids was only given for a short period, after which no immunosuppressive treatment has been given. The operation and results for both donor and recipient are described. The early results are promising, but rehabilitation is progressing slowly.

Successful construction of a mediastinal stoma after total removal of larynx and trachea.

In a 54-year-old woman the entire trachea and larynx were removed because of malignant tumor. The first attempt to construct a mediastinal tracheostoma with 1.5 cm left of the distal trachea failed due to stomal infection with aortic wall necrosis and bleeding. Dividing the ascending aorta mobilized the left main bronchus and allowed a stoma at the level of the carina to be constructed without tension. The aortic continuity was restored by a vascular prosthesis from ascending to abdominal aorta. The patient survived and the stoma healed primarily. One year postoperatively the patient is doing well without signs of recurrent tumor.

[Switching of the great vessels (arterial switch surgery) in transpositio vasorum]. / Omskifning af de store kar (arteriel switch operation) ved transpositio vasorum.

Since April 1992 the arterial switch operation (ASO) has been the treatment of neonates with transposition of the great arteries (TGA) at Rigshospitalet, Copenhagen. Thirteen mature neonates with TGA underwent ASO. Ten patients had simple TGA, two had TGA associated with a ventricular septal defect (VSD), and one had TGA with VSD and in addition moderate right ventricular hypoplasia. All patients survived the operation and are still alive. Perioperative bleeding was a problem in three cases. Eleven patients had an uncomplicated postoperative course. One patient had peri- and postoperative left ventricular failure and was reoperated after three months for a residual VSD. One child developed renal failure and needed peritoneal dialysis. The patients have been followed for 5.5 (range 0-12) months, they are all in good condition and thriving well. The presented early results after ASO justify continued recommendation of ASO as the operation of choice for TGA in neonates at Rigshospitalet.

Abdominal aortic aneurysm surgery: survival and quality of life in patients requiring prolonged postoperative intensive therapy.

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.

[Anesthesiologic aspects of multiorgan donation]. / Anaestesiologiske aspekter ved multiorgandonation.

As of July 1990 brain death was legally recognized in Denmark thereby rendering transplantation of heart, liver and lung possible. Brain death donors are usually treated in neurosurgical or anaesthetic intensive care units. The staff of these units influence the number of donors and also the quality of organs donated. Physiological factors pertinent to brain death donors and pre- and peroperative donor therapy in relation to multiorgan procurement are discussed from the viewpoint of the anaesthetist. Symptomatic therapy aimed at optimizing and maintaining organ function is employed; thus continuing intensive care. Sympathetic and somatic reflex responses to surgical stimulation are to be anticipated, often necessitating analgesics to blunt haemodynamic responses and neuromuscular blocking agents to inhibit movements and/or rigidity.

Cardiovascular function measured by ultrasound Doppler in healthy young men after ingestion of dextropropoxyphene napsylat.

In a double blind cross-over study 10 healthy male volunteers were given either 300 mg dextropropoxyphene napsylat (DP) or placebo daily for 16 days. The serum levels of DP and the metabolite nordextropropoxyphene were measured on day 3, 6 and 16. Haemodynamic measurements were made on day 1 and day 16, both at rest and during exercise. The measurements were made non-invasively, with a pulsed ultrasound Doppler. Blood pressure, heart rate, velocity, cardiac output, left cardiac work, increased during work, but showing no significant differences between the groups. The systolic time intervals were also measured by the ultrasound Doppler. The preejection period increased significantly in the DP-group, whereas the ratio preejection period/left ventricular ejection time which reflects the contractility of the heart did not differ significantly. It is concluded that DP taken daily in a normal dose for 16 days did not affect the heart function in healthy young men.

Acute carbon monoxide poisoning.

The course and outcome in terms of cerebral morbidity and hospital mortality in 79 severely carbon monoxide poisoned patients admitted to the intensive care unit during a period of 15 years is presented. Treatment consisted of administration of pure oxygen. Ninety-four per cent of the patients were artificially hyperventilated, and the majority of the patients were also treated with moderate hypothermia, steroid hormones and diuretics. Hospital mortality was 30%, and 14% of the patients were discharged after long-term hospital treatment with signs of brain damage. Due to the unpredictable cerebral course after the acute incident long-term follow-up is recommended.

Intravenous infusion of Diazemuls in the control of status-like epileptic seizures of different etiology.

This report concerns three patients in whom continuous intravenous infusion of Diazemuls (diazepam dissolved in soya bean oil and emulsified) diluted in 5.5% glucose was used for the controlling of epileptic seizures (status). Diazemuls infusion was effective in one patient with complex partial status epilepticus; in another patient with convulsion secondary to a brain stem infarct, the convulsions were abolished; while only reduced jerking was achieved in the third patient suffering from myoclonic jerks caused by anoxic brain damage. Infusion time ranged from 15 to 33 h. The serum concentrations of diazepam obtained during the infusions were higher than recommended in the literature for treatment of status epilepticus, but could not be correlated to either clinical efficacy or infusion rate.

Acute salicylate self-poisoning in 177 consecutive patients treated in ICU.

The course of 177 consecutive patients with severe salicylate self-poisoning treated in an intensive care unit (ICU) during a period of 15 years is presented. On admission, cerebral depression was observed in 61% respiratory failure was present in 47%, acidosis in 36% and cardiovascular function was impaired in 14%. A mortality rate of 15% was observed, which was proportionally higher in patients more than 40 years old and in patients with delayed diagnosis. Twenty-seven patients died and an autopsy was performed on 26 patients. The main autopsy diagnosis was ulcers of the gastrointestinal tract in 46%, pulmonary oedema in 46%, cerebral oedema in 31% and cerebral haemorrhage in 23%.

Severe acute propoxyphene overdose: plasma concentrations of propoxyphene and norpropoxyphene and the effect of dopamine on circulatory failure.

Twelve patients with cardiovascular failure because of propoxyphene self-poisoning were treated with dopamine. The patients responded favourably to dopamine infusion (2-17 micrograms/kg/min) with a dose-dependent rise in systolic arterial blood pressure and a fall in central venous pressure and copious urinary output. Side effects during infusion were few, and in periods where dopamine infusion exceeded 10 micrograms/kg/min no tachyarrhythmias were seen. Eleven of the patients were treated on a respirator. Two patients were discharged from the ICU with signs of hypoxic brain damage, one of whom recovered completely after 2 weeks. Serum propoxyphene and norpropoxyphene were measured in nine patients. All but one patient had either propoxyphene or norpropoxyphene concentrations above 3 mumol/l.

Self-poisoning treated in an ICU: drug pattern, acute mortality and short-term survival.

A total of 1558 admissions to an ICU over 5 years because of severe self-poisoning with drugs provides the basis for this study. Three drugs accounted for 60% of the admissions: overdose with barbiturates in 28%, with tricyclic antidepressants in 19% and with propoxyphene in 14%. The annual incidence of poisonings with barbiturates and tricyclic antidepressants was the same during the period, whereas the incidence of propoxyphene intoxication increased by 80%. Intensive supportive care was the main principle of treatment. All patients were artificially ventilated. The mortality rate was 6.1%, salicylate, propoxyphene and strong analgesics having the highest mortalities (11%, 9% and 9%, respectively). A mortality rate of 3% was found following overdose with tricyclic antidepressants. By 36 months after the overdose, 235 patients (18%) had died. The expected number of deaths was 39 (3%). The suicide rate in the follow-up period was 10%, in the majority (75%) of whom death was caused by a new episode of self-poisoning.

Severe, acute propoxyphene overdose treated with dopamine.

Six patients suffering from cardiovascular failure due to acute propoxyphene overdose, were treated with dopamine infusion in doses of 2-17 microgram/kg/min. All patients responded with increased systolic arterial blood pressure, increased urinary output and decreased central venous pressure. The two most severely poisoned patients showed no increase in heart rate in spite of dopamine infusion in positively chronotropic doses. In two out of three patients the initially abnormal ECGs normalised during treatment. It is concluded that dopamine seems suitable for reversal of propoxyphene induced circulatory failure.