Anaesthesia praCtice for Caesarean dElivery Snapshot Study (ACCESS): Protocol and baseline characteristics of registered centres.

BACKGROUND: Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created. OBJECTIVE: The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology. DESIGN AND SETTING: The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter. RESULTS: The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist. CONCLUSION: The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies.

Molecular Identification and Genotyping of Theileria Orientalis Type 3 (Buffeli) Isolated from Cattle Using Nested-PCR Assay in Guilan Province, Iran.

Protozoan parasites of the genus Theileria are tick-borne parasites that have been found in many species of mammals. More than a dozen species of Theileria have been found in cattle, water buffalo, sheep, and goats. Theileria orientalis is a non-pathogenic blood protozoan parasite that was detected and identified during a regular investigation of piroplasmida infection in indigenous cattle in the spring of 2019 in Northern Provinces of Iran. In total, 92 blood samples were collected from different areas of Guilan and Mazandaran Provinces, Iran during the spring. The Giemsa stained blood smears did not show any parasitic infection; however, T. orientalis was identified by 18S rRNA gene polymerase chain reaction (PCR) and DNA sequencing. The specific sequenced DNA for T. orientalis was registered in GenBank under the accession number MN453385. The partial 18S rRNA gene sequence of the obtained DNA showed 100% nucleotide identity with reference sequences for the T. orientalis that have been registered from Europe, Africa, and Asia. Additionally, molecular phylogenetic studies have shown that T. orientalis Iran GC98-01 isolate belongs to nonpathogenic T. orientalis type 3 (buffeli). In this study, the indigenous Bos indicus cattle were detected as asymptomatic carriers of Theileria spp. infection. Here, we identified and genotyped T. orientalis for the first time as T. orientalis type 3 (buffeli) in Iran using molecular phylogenetic analysis and registered the 18S rRNA gene sequence of the T. orientalis GC98-01 isolate in GenBank. Moreover, rare T. annulata infection was detected in cattle using semi-nested PCR in Mazandaran (Miankaleh peninsula). The T. orientalis can be differentiated from other Theileria and Babesia haemoprotozoan parasites by specific molecular assays.

Molecular Characterization and Phylogenetic Analysis of Pathogenic Theileria spp. Isolated from Cattle and Sheep based on Cytochrome b Gene in Iran.

The present study investigated the phylogenetic relationship based on cytochrome b gene sequences among pathogenic Theileria species (spp.) in Iran, including Theileria annulata and Theileria lestoquardi, along with other data available in GenBank. A total of 136 (cattle) and 80 (sheep) blood samples suspected of piroplasm infection were obtained from six different provinces of Iran. Both microscopic and molecular methods using species-specific primers were used for screening T. annulata and T. lestoquardi positive samples. Finally, the partial cytochrome b gene of 30 T. annulata and 5 T .lestoquardi were amplified, sequenced, and deposited in GenBank. The results indicated that there were 12 different genotypes among T. annulata isolates, while only one genotype was observed among T. lestoquardi isolates. T. lestoquardi infection in cattle was detected in one sample, and no T. annulata and T. lestoquardi coinfection were detected in sheep and cattle. In the phylogenetic tree, different Theileria spp. were placed in separate clades, and the reliability of depicted tree and monophyly of T. annulata and T. lestoquardi ingroups were supported by the bootstrap value of 94% which significantly indicated that these two species evolved from a common ancestor. The tree also showed that these two pathogenic spp. shared a more recent common ancestor, compared to another species of Theileria parasites. To the best of our knowledge, this study is the first phylogenic analysis of pathogenic Theileria spp. in Iran based on the cytochrome b gene sequences. In addition, the first T. lestoquardi cytochrome b gene was sequenced and deposited in GenBank.

Importance of miR-UL-148D Expression Pattern in Cytomegalovirus Infected Transplant Patients.

Background: MicroRNAs (miRNAs) are endogenous, 18-22 nucleotide non-coding RNA molecules. Human cytomegalovirus (HCMV) is a ubiquitous and particular herpes virus that encodes miRNAs, which increases gradually in the presence of infection. One of the important viral miRNAs is HCMV-miRUL-148D, which plays a role in establishing and maintaining viral latency. Objective: The current study aimed to evaluate the expression levels of HCMV-miRUL-148D in active and inactive HCMV infected transplant patient groups compared to healthy individuals. Methods: Total RNA was extracted from blood samples of 60 solid organ transplant patients and 30healthy controls. In-house SYBR Green Real-Time PCR evaluated the expression levels of studied miRNAand gene. Results: The expression level of the UL-148D gene was significantly higher in the active HCMV infectedpatients (p=0.001) compared to other groups. While the miRUL-148D expression level significantly increased in the inactive HCMV-infected patients (p<0.001) compared to other groups. Conclusion: Increased miRUL-148D expression level in the inactive HCMV-infected transplant patients indicates the potential role of this miRUL-148D as a biomarker of the HCMV latent stage.

Association between Interleukin-21, 23 and 27 Expression and Protein Level with Cytomegalovirus Infection in Liver Transplant Recipients.

BACKGROUND: Cytokines have regulatory crosstalk with CMV infection leading to manage of post-liver transplantation virus-related outcomes. OBJECTIVE: To investigate the link between IL-21, IL-23 and IL-27 mRNA and protein level with active CMV infection, which was evaluated in reactivated and non-reactivated liver transplant recipients. METHODS: Two groups of liver transplant recipients were enrolled in this study-54 without and 15 with active CMV infection. 3 EDTA-treated blood samples were taken on day 1, 4, and 7 post-liver transplantation. Plasma and buffy coats of all samples were separated. All samples were analyzed for CMV reactivation using antigenemia technique. The separated plasma of positive samples was used for viral DNA extraction and protein evaluation. For evaluating the mRNA expression level by real-time PCR, RNA extraction and cDNA synthesis were done for all samples. Also, the protein level of studied genes was estimated by ELISA. RESULTS: The expression level of IL-21, IL-23A and IL-27A cytokine genes was increased in CMV reactivated liver transplant recipients in comparison with CMV non-reactivated ones; IL-27A expression pattern was significant (p=0.001) at all sampling times. IL-21 significantly increased on the 2nd and 3rd (p=0.028 and 0.01, respectively) sampling days in CMV reactivated compared with non-reactivated patients. The expression level of IL-23A cytokine significantly increased on the 3rd (p=0.017) sampling day in CMV reactivated compared with non-reactivated liver transplant recipients. CONCLUSION: Elevation in the expression level of IL-21, IL-23A and IL-27A mRNA and protein level in CMV reactivated patients emphasized on the antiviral role of these cytokines in CMV reactivated liver transplant recipients.

Molecular detection of Theileria spp. and Babesia ovis Infection in Sheep in Baneh, Iran.

The purpose of the present study was to investigate the Theileria and Babesia infection in sheep using polymerase chain reaction (PCR) assay in Baneh, Iran. Theileria and Babesia are apicomplexan parasites that have both vertebral and invertebrate hosts. These protozoa, which are transmitted by tick vectors, are considered to be the most important causes of parasitic diseases in Iran.The detection methods of Babesia and Theileria spp. are morphological examination, serology tests, and more recently, molecular assays, such as PCR. In this study, a total of 66 blood samples were collected and analyzed using specific primers for Theileria annulata, T. ovis, T. lestoquardi, and Babesia ovis. Two PCR methods were used, namely semi-nested PCR and competitive PCR. Based on the results of the PCR assay of 66 sheep blood samples, B. ovis, T. ovis, T. lestoquardi, and T. annulata were detected in 57 (86.4%), 28 (42.4%), 0, and 16 (24%) cases, respectively. Detection of low levels of protozoan infection with high morbidity in the tested animals shows their status as a carrier that keeps the infection in the region and extends the protozoan life cycle. Another important factor is the geographical situation of Baneh as a border city since the hemoprotozoan infection is present in this region. Moreover, piroplasmida infection was found in Iraq and other neighboring provinces. Therefore, animal husbandry in Baneh is at the risk of infection with Babesia and Theileria. The collected data in this study are useful for reaching a better understanding of the epizootiology of theileriosis and babesiosis, in order to control and prevent the diseases in this region.

Antibacterial activity and sensory properties of Heracleum persicum essential oil, nisin, and Lactobacillus acidophilus against Listeria monocytogenes in cheese.

AIM: The aim of this study was to evaluate the antibacterial and chemical effect of Heracleum persicum essential oil (EO), nisin, Lactobacillus acidophilus, and their combination against Listeria monocytogenes both in vitro and in Iranian white cheese model. MATERIALS AND METHODS: Chemical compositions of H. persicum EO were analyzed by gas chromatography-mass spectrometry. After production of Iranian white cheese, minimum inhibitory concentration (MIC) and minimum bactericidal concentration of EO and nisin and agar spot test of L. acidophilus against L. monocytogenes were evaluated. RESULTS: Hexyl butanoate (25.98%), octyl isobutyrate (17.82%), methyl butyrate (14.37%), and pentyl cyclopropane (12.77%) were the main components of the EO. MIC of the EO against L. monocytogenes was 2.5 mg/mL. Combination of nisin (5.3 IU/mL) and H. persicum EO (2500 µg/mL) showed increasing effect against L. monocytogenes (fractional inhibitory concentration = 0.9), while a higher concentration of EO and nisin showed undesirable effect on the cheese flavor. Furthermore, a combination of 1012 CFU/g L. acidophilus with H. persicum EO at the concentration of 2.5 mg/mL (T12) showed acceptable sensorial and also antibacterial results in Iranian white cheese. CONCLUSION: Combination of H. persicum EO, L. acidophilus, and nisin can be recommended as natural preservatives and flavoring agents in cheese.

Characteristics of children aged 2-17 years undergoing anaesthesia in Danish hospitals 2005-2015: a national observational study.

Provision of paediatric anaesthesia requires careful consideration of the child's cognitive state, unique body composition and physiology. In an observational cohort study, we describe the population characteristics and conduct of anaesthesia in children aged 2-17 years from 1 January 2005 to 31 December 2015. Children were identified from the Danish Anaesthesia Database. We recorded the following variables: age; sex; comorbidities; indications for anaesthesia; practice of anaesthesia; and complications. Results are presented for two age groups: 2-5 and 6-17 years. In total, 32,840 (61% male) children aged 2-5 years received 50,484 anaesthesia episodes and 91,418 (54% male) children aged 6-17 years received 141,082 anaesthesia episodes. The younger children, compared with the older children, were more frequently anaesthetised at a university hospital (50% vs. 36%) and for non-surgical procedures (24% vs. 8%). For both age groups, general anaesthesia was the primary choice of anaesthesia regardless of the reason for anaesthesia. For surgery, general anaesthesia using inhalational agents in addition to intravenous agents or alone was more frequently used in younger children (49% vs. 15%), whereas older children commonly received total intravenous anaesthesia (50% vs. 83%). Regional anaesthesia was infrequently utilised. Complications occurred in 3.3% of anaesthesia episodes among 2-5 year olds compared with 3.7% of anaesthesia episodes among children aged 6-17 years. In conclusion, we found younger children (aged 2-5), compared with older children (aged 6-17) were more frequently anaesthetised for non-surgical reasons, at a university hospital and using inhalational agents. Complications were rare.

Probiotic white cheese production using coculture with Lactobacillus species isolated from traditional cheeses.

AIM: The aim of the present study was to investigate the viability of lactic acid bacteria isolated from traditional cheeses and cocultured in Iranian white cheese during ripening. MATERIALS AND METHODS: A total of 24 samples were isolated from 8 types of traditional cheeses in West Azerbaijan, Iran. Isolated species were cocultured with starter bacteria during the production of Iranian white cheese, and their viability was investigated up to 60 days of the refrigerated storage. RESULTS: Of 118 isolates of Lactobacillus, 73 isolates (62%) were confirmed as facultative heterofermentative and 45 isolates (38%) as obligate homofermentative. Of the facultative heterofermentatives, 28 isolates (24%) were Lactobacillus plantarum, 24 isolates (20%) were Lactobacillus casei, and 21 isolates (18%) were Lactobacillus agilis. Obligate homofermentatives were Lactobacillus delbrueckii (21%), Lactobacillus helveticus (14%), and Lactobacillus salivarius (3%). L. plantarum, L. casei and L. helveticus were found in high enough levels(106 CFU/g). CONCLUSION: According to the obtained data, it is recommended that complex starters such as L. helveticus, L. plantarum, and L. casei can be used in industrial productions of cheese to obtain exclusive properties of traditional cheeses.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology

The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.(AU)

Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005-2015: a national observational study.

There are few data available that describe the current anaesthetic management of children. We have analysed anaesthetic practice and peri-operative complications for children in Denmark aged less than two years. We conducted a population-based observational cohort study using the Danish Anaesthesia Database to identify children who received anaesthesia in hospital from 1 January 2005 until 31 December 2015. Data were combined with that from the Danish National Patient Registry and the Danish Civil Registration System. Age, sex, height, weight, ASA physical status, days in hospital before anaesthesia, number of anaesthetics per child, indications for anaesthesia, methods of anaesthesia, airway management and complications were all recorded. A total of 17,436 children (64% of whom were male) received 27,653 anaesthetics during the study period. In 58% of cases, the child had an ASA physical status score of 1. Thirty-seven percent had a previous anaesthetic episode. Seventy-nine percent were anaesthetised at a university hospital. The indications for anaesthesia were surgery (70%), diagnostic radiology (16%), non-surgical care (11%) and other indications (3%). General anaesthesia combining intravenous and inhalational agents was the most common approach for surgery (68%) and diagnostic radiology (47%). For non-surgical care, general anaesthesia using inhalational agents was the most common method (42%). Neuraxial blocks were used infrequently. The most common regional anaesthetic nerve block was an infraclavicular brachial plexus block (11%). Peri-operative complications occurred in 1.71% of cases. A large proportion of anaesthetics were conducted in children with comorbidities. Non-surgical indications for anaesthesia were frequent and peri-operative complications were rare.

The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta-analysis and trial sequential analysis.

We compared the efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. Our outcomes were: recovery time from second twitch to train-of-four ratio > 0.9; recovery time from post-tetanic count 1-5 to train-of-four ratio > 0.9; and risk of composite adverse and serious adverse events. We searched for randomised clinical trials irrespective of publication status and date, blinding status, outcomes reported or language. We included 41 studies with 4206 participants. Time to reversal of neuromuscular blockade from second twitch to a train-of-four ratio > 0.9 was 2.0 min with sugammadex 2 mg.kg-1 and 12.9 min with neostigmine 0.05 mg.kg-1 , with a mean difference (MD) (95%CI)) of 10.2 (8.5-12.0) (I2  = 84%, 10 studies, n = 835, Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate quality). Time to reversal of neuromuscular blockade from a post-tetanic count of 1-5 to a train-of-four ratio > 0.9 was 2.9 min with sugammadex 4 mg.kg-1 and 48.8 min with neostigmine 0.07 mg.kg-1 , with a MD (95%CI) of 45.8 (39.4-52.2) (I2  = 0%, 2 studies, n = 114, GRADE: low quality). There were significantly fewer composite adverse events in the sugammadex group compared with neostigmine, with a risk ratio (95%CI) of 0.60 (0.49-0.74) (I2  = 40%, 28 studies, n = 2298, number needed to treat (NNT): 8, GRADE: moderate quality). Specifically, the risk of bradycardia (RR (95%CI) 0.16 (0.07-0.34), n = 1218, NNT: 14, GRADE: moderate quality), postoperative nausea and vomiting (RR (95%CI) 0.52 (0.28-0.97), n = 389, NNT: 16, GRADE: low quality) and overall signs of postoperative residual paralysis (RR (95%CI) 0.40 (0.28-0.57), n = 1474, NNT: 13, GRADE: moderate quality) were all reduced. There was no significant difference regarding the risk of serious adverse events (RR 0.54, 95%CI 0.13-2.25, I2  = 0%, n = 959, GRADE: low quality). Sugammadex reverses neuromuscular blockade more rapidly than neostigmine and is associated with fewer adverse events.

Association between IRF1 Gene Expression and Liver Enzymes in HBV-infected Liver Transplant Recipients with and without Experience of Rejection.

BACKGROUND: Liver function indices and anti-viral immune regulatory markers can both improve graft outcomes, which lead to better post-transplantation management and increase the possibility of surveillance in liver transplant recipients with chronic hepatitis B virus (HBV) infection. OBJECTIVE: To determine the association between the interferon regulatory factor 1 (IRF1) mRNA levels and liver enzymes in HBV-infected liver transplant recipients with and without experience of rejection. METHODS: A total of 46 chronic HBV-infected patients who had undergone liver transplant surgery was divided into 2 groups of recipients "with rejection" and "without rejection.". Blood samples were collected form each patient on days 1, 4, and 7 post-transplantation. A SYBER GREEN real-time PCR was used to evaluate the expression level of IRF1 in liver recipients. Liver enzyme activities were also measured in all patients. RESULTS: The expression of IRF1 in the patients with rejection was up-regulated at all 3 follow-up days compared with those without rejection. The serum levels of ALT and AST were more than normal levels at 3 follow-up times in both study groups. Significant differences were found in IRF1 gene expression levels and also serum ALT levels between those with and without rejection after 7 days post-transplantation. CONCLUSION: The IRF1 expression and serum ALT levels were increased significantly in patient with rejection compared to those without rejection. IRF1, an inflammatory factor, may also intensify induction of inflammatory pathways in engrafted liver and promote liver inflammation and injuries leading to liver enzymes elevation in patients with graft rejection.

Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review.

We aimed to assess the effectiveness of remifentanil used as intravenous patient-controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster-randomised trials of women in labour with planned vaginal delivery receiving patient-controlled remifentanil compared principally with other parenteral and patient-controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. The primary outcomes were patient satisfaction with pain relief and the occurrence of adverse events for mothers and newborns. We assessed risk of bias for each included study and applied the GRADE approach for the quality of evidence. We included total zero event trials, using a constant continuity correction of 0.01 and a random-effect meta-analysis. Twenty studies were included in the qualitative analysis; within these, 3713 participants were randomised and 3569 analysed. Most of our pre-specified outcomes were not studied in the included trials. However, we found evidence that women using patient-controlled remifentanil were more satisfied with pain relief than women receiving parenteral opioids (four trials, 216 patients, very low quality evidence) with a standardised mean difference ([SMD] 95%CI) of 2.11 (0.72-3.49), but were less satisfied than women receiving epidural analgesia (seven trials, 2135 patients, very low quality evidence), -0.22 (-0.40 to -0.04). Data on adverse events were sparse. However, the relative risk (95%CI) for maternal respiratory depression for patient-controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low-quality evidence) was 0.91 (0.51-1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low-quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low-quality evidence) was 1.26 (0.62-2.57).

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to monitor haemostatic treatment in bleeding patients: a systematic review with meta-analysis and trial sequential analysis.

Coagulopathy and severe bleeding are associated with high mortality. We evaluated haemostatic treatment guided by the functional viscoelastic haemostatic assays, thromboelastography or rotational thromboelastometry in bleeding patients. We searched for randomised, controlled trials irrespective of publication status, publication date, blinding status, outcomes published or language from date of inception to 5 January 2016 in six bibliographic databases. We included 17 trials (1493 participants), most involving cardiac surgery. Thromboelastography or rotational thromboelastometry seemed to reduce overall mortality compared to any of our comparisons (3.9% vs. 7.4%, RR (95% CI) 0.52 (0.28-0.95); I2 = 0%, 8 trials, 717 participants). However, the quality of evidence is graded as low due to the high risk of bias, heterogeneity, imprecision and low event rate. Thromboelastography or rotational thromboelastometry significantly reduced the proportion of patients transfused with red blood cells (RR (95% CI) 0.86 (0.79-0.94); I2 = 0%, 10 trials, 832 participants), fresh frozen plasma (RR (95% CI) 0.57 (0.33-0.96); I2 = 86%, 10 trials, 832 participants) and platelets (RR (95% CI) 0.73 (0.60-0.88); I2 = 0%, 10 studies, 832 participants). There was no difference in proportion needing surgical re-interventions (RR (95% CI) 0.75 (0.50-1.10); I2 = 0%, 9 trials, 887 participants). Trial sequential analysis of mortality suggests that only 54% of the required information size has been reached so far. Transfusion strategies guided by thromboelastography or rotational thromboelastometry may reduce the need for blood products in patients with bleeding, but the results are mainly based on trials of elective cardiac surgery involving cardiopulmonary bypass, with low-quality evidence.

Prediction of difficult mask ventilation using a systematic assessment of risk factors vs. existing practice - a cluster randomised clinical trial in 94,006 patients.

We compared implementation of systematic airway assessment with existing practice of airway assessment on prediction of difficult mask ventilation. Twenty-six departments were cluster-randomised to assess eleven risk factors for difficult airway management (intervention) or to continue with their existing airway assessment (control). In both groups, patients predicted as a difficult mask ventilation and/or difficult intubation were registered in the Danish Anaesthesia Database, with a notational summary of airway management. The trial's primary outcome was the respective incidence of unpredicted difficult and easy mask ventilation in the two groups. Among 94,006 patients undergoing mask ventilation, the incidence of unpredicted difficult mask ventilation in the intervention group was 0.91% and 0.88% in the control group; (OR) 0.98 (95% CI 0.66-1.44), p = 0.90. The incidence of patients predicted difficult to mask ventilate, but in fact found to be easy ('falsely predicted difficult') was 0.64% vs. 0.35% (intervention vs. control); OR 1.56 (1.01-2.42), p = 0.045. In the intervention group, 86.3% of all difficult mask ventilations were not predicted, compared with a higher proportion 91.2% in the control group, OR 0.61 (0.41-0.91), p = 0.016. The systematic intervention did not alter the overall incidence of unpredicted difficult mask ventilations, but of the patients who were found to be difficult to mask ventilate, the proportion predicted was higher in the intervention group than in the control group. However, this was at a 'cost' of increasing the number of mask ventilations falsely predicted to be difficult.

The effect of inhaled nitric oxide in acute respiratory distress syndrome in children and adults: a Cochrane Systematic Review with trial sequential analysis.

Acute respiratory distress syndrome is associated with high mortality and morbidity. Inhaled nitric oxide has been used to improve oxygenation but its role remains controversial. Our primary objective in this systematic review was to examine the effects of inhaled nitric oxide administration on mortality in adults and children with acute respiratory distress syndrome. We included all randomised, controlled trials, irrespective of date of publication, blinding status, outcomes reported or language. Our primary outcome measure was all-cause mortality. We performed several subgroup and sensitivity analyses to assess the effect of inhaled nitric oxide. There was no statistically significant effect of inhaled nitric oxide on longest follow-up mortality (inhaled nitric oxide group 250/654 deaths (38.2%) vs. control group 221/589 deaths (37.5%; relative risk (95% CI) 1.04 (0.9-1.19)). We found a significant improvement in PaO2 /FI O2 ratio at 24 h (mean difference (95% CI) 15.91 (8.25-23.56)), but not at 48 h or 72 h, while four trials indicated improved oxygenation in the inhaled nitric oxide group at 96 h (mean difference (95% CI) 14.51 (3.64-25.38)). There were no statistically significant differences in ventilator-free days, duration of mechanical ventilation, resolution of multi-organ failure, quality of life, length of stay in intensive care unit or hospital, cost-benefit analysis and methaemoglobin and nitrogen dioxide levels. There was an increased risk of renal impairment (risk ratio (95% CI) 1.59 (1.17-2.16)) with inhaled nitric oxide. In conclusion, there is insufficient evidence to support inhaled nitric oxide in any category of critically ill patients with acute respiratory distress syndrome despite a transient improvement in oxygenation, since mortality is not reduced and it may induce renal impairment.