Pre-operative transnasal endoscopy as a predictor of difficult airway: A prospective cohort study.

BACKGROUND: Consequences of failed endotracheal intubation can be catastrophic and predicting difficulty is therefore a critical issue. There is no consensus on the best way to predict difficulty. OBJECTIVE: To evaluate the role of transnasal flexible endoscopic laryngoscopy (TFEL), a minimally invasive procedure, in the prediction of difficult intubation. DESIGN: Prospective cohort study. SETTING: San Raffaele Hospital, Milan, a tertiary university hospital. PATIENTS: One hundred and sixty nine adults scheduled for elective ear, nose and throat surgery under general anaesthesia with pre-operative TFEL. INTERVENTION: In addition to routine pre-operative evaluation by an anaesthesiologist, glottis exposure during TFEL was assessed with a scoring system similar to the modified Cormack-Lehane (MCL). MAIN OUTCOME MEASURES: The extent to which TFEL improves the prediction of difficult direct laryngoscopy, measured with the MCL score, and of difficult intubation, measured with the intubation difficulty scale score. RESULTS: When added to bedside evaluation, TFEL performed during tongue protrusion significantly (P = 0.005) improved the prediction of MCL. The area under the receiver operating characteristics curve was 0.75 [95% confidence interval (CI) 0.67 to 0.83] vs. 0.65 (95% CI 0.58 to 0.74). For the intubation difficulty scale (P = 0.049), the area under the receiver operating characteristics curve was 0.70 (95% CI 0.61 to 0.80) vs. 0.66 (95% CI 0.58 to 0.74). CONCLUSION: TFEL is a useful tool in predicting difficult intubation, improving predictability of routine bedside evaluation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02671877.

Intrathecal lactate as a predictor of early- but not late-onset spinal cord injury in thoracoabdominal aneurysmectomy.

OBJECTIVE: To evaluate the role of intrathecal lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysmectomy. DESIGN: Observational study. SETTING: University hospital. PARTICIPANTS: Forty-four consecutive patients scheduled to undergo thoracoabdominal aortic aneurysmectomy. Two patients had a type-B dissecting aneurysm while the other 42 patients suffered from degenerative aneurysm. INTERVENTIONS: None. METHODS: During surgery, samples of cerebrospinal fluid and arterial blood were withdrawn simultaneously to evaluate lactate concentration. Samples were collected at 4 fixed times during and after surgery: T1 (beginning of the intervention), T2 (15 minutes after aortic cross-clamping), T3 (just before unclamping), T4 (end of surgery). MEASUREMENTS AND MAIN RESULTS: Mean lactate levels in cerebrospinal fluid rose consistently and steadily from the beginning of the intervention until after surgery (T1 = 1.83 mmol/L), T2 = 2.10 mmol/L, T3 = 2.72 mmol/L, T4 = 3.70 mmol/L). Seven patients developed spinal cord injury; two of them had delayed injury occurring 24 hours after the end of surgery; the remaining 5 had early onset. In this group of 5 patients, preoperative cerebrospinal fluid lactate levels were significantly (p = 0.04) higher than those of the other 37 patients preoperatively (2.12 ± 0.35 v 1.79 ± 0.29 mmol/L). CONCLUSIONS: Preoperative cerebrospinal lactate concentration is elevated in patients who will develop early-onset spinal cord injury after thoracoabdominal aortic aneurysmectomy. This may allow a better stratification of these patients, suggesting a more aggressive strategy of spinal cord function preservation, such as systematic reimplanting of intercostal arteries, and possibly obtaining a better outcome.

Intrathecal lactate concentration and spinal cord injury in thoracoabdominal aortic surgery.

OBJECTIVE: The aim of this study was to evaluate the role of lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysm repair. DESIGN: Observational study. SETTING: University hospital. PARTICIPANTS: Sixteen consecutive patients (10 men and 6 women) scheduled to undergo thoracoabdominal aortic aneurysm repair were enrolled in the study. All patients were affected by atherosclerotic aneurysmal pathology. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During surgery, the authors simultaneously withdrew samples of cerebrospinal fluid and arterial blood to evaluate pO(2), pCO(2), pH, and lactate concentration. Samples were collected at 5 fixed times during and after surgery: T1 (before aortic cross-clamping), T2 (15 minutes after clamping), T3 (just before unclamping), T4 (end of surgery), and T5 (4 hours after the end of surgery). Lactate levels in cerebrospinal fluid rose consistently during aortic cross-clamping (T1 = 1.89 mmol/L, T2 = 2.21 mmol/L, T3 = 2.88 mmol/L, T4 = 3.655 mmol/L, and T5 = 3.16 mmol/L). Lactate concentrations in the cerebrospinal fluid were significantly higher in the 4 patients who developed neurologic injury, even at T1 (before surgery), than in those who did not end in spinal cord injury with the 4 highest values belonging to the 4 patients who later developed spinal cord injury. CONCLUSIONS: This study has the potential to elucidate the time course of early lactate level elevation during thoracoabdominal aortic aneurysm repair and its clinical use in predicting the development of postoperative spinal cord injury.

Publication trends in the journal of cardiothoracic and vascular anesthesia: a 10-year analysis.

OBJECTIVE: Good quality clinical research in anesthesiology is now performed all over the world. The aim of this article was to present and analyze the scientific contributions published in the Journal of Cardiothoracic and Vascular Anesthesia and to give a structured view focused on the countries where these studies were performed. DESIGN: Bibliometric analysis. SETTING: Teaching hospital. PARTICIPANTS: None. INTERVENTIONS: The authors analyzed the geographic distribution of the authors publishing in cardiac anesthesia. MEASUREMENTS AND MAIN RESULTS: Data were obtained from the Scopus database. All works belonging to document-type articles, reviews, letters, and editorials published over a 10-year period (2000-2009) in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) were tracked. For each article, the country of origin of the corresponding author was retrieved. JCVA published 1,816 articles from 45 different countries. The United States accounted for 43.8% of the total, followed by India (8.3%), Germany (5.5%), United Kingdom (4.7%), and Italy (4.4%). CONCLUSIONS: JCVA has a widespread influence and receives contributions from all over the world. More and more biomedical research is conducted outside North America and Europe, with India leading the group of "rest of the world" countries. The recent development of Asian countries clearly challenges North America and European countries that can no longer ignore the scientific contribution from these parts of the world. With this in mind, some journals such as JCVA are giving voice to these prolific countries, which represents a fundamental forum for these newcomers to the field of cardiac anesthesia.

Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials.

OBJECTIVE: The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing cardiac surgery under general anesthesia. DESIGN: Meta-analysis. SETTING: Hospitals. PARTICIPANTS: A total of 2366 patients from 33 randomized trials. INTERVENTIONS: None. DATA SOURCES AND STUDY SELECTION: PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 [2.7%] in the epidural group v 64/1241 [5.2%] in the control arm, odds ratio [OR] = 0.61 [0.40-0.95], p = 0.03 number needed to treat [NNT] = 40), the risk of acute renal failure (35/590 [5.9%] in the epidural group v 54/618 [8.7%] in the control arm, OR = 0.56 [0.34-0.93], p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = -2.48 hours [-2.64, -2.32], p < 0.001). CONCLUSIONS: This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint of mortality and myocardial infarction in patients undergoing cardiac surgery.