Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis.

BACKGROUND: Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS: CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS: Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS: Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.

Sleep and pain management: a review.

There is a complex interplay between sleep disturbance and patients in pain. There is an increasing appreciation of the direct effects of analgesic drugs and sleep quality. This review provides an overview of the effects of different analgesic drugs and their effects on phases of sleep. The effects of different pain conditions and their direct effects on sleep physiology are also discussed. A structured search of the scientific literature using MEDLINE and PubMed databases. Original human and animal studies were included. A multi-search term strategy was employed. An appreciation of the physiological effects of these drugs will allow a more considered prescription of them to better manage sleep disturbance.

General anaesthesia during caesarean sections: implications for the mother, foetus, anaesthetist and obstetrician.

PURPOSE OF REVIEW: A general anaesthetic is usually given for an emergency caesarean section (Category 1), where there is imminent threat to the mother or foetus. There are many risks in performing a general anaesthetic. The aim of this review is to highlight the effects and risks to the mother and foetus of each step of a general anaesthetic. RECENT FINDINGS: Anaesthetic techniques are changing, and the traditional mantra of using a general anaesthetic for an emergency caesarean sections is being challenged. There are also multiple potential risks of a general anaesthetic that are being better defined. This ranges from awareness during surgery, through to foetal and maternal risks of complications. SUMMARY: This review will outline the different stages of a general anaesthetic and highlight the risks. This summary will allow a better understanding of anaesthetic risks. This will allow obstetricians to have a more informed conversation with an anaesthetist as to form of anaesthetic required (general anaesthetic versus spinal or epidural top-up). The review will also allow obstetricians to give more informed consent to mothers and be aware of the postoperative risks.

Clinical pearls part 3: anaesthetic management of abnormally invasive placentation.

PURPOSE OF REVIEW: Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature. RECENT FINDINGS: Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients. SUMMARY: A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

Clinical 'pearls' of maternal critical care Part 2: sickle-cell disease in pregnancy.

PURPOSE OF REVIEW: The current review outlines the challenges in managing pregnant women with sickle-cell anemia, who are at risk of becoming critically ill during pregnancy. RECENT FINDINGS: Sickle obstetric patients pose unique challenges to the anesthetist and intensivist. We discuss the role of prophylactic transfusions for specific indications like acute anemia and twin pregnancies. The management and prevention of vaso-occlusive crises and chest crisis are also outlined. The role of the multidisciplinary team cannot be overstated.Massive obstetric hemorrhage in this population is difficult, and unique considerations such as cell-saver technology and tranexamic acid usage are discussed. Secondary complications such as pulmonary hypertension and stroke are also considered, with a summary of the latest treatment guidelines. SUMMARY: This is a challenging cohort of pregnant patients who have a significantly increased morbidity and mortality. This review aims to aid management of these patients on the labor ward for both obstetric anesthetists and intensivists.

Anaesthesia for neuroradiology: thrombectomy: 'one small step for man, one giant leap for anaesthesia'.

PURPOSE OF REVIEW: Endovascular management of acute thrombotic strokes is a new management technique. Anaesthesia will play a key role in the management of these patients. To date there is no established method of managing these patients from an anaesthetic perspective. RECENT FINDINGS: In 2015, five landmark studies popularized intra-arterial clot retrieval for ischaemic strokes. Since then there have been a number of small studies investigating the best anaesthetic technique, taking into account patient, technical, and clinical factors. This review summarizes these studies and discusses the different anaesthetic options, with their relative merits and pitfalls. SUMMARY: There is a paucity of robust evidence for the best anaesthetic practice in this cohort of patients. Airway protection seems to be an issue in 2.5% of cases. Timing of the procedure is vital, and any delay may be detrimental to neurological outcome. In a survey of neurointerventionalists, the main concern they expressed was the potential delay to revascularization posed by anaesthesia. Patients complain of pain during mechanical clot retrieval if awake. The overall consensus seems to be favouring conscious sedation over general anaesthesia in the acute setting.

Acute skeletal muscle wasting in critical illness.

IMPORTANCE: Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment. OBJECTIVE: To perform a comprehensive prospective characterization of skeletal muscle wasting, defining the pathogenic roles of altered protein synthesis and breakdown. DESIGN, SETTING, AND PARTICIPANTS: Sixty-three critically ill patients (59% male; mean age: 54.7 years [95% CI, 50.0-59.6 years]) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 (95% CI, 21.9-25.2) were prospectively recruited within 24 hours following intensive care unit (ICU) admission from August 2009 to April 2011 at a university teaching and a community hospital in England. Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours, to spend more than 7 days in critical care, and to survive ICU stay. MAIN OUTCOMES AND MEASURES: Muscle loss was determined through serial ultrasound measurement of the rectus femoris cross-sectional area (CSA) on days 1, 3, 7, and 10. In a subset of patients, the fiber CSA area was quantified along with the ratio of protein to DNA on days 1 and 7. Histopathological analysis was performed. In addition, muscle protein synthesis, breakdown rates, and respective signaling pathways were characterized. RESULTS: There were significant reductions in the rectus femoris CSA observed at day 10 (−17.7% [95% CI, −25.9% to 8.1%]; P < .001). In the 28 patients assessed by all 3 measurement methods on days 1 and 7, the rectus femoris CSA decreased by 10.3% (95% CI, 6.1% to 14.5%), the fiber CSA by 17.5% (95% CI, 5.8% to 29.3%), and the ratio of protein to DNA by 29.5% (95% CI, 13.4% to 45.6%). Decrease in the rectus femoris CSA was greater in patients who experienced multiorgan failure by day 7 (−15.7%; 95% CI, −27.7% to 11.4%) compared with single organ failure (−3.0%; 95% CI, −5.3% to 2.1%) (P < .001), even by day 3 (−8.7% [95% CI, −59.3% to 50.6%] vs −1.8% [95% CI, −12.3% to 10.5%], respectively; P = .03). Myofiber necrosis occurred in 20 of 37 patients (54.1%). Protein synthesis measured by the muscle protein fractional synthetic rate was depressed in patients on day 1 (0.035%/hour; 95% CI, 0.023% to 0.047%/hour) compared with rates observed in fasted healthy controls (0.039%/hour; 95% CI, 0.029% to 0.048%/hour) (P = .57) and increased by day 7 (0.076% [95% CI, 0.032%-0.120%/hour]; P = .03) to rates associated with fed controls (0.065%/hour [95% CI, 0.049% to 0.080%/hour]; P = .30), independent of nutritional load. Leg protein breakdown remained elevated throughout the study (8.5 [95% CI, 4.7 to 12.3] to 10.6 [95% CI, 6.8 to 14.4] µmol of phenylalanine/min/ideal body weight × 100; P = .40). The pattern of intracellular signaling supported increased breakdown (n = 9, r = −0.83, P = .005) and decreased synthesis (n = 9, r = −0.69, P = .04). CONCLUSIONS AND RELEVANCE: Among these critically ill patients, muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure. These findings may provide insights into skeletal muscle wasting in critical illness.

Neuromuscular blockade and skeletal muscle weakness in critically ill patients: time to rethink the evidence?

Neuromuscular blocking agents are commonly used in critical care. However, concern after observational reports of a causal relationship with skeletal muscle dysfunction and intensive care-acquired weakness (ICU-AW) has resulted in a cautionary and conservative approach to their use. This integrative review, interpreted in the context of our current understanding of the pathophysiology of ICU-AW and integrated into our current conceptual framework of clinical practice, challenges the established clinical view of an adverse relationship between the use of neuromuscular blocking agents and skeletal muscle weakness. In addition to discussing data, this review identifies potential confounders and alternative etiological factors responsible for ICU-AW and provides evidence that neuromuscular blocking agents may not be a major cause of weakness in a 21st century critical care setting.