The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial.

The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248-577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186-474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.

The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients.

Facemask ventilation is an essential part of airway management. Correctly predicting difficulties in facemask ventilation may reduce the risk of morbidity and mortality among patients at risk. We aimed to develop and evaluate a weighted risk score for predicting difficult facemask ventilation during anaesthesia. We analysed a cohort of 46,804 adult patients who were assessed pre-operatively airway for 13 predictors of difficult airway management and subsequently underwent facemask ventilation during general anaesthesia. We developed the Difficult Facemask (DIFFMASK) score in two consecutive steps: first, a multivariate regression analysis was performed; and second, the regression coefficients of the adjusted regression model were converted into a clinically applicable weighted point score. The predictive accuracy of the DIFFMASK score was evaluated by assessment of receiver operating characteristic curves. The prevalence of difficult facemask ventilation was 1.06% (95%CI 0.97-1.16). Following conversion of regression coefficients into 0, 1, 2 or 3 points, the cumulated DIFFMASK score ranged from 0 to 18 points and the area under the receiver operating characteristic curve was 0.82. The Youden index indicated a sum score ≥ 5 as an optimal cut-off value for prediction of difficult facemask ventilation giving a sensitivity of 85% and specificity of 59%. The DIFFMASK score indicated that a score of 6-10 points represents a population of patients who may require heightened attention when facemask ventilation is planned, compared with those patients who are obviously at a high- or low risk of difficulties. The DIFFMASK score may be useful in a clinical context but external, prospective validation is needed.

Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database.

Indications for using supraglottic airway devices have widened over time and they now hold a prominent role in guidelines for difficult airway management. We aimed to describe the use of supraglottic airway devices in difficult airway management. We included adult patients undergoing general anaesthesia registered in the Danish Anaesthesia Database from 2008 to 2012 whose airway management had been recorded as difficult, defined as: ≥ 3 tracheal intubation attempts; failed tracheal intubation; or difficult facemask ventilation. In the Danish Anaesthesia Database, a separate difficult airway management module requires the technique used in each successive airway management attempt to be recorded. The primary aim of the study was to describe the use of supraglottic airway devices in cases of difficult airway management. Secondary aims were to examine success rates of supraglottic airway devices in difficult airway management cases, and specifically in the cases of 'cannot intubate, cannot facemask ventilate'. Difficult airway management occurred in 4898 (0.74% (95%CI 0.72-0.76%)) of 658,104 records of general anaesthesia. Supraglottic airway devices were used or use was attempted in 607 cases of difficult airway management (12.4% (95%CI 11.5-13.3%)), and were successful in 395 (65.1% (95%CI 61.2-68.8%)) cases. In 'cannot intubate, cannot facemask ventilate' situations, supraglottic airway devices were used in 86 (18.9% (95%CI 15.6-22.8%)) of 455 records and were successful in 54 (62.8% (95%CI 52.2-72.3%)) cases. We found that supraglottic airway devices are not widely used in the management of the difficult airway despite their prominent role in difficult airway management guidelines.

Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review.

Cohort studies have indicated that avoidance of neuromuscular blocking agents (NMBA) is a risk factor for difficult tracheal intubation. However, the impact of avoiding NMBA on tracheal intubation, possible adverse effects, and postoperative discomfort has not been evaluated in a systematic review of randomised trials. We searched several databases for trials published until January 2017. We included randomised controlled trials comparing the effect of avoiding vs using NMBA. Two independent authors assessed risk of bias and extracted data. The risk of random errors was assessed by trial sequential analysis (TSA). We included 34 trials (3565 participants). In the four trials judged to have low risk of bias, there was an increased risk of difficult tracheal intubation with no use of NMBA [random-effects model, risk ratio (RR) 13.27, 95% confidence interval (CI) 8.19-21.49, P<0.00001, TSA-adjusted CI 1.85-95.04]. The result was confirmed when including all trials, (RR 5.00, 95% CI 3.49-7.15, P<0.00001, TSA-adjusted CI 1.20-20.77). There was a significant risk of upper airway discomfort or injury by avoiding NMBA (RR=1.37, 95% CI 1.09-1.74, P=0.008, TSA-adjusted CI 1.00-1.86). None of the trials reported mortality. Avoiding NMBA was significantly associated with difficult laryngoscopy, (RR 2.54, 95% CI 1.53-4.21, P=0.0003, TSA-adjusted CI 0.27-21.75). In a clinical context, one must balance arguments for using NMBA when performing tracheal intubation.

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.

Emergency surgical airway management in Denmark: a cohort study of 452 461 patients registered in the Danish Anaesthesia Database.

BACKGROUND: The emergency surgical airway (ESA) is the final option in difficult airway management. We identified ESA procedures registered in the Danish Anaesthesia Database (DAD) and described the performed airway management. METHODS: We extracted a cohort of 452 461 adult patients undergoing general anaesthesia and tracheal intubation from the DAD from June 1, 2008 to March 15, 2014. Difficult airway management involving an ESA was retrieved for analysis and compared with hospitals files. Two independent reviewers evaluated airway management according to the ASAs'2003 practice guideline for difficult airway management. RESULTS: In the DAD cohort 27 out of 452 461 patients had an ESA representing an incidence of 0.06 events per thousand (95% CI; 0.04 to 0.08). A total of 12 149/452 461 patients underwent Ear-Nose and Throat (ENT) surgery, giving an ESA incidence among ENT patients of 1.6 events per thousand (95% CI; 1.0-2.4). A Supraglottic Airway Device and/or the administration of a neuromuscular blocking agent before ESA were used as a rescue in 6/27 and 13/27 of the patients, respectively. In 19/27 patients ENT surgeons performed the ESA's and anaesthetists attempted 6/27 of the ESAs of which three failed. Reviewers evaluated airway management as satisfactory in 10/27 patients. CONCLUSIONS: The incidence of ESA in the DAD cohort was 0.06 events per thousand. Among ENT patients, the ESA Incidence was 1.6 events per thousand. Airway management was evaluated as satisfactory for 10/27 of the patients. ESA performed by anaesthetists failed in half of the patients.

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.

Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.

Both the American Society of Anesthesiologists and the UK NAP4 project recommend that an unspecified pre-operative airway assessment be made. However, the choice of assessment is ultimately at the discretion of the individual anaesthesiologist. We retrieved a cohort of 188 064 cases from the Danish Anaesthesia Database, and investigated the diagnostic accuracy of the anaesthesiologists' predictions of difficult tracheal intubation and difficult mask ventilation. Of 3391 difficult intubations, 3154 (93%) were unanticipated. When difficult intubation was anticipated, 229 of 929 (25%) had an actual difficult intubation. Likewise, difficult mask ventilation was unanticipated in 808 of 857 (94%) cases, and when anticipated (218 cases), difficult mask ventilation actually occurred in 49 (22%) cases. We present a previously unpublished estimate of the accuracy of anaesthesiologists' prediction of airway management difficulties in daily routine practice. Prediction of airway difficulties remains a challenging task, and our results underline the importance of being constantly prepared for unexpected difficulties.