Channelled versus nonchannelled Macintosh videolaryngoscope blades in patients with a cervical collar: a randomized controlled noninferiority trial.

PURPOSE: Channelled blades have the advantage of avoiding stylet use and potential airway injury during videolaryngoscopic intubation. Nevertheless, the effectiveness of channelled Macintosh-type blades has not yet been fully established. We sought to assess the utility of channelled Macintosh-type blades for videolaryngoscopic intubation under cervical spine immobilization. METHODS: We conducted a randomized controlled noninferiority trial in neurosurgical patients with a difficult airway simulated by a cervical collar. Videolaryngoscopic intubation with a reinforced tracheal tube was performed using a channelled Macintosh-type blade without a stylet (channelled group, n = 130) or a nonchannelled Macintosh-type blade with a stylet (nonchannelled group, n = 131). The primary outcome was intubation success rate. Secondary outcomes included time to intubation and incidence or severity of intubation-related complications (subglottic, lingual, and dental injuries; bleeding; sore throat; and hoarseness). RESULTS: The initial intubation success rate was 98% and 99% in the channelled and nonchannelled groups, respectively, showing the noninferiority of the channelled group (difference in proportions -0.8%; 95% confidence interval [CI], -4.8% to 2.9%; predefined noninferiority margin, -5%; P = 0.62). Fewer participants in the channelled group had subglottic injuries than in the nonchannelled group (32% [32/100] vs 57% [54/95]; difference in proportions, -25%; 95% CI, -39% to -11%; P < 0.001). There were no significant differences between the two groups in the overall intubation success rate, time to intubation, and incidence or severity of other intubation-related complications. CONCLUSIONS: For videolaryngoscopic intubation in patients with a cervical collar, channelled Macintosh-type blades are an alternative to nonchannelled Macintosh-type blades, with a noninferior initial intubation success rate and a lower incidence of subglottic injury. STUDY REGISTRATION: CRIS.nih.go.kr ( KCT0005186 ); first submitted 29 June 2020.

RéSUMé: OBJECTIF: Les lames avec canal ont l'avantage de ne pas nécessiter l'utilisation d'un stylet et d'ainsi éviter les lésions potentielles des voies aériennes lors de l'intubation vidéolaryngoscopique. Néanmoins, l'efficacité des lames avec canal de type Macintosh n'a pas encore été pleinement établie. Nous avons cherché à évaluer l'utilité des lames avec canal de type Macintosh pour l'intubation vidéolaryngoscopique lorsque le rachis cervical était immobilisé. MéTHODE: Nous avons mené une étude randomisée contrôlée de non-infériorité chez des patient·es de neurochirurgie présentant des voies aériennes difficiles simulées par le port d'un collier cervical. L'intubation vidéolaryngoscopique avec une sonde trachéale renforcée a été réalisée à l'aide d'une lame Macintosh avec canal sans stylet (groupe avec canal, n = 130) ou d'une lame Macintosh sans canal avec stylet (groupe sans canal, n = 131). Le critère d'évaluation principal était le taux de réussite de l'intubation. Les critères d'évaluation secondaires comprenaient le temps d'intubation et l'incidence ou la gravité des complications liées à l'intubation (lésions sous-glottiques, linguales et dentaires, saignements, maux de gorge et enrouement). RéSULTATS: Le taux de réussite initial de l'intubation était de 98 % et 99 % dans les groupes avec et sans canal, respectivement, montrant la non-infériorité du groupe lame avec canal (différence de proportions −0,8 %; intervalle de confiance [IC] à 95 %, −4,8 % à 2,9 %; marge de non-infériorité prédéfinie, −5 %; P = 0,62). Les lésions sous-glottiques ont été moins nombreuses dans le groupe avec canal que dans le groupe sans canal (32 % [32/100] vs 57 % [54/95]; différence de proportions, −25 %; IC 95 %, −39 % à −11 %; P < 0,001). Il n'y avait pas de différences significatives entre les deux groupes en matière de taux global de réussite de l'intubation, de temps d'intubation et d'incidence ou de gravité des autres complications liées à l'intubation. CONCLUSION: Pour l'intubation vidéolaryngoscopique des patient·es portant un collier cervical, les lames avec canal de type Macintosh constituent une alternative aux lames sans canal de type Macintosh, avec un taux de réussite d'intubation initial non inférieur et une incidence plus faible de lésions sous-glottiques. ENREGISTREMENT DE L'éTUDE: CRIS.nih.go.kr ( KCT0005186 ); première soumission le 29 juin 2020.

Multicentre validation of a machine learning model for predicting respiratory failure after noncardiac surgery.

BACKGROUND: Postoperative respiratory failure is a serious complication that could benefit from early accurate identification of high-risk patients. We developed and validated a machine learning model to predict postoperative respiratory failure, defined as prolonged (>48 h) mechanical ventilation or reintubation after surgery. METHODS: Easily extractable electronic health record (EHR) variables that do not require subjective assessment by clinicians were used. From EHR data of 307,333 noncardiac surgical cases, the model, trained with a gradient boosting algorithm, utilised a derivation cohort of 99,025 cases from Seoul National University Hospital (2013-9). External validation was performed using three separate cohorts A-C from different hospitals comprising 208,308 cases. Model performance was assessed by area under the receiver operating characteristic (AUROC) curve and area under the precision-recall curve (AUPRC), a measure of sensitivity and precision at different thresholds. RESULTS: The model included eight variables: serum albumin, age, duration of anaesthesia, serum glucose, prothrombin time, serum creatinine, white blood cell count, and body mass index. Internally, the model achieved an AUROC of 0.912 (95% confidence interval [CI], 0.908-0.915) and AUPRC of 0.113. In external validation cohorts A, B, and C, the model achieved AUROCs of 0.879 (95% CI, 0.876-0.882), 0.872 (95% CI, 0.870-0.874), and 0.931 (95% CI, 0.925-0.936), and AUPRCs of 0.029, 0.083, and 0.124, respectively. CONCLUSIONS: Utilising just eight easily extractable variables, this machine learning model demonstrated excellent discrimination in both internal and external validation for predicting postoperative respiratory failure. The model enables personalised risk stratification and facilitates data-driven clinical decision-making.

High Intraoperative Serum Lactate Level is Associated with Acute Kidney Injury after Brain Tumor Resection.

BACKGROUND: Postoperative acute kidney injury (AKI) is associated with poor clinical outcomes. Identification of risk factors for postoperative AKI is clinically important. Serum lactate can increase in situations of inadequate oxygen delivery and is widely used to assess a patient's clinical course. We investigated the association between intraoperative serum lactate levels and AKI after brain tumor resection. METHODS: Demographics, medical and surgical history, tumor characteristics, surgery, anesthesia, preoperative and intraoperative blood test results, and postoperative clinical outcomes were retrospectively collected from 4131 patients who had undergone brain tumor resection. Patients were divided into high (n=1078) and low (n=3053) lactate groups based on an intraoperative maximum serum lactate level of 3.35 mmol/L. After propensity score matching, 1005 patients were included per group. AKI was diagnosed using the Kidney Disease Improving Global Outcomes criteria, based on serum creatinine levels within 7 days after surgery. RESULTS: Postoperative AKI was observed in 53 (1.3%) patients and was more frequent in those with high lactate both before (3.2% [n=35] vs. 0.6% [n=18]; P < 0.001) and after (3.3% [n=33] vs. 0.6% [n=6]; P < 0.001) propensity score matching. Intraoperative predictors of postoperative AKI were maximum serum lactate levels > 3.35 mmol/L (odds ratio [95% confidence interval], 3.57 [1.45-8.74], P = 0.005), minimum blood pH (odds ratio per 1 unit, 0.01 [0.00-0.24], P = 0.004), minimum hematocrit (odds ratio per 1%, 0.91 [0.84-1.00], P = 0.037), and mean serum glucose levels > 200 mg/dL (odds ratio, 6.22 [1.75-22.16], P = 0.005). CONCLUSION: High intraoperative serum lactate levels were associated with AKI after brain tumor resection.

A High Immediate Postoperative Neutrophil-to-Albumin Ratio is Associated With Unfavorable Clinical Outcomes at Hospital Discharge in Patients With Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Inflammation is associated with unfavorable clinical outcomes after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the relationship between postoperative neutrophil-to-albumin ratio (NAR) and unfavorable clinical outcomes (modified Rankin score ≥ 3) at hospital discharge in aSAH patients. METHODS: Five hundred sixty aSAH patients undergoing surgical or endovascular treatment were included in this retrospective study. Patients were initially allocated to high (n=247) or low (n=313) postoperative NAR groups based on the immediate postoperative NAR cutoff value identified by receiver operating characteristic analysis, and then further subclassified into 4 groups: HH (high pre- and high postoperative NAR, n=156), LH (low preoperative and high postoperative NAR, n=91), HL (high preoperative and low postoperative NAR, n=68), and low pre- and low postoperative NAR (n=245). RESULTS: Optimum cutoff values of immediate postoperative and preoperative NAR were 2.45 and 2.09, respectively. Unfavorable clinical outcomes were more frequent in patients with high compared with low postoperative NAR (45.3% vs. 13.4%; P < 0.001). In multivariate analysis, postoperative NAR was a significant predictor of unfavorable clinical outcomes (odds ratio, 2.10; 95% CI, 1.42-3.10; P < 0.001). Unfavorable clinical outcomes were less frequent in group low pre- and low postoperative NAR than in groups HH, LH, and HL (9.4% vs. 44.9%, 46.2% and 27.9%, respectively; all P < 0.001) and also in Group HL compared with groups HH and LH ( P =0.026 and P =0.030); clinical outcomes did not differ between Groups HH and LH. CONCLUSIONS: A high immediate postoperative NAR was associated with unfavorable clinical outcomes at hospital discharge in aSAH patients.

The Warburg effect in patients with brain tumors: a comprehensive analysis of clinical significance.

PURPOSE: The Warburg Effect, referring to an elevation in serum lactate level attributable to increased tumor metabolism, is present in patients with brain tumors. This study comprehensively analyzes the Warburg effect in patients undergoing brain tumor resection. METHODS: We retrospectively analyzed the baseline intraoperative serum lactate levels of 2,053 patients who underwent craniotomies, including 415 with cerebral aneurysms and 1,638 with brain tumors. The brain tumor group was divided into subgroups based on the tumor pathology (extra-axial and intra-axial tumor) and the WHO tumor grade (high-grade and low-grade). RESULTS: Serum lactate level was significantly higher in the tumor group than in the aneurysm group (1.98 ± 0.97 vs. 1.09 ± 0.57 mmol/L, p < 0.001). The hyperlactatemia incidence (serum lactate level > 2.2 mmol/L) was higher in the tumor group (33.5 vs. 3.1%, p < 0.001). Severe hyperlactatemia (serum lactate level > 4.4 mmol/L) was found in 34 patients (2.1%) of only the tumor group. In patients with intra-axial tumors, serum lactate level was greater in high- than low-grade tumors (2.10 ± 1.05 vs. 1.88 ± 0.92 mmol/L, p = 0.006). Factors predictive of hyperlactatemia included supratentorial tumor location (odds ratio[95%CI] 2.926[2.127-4.025], p < 0.001) and a long tumor diameter (1.071[1.007-1.139], p = 0.028). In high-grade intra-axial brain tumor patients, there was a significant difference in overall survival between patients with hyperlactatemia than those without (p = 0.048). CONCLUSION: Our results show that brain tumor patients exhibit the Warburg effect and serum lactate may be a useful diagnostic and prognostic biomarker in patients with high-grade intra-axial brain tumors.

Direct versus indirect epiglottis elevation in cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization: a randomized controlled trial.

BACKGROUND: During videolaryngoscopic intubation, direct epiglottis elevation provides a higher percentage of glottic opening score than indirect epiglottis elevation. In this randomized controlled trial, we compared cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization between the two glottis exposure methods. METHODS: Videolaryngoscopic intubation under manual in-line stabilization was performed using C-MAC® D-blade: direct (n = 51) and indirect (n = 51) epiglottis elevation groups. The percentage of glottic opening score was set equally at 50% during videolaryngoscopic intubation in both groups. The primary outcome measure was cervical spine movement during videolaryngoscopic intubation at the occiput-C1, C1-C2, and C2-C5. The secondary outcome measures included intubation performance (intubation success rate and intubation time). RESULTS: Cervical spine movement during videolaryngoscopic intubation was significantly smaller at the occiput-C1 in the direct epiglottis elevation group than in the indirect epiglottis elevation group (mean [standard deviation] 3.9 [4.0] vs. 5.8 [3.4] °, P = 0.011), whereas it was not significantly different at the C1-C2 and C2-C5 between the two groups. All intubations were successful on the first attempt, achieving a percentage of glottic opening score of 50% in both groups. Intubation time was longer in the direct epiglottis elevation group (median [interquartile range] 29.0 [24.0-35.0] vs. 22.0 [18.0-27.0] s, P < 0.001). CONCLUSIONS: When performing videolaryngoscopic intubation under manual in-line stabilization, direct epiglottis elevation can be more beneficial than indirect epiglottis elevation in reducing cervical spine movement during videolaryngoscopic intubation at the occiput-C1. TRIAL REGISTRATION: Clinical Research Information Service (number: KCT0006239, date: 10/06/2021).

Functional Magnetic Resonance Imaging and Diffusion Tensor Imaging for Language Mapping in Brain Tumor Surgery: Validation With Direct Cortical Stimulation and Cortico-Cortical Evoked Potential.

OBJECTIVE: Functional magnetic resonance imaging (fMRI) and diffusion tensor imaging-derived tractography (DTI-t) contribute to the localization of language areas, but their accuracy remains controversial. This study aimed to investigate the diagnostic performance of preoperative fMRI and DTI-t obtained with a simultaneous multi-slice technique using intraoperative direct cortical stimulation (DCS) or corticocortical evoked potential (CCEP) as reference standards. MATERIALS AND METHODS: This prospective study included 26 patients (23-74 years; male:female, 13:13) with tumors in the vicinity of Broca's area who underwent preoperative fMRI and DTI-t. A site-by-site comparison between preoperative (fMRI and DTI-t) and intraoperative language mapping (DCS or CCEP) was performed for 226 cortical sites to calculate the sensitivity and specificity of fMRI and DTI-t for mapping Broca's areas. For sites with positive signals on fMRI or DTI-t, the true-positive rate (TPR) was calculated based on the concordance and discordance between fMRI and DTI-t. RESULTS: Among 226 cortical sites, DCS was performed in 100 sites and CCEP was performed in 166 sites. The specificities of fMRI and DTI-t ranged from 72.4% (63/87) to 96.8% (122/126), respectively. The sensitivities of fMRI (except for verb generation) and DTI-t were 69.2% (9/13) to 92.3% (12/13) with DCS as the reference standard, and 40.0% (16/40) or lower with CCEP as the reference standard. For sites with preoperative fMRI or DTI-t positivity (n = 82), the TPR was high when fMRI and DTI-t were concordant (81.2% and 100% using DCS and CCEP, respectively, as the reference standards) and low when fMRI and DTI-t were discordant (≤ 24.2%). CONCLUSION: fMRI and DTI-t are sensitive and specific for mapping Broca's area compared with DCS and specific but insensitive compared with CCEP. A site with a positive signal on both fMRI and DTI-t represents a high probability of being an essential language area.

Effects of Scalp Nerve Block on the Quality of Recovery after Minicraniotomy for Clipping of Unruptured Intracranial Aneurysms : A Randomized Controlled Trial.

OBJECTIVE: This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). METHODS: Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. RESULTS: All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). CONCLUSION: After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.

High peak inspiratory pressure may be associated with intraoperative coughing during neurosurgery under general anesthesia without neuromuscular blockade: a retrospective study.

BACKGROUND: The endotracheal cuff pressure depends on the airway pressure during positive-pressure ventilation. A high endotracheal cuff pressure may be related to intraoperative coughing, which can be detrimental during neurosurgery. We investigated the incidence of intraoperative coughing and its association with peak inspiratory pressure (PIP) during neurosurgery under general anesthesia without neuromuscular blockade. METHODS: This retrospective study divided 1656 neurosurgical patients who underwent total intravenous anesthesia without additional neuromuscular blockade after tracheal intubation into high (PIP > 21.6 cmH2O, n = 318) and low (PIP ≤ 21.6 cmH2O, n = 1338) PIP groups. After propensity score matching, 206 patients were selected in each group. Demographic, preoperative, surgical, and anesthetic data were collected retrospectively from electronic medical records and continuous ventilator, infusion pump, and bispectral index data from a data registry. RESULTS: Intraoperative coughing occurred in 30 (1.8%) patients, including 9 (0.5%) during the main surgical procedure. Intraoperative coughing was more frequent in the high PIP group than in the low PIP group before (14/318 [4.4%] vs. 16/1338 [1.2%], P < 0.001) and after (13/206 [6.3%] vs. 1/206 [0.5%], P = 0.003) propensity score matching. In multivariable logistic regression analysis after propensity score matching, a high PIP (odds ratio [95% confidence interval] 14.22 [1.81-111.73], P = 0.012), tidal volume divided by predicted body weight (mL/kg, 1.36 [1.09-1.69], P = 0.006), and surgical duration (min, 1.01 [1.00-1.01], P = 0.025) predicted intraoperative coughing. CONCLUSION: The incidence of intraoperative coughing was 1.8% in neurosurgical patients undergoing general anesthesia without neuromuscular blockade and might be associated with a high PIP.

Sevoflurane anesthesia rather than propofol anesthesia is associated with 3-month postoperative hypocortisolism in patients undergoing endoscopic transsphenoidal surgery for non-functional pituitary adenoma with preoperative normal hypothalamic-pituitary-adrenal axis.

PURPOSE: The effects of anesthetic technique on intermediate-term postoperative adrenocorticotropic hormone (ACTH) functional outcomes have not been fully determined in non-functioning pituitary adenoma (NFPA) patients. Postoperative hypocortisolism is potentially life-threatening and requires steroid replacement after pituitary surgery. The present study determined whether sevoflurane anesthesia was predictive of 3-month postoperative hypocortisolism in NFPA patients with preoperative normal hypothalamic-pituitary-adrenal (HPA) axis. METHODS: Demographics, preoperative pituitary hormone status, intraoperative data, and tumor characteristics were retrospectively collected from 429 NFPA patients, who had preoperative normal HPA axis and underwent endoscopic transsphenoidal surgery. Patients were divided into two groups based on intraoperative anesthetic technique: sevoflurane-based inhalation anesthesia group (n = 74) and propofol-based intravenous anesthesia group (n = 355). After propensity score matching, 73 patients were selected in each group and the incidence of 3-month postoperative hypocortisolism (primary outcome measure) was compared between the two groups. RESULTS: The incidence of 3-month postoperative hypocortisolism was higher in the sevoflurane anesthesia group than the propofol anesthesia group before (n = 20[27.0%] vs. n = 49[13.8%], P = 0.008) and after (n = 20 [27.4%] vs. n = 5 [6.8%], P = 0.002) propensity score matching, respectively. Sevoflurane anesthetic use (odds ratio [95% CI] 5.37[1.80-15.98], P = 0.003) and postoperative steroid administration (2.89 [1.06-7.92], P = 0.039) were predictors of 3-month postoperative hypocortisolism. CONCLUSION: In patients with preoperative normal HPA axis undergoing endoscopic transsphenoidal surgery for NFPA, sevoflurane anesthesia and postoperative steroid administration were associated with the development of 3-month postoperative hypocortisolism. A large-scale prospective study is needed to confirm the negative association between sevoflurane anesthesia and postoperative ACTH functional outcome.

Preservation of language function by mapping the arcuate fasciculus using intraoperative corticocortical evoked potential under general anesthesia in glioma surgery.

OBJECTIVE: Intraoperative language mapping under general anesthesia is imperative for brain tumor surgery because awake surgery is not always feasible. Monitoring corticocortical evoked potential (CCEP) is known to be a useful method for tracking neuronal connectivity and localizing functional areas. The authors evaluated the clinical benefit of intraoperative CCEP monitoring for language function preservation in patients undergoing glioma surgery. METHODS: Between January 2019 and June 2021, the authors performed a total of 29 consecutive glioma surgeries using CCEP monitoring under general anesthesia because of a risk of speech impairment; these were analyzed. Language area mapping was implemented by the anterior language area to posterior language area CCEP method for arcuate fasciculus mapping, and tumor resection was performed while avoiding the localized language areas. Language function before and after surgery was evaluated by the Controlled Oral Word Association Test (COWAT). RESULTS: Intraoperative CCEP was successfully monitored in 25 patients (86.2%), and a valid signal was undetectable in the other 4 patients. Language function evaluation was possible before and after surgery in a total of 20 patients. Overall, the preservation rate of language function was 65.0%, and the deterioration rate was 35.0% after tumor resection with CCEP monitoring. Among those 8 patients with preoperative COWAT scores ≥ 18, 5 patients (62.5%) successfully preserved their language function, with COWAT scores > 18 after tumor resection. Among the 12 patients with preoperative deteriorated language function (COWAT score < 18), 8 patients (66.7%) showed improvement or preserved language function after surgery. CONCLUSIONS: Intraoperative CCEP monitoring of the arcuate fasciculus is an acceptable technology for the preservation of language function under general anesthesia in glioma surgery in patients in whom awake surgery is not feasible.

Intraarterial catheter diameter and dynamic response of arterial pressure monitoring system: a randomized controlled trial.

The dynamic response (DR) of the arterial pressure monitoring system (APMS) may depend on the intraarterial catheter (IAC) diameter. We hypothesized that adequate DR would be more common when using a smaller IAC. We compared the DR of the AMPS (Auto Transducer™) between three IACs (BD Angiocath Plus™) with different diameters. 353 neurosurgical patients were randomized into three groups undergoing catheterization with a 20-, 22-, or 24-gauge IAC: 20G (n = 119), 22G (n = 117), and 24G (n = 117) groups, respectively. The DR, which depends on the natural frequency and damping coefficient, was divided into four types: adequate (primary outcome measure), underdamped, overdamped, and unacceptable. The frequency of intraoperative IAC malfunction was noted. Adequate DR was observed more frequently in the 22G and 24G groups than the 20G group (13.7% and 15.4% vs. 4.2%, P = 0.011 and 0.004, respectively). The frequency of underdamped DR was higher in the 20G group than the 24G group (86.6% vs. 69.2%, P = 0.001), whereas overdamped DR was more frequent in the 24G group than the 20G and 22G groups (6.0% vs. 0.0% and 0.0%, P = 0.007 and 0.014, respectively). IAC malfunctioned more frequently during surgery in the 24G group than the 20G and 22G groups (15.4% vs. 0.0% and 1.7%, P < 0.001 and P < 0.001, respectively). The frequency of adequate DR was low regardless of the IAC diameter. Nonetheless, in terms of DR and IAC malfunction, a 22-gauge BD Angiocath Plus™ was more suitable for invasive blood pressure monitoring with Auto Transducer™ than a 20- or 24-gauge BD Angiocath Plus™. Registration Registry: ClinicalTrials.gov. Registration number: NCT03642756. Date of Registration: July 27, 2018.

Radiographic Predictors of Difficult McGrath MAC Videolaryngoscopy in Patient Undergoing Cervical Spine Surgery.

BACKGROUND: McGrath MAC videolaryngoscopy is a useful technique for successful intubation in cervical spine-injured patients with manual in-line stabilization of the neck during intubation. We aimed to identify radiographic predictors of difficult McGrath MAC videolaryngoscopy in patient undergoing cervical spine surgery. METHODS: Patients undergoing cervical spine surgery who were intubated with a McGrath MAC videolaryngoscope under manual in-line stabilization of the neck between June 2016 and August 2018 were included in this study. Data on airway-related variables and radiographic indices obtained from preoperative lateral cervical spine x-ray, magnetic resonance imaging, and computed tomography (CT) scans were retrospectively collected. Patients were divided into difficult and easy McGrath MAC videolaryngoscopic intubation groups on the basis of intubation time and the number of intubation attempts. RESULTS: In total, 183 patients were included in the study of which 33 (18%) showed difficult videolaryngoscopic intubation. In multivariate logistic regression analysis, atlanto-occipital distance (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.62-0.89; P=0.001) on lateral cervical spine x-ray, incisor-C1-C6 angle in neck extension on lateral cervical spine x-ray (OR, 1.12; 95% CI, 1.02-1.22; P=0.015), tongue area/oral cavity area ratio in the mid-sagittal plane of cervical magnetic resonance imaging or computed tomography (OR, 1.12; 95% CI, 1.05-1.19; P<0.001), and interincisor gap (OR, 0.92; 95% CI, 0.86-0.98; P=0.015) were independent risk factors for difficult videolaryngoscopic intubation. CONCLUSIONS: Radiographic variables indicating enlarged tongue relative to the oral cavity and limited neck extension were associated with difficult McGrath MAC videolaryngoscopy in patients undergoing cervical spine surgery with manual in-line cervical stabilization during intubation.

Prognostic significance of the postoperative prognostic nutritional index in patients with glioblastoma: a retrospective study.

BACKGROUND: The prognostic nutritional index (PNI) reflects immunonutritional status. We evaluated the effects of postoperative PNI and perioperative changes in the PNI on overall survival (OS) in glioblastoma (GBM) patients. METHODS: Demographic, laboratory, and clinical data were retrospectively collected from 335 GBM patients. Preoperative and postoperative PNIs were calculated from serum albumin concentration and lymphocyte count, which were measured within 3 weeks before surgery and 1 month after surgery. Patients were classified into high (n = 206) or low (n = 129) postoperative PNI groups according to the postoperative PNI cutoff value and further classified into four groups according to the cutoff values of the preoperative and postoperative PNIs, as follows: Group HH (both high PNIs, n = 92), Group HL (high preoperative and low postoperative PNI, n = 70), Group LH (low preoperative and high postoperative PNI, n = 37), and Group LL (both low PNIs, n = 136). RESULTS: The median OS was significantly longer in the high postoperative PNI (PNI ≥ 50.2) group than the low postoperative PNI (PNI < 50.2) group (24.0 vs. 15.0 months, p <  0.001). In multivariate analysis, high postoperative PNI was a significant predictor of OS. OS was significantly longer in Group HH than in Group LL and seemed longer in Group HH than in Group HL and in Group LH than in Group LL. OS was not different between Groups HH and LH or between Groups HL and LL. CONCLUSIONS: High postoperative PNI was associated with improved OS and perioperative changes in PNI may provide additional important information for prognostic prediction in GBM patients.

Effects of External Laryngeal Manipulation on Cervical Spine Motion during Videolaryngoscopic Intubation under Manual In-Line Stabilization: A Randomized Crossover Trial.

We hypothesized that external laryngeal manipulation would reduce cervical spine motion during video laryngoscopic intubation under manual in-line stabilization by reducing the force required to lift the videolaryngoscope. In this randomized crossover trial, 27 neurointerventional patients underwent two consecutive videolaryngoscopic intubation attempts under manual in-line stabilization. External laryngeal manipulation was applied to all patients in either the first or second attempt. In the second attempt, we tried to reproduce the percentage of glottic opening score obtained in the first attempt. Primary outcomes were cervical spine motion during intubation at the occiput-C1, C1-C2, and C2-C5 segments. The intubation success rate (secondary outcome measure) was recorded. Cervical spine motion during intubation at the occiput-C1 segment was significantly smaller with than without external laryngeal manipulation (7.4° ± 4.6° vs. 11.5° ± 4.8°, mean difference -4.1° (98.33% confidence interval -5.8° to -2.3°), p < 0.001), showing a reduction of 35.7%. Cervical spine motion during intubation at the other segments was not significantly different with versus without external laryngeal manipulation. All intubations were achieved successfully regardless of the application of external laryngeal manipulation. External laryngeal manipulation is a useful method to reduce upper cervical spine motion during videolaryngoscopic intubation under manual in-line stabilization.

Cephalocaudal tumor diameter is a predictor of diabetes insipidus after endoscopic transsphenoidal surgery for non-functioning pituitary adenoma.

PURPOSE: Diabetes insipidus (DI) develops commonly after endoscopic transsphenoidal surgery (ETS). We retrospectively investigated the incidence, onset, duration and predictors of DI after ETS in patients with non-functioning pituitary adenoma (NFPA). METHODS: A total of 168 patients who underwent ETS to remove NFPAs were included. Various perioperative data on demographics, comorbidities, previous treatments, perioperative hormone deficiencies, tumor characteristics, surgery, anesthesia, intraoperative fluid balance, perioperative laboratory findings, postoperative complications, readmission and hospital length of stay were collected and analyzed. Patients were diagnosed with DI and treated with desmopressin when they showed urine output > 5 mL/kg/hr with a serum sodium concentration > 145 mmol/L or an increase ≥ 3 mmol/L in serum sodium concentration between two consecutive tests after surgery. DI was considered permanent when desmopressin was prescribed for > 6 months after surgery. RESULTS: Seventy-seven (45.8%) patients experienced postoperative DI and 10 (6.0%) patients suffered from permanent DI. The median onset of DI and the median duration of transient DI were postoperative day 1 and 5 days, respectively. In multivariable logistic regression analysis, cephalocaudal tumor diameter (odds ratio [95% confidence interval] 2.59 [1.05-6.36], P = 0.038) was related to postoperative DI. In receiver operating characteristic analysis, its area under the curve was 0.68 (95% confidence interval 0.59-0.76, P < 0.001). Its optimal cutoff value that maximized the sum of sensitivity and specificity for postoperative DI was 2.7 cm. CONCLUSIONS: Postoperative DI was observed in 45.8% of patients undergoing ETS to remove NFPAs. A large cephalocaudal tumor diameter was predictive of postoperative DI in such patients.

Preoperative platelet count may predict postoperative symptomatic cerebral hyperperfusion syndrome after superficial temporal artery-middle cerebral artery anastomosis in moyamoya patients.

OBJECTIVE: Platelets play a critical role in the inflammatory response, accompanied by microvascular endothelial dysfunction, underlying postoperative symptomatic cerebral hyperperfusion syndrome (PSCHS) after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in moyamoya patients. We examined whether the preoperative platelet count can predict PSCHS after STA-MCA anastomosis in such patients. METHODS: In 160 adult moyamoya patients undergoing 186 STA-MCA anastomoses, preoperative (demographics, initial clinical manifestation, and Suzuki grade), intraoperative (surgical time, operative side, fluid balance, and maximum and minimum mean blood pressure before and after vessel anastomosis), immediate postoperative (APACHE 2 score), and laboratory (hemoglobin and C-reactive protein levels and white blood cell and platelet counts) data were collected retrospectively. RESULTS: 84 patients (90 sides, 48.4 %) developed PSCHS with a median(IQR) onset of postoperative day 1(0-3) and duration of 4(3-7) days. The preoperative (25.2[22.8-28.0] vs. 23.1[19.7-26.2] ×104/µL, p = 0.009) platelet count was significantly higher in patients with PSCHS than in those without. The preoperative platelet count (odds ratio[95 % confidence interval], 1.14[1.03-1.27], p = 0.011), operation on the dominant hemisphere (6.84 [3.26-14.36], p < 0.001), and negative fluid balance (2.41[1.04-5.59], p = 0.040) were significant independent predictors of PSCHS. The optimal cut-off value for preoperative platelet count was 22.7 ×104/µL, and PSCHS developed more frequently in cases with a preoperative platelet count ≥ 22.7 × 104/µL (2.90[1.54-5.45]; p = 0.001). CONCLUSION: A high preoperative platelet count may be associated with the development of PSCHS after STA-MCA anastomosis in adult moyamoya patients.

Effects of anesthetics on post-operative 3-month neuroendocrine function after endoscopic transsphenoidal non-functional pituitary adenoma surgery.

BACKGROUND: Anesthetic techniques can affect perioperative neuroendocrine function. The objective of this study was to compare 3-month post-operative neuroendocrine functional outcomes between sevoflurane and propofol anesthesia in patients undergoing endoscopic transsphenoidal surgery (ETS) for removal of non-functional pituitary adenomas (NFPAs) retrospectively. METHODS: Among 356 patients who underwent ETS for removal of NFPAs under sevoflurane-remifentanil anesthesia (sevoflurane group, n = 103) or propofol-remifentanil anesthesia (propofol group, n = 253), 92 patients in each group were selected and their 3-month post-operative neuroendocrine functional outcomes (primary outcome measure) were compared after propensity score matching. RESULTS: Overall changes in post-operative 3-month neuroendocrine function compared to pre-operative baseline did not differ between the sevoflurane and propofol groups (worsened: 32.6% vs 29.3%, persistently decreased: 9.8% vs 12.0%, improved: 12.0% vs 20.7%, normalized: 9.8% vs 12.0%, persistently normal: 18.5% vs 19.6%; P = .400). The incidence of pituitary hormone deficiency at 3 months post-operatively did not differ between the sevoflurane and propofol groups (adrenocorticotropic hormone deficiency: 18.5% vs 17.4%, P = 1.000; thyroid-stimulating hormone deficiency: 10.9% vs 3.3%, P = .081; gonadotropin deficiency: 54.3% vs 48.9%, P = .555; growth hormone deficiency: 45.7% vs 48.9%, P = .768; panhypopituitarism: 1.1% vs 1.1%, P = 1.000). CONCLUSION: In patients undergoing ETS for removal of NFPAs, the effects of both sevoflurane-remifentanil and propofol-remifentanil anesthetic techniques on post-operative 3-month neuroendocrine functional outcomes were similar, suggesting that propofol and sevoflurane can be freely used in such patients in terms of post-operative intermediate-term neuroendocrine functional outcome.

No radiographic index predicts difficult intubation using the Optiscope™ in cervical spine surgery patients: a retrospective study.

BACKGROUND: The Optiscope™ can be used for intubation with minimal neck motion. We retrospectively investigated radiographic predictors of difficult intubation using the Optiscope™ by analyzing preoperative radiographic images. METHODS: One hundred eighty-four patients who were intubated with the Optiscope™ under manual in-line cervical stabilization for cervical spine surgery were enrolled. Radiographic indices were measured on preoperative cervical spine lateral X-ray and magnetic resonance imaging images. Difficult intubation was defined as failure or time consumption more than 90 s on the first attempt. To identify significant predictors of difficult intubation using the Optiscope™ and evaluate their diagnostic value, multivariable logistic regression and receiver operating characteristic analyses were used. RESULTS: Fourty-seven patients showed difficult intubation. There was no significant difference in radiographic indices between the difficult and easy intubation groups, but higher body mass index (BMI) (26.5 [3.0] vs. 24.6 [3.5] kg/m2, P = 0.001), shorter sternomental distance (SMD) (122.0 [104.0 to 150.0] vs. 150.0 [130.0 to 170.0] mm, P = 0.001), shorter interincisor gap (40.0 [35.0 to 45.0] vs. 43.0 [40.0 to 50.0] mm, P = 0.006), and higher incidence of excessive oral secretions (10.6% vs. 2.9%, P = 0.049) were observed in patients with difficult intubation. In multivariable analysis, BMI (odds ratio [95% confidence interval]; 1.15 [1.03 to 1.28], P = 0.011) and SMD (odds ratio [95% confidence interval]; 0.98 [0.97 to 1.00], P = 0.008) were associated with difficult intubation with the Optiscope™. In receiver operating characterstic analysis, the area under the curve for body mass index was 0.68 (95% confidence interval; 0.60 to 0.77, P < 0.001) and that for sternomental distance was 0.66 (95% confience interval; 0.57 to 0.75, P = 0.001). CONCLUSIONS: The incidence of difficult intubation using the Optiscope™ under manual in-line cervical stabilization was 25.5% in cervical spine surgery patients. No significant predictor of difficult intubation with the Optiscope™ was identified among the measured radiographic indices. Although high BMI and short SMD were predictive of difficult intubation with the Optiscope™, their discrimination power was weak.

McGrath MAC Videolaryngoscope Versus Optiscope Video Stylet for Tracheal Intubation in Patients With Manual Inline Cervical Stabilization: A Randomized Trial.

BACKGROUND: Manual inline stabilization of the head and neck is a recommended maneuver for tracheal intubation in patients with a suspected cervical injury. However, because applying this maneuver inevitably restricts neck flexion and head extension, indirect intubating devices such as a videolaryngoscope or a video stylet could be required for successful tracheal intubation. In this study, we compared the clinical performance of the McGrath MAC videolaryngoscope versus the Optiscope video stylet in patients with manual inline cervical stabilization during tracheal intubation. METHODS: In 367 consecutive patients undergoing elective cervical spine surgery, tracheal intubation was randomly performed with manual inline stabilization using either the McGrath MAC videolaryngoscope (group M, n = 183) or the Optiscope video stylet (group O, n = 184) by 2 experienced anesthesiologists in a single institution. The primary outcome was the first-attempt success rate of tracheal intubation. Secondary outcomes were intubation time and the incidence of postoperative airway complications, such as sore throat, hoarseness, blood in the oral cavity, and blood staining on the endotracheal tube. RESULTS: The first-attempt success rate of tracheal intubation was significantly higher in group M compared with group O (92.3% vs 81.0%; risk difference [95% confidence interval], 0.11 [0.05-0.18]; P = .002). The intubation time was significantly shorter in group M than in group O (35.7 ± 27.8 vs 49.2 ± 43.8; mean difference [95% confidence interval], 13.5 [5.9-21.1]; P = .001). The incidence of postoperative airway complications was not significantly different between the 2 groups. CONCLUSIONS: The McGrath MAC videolaryngoscope showed a higher first-attempt success rate for tracheal intubation and a shorter intubation time than the Optiscope video stylet in cervical spine patients with manual inline stabilization during tracheal intubation. These results suggest that the McGrath MAC videolaryngoscope may be a better option for tracheal intubation in such patients.