Obesity and anesthesia.

PURPOSE OF REVIEW: Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS: Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY: Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

Efficacy and safety of three inflation methods of the laryngeal mask airway Ambu® Auraonce™: a randomized controlled study.

The laryngeal mask airway (LMA) is commonly used for airway management. Cuff hyperinflation has been associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnce™ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnce™ LMA. 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnce™ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4 ± 32.4 cm H2O; RV: 75.1 ± 21.1 cm H2O; NV: 83.1 ± 25.5 cmH20; P < 0.01). The incidence of IP > 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); p < 0.01). The insertion success rate was 89,6% (180/201) at first attempt, with no difference between groups (p = 0.38). No difference between groups was found either for OLP (p = 0.53), LV (p = 0.26) and PC (p = 0.16). When a cuff manometer is not available, a partial inflation of AuraOnce™ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method.Registration clinical trial: NCT04769791.

Simple steps towards improving safety in obstetric airway management: A quality improvement project.

BACKGROUND: Guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society state that 'a videolaryngoscope should be immediately available for all obstetric general anaesthetics'. OBJECTIVE: To report the incidence of videolaryngoscopy use, and other airway management safety interventions, in an obstetric population before and after various quality improvement interventions. DESIGN: Prospective data collection was undertaken over 18 months, divided into three separate 6-month periods: June to November 2019; March to August 2021; January to June 2022. These periods relate to evaluation of specific quality improvement interventions. SETTING: The project was carried out in a large tertiary referral obstetric unit. PATIENTS: We identified 401 pregnant women (> 20 weeks' gestation) and postnatal women (up to 48 h post delivery) undergoing an obstetric surgical procedure under general anaesthesia. INTERVENTIONS: To standardise practice, an intubation checklist was introduced in December 2020 and multidisciplinary staff training in August 2021. MAIN OUTCOME MEASURES: Primary outcome measures were use of a Macintosh-style videolaryngoscope and tracheal intubation success. Secondary outcome measures were use of an intubation checklist; low flow nasal oxygen; and ramped patient positioning. RESULTS: Data from 334 tracheal intubations (83.3% of cases) were recorded. Videolaryngoscope use increased from 60% in 2019, to 88% in 2021, to 94% in 2022. Tracheal intubation was successful in all patients, with 94% first pass success overall and only 0.9% requiring three attempts. Use of secondary outcome measures also increased: low flow nasal oxygen from 48% in 2019 to 90% in 2022; ramped positioning from 95% in 2021 to 97% in 2022; and checklist use from 63% in 2021 to 92% in 2022. CONCLUSIONS: We describe the successful adoption of simple safety measures introduced into routine practice. These comprised videolaryngoscopy, ramped positioning and low flow nasal oxygen. Their introduction was supported by the implementation of an intubation checklist and multidisciplinary team training.

A Cross-Sectional Survey of Anesthetic Airway Equipment and Airway Management Practices in Uganda.

BACKGROUND: Anesthesia-related causes contribute to a significant proportion of perioperative deaths, especially in low and middle-income countries (LMICs). There is evidence that complications related to failed airway management are a significant contributor to perioperative morbidity and mortality. While existing data have highlighted the magnitude of airway management complications in LMICs, there are inadequate data to understand their root causes. This study aimed to pilot an airway management capacity tool that evaluates airway management resources, provider practices, and experiences with difficult airways in an attempt to better understand potential contributing factors to airway management challenges. METHODS: We developed a novel airway management capacity assessment tool through a nonsystematic review of existing literature on anesthesia and airway management in LMICs, internationally recognized difficult airway algorithms, minimum standards for equipment, the safe practice of anesthesia, and the essential medicines and health supplies list of Uganda. We distributed the survey tool during conferences and workshops, to anesthesia care providers from across the spectrum of surgical care facilities in Uganda. The data were analyzed using descriptive methods. RESULTS: Between May 2017 and May 2018, 89 of 93 surveys were returned (17% of anesthesia providers in the country) from all levels of health facilities that provide surgical services in Uganda. Equipment for routine airway management was available to all anesthesia providers surveyed, but with a limited range of sizes. Pediatric airway equipment was always available 54% of the time. There was limited availability of capnography (15%), video laryngoscopes (4%), cricothyroidotomy kits (6%), and fiber-optic bronchoscopes (7%). Twenty-one percent (18/87) of respondents reported experiencing a "can't intubate, can't ventilate" (CICV) scenario in the 12 months preceding the survey, while 63% (54/86) reported experiencing at least 1 CICV during their career. Eighty-five percent (74/87) of respondents reported witnessing a severe airway management complication during their career, with 21% (19/89) witnessing a death as a result of a CICV scenario. CONCLUSIONS: We have developed and implemented an airway management capacity tool that describes airway management practices in Uganda. Using this tool, we have identified significant gaps in access to airway management resources. Gaps identified by the survey, along with advocacy by the Association of Anesthesiologists of Uganda, in partnership with the Ugandan Ministry of Health, have led to some progress in closing these gaps. Expanding the availability of airway management resources further, providing more airway management training, and identifying opportunities to support skilled workforce expansion have the potential to improve perioperative safety in Uganda.

Epidemiology of adverse events attributed to airway management in paediatric anaesthesia: protocol for the prospective, multicentre, registry-based, cross-sectional Japan Pediatric Difficult Airway in Anesthesia study (J-PEDIA).

INTRODUCTION: Failure to secure an airway during general anaesthesia is a major cause of adverse events (AEs) in children. The safety of paediatric anaesthesia may be improved by identifying the incidence of AEs and their attributed risk factors. The aim of the current study is to obtain real-world data on the incidence of adverse peri-intubation events and assess their association with patient characteristics (including the prevalence of difficult airway features) and choice of anaesthesia management. These data can be used to develop a targeted education programme for anaesthesia providers towards quality improvement activities. METHODS AND ANALYSIS: This prospective, multicentre, registry-based, cross-sectional study will be conducted in four tertiary care hospitals in Japan from June 2022 to May 2025. Children <18 years of age undergoing surgical and/or diagnostic test procedures under general anaesthesia or sedation by anaesthesiologists will be enrolled in this study. Data on patient characteristics, discipline of anaesthesia providers and methodology of airway management will be collected through a standardised verification system. The exposure of interest is the presence of difficult airway features defined based on the craniofacial appearance. The primary and secondary endpoints are all AEs associated with airway management and reduced peripheral capillary oxygen saturation values. Potential confounders are related to the failure to secure the airway and variations in the anaesthesia providers' levels, adjusted using hierarchical multivariable regression models with mixed effects. The sample size was calculated to be approximately 16 000 assuming a 99% probability of obtaining a 95% Wilson CI with±0.3% of the half-width for the 2.0% of the incidence of critical AEs. ETHICS AND DISSEMINATION: The study protocol was approved by the Institutional Review Board at Aichi Children's Health and Medical Center (2021051). The results will be reported in a peer-reviewed journal and a relevant academic conference. TRIAL REGISTRATION NUMBER: UMIN000047351.

The role of supraglottic airway devices in obstetric anaesthesia.

PURPOSE OF REVIEW: To discuss the role of supraglottic airway devices as rescue and primary airway devices in pregnant patients. RECENT FINDINGS: General anaesthesia in pregnant patients is associated with increased incidence of difficult and failed intubation, especially when performed for caesarean deliveries. The Difficult Airway Society and the Obstetric Anaesthetists' Association guidelines for the management of failed intubation recommend the use of second-generation supraglottic airway devices as a rescue airway strategy when failed intubation occurs. This practice is now widely accepted and embedded in routine teaching and clinical practice. On the other hand, there is little but growing evidence describing the use of supraglottic airway devices as the primary airway device and an alternative to endotracheal intubation for patients undergoing elective and emergency caesarean deliveries under general anaesthesia. Most of the published research supporting this practice was done on carefully selected patients who were nonobese and who did not have gastroesophageal reflux or anticipated difficult airway. Despite demonstrating high insertion success rates and low complication rates, these studies were underpowered and have thus far, failed to provide robust data on the true risk of aspiration in this setting. SUMMARY: Based on current scientific data, the evidence for the safe use of supraglottic airway devices as primary airway devices during general anaesthesia for caesarean deliveries is not compelling. However, their use as rescue airway devices remains a well established strategy supported by international guidelines.

Risk patterns of consecutive adverse events in airway management: a Bayesian network analysis.

BACKGROUND: Minor adverse airway events play a pivotal role in the safety of airway management. Changes in airway management strategies can reduce such events, but the broader impact on airway management remains unclear. METHODS: Minor, frequently occurring adverse airway events were audited before and after implementation of changes to airway management strategies. We used two Bayesian networks to examine conditional probabilities of subsequent airway events and to compute the likelihood of certain events given that certain previous events occurred. RESULTS: Independent of sex, age, and American Society of Anesthesiologists physical status, targeted changes to airway management strategies reduced the risk of a first event. Obese patients were an exception, in whom no risk reduction was achieved. Frequently occurring event sequences were identified, for example the most likely event to follow difficult bag-mask ventilation was a Cormack-Lehane grade ≥3, with a risk of 14.3% (95% credible interval [CI], 11.4-17.2%). An impact of the targeted changes was detected on the likelihood of some event sequences, for example the likelihood of no consecutive event after a tracheal tube-related event increased from 43.3% (95% CI, 39.4-47.6%) to 56.4% (95% CI, 52.0-60.5%). CONCLUSIONS: Identification of risk patterns and typical structures of event sequences provides a clinically relevant perspective on airway incidents. It further provides a means to quantify the impact of targeted airway management changes. These targeted changes can influence some event sequences, but overall, the benefit results from the cumulative effect of improvements in multiple events. Targeted airway management changes with knowledge of risk patterns and event sequences can potentially further improve patient safety in airway management. CLINICAL TRIAL REGISTRATION: NCT02743767.

Analysis of a national difficult airway database.

Difficult airway management continues to adversely affect patient care and clinical outcomes and is poorly predicted. Previous difficult airway management is the most accurate predictor of future difficulty. The Difficult Airway Society initiated a national airway database to allow clinicians to access details of previous difficult airway episodes in patients issued with a difficult airway alert card. We aimed to analyse this database, reporting patient characteristics, airway management and patient outcomes. We included all living adult patients reported in the first 5 years of the database (n = 675). Clinical airway assessment was reported in 634 (94%) patients, with three or more parameters assessed in 488 (72%). A history of difficult airway was known in 136 (20%) patients and difficult airway management was anticipated in 391 (58%). In all, 75 (11%) patients had an airway-related critical incident, with 1 in 29 being awoken from anaesthesia, 1 in 34 requiring unplanned or prolonged stay in the intensive care unit and 1 in 225 needing an emergency front-of-neck airway or had a cardiac arrest/peri-arrest episode. Airway-related critical incidents were associated with out-of-hours airway management, but no other associations were apparent. Our data report the first analysis of a national difficult airway database, finding that unanticipated difficult airway management continues to occur despite airway assessment, and the rate of critical incidents in this cohort of patients is high. This database has the potential to improve airway management for patients in the future.

Comparison of the Jcerity Endoscoper Airway with the LMA supreme for airway management in patients undergoing cerebral aneurysm embolization: a randomized controlled non-inferiority trial.

BACKGROUND: Jcerity Endoscoper Airway is a new back-open endoscopic laryngeal mask airway device with a unique design. Our study sought to compare the implantation, ventilation quality and complications of JEA (Jcerity Endoscoper airway) versus LMA (Laryngeal Mask Airway) Supreme in the procedure of cerebral aneurysm embolization. METHODS: In this prospective, randomised clinical trial, 182 adult patients with American Society of Anesthesiologists class Ι-II scheduled for interventional embolization of cerebral aneurysms were randomly allocated into the Jcerity Endoscoper airway group and the LMA Supreme group. We compared success rate of LMA implantation, ventilation quality, airway sealing pressure, peak airway pressure, degree of blood staining, postoperative oral hemorrhage, sore throat and other complications between the groups. RESULTS: There were no significant differences between the groups in terms of one-time success rate of LMA implantation, ventilation quality, airway sealing pressure or airway peak pressure. However, LMA Supreme group showed a higher degree of blood staining than the JEA group when the laryngeal mask airway was removed (P = 0.04), and there were also more oral hemorrhages and pharyngeal pain than JEA group (P = 0.03, P = 0.02). No differences were observed between groups in terms of other airway complications related to the LMA. CONCLUSIONS: The JEA could not only achieve comparable one-time success rate of implantation and quality of ventilation as the LMA Supreme, but also have lower blood staining degree of mask and less sore throat in patients undergoing perioperative anticoagulation for cerebral aneurysm interventional embolization. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2100044133 ; Registered 11/03/2021. Statement: This study adheres to CONSORT guidelines.

Complications of dental infections due to diagnostic delay during COVID-19 pandemic.

We present three cases who presented to the emergency department with severe complications of dental infections: Ludwig's angina, necrotising fasciitis and peritonsillar abscess. All of our cases presented at the beginning of COVID-19 pandemic, with complications of dental infections. They delayed their dental treatment due to the pandemic. The airway management was difficult in our cases. Their mortality risk increased due to complications. We aimed to draw attention to complicated odontogenic infections which are rarely seen in emergency department in the past, however started to show up increasingly particularly at the beginning of the COVID-19 pandemic.

Tapia's Syndrome: keep it in mind!

INTRODUCTION: The aim of this study was to revise the etiologic features about Tapia's Syndrome (TS), a condition to particularly consider in the era of the COVID-19 pandemic. EVIDENCE ACQUISITION: A systematic review was performed according to the PRISMA criteria. The Medline and Embase databases were searched from January 1, 1990, to December 31, 2020. Initially the search yielded 399 manuscripts, which were reduced to 50, upon the application of inclusion criteria. EVIDENCE SYNTHESIS: A total of 65 patients were included in the present review. Mean age was 44±17.5 (DS) years (15-95); M:F ratio was 2.3:1. TS involved mainly the left side (3:2) and was rarely bilateral. Only 2 TS reported cases were due to central causes. Peripheral causes were mainly due to postintubation edema (77%), extrinsic compression (15%), vascular disease (3%), other/not defined (5%). CONCLUSIONS: TS is a rare syndrome that has been related to a combined cranial nerve palsy; while TS due to central causes is very rare, it is mainly related to peripheral causes. A particular attention to TS should be given during the SARS-CoV-2 pandemic, either since the correlation between Tapia's syndrome, airway management and anesthetic procedures, since the possible implication of the viral infection itself.

Major complications of airway management: a prospective multicentre observational study.

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

The efficacy of apneic oxygenation to prevent hypoxemia during rapid sequence intubation in trauma patients.

PURPOSE OF REVIEW: Rapid and effective airway management is priority for trauma patients. Trauma patients are often at an increased risk of experiencing hypoxia, and thus at increased risk of morbidity and mortality. Apneic oxygenation has been widely debated but has been reported to provide benefit in terms of increased peri-intubation oxygen saturation and decreased rates of desaturation. This review aims to evaluate the current literature on the efficacy of apneic oxygenation in the setting of rapid sequence intubation (RSI) in trauma patients. RECENT FINDINGS: Two prospective studies published this year, demonstrated that apneic oxygenation was effective in reducing hypoxic events and hypoxic duration during RSI. SUMMARY: The use of apneic oxygenation can play an important role in preventing hypoxic events in trauma patients undergoing RSI. The use of apneic oxygenation is cheap, and should be considered to reduce hypoxemic events. Additional studies are required to see the effects of apneic oxygenation on outcomes in trauma patients undergoing RSI, specifically desaturation and hypoxemic events and duration, and early onset mortality.

Challenges and outcomes in airway management outside the operating room.

PURPOSE OF REVIEW: Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes. RECENT FINDINGS: Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure. SUMMARY: Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.

The physiologically difficult airway: an emerging concept.

PURPOSE OF REVIEW: The physiologically difficult airway is one in which physiologic alterations in the patient increase the risk for cardiorespiratory and other complications during tracheal intubation and transition to positive pressure ventilation. This review will summarize the recent literature around the emerging concept of the physiologically difficult airway, describe its relevance and various patient types in which this entity is observed. RECENT FINDINGS: Physiologic derangements during airway management occur due acute illness, pre-existing disease, effects of anesthetic agents, and positive pressure ventilation. These derangements are especially recognized in critically ill patients, but can also occur in otherwise healthy patients including obese, pregnant and pediatric patients who have certain physiological alterations. Critically ill patients may have a physiologically difficult airway due to the presence of acute respiratory failure, hypoxemia, hypotension, severe metabolic acidosis, right ventricular failure, intracranial hypertension, and risk of aspiration of gastric contents during tracheal intubation. SUMMARY: Understanding the physiological alterations and the risks involved in patients with a physiologically difficult airway is necessary to optimize the physiology and adopt strategies to avoid complications during tracheal intubation. Further research will help us better understand the optimal strategies to improve outcomes in these patients.

Perioperative management of patients undergoing tracheal resection and reconstruction: a retrospective observational study.

BACKGROUND: Perioperative management of Tracheal Resection and Reconstruction (TRR) presents many challenges to the physicians involved in airway management. Factors related to postoperative outcomes can be identified as early as the preoperative setting and can even be linked to demographic characteristics of patients affected by tracheal stenosis. The primary aim of this study is to describe the experience of patients undergoing TRR at our hospital from an anesthesiology perspective, describing as a second aim demography, preoperative conditions, and postoperative complications. METHODS: This was a single institution retrospective review of patients who underwent TRR between 2009 and 2020. We did a post-hoc exploratory analysis to identify possible associations between perioperative complications and perioperative management. RESULTS: Forty-three ASA I-IV adult patients aged 18-72 years who underwent TRR were included. Prolonged intubation (72%) is the primary cause of tracheal stenosis. Intraoperative management: intravenous induction and laryngeal masks are now the most frequently used for airway management, especially in subglottic stenosis. Perioperative complications were vocal cord paralysis (25.6%), postoperative ventilatory support (20.9%), and need for surgical reintervention (20.9%). One patient (2%) died in the postoperative period due to anastomotic complication. After resection, dexmedetomidine is the preferred choice (48.8%) for sedoanalgesia in the ICU. CONCLUSIONS: Perioperative management of TRR at our hospital has a low mortality and high morbidity rate. We did not find an association between perioperative anesthetic interventions and postoperative complications. Further studies are needed to evaluate which anesthetic interventions may be associated with better outcomes.

Sealing mechanism study of laryngeal mask airways via 3D modelling and finite element analysis.

Proper sealing of laryngeal mask airways (LMAs) is critical for airway management in clinical use. Understanding the sealing mechanism can significantly help front-line anaesthetists to reduce the incidence of adverse events. However, anaesthetists, who may not have the most substantial engineering backgrounds, lack intuitive ways to develop an understanding of the LMA sealing mechanism effectively. The paper aims to study the LMA-pharynx sealing mechanisms from the perspective of front-line anaesthetists. We use a computer-aided 3D modelling technique to visualise the LMA-pharynx interactions, which helps anaesthetists identify the critical areas of complications. Furthermore, we conduct a quantitative pressure distribution analysis of the LMA-pharynx contacting surface using the finite element analysis technique, which helps further understand the sealing mechanics in those areas. We present two cases studies based on one male volunteer, aged 50, inserted with a ProSeal LMA. In the first case, a relatively low cuff pressure (CP) was applied to simulate the clinical circumstances in which complications related to air leakage are most likely to happen; in the second case, we increase the CP to a relatively high value to simulate the scenarios with an increased risk of complications related to high mucosal pressure. The experiments suggest the follows: (1) Sore throat complications related to high mucosal pressure is most likely to occur in the hypopharynx with a high CP setting, particularly in the areas where the cricoid cartilage presses the mucosa. (2) The narrow hyoid bone super horn width likely causes LMA insertion difficulties. (3) Insufficient CP will significantly increase the risk of air leakage in the oropharynx. A complete sealing pressure line in the contacting surface will be formed with sufficient CP, thereby preventing the air leakage into the oral.