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.

[Death under anesthesia. Definition, causes, risk factors and prevention]. / Anaestesidødsfald. Definition, årsager, risikofaktorer og forebyggelse.

Death associated with anaesthetic procedures is rare, 1-4 deaths per 10,000 anaesthesias. However, each case gives rise to discussion about causality and who is to blame. Prospective studies are few, and comparison between them is difficult because of the use of different definitions of anaesthesia related death. A critically ill patient with impaired function of multiple organs seems to be at a higher risk of anaesthesia related death than a more healthy patient. However, no study has so far identified preoperative risk factors of anaesthesia related death. This is probably due to the low incidence of anaesthesia related death. The most common causes of anaesthesia related deaths are: 1) circulatory failure due to hypovolaemia in combination with overdosage of anaesthetic agents such as thiopentone, opioids, benzodiazepines or regional anaesthesia; 2) hypoxia and hypoventilation after for instance undetected oesophageal intubation, difficult intubation, technical failure in the anaesthetic equipment, or aspiration of gastric content, 3) anaphylactoid reactions including malignant hyperthermia, and 4) human negligence such as lack of vigilance or errors in the administration of drugs and in the maintenance and control of the anaesthetic equipment. We discuss the importance of continuing education for anaesthesiologists, development of a standard for surveillance during anaesthesia and quality control of the anaesthetic procedure with registration of undesired incidents. National registration of serious incidents will make it possible to determine the incidence of serious complications and death associated with anaesthesia. Hopefully this registration will provide information about causality and thereby facilitate prevention and improve patient safety during anaesthesia.

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

BACKGROUND: The purpose of the present study was to measure the incidence and type of incidents that occurred in relation to anaesthesia and surgery during a 1-year period in six Danish hospitals. Furthermore, we wanted to identify risk factors for incidents, as well as risk factors for incidents being deemed critical. METHODS: A four-page questionnaire describing patient data, type of anaesthesia and surgery, and occurrence of incidents was filled in for all anaesthesias in the period, and subsequently processed. The incident reporting form incorporated 59 predefined adverse events. The occurrence of one or more of these events described the incident. When the reporting anaesthetist deemed that an incident had harmed the patient, that incident was defined as critical. RESULTS: A total of 64,312 anaesthesias were reported, and in 7754 of them one or more incidents occurred. A total of 8510 incidents occurred, 4077 of them were solely related to the anaesthetic procedure, 3702 described events related to physiological alterations in the patient (physiological incidents). Three hundred and twenty-three of the incidents were deemed critical. High ASA score, high age, abdominal surgery, urgent surgery, and complex anaesthetic procedure were significant risk factors for physiological incidents and critical incidents. We could not identify a simple subset of adverse events that could adequately be used to describe the critical incidents. However, complex incidents, i.e. incidents involving more than one adverse event, were more likely to be deemed critical than simple incidents. CONCLUSION: The incidence of incidents was 12.1%, and the incidence of critical incidents was 0.5%. Incidents were more likely to be deemed critical in patients with an ASA score of III and above undergoing urgent surgery.

Postoperative intensive care admittance: the role of tobacco smoking.

BACKGROUND: Smokers have been shown to have increased risk of intraoperative pulmonary complications and of a wide range of postoperative complications, but an increased risk of postoperative intensive care admittance has not yet been described. The aim of this study was to estimate the risk of pulmonary complications and postoperative intensive care admittance in smokers and non-smokers in a general and orthopaedic surgical population. METHODS: A total of 4725 surgical patients were assessed. The following information was noted: age, sex and smoking status, history of heart and lung disease, ASA classification, type of anaesthesia, intensive care admittance and postoperative pulmonary or cardiovascular complications. A logistic regression model was used to determine the probability of intensive care admittance and pulmonary complications as a function of smoking status, age, and chronic heart and lung disease. RESULTS: Of the patients, 39.9% were smokers, 45.5% were non-smokers and in 14.6% of the cases smoking status was unspecified. Postoperative intensive care admittance and pulmonary complications were found in 2.0% and 4.3% of the patients, respectively. Non-smokers were more often female (P<0.01), and smokers had a higher incidence of emergency surgical procedures (P<0.05). When applying multiple regression analysis, we found that smoking, age >65 years, and a history of chronic lung disease increased the risk of unplanned intensive care admittance (odds ratio 1.55, 12.52 and 2.73). CONCLUSION: Our results indicate a relationship between a history of tobacco smoking and postoperative intensive care admittance.