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European Journal of Anaesthesiology Jan 2024Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent...
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Topics: Infant, Newborn; Infant; Humans; Anesthesiology; Airway Management; Intubation, Intratracheal; Anesthesia, General; Critical Care
PubMed: 38018248
DOI: 10.1097/EJA.0000000000001928 -
Anaesthesia, Critical Care & Pain... Feb 2020To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal...
OBJECTIVES
To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded.
METHODS
The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system.
RESULTS
The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations.
CONCLUSION
Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
Topics: Airway Management; Anesthesia; Consensus; France; Guidelines as Topic; Humans; Intubation, Intratracheal; Monitoring, Intraoperative; Muscle Relaxants, Central; Neuromuscular Blockade; Respiration, Artificial
PubMed: 31926308
DOI: 10.1016/j.accpm.2020.01.005 -
Canadian Journal of Anaesthesia =... Sep 2021Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore...
Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient.
PURPOSE
Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.
SOURCE
Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.
FINDINGS AND KEY RECOMMENDATIONS
Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
Topics: Adult; Airway Management; Canada; Consensus; Focus Groups; Humans; Intubation, Intratracheal; Laryngoscopy
PubMed: 34143394
DOI: 10.1007/s12630-021-02007-0 -
Anesthesia and Analgesia May 2022The American Society of Anesthesiologists' (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to...
The American Society of Anesthesiologists' (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist's choice of pathway in the ASA's Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist's unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.
Topics: Airway Management; Algorithms; Anesthesiologists; Decision Trees; Humans; Intubation, Intratracheal; Laryngoscopy; Oxyhemoglobins
PubMed: 35171880
DOI: 10.1213/ANE.0000000000005930 -
British Journal of Anaesthesia Jul 2020
Topics: Airway Management; Emergencies; Humans; Trachea
PubMed: 32402374
DOI: 10.1016/j.bja.2020.04.008 -
Acta Clinica Croatica Apr 2023Neurosurgical patients have specific airway management. Various conditions and diagnoses make intubation difficult and may also cause neurological damage. Spinal... (Review)
Review
Neurosurgical patients have specific airway management. Various conditions and diagnoses make intubation difficult and may also cause neurological damage. Spinal pathology, neurotrauma, cervical spine surgery, and pituitary gland surgery are just some examples. The aim of this review article is to present a broad spectrum of neurosurgical operations and potential complications in maintaining airway patency related to these issues. Quality perioperative preparation is a prerequisite to avoid the potentially irreversible consequences of difficult airways with a poor neurological or even fatal outcome. Patients with tumors of the pituitary region who present with Cushing's disease are prone to difficult ventilation, tracheal obstruction and difficult intubation. Awake craniotomy is also a challenge for the anesthesiologist, given that access to the airway is problematic due to the fixed frame. Unstable cervical spine occurs in cases of rheumatoid arthritis or blunt trauma, requiring precautions to be taken with spinal stabilization during intubation and induction. Pharyngeal edema and hematomas, possible complications of cervical spine surgery can endanger airway patency after extubation; postoperative patient supervision is thus required. Due to the potential threat to the patient's airway during neurosurgical procedures, quality anesthetic preoperative preparation is necessary to avoid irreversible damage and death.
Topics: Humans; Airway Management; Neurosurgical Procedures; Anesthesia; Intubation, Intratracheal; Neuroanesthesia
PubMed: 38746598
DOI: 10.20471/acc.2023.62.s1.15 -
Canadian Journal of Anaesthesia =... Sep 2021
Topics: Airway Management; Curriculum; Humans; Leadership
PubMed: 34231130
DOI: 10.1007/s12630-021-02057-4 -
British Journal of Anaesthesia Dec 2022Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error.... (Review)
Review
Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error. Unrecognised oesophageal intubation can occur in any patient of any age whenever intubation occurs regardless of the seniority or experience of the airway practitioner or others involved in the patient's airway management. The tragic fact is that it continues to happen despite improvements in monitoring, airway devices, and medical education. We review these improvements with strategies to eliminate this problem.
Topics: Humans; Intubation, Intratracheal; Esophagus; Airway Management
PubMed: 36192220
DOI: 10.1016/j.bja.2022.08.027 -
Acta Clinica Croatica Apr 2023Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general... (Review)
Review
Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.
Topics: Humans; Airway Management; Pregnancy; Female; Practice Guidelines as Topic; Intubation, Intratracheal; Algorithms; Anesthesia, Obstetrical; Obstetrics
PubMed: 38746607
DOI: 10.20471/acc.2023.62.s1.10 -
Journal of Clinical Monitoring and... Apr 2022
Review
Topics: Airway Management; Humans; Intubation, Intratracheal
PubMed: 35262837
DOI: 10.1007/s10877-022-00839-9