Francisco López-Timoneda

Straight blades improve visualization of the larynx while curved blades increase ease of intubation: a comparison of the Macintosh, Miller, McCoy, Belscope and Lee-Fiberview blades

PurposeTo compare the Macintosh (M), McCoy (MC), Miller (MIL), Belscope (BP) and Lee-Fiberview (LF) laryngoscopes with respect to the grade of laryngeal visualization and the difficulty of intubation.MethodsWe included 500 patients scheduled to undergo elective surgery and who required tracheal intubation. Patients were randomly assigned to five groups of 100 patients each. Anesthesia was induced intravenously using 1–3 mg·kg−1 of propofol, fentanyl 1.5 μg·kg−1 and atracurium 0.5 mg·kg−1 or suxamethonium I mg·kg−1. The laryngeal view was classified according to Cormack and Lehane. The degree of difficulty with intubation was rated as: Grade I, intubation easy; Grade 2, intubation requiring an increased anterior lifting force and assistance to pull the right corner of the mouth upwards to increase space; Grade 3, intubation requiring multiple attempts and a curved stylet; Grade 4, failure to intubate with the assigned laryngoscope. Data were examined using analysis of variance, Χ2 or Fisher test, Student’s t test and odds ratio.P < 0.05 was considered statistically significant.ResultsLaryngoscopic views obtained with the BP and MIL laryngoscopes were similar, and better than with the other types of laryngoscopes (P < 0.001). The levering tip of the MC blade (P = 0.02) and the fibreoptic device of the LF (P < 0.001) significantly improved the laryngoscopic view. Regarding the degree of difficulty with intubation, the best results were obtained with the MC and M blades (P < 0.001).ConclusionLaryngoscopy was better with straight blades but curved blades provided better intubating conditions.RésuméObjectifComparer les laryngoscopes Macintosh (M), McCoy (MC), Miller (MIL), Belscope (BP) et Lee-Fiberview (LF) quant au degré de visualisation du larynx et à la difficulté d’intubation.MéthodeLétude a porté sur 500 patients devant subir une intervention chirurgicale réglée nécessitant une intubation endotrachéale. Les patients ont été répartis en cinq groupes de 100 patients chacun. Lanesthésie a été induite par l’administration intraveineuse de 1–3 mg·kg−1 de propofol, 1,5 μg·kg−1 de fentanyl et 0,5 mg·kg−1 d’atracurium ou I mg·kg−1 de suxaméthonium. La visualisation du larynx a été cotée selon Cormack et Lehane. Le degré de difficulté d’intubation a été noté comme suit: Classe I, intubation facile; Classe 2, intubation nécessitant de soulever l’appareil vers l’avant avec une force croissante et une assistance pour pousser le coin droit de la bouche vers le haut pour accentuer l’ouverture; Classe 3, intubation nécessitant plus d’un essai et un stylet courbe; Classe 4, échec de l’intubation avec le laryngoscope testé. Les données ont été étudiées avec une analyse de variance, le test du Χ2 ou le test de Fisher, le test de Student et le risque relatif. P < 0,05 a été considéré significatif.RésultatsLa visualisation laryngoscopique a été similaire avec le BP et le MIL, et meilleure qu’avec les autres appareils (P < 0,001). La pointe levier de la lame MC (P = 0,02) et la composante fibroscopique du LF (P < 0,001) ont significativement amélioré la visualisation du larynx. Relativement au degré de difficulté d’intubation, les meilleurs résultats ont été obtenus avec les lames MC et M (P < 0,001).ConclusionLa laryngoscopie a été meilleure avec les lames droites, mais les lames courbes ont facilité les conditions d’intubation.

A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade.

We reviewed systematically sugammadex vs neostigmine for reversing neuromuscular blockade. We included 17 randomised controlled trials with 1553 participants. Sugammadex reduced all signs of residual postoperative paralysis, relative risk (95% CI) 0.46 (0.29–0.71), p = 0.0004 and minor respiratory events, relative risk (95% CI) 0.51 (0.32–0.80), p = 0.0034. There was no difference in critical respiratory events, relative risk (95% CI) 0.13 (0.02–1.06), p = 0.06. Sugammadex reduced drug‐related side‐effects, relative risk (95% CI) 0.72 (0.54–0.95), p = 0.02. There was no difference in the rate of postoperative nausea or the rate of postoperative vomiting, relative risk (95% CI) 0.94 (0.79–1.13), p = 0.53, and 0.87 (0.65–1.17), p = 0.36 respectively.

Perioperative goal-directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

STUDY OBJECTIVE Goal-directed fluid therapy (GDHT) has been proposed as a method to reduce complications and mortality. DESIGN Meta-analysis of the effects of perioperative GDHT in adult noncardiac surgery on mortality and postoperative complications was performed using the PRISMA methodology. A systematic search was performed in MEDLINE, PubMed, EMBASE, and the Cochrane Library (last update, October 2014). Inclusion criteria were as follows: randomized clinical trials (RCTs) in which perioperative GDHT was compared with conventional fluid management in noncardiac surgery. Exclusion criteria were as follows: trauma and pediatric surgery studies. End points were mortality and number of patients with complications. SETTING District general hospital. PATIENTS Thirty-nine RCTs were initially identified, with 8 fulfilling the inclusion criteria. Two RCTs were added by manual search, resulting in 10 RCTs in the final analysis, including 1527 patients. MEASUREMENTS Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by supraphysiological or physiological hemodynamic goal and by time the intervention was carried out, perioperative or postoperative), and predefined sensitivity analysis. MAIN RESULTS A significant reduction was observed in mortality associated with GDHT compared with conventional fluid therapy (risk ratio, 0.63; 95% confidence interval, 0.42-0.94; P = .02). However, no differences were found in the number of patients with complications (risk ratio, 0.75; 95% confidence interval, 0.50-1.17; P = .21), and the sensitivity analysis did not confirm the results. CONCLUSIONS This meta-analysis, with its limitations, shows that the use of perioperative GDHT may reduce postoperative mortality, but it is unable to show a reduction in the number of patients with complications.

Perioperative Use of Clevidipine: A Systematic Review and Meta-Analysis

Background Clevidipine is an ultrashort-acting drug for rapid reduction of blood pressure by selectively acting on the L-type Ca2+ channels on arteriolar smooth muscle. The drug’s ultrashort action in reducing the blood pressure is due to its rapid hydrolysis by blood and extravascular tissue esterases, which does not depend on hepato-renal metabolism and excretion. An analysis of the perioperative management of blood pressure should be considered to compare with other intravenous antihypertensive agents. Methods Analyses of the available evidence in randomized clinical trials following the PRISMA methodology as well as clinical significance according to the GRADE system were conducted. Placebo versus other antihypertensive drugs studies were included. Statistical assessments were done using the X2 and I2 tests. Results Clevidipine was more effective in maintaining the blood pressure within pre-specified ranges compared with other antihypertensive drugs (MD, -17.87 CI 95%: -29.02 to -6.72; p = 0.02). The use of Clevidipine versus placebo and rescue antihypertensive intravenous drug showed a clear reduction in rates of treatment failure (RR 0.10; IC 95%; 0.05–0.18; p <0.0001). There was no difference in the incidence of adverse events compared with placebo (RR 1.47; 95% CI 0.89 to 2.43, p = 0.14) and with other antihypertensive drugs (RR 0.78, 95% CI 0.45 to 1.35; p = 0.37). In addition, there was no difference in the incidence of atrial fibrillation (AF) between clevidipine and control groups (RR 1.09, IC del 95%: 0.65 a 1.83; p = 0.73). Conclusions Clevidipine is an ultrafast-acting drug that is highly effective for management of perioperative arterial hypertension. It is devoid of adverse effects associated with the use of other IV antihypertensives. Its favorable pharmacodynamic and pharmacokinetic properties make clevidipine the drug of choice for the management of acute perioperative hypertension. It is important to emphasize the need for further studies with a larger number of patients to confirm these findings and increase the degree of evidence.

[Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis].

BACKGROUND The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Terapia hemodinâmica alvo‐dirigida no intraoperatório de cirurgia não cardíaca: revisão sistemática e meta‐análise

BACKGROUND The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Laryngeal Mask, Laryngeal Tube, and Frova Introducer in Simulated Difficult Airway

BACKGROUND The use of supraglottic devices is rising in the prehospital management of difficult airway; moreover, we think that patients with multiple trauma or cervical instability can take advantage of these devices without opening or retiring the cervical collar. OBJECTIVE To compare speed and ease of use between Laryngeal Tube S (LTS) and the Ambu AuraOnce laryngeal mask (LMA).Our second objective was to evaluate changing these devices to an endotracheal tube (ETT) using a Frova introducer. METHODS We studied the use of LTS and LMA in an experimental model, represented by a manikin with a rigid cervical collar and a limited mouth opening. This study was carried out in Complutense University of Madrid with 145 2(nd)-year students for the degree in Dentistry who have knowledge of the airway but lack experience in intubation. Number of attempts and time for the devices insertion were measured, as well as time for the exchange maneuver using the Frova introducer. RESULTS Insertion of all devices was possible on the first attempt; time for insertion was LTS 12.2 ± 1.28 s and LMA 6.87 ± 0.97 s. Once these devices were inserted, a Frova introducer is used to perform an exchange by an endotracheal tube; all devices could be exchanged on the first attempt, and exchange time was LTS 26.9 ± 1.2 s and LMA 16.79 ± 1.32 s. Results for both time for insertion and exchange of the LMA were significantly lower than those for the LTS (p < 0.001). CONCLUSION The method used can be considered quick and easy, even for personnel inexperienced in intubation. This exchange maneuver has not been described previously, so we can consider it as a new application of the Frova introducer.