Daily Anesthesiology Research Analysis

IMPORTANCE: Indication criteria for camera-assisted and awake tracheal intubation are vague. It is unknown if diagnostic and clinical data from multiple sources, such as transnasal videoendoscopy or symptoms for pharyngolaryngeal lesions, might improve preanesthesia airway management planning and decision-making in patients undergoing head and neck surgery. OBJECTIVE: To develop and validate a new decision-making tool (Evidence-Based Algorithm for the Expected Difficult Intubation [Expect-It]) and show noninferiority to the clinical standard (nonalgorithm-based decision-making). DESIGN, SETTING, AND PARTICIPANTS: This single-center study prospectively developed and validated a decision-making tool with a 2-stage design that included anesthetic cases from patients undergoing head and neck surgery between May 1, 2021, and January 29, 2022. Data were analyzed between August 2021 (first stage) and December 2023. EXPOSURES: Airway-related risk factors from 4 domains (previous intubation difficulties, physical examination, physician's rating of difficult airway indicators, and pharyngolaryngeal lesions/transnasal videoendoscopy findings) were preoperatively assessed. During airway management planning, physicians proposed a first-line tracheal intubation technique (camera-assisted or direct laryngoscopy) and strategy (awake or asleep tracheal intubation). In the development cohort, these proposals were nonalgorithm-based (clinical standard); in the validation cohort, they relied on the Expect-It decision-making tool. MAIN OUTCOMES AND MEASURES: Regularized regression was used to select potentially predictive airway-related risk factors (covariables). The final decision-making tool is a combined score originating from 2 multivariable logistic regression models that predict 2 different primary outcomes: the most appropriate (1) tracheal intubation technique (camera-assisted or direct laryngoscopy) and (2) strategy (awake or asleep), as determined by the anesthesiologists after tracheal intubation. RESULTS: Of 1201 patients (mean [SD] age, 50.3 [19.0] years; 695 [58%] male), 1282 anesthetic cases were included in the analysis: 602 in the development and 680 in the validation cohort. The area under the curve of the decision-making tool was 0.86 (95% CI, 0.81-0.90) to predict appropriate camera-assisted and 0.97 (95% CI, 0.96-0.99) to predict appropriate awake tracheal intubation in the development cohort. The sensitivity of the Expect-It tool to predict both appropriate camera-assisted and awake tracheal intubation was superior compared to the clinical standard (camera-assisted: 88% [95% CI, 81%-93%] vs 35% [95% CI, 27%-44%], respectively; awake tracheal intubation: 97% [95% CI, 81%-100%] vs 29% [95% CI, 15%-50%], respectively), and specificity was noninferior to the clinical standard (camera-assisted: 97% [95% CI, 96%-98%] vs 96% [95% CI, 93%-97%], respectively; awake tracheal intubation: 100% [95% CI, 99%-100%] vs 98% [95% CI, 97%-99%], respectively). After tool implementation, the first-attempt success rate increased from the development to validation cohort (437 [73%] vs 557 [82%], respectively; odds ratio, 1.72 [95% CI, 1.32-2.22]), while failed direct laryngoscopy decreased from the development to validation cohort (45 [8%] vs 10 [2%], respectively; odds ratio, 0.18 [95% CI, 0.09-0.37]). CONCLUSIONS AND RELEVANCE: In this study, the Expect-It tool for airway management planning was prospectively developed and validated. The tool was found to support airway management planning accurately and may serve as a precursor for intelligent algorithms.

This article was developed by a diverse group of 25 international experts from the European Society of Anaesthesiology and Intensive Care (ESAIC), who formulated recommendations on intra-operative haemodynamic monitoring and management of adults having noncardiac surgery based on a review of the current evidence. We recommend basing intra-operative arterial pressure management on mean arterial pressure and keeping intra-operative mean arterial pressure above 60 mmHg. We further recommend identifying the underlying causes of intra-operative hypotension and addressing them appropriately. We suggest pragmatically treating bradycardia or tachycardia when it leads to profound hypotension or likely results in reduced cardiac output, oxygen delivery or organ perfusion. We suggest monitoring stroke volume or cardiac output in patients with high baseline risk for complications or in patients having high-risk surgery to assess the haemodynamic status and the haemodynamic response to therapeutic interventions. However, we recommend not routinely maximising stroke volume or cardiac output in patients having noncardiac surgery. Instead, we suggest defining stroke volume and cardiac output targets individually for each patient considering the clinical situation and clinical and metabolic signs of tissue perfusion and oxygenation. We recommend not giving fluids simply because a patient is fluid responsive but only if there are clinical or metabolic signs of hypovolaemia or tissue hypoperfusion. We suggest monitoring and optimising the depth of anaesthesia to titrate doses of anaesthetic drugs and reduce their side effects.

BACKGROUND: Remimazolam is a new type of ultra-short-acting benzodiazepine. The aim of this study was to investigate the effects of remimazolam, propofol and sevoflurane anesthesia on rocuronium-induced neuromuscular block. METHODS: Ninety-nine consenting patients were randomly assigned to a remimazolam group (R-group), sevoflurane group (S-group), or propofol group (P-group). Train-of-four (TOF) responses evoked on the abductor digiti minimi muscle to ulnar nerve stimulation following bolus administration of 0.9-mg/kg rocuronium were monitored with electromyography-based neuromuscular monitor. The primary outcomes were times from administration of rocuronium to first reappearance of post-tetanic count (PTC). Free plasma concentrations of rocuronium were concurrently measured at these events. RESULTS: Ninety patients were analyzed. No significant differences were seen in time to first PTC among the three groups. Mean (± standard deviation) and median (inter-quartile range) times for the reappearance of TOF counts 1 and 2 were significantly prolonged in S-group [50.7 ± 13.9 min, P = 0.043 and 61.6 (54.3-78.0) min, P = 0.020, respectively], when compared with P-group [42.6 ± 10.3 min and 52.9 (45.4-58.8) min, respectively]. However, no significant differences were seen between S-group and R-group. Median (inter-quartile range) free plasma concentration of rocuronium measured at first PTC was significantly lower in R-group [1255 (1126-1717) ng/mL] than in P-group [1717 (1592-1961) ng/mL, P = 0.031]. CONCLUSIONS: These results suggest that the potentiating effects of remimazolam on rocuronium-induced neuromuscular block are weaker than those of sevoflurane and similar to those of propofol.