Daily Anesthesiology Research Analysis

INTRODUCTION: The utility of bedside screening tests for the prediction of difficult airways is limited. There is growing interest in the role of point-of-care-ultrasound in airway assessment and management. This systematic review and meta-analysis aimed to determine the diagnostic utility and clinical application of various upper airway point-of-care-ultrasound parameters in the prediction of difficult airways. METHODS: We searched databases for randomised controlled trials, observational studies and case series with more than five cases. RESULTS: In total, 60 studies involving 10,580 patients, evaluating 58 parameters were included. For difficult facemask ventilation, a narrative synthesis showed that increased tongue thickness was associated with an increased incidence of a difficult airway. For prediction of difficult laryngoscopy, the sensitivity, specificity and area under the receiver operator characteristic curve (AUROC) for distance from-skin-to-vocal-cords were 0.84 (95%CI 0.74-0.91), 0.81 (95%CI 0.61-0.92) and 0.87 (95%CI 0.78-0.89), respectively (high certainty of evidence). For prediction of difficult tracheal intubation, distance from skin-to-epiglottis had the highest sensitivity (0.80 (95%CI 0.74-0.85)) and specificity (0.86 (95%CI 0.74-0.91)) (high certainty of evidence), while distance from skin-to-hyoid had the highest AUROC of 0.86 (95% CI 0.73-0.92), with a sensitivity and specificity of 0.78 (95%CI 0.60-0.89) and 0.81 (95%CI 0.63-0.91), respectively (moderate certainty of evidence). Ultrasound use was associated with higher first pass success in percutaneous tracheostomy (odds ratio (95%CI) 3.9 (2.1-71), (low-moderate certainty of evidence)) and improved cricothyroid membrane identification compared with palpation (odds ratio (95%CI) 3.61 (2.20-5.92) (moderate-high certainty of evidence)). DISCUSSION: Upper airway point-of-care ultrasound may improve prediction of difficult airways; its use is associated with improved first pass success in percutaneous tracheostomy. Future research should focus on evaluating its use in combination with a focused history and standard bedside examination tests, and in at-risk patient populations. Doctors sometimes have a hard time knowing if they will have trouble managing a patient's airway during a medical procedure. Simple tests done at the bedside don't always give enough information. More doctors are now using a special tool called an ultrasound, which lets them see inside the body in real time, to check the airway. This study looked at how good ultrasound is at helping doctors spot airway problems before they happen. The researchers looked through many medical studies. They found 60 different studies with over 10,000 patients. These studies used ultrasound in many ways to check the airway. For looking into the throat (laryngoscopy), one helpful sign was how far the vocal cords were from the skin. The best sign for putting a tube into the windpipe (intubation) was how far the skin was from the epiglottis (a flap in the throat). Another good sign was the distance from the skin to the hyoid bone (a bone in the neck). Using ultrasound helped doctors succeed more often on the first try when placing a breathing tube through the neck (called a tracheostomy). Using ultrasound on the neck can help doctors find out if a patient might have a hard‐to‐manage airway. It also helps with placing tubes more safely and quickly. More studies are needed to see how it works when used together with regular tests and patient history, especially in people who might have higher risks.

BACKGROUND: The role of supplemental parenteral nutrition (SPN) following pancreatoduodenectomy (PD) in the context of an enhanced recovery program is unexplored. This study aimed to determine whether SPN is superior to early oral feeding alone in reducing postoperative complications. METHODS: This pragmatic, multicenter, randomized controlled, trial, across five centers in Italy, enrolled patients aged 18-89 years undergoing open PD for cancer. We excluded patients with an American Society of Anaesthesiology physical status >3 and a preoperative body weight loss of ≥15%. Patients were randomly assigned (1:1) postoperatively to either SPN from day 1 to 5 or no-SPN. All patients were free to begin oral feeding after the operation as desired in the context of a full enhanced recovery after surgery (ERAS) program. The primary outcome was morbidity burden, measured using the comprehensive complication index (CCI). Secondary outcomes included the overall rate of morbidity. Outcomes were assessed up to 90 days postoperatively. Overall, 120 patients per group were required to achieve 80% power and detect at least 30% reduction in the CCI in the SPN group, which was expected to be 23 (median) (interquartile range 21-31). The expected complication rate was 60%, and the type I error rate was set at 5%. Registration at ClinicalTrials.gov (#NCT04438447). FINDINGS: From June 1, 2022, to December 20, 2023, 405 patients were screened for eligibility and 254 patients were randomly allocated to control (no-SPN; n = 129) or treatment (SPN; n = 125) group. All patients were included in the primary and secondary outcome analysis according to the intent-to-treat principle. The median CCI was 20.9 in both arms (median difference 0 [95% CI: -1.07 to 1.7]). The proportion of patients with at least one complication (CCI >0) was similar in both groups [(29.6% vs 29.2%; risk difference 0.4 (95% CI -11.1 to 7.0)]. The overall 90-day morbidity was 67.4% and 63.2% in the no-SPN arm and SPN arm groups, respectively [risk difference -4.2 (95% CI -16.7 to 8.2)]. In high nutritional risk patients (nutritional risk score ≥3), SPN was not protective against the primary outcome when compared with low-risk patients [OR 1.16 (95% CI 0.71-1.91)]. INTERPRETATION: In an ERAS program emphasizing early postoperative oral feeding, SPN does not affect outcome measures, even in patients at high nutritional risk. However, these results do not apply to severely malnourished patients or with critical comorbidities. FUNDING: The Italian Society for Artificial Nutrition and Metabolism (SINPE) and Baxter Italia S.p.A (Rome, Italy).

BACKGROUND: Transnasal humidified rapid-insufflation ventilatory exchange is a novel ventilation modality which can provide very high flow (up to 70 l/min) heated and humidified gas with adjustable temperatures (31-37 °C) and oxygen concentrations (21-100%). However its application in sedated gastroscopy in children has received little attention. OBJECTIVE: To observe transnasal humidified rapid-insufflation ventilatory exchange in sedated gastroscopy in children and its effect on the incidence of hypoxemia. DESIGN: A prospective randomized clinical trial. SETTING: Endoscopy Center in Shenzhen Children's Hospital. PATIENTS: 120 children (ASA grade I-II), aged 6-12 years with a body mass index of 18-25 kg m-2, who underwent sedated gastroscopy at Shenzhen Children's Hospital between June 2022 and November 2022. INTERVENTIONS: The participants were randomly assigned in a 1:1 ratio to receive transnasal humidified rapid-insufflation ventilatory exchange or nasal cannula oxygen therapy. MAIN OUTCOME MEASURES: The primary outcome was hypoxemia incidence. The secondary outcomes included the lowest oxygen saturation index, duration of hypoxemia, incidence of adverse respiratory conditions, intervention rate, and endoscopist satisfaction. RESULTS: Five children (8.3%) in thetransnasal humidified rapid-insufflation ventilatory exchange group had hypoxemia compared with 17 (28.3%) in the nasal cannula group, with a significant difference (P<0.01). The lowest oxygen saturation index in two groups shows no significant difference [98 (95, 99) vs. 98 (90, 99), P=0.087]. However compared with the nasal cannula group, the duration of hypoxaemia was significantly shorter (9.00 ± 1.73 s vs. 13.18 ± 3.49 s, 95% CI -6.63 to -1.72; P<0.01), the intervention rate was significantly lower (n=7, 11% vs. n=18, 30%; P<0.05), the incidence of adverse breathing complications was significantly lower (n=8, 13.3% vs. n=18, 30%; P<0.05), and the satisfaction of endoscopists was significantly higher (88.3% vs. 68.3%, P<0.05) in the transnasal humidified rapid-insufflation ventilatory exchange group. CONCLUSION: Transnasal humidified rapid-insufflation ventilatory exchange can promote oxygenation reducing the incidence of hypoxemia in sedated gastroscopy in children. TRIAL REGISTRATION: ChiCTR2200060799.