Anaesthesia
-
Difficult airway management continues to adversely affect patient care and clinical outcomes and is poorly predicted. Previous difficult airway management is the most accurate predictor of future difficulty. The Difficult Airway Society initiated a national airway database to allow clinicians to access details of previous difficult airway episodes in patients issued with a difficult airway alert card. ⋯ Airway-related critical incidents were associated with out-of-hours airway management, but no other associations were apparent. Our data report the first analysis of a national difficult airway database, finding that unanticipated difficult airway management continues to occur despite airway assessment, and the rate of critical incidents in this cohort of patients is high. This database has the potential to improve airway management for patients in the future.
-
A model to classify the difficulty of videolaryngoscopic tracheal intubation has yet to be established. The videolaryngoscopic intubation and difficult airway classification (VIDIAC) study aimed to develop one based on variables associated with difficult videolaryngoscopic tracheal intubation. We studied 374 videolaryngoscopic tracheal intubations in 320 adults scheduled for ear, nose and throat or oral and maxillofacial surgery, for whom airway management was expected to be difficult. ⋯ The calibration belt for the coefficient model was consistent with observed alert probabilities, from 0% to 100%, while the unitary VIDIAC score overestimated probabilities < 20% and underestimated probabilities > 70%. Discrimination of the VIDIAC score for patients more or less likely to be issued an alert was better than discrimination by the Cormack-Lehane classification, with mean (95%CI) areas under the receiver operating characteristic curve of 0.92 (0.89-0.95) vs. 0.75 (0.70-0.80), respectively, p < 0.001. Our model and score can be used to calculate the probabilities of difficult airway alerts after videolaryngoscopy.
-
The interscalene brachial plexus block is recommended for analgesia after shoulder surgery but it may cause hemidiaphragmatic dysfunction. We tested whether ipsilateral hemidiaphragmatic contraction was better after a smaller dose of local anaesthetic without impairing analgesic effect. We randomly allocated 48 adults to 10 ml or 20 ml levobupivacaine 0.25% before arthroscopic shoulder surgery. ⋯ Median (IQR [range]) morphine doses in the first 24 postoperative hours after 10 ml and 20 ml levobupivacaine 0.25% were 2 (0-6 [0-23]) mg vs. 1 (0-2 [0-11]) mg, respectively, p = 0.12. No participant had a complication after 10 ml interscalene levobupivacaine, whereas seven had complications after 20 ml levobupivacaine, p = 0.009. Hemidiaphragmatic function was better after 10 ml vs. 20 ml interscalene levobupivacaine 0.25% without impairing analgesia for 24 postoperative hours.