In Response No abstract available

A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching BACKGROUND: Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS: We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children’s hospitals. We categorized the attending anesthesiologist’s ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS: Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%–20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = −2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = −1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36–3.15; P = .001). CONCLUSIONS: Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications. Accepted for publication July 17, 2019. Funding: This study was supported by the Department of Anesthesiology and Critical Care Medicine at the Children’s Hospital of Philadelphia. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). A full list of contributors can be found at the end of the article. Reprints will not be available from the authors. Address correspondence to Annery G. Garcia-Marcinkiewicz, MD, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to garciamara@email.chop.edu. © 2019 International Anesthesia Research Society

Trends in Postpartum Hemorrhage in the United States From 2010 to 2014 Postpartum hemorrhage (PPH) is a leading cause of morbidity and mortality in the United States; its prevalence increased during the 1990s–2000s. The purpose of this study was to reevaluate trends in PPH using the National Inpatient Sample. From 2010 to 2014, the prevalence of PPH increased from 2.9% (95% confidence interval [CI], 2.7%–3.1%) to 3.2% (95% CI, 3.1%–3.3%) of deliveries. Adjusting for PPH risk factors did not substantially attenuate this trend. Among patients with PPH, there was a decline in associated coagulopathy, acute respiratory failure, and maternal death, but an increase in sepsis and acute renal failure. Continued focus on PPH management is warranted. Accepted for publication August 13, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Reprints will not be available from the authors. Address correspondence to Sharon C. Reale, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis St, CWN L1, Boston, MA 02115. Address e-mail to screale@bwh.harvard.edu. © 2019 International Anesthesia Research Society

Educating Patients Regarding Pain Management and Safe Opioid Use After Surgery: A Narrative Review In recent years, there have been escalating concerns related to the opioid epidemic. With a steadily increasing opioid supply, it is critical to provide proper education to patients who are prescribed these medications. Education should be emphasized as a means of ensuring safe use and potentially as a strategy for curbing the opioid supply. Patients who undergo surgery are frequently prescribed opioids for postoperative pain; however, the content and delivery of information related to usage is inconsistent and often inadequate. Lack of education on postoperative pain management and opioid use places patients at risk for poor compliance and worse pain control. Furthermore, patients are often not properly educated on opioid-related side effects and risks or about safe behaviors when taking medications. The majority of patients are also not informed about how to store and dispose of leftover medications. Patients who are prescribed opioids require education preoperatively to cover the topics of pain management, opioid-related side effects, and risks, storage, and disposal. Evidence from various studies demonstrates that educational interventions improve knowledge and potentially lead to safer behaviors and reduced opioid use. Education can be provided in various formats with each having unique advantages and limitations. Accepted for publication August 7, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Bradley H. Lee, MD, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. Address e-mail to leeb@hss.edu. © 2019 International Anesthesia Research Society

Neurocritical Care No abstract available

McGrath MAC Videolaryngoscope Versus Optiscope Video Stylet for Tracheal Intubation in Patients With Manual Inline Cervical Stabilization: A Randomized Trial BACKGROUND: Manual inline stabilization of the head and neck is a recommended maneuver for tracheal intubation in patients with a suspected cervical injury. However, because applying this maneuver inevitably restricts neck flexion and head extension, indirect intubating devices such as a videolaryngoscope or a video stylet could be required for successful tracheal intubation. In this study, we compared the clinical performance of the McGrath MAC videolaryngoscope versus the Optiscope video stylet in patients with manual inline cervical stabilization during tracheal intubation. METHODS: In 367 consecutive patients undergoing elective cervical spine surgery, tracheal intubation was randomly performed with manual inline stabilization using either the McGrath MAC videolaryngoscope (group M, n = 183) or the Optiscope video stylet (group O, n = 184) by 2 experienced anesthesiologists in a single institution. The primary outcome was the first-attempt success rate of tracheal intubation. Secondary outcomes were intubation time and the incidence of postoperative airway complications, such as sore throat, hoarseness, blood in the oral cavity, and blood staining on the endotracheal tube. RESULTS: The first-attempt success rate of tracheal intubation was significantly higher in group M compared with group O (92.3% vs 81.0%; risk difference [95% confidence interval], 0.11 [0.05–0.18]; P = .002). The intubation time was significantly shorter in group M than in group O (35.7 ± 27.8 vs 49.2 ± 43.8; mean difference [95% confidence interval], 13.50 [5.90–21.10]; P = .001). The incidence of postoperative airway complications was not significantly different between the 2 groups. CONCLUSIONS: The McGrath MAC videolaryngoscope showed a higher first-attempt success rate for tracheal intubation and a shorter intubation time than the Optiscope video stylet in cervical spine patients with manual inline stabilization during tracheal intubation. These results suggest that the McGrath MAC videolaryngoscope may be a better option for tracheal intubation in such patients. Accepted for publication August 14, 2019. Funding: None. The authors declare no conflicts of interest. Clinical trial registration: NCT02769221 (http://clinicaltrials.gov). Reprints will not be available from the authors. Address correspondence to Hyung-Chul Lee, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakro, Jongno-gu, Seoul 03080, Korea. Address e-mail to vital@snu.ac.kr. © 2019 International Anesthesia Research Society

Positive End-Expiratory Pressure During Anesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials BACKGROUND: Whether intraoperative positive end-expiratory pressure (PEEP) can reduce the risk of postoperative pulmonary complications remains controversial. We performed a systematic review of currently available literature to investigate whether intraoperative PEEP decreases pulmonary complications in anesthetized patients undergoing surgery. METHODS: We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared intraoperative PEEP versus zero PEEP (ZEEP) for postoperative pulmonary complications in adults. The prespecified primary outcome was postoperative pulmonary atelectasis. RESULTS: Fourteen RCTs enrolling 1238 patients met the inclusion criteria. Meta-analysis using a random-effects model showed a decrease in postoperative atelectasis (relative risk [RR], 0.51; 95% confidence interval [CI], 0.35–0.76; trial sequential analyses [TSA]-adjusted CI, 0.10–2.55) and postoperative pneumonia (RR, 0.48; 95% CI, 0.27–0.84; TSA-adjusted CI, 0.05–4.86) in patients receiving PEEP ventilation. However, TSA showed that the cumulative Z-curve of 2 outcomes crossed the conventional boundary but did not cross the trial sequential monitoring boundary, indicating a possible false-positive result. We observed no effect of PEEP versus ZEEP ventilation on postoperative mortality (RR, 1.78; 95% CI, 0.55–5.70). CONCLUSIONS: The evidence that intraoperative PEEP reduces postoperative pulmonary complications is suggestive but too unreliable to allow definitive conclusions to be drawn. Accepted for publication August 1, 2019. Funding: This work was supported by grant from the National Natural Science Foundation of China (No. 81671947, 81272142). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). P. Zhang, L. Wu, and X. Shi contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to Xin Lv, MD, PhD, Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, 230022, China; and Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China. Address e-mail to xinlvg@126.com. © 2019 International Anesthesia Research Society

Anesthesia in Day Care Surgery, 1st ed No abstract available

A Narrative Review of Oxygenation During Pediatric Intubation and Airway Procedures Hypoxemia is a common complication in the pediatric operating room during endotracheal intubation and airway procedures and is a precursor to serious adverse events. Small children and infants are at greater risk of hypoxemia due to their high metabolic requirements and propensity to alveolar collapse during general anesthesia. To improve the care and safety of this vulnerable population, continued efforts must be directed to mitigate hypoxemia and the risk of subsequent serious adverse events. Apneic oxygenation has been shown to significantly prolong the safe apnea time until desaturation in infants, children, and adults and may reduce the incidence of desaturation during emergency intubation of critically ill patients. Successful apneic oxygenation depends on adequate preoxygenation, patent upper and lower airways, and a source of continuous oxygen delivery. Humidified, high-flow nasal oxygenation systems have been shown to provide excellent conditions for effective apneic oxygenation in adults and children and have the added benefit of providing some carbon dioxide clearance in adults; although, this latter benefit has not been shown in children. Humidified, high-flow nasal oxygenation systems may also be useful during spontaneous ventilation for airway procedures in children by minimizing room air entrainment and maintaining adequate oxygenation allowing for a deeper anesthetic. The use of apneic oxygenation and humidified, high-flow nasal oxygenation systems in the pediatric operating room reduces the incidence of hypoxemia and may be effective in decreasing related complications. Accepted for publication July 23, 2019. S. D. N. Else is currently affiliated with the Department of Anesthesiology, Perioperative and Pain Medicine, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Scott D. N. Else, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Alberta Children’s Hospital, 28 Oki Dr, Calgary, AB, Canada T3B 6AC. Address e-mail to scott.else@ahs.ca. © 2019 International Anesthesia Research Society

Interpretation Woes of Bispectral Index–Based Closed-Looped Anesthesia Delivery Systems No abstract available