Supraglottic airway versus tracheal intubation and the risk of postoperative pulmonary complications

Ventilation strategies and risk factors for intraoperative respiratory critical events and postoperative pulmonary complications in neonates and small infants: a secondary analysis of the NECTARINE cohort☆

BACKGROUND

Optimal ventilation strategies and use of neuromuscular blocking agents (NMBAs) in neonates and small infants undergoing anaesthesia remain unclear. We examined the association of perioperative ventilation strategies and administration of NMBAs on respiratory adverse events in the NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) cohort.

METHODS

We performed a secondary analysis of NECTARINE, which included infants up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures. The primary endpoint was the association between ventilation mode and intraoperative respiratory adverse events. Secondary endpoints were use of NMBA, and 30-day postoperative pulmonary complications (PPCs).

RESULTS

The dataset comprised 5609 patients undergoing 6542 procedures. Pressure-controlled ventilation was the primary ventilation modality, accounting for 52.4% (n=3428) of cases. The incidence of intraoperative respiratory critical events was 20.7% (95% confidence interval [CI] 19.7-21.7%), while PPCs were observed in 17% of cases (95% CI 16.0-18.1%). Preanaesthesia respiratory conditions and NMBA use after tracheal intubation were associated with higher incidence of PPCs. Of the children receiving NMBAs, reversal was reported in 29.8%. The absence of reversal was associated with a higher incidence of PPCs, with a relative risk of 1.50 (95% CI 1.17-1.93). Conversely, NMBA reversal was associated with a reduced relative risk of 0.43 (95% CI 0.26-0.70).

CONCLUSIONS

Regardless of ventilation strategy used, mechanical ventilation and baseline respiratory conditions were risk factors for a greater incidence of adverse respiratory events and PPCs. Reversal of NMBAs before tracheal extubation was significantly associated with reduced PPCs in neonates and should be routine clinical practice.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT02350348).

Evaluation of the i-gel® Plus supraglottic airway device in elective surgery: a prospective international multicentre study

BACKGROUND

The i-gel® Plus is a modified version of the i-gel® supraglottic airway device. It contains a wider drainage port; a longer tip; ramps inside the breathing channel; and an additional port for oxygen delivery. There has been no prospective evaluation of this device in clinical practice.

METHODS

This international, multicentre, prospective cohort study aimed to evaluate the performance of the i-gel Plus in adult patients undergoing elective procedures under general anaesthesia. The primary outcome was overall insertion success rate, defined as the ability to provide effective airway management through the device from insertion until the end of the surgical procedure. Secondary outcomes included device performance and incidence of postoperative adverse events. Data from the first 1000 patients are reported.

RESULTS

In total, 1012 patients were enrolled; 12 forms were excluded from the final analysis due to incomplete data leaving 1000 included patients (545 female). Overall insertion success rate was 98.6%, with a first-attempt success rate of insertion of 88.2%. A significant difference between females and males was seen for the overall success rate (97.4% vs. 99.6% respectively) but not for first-attempt successful insertion. Mean (SD) oropharyngeal seal pressure was 32 (7) cmH2O. The only independent factor that increased the risk of first-attempt failure was low operator experience. Complications included desaturation < 85% in 0.6%; traces of blood on the device in 7.4%; laryngospasm in 0.5%; and gastric contents inside the bowl in 0.2% of patients.

CONCLUSIONS

The i-gel Plus appears to be an effective supraglottic airway device that is associated with a high insertion success rate and a reasonably low incidence of complications.

Gastric insufflation with and without an inserted gastric tube in second-generation laryngeal mask airways: A randomized controlled cross-over trial

STUDY OBJECTIVE

Second-generation laryngeal mask airways are equipped with an additional lumen for a gastric tube, with the intention to reduce the risk of aspiration by draining gastric content. However, the effect of an inserted gastric tube through the gastric channel on gastric insufflation, a substantial part of the pathomechanism of aspiration, during positive-pressure ventilation is not clear. We hypothesized, that an inserted gastric tube increases the risk of gastric insufflation.

DESIGN

Single center, prospective, randomized-controlled cross-over trial.

SETTING

Tertiary academic hospital in Germany.

PATIENTS

152 patients, ASA I-III, scheduled for general anesthesia with a laryngeal mask airway.

INTERVENTIONS

Gastric insufflation was investigated during an incremental pressure trial up to a maximum airway pressure of 30 cmH2O and during oropharyngeal leak pressure measurement with and without an inserted gastric tube while one of two laryngeal mask airways with different cuff designs (inflatable or thermoelastic) was used.

MEASUREMENTS

Gastric insufflation was detected with real-time ultrasound.

MAIN RESULTS

Frequency of gastric insufflation was higher with than without inserted gastric tube during the incremental pressure trial (10.9 % (16/147) vs. 2.7 % (4/147), p = 0.009) and during oropharyngeal leak pressure measurement (16.3 % (24/147) vs. 5.4 % (8/147), p = 0.004). Risk of gastric insufflation didn't differ between the two cuff-types (p = 0.100). Flow over the open gastric channel was associated with gastric insufflation during positive-pressure ventilation (p = 0.003) and during oropharyngeal leak pressure measurement (p = 0.049). Incidence of postoperative nausea and vomiting was higher in patients in which gastric insufflation was detected, compared to others (17.1 % (6/35) vs. 5.4 % (6/112), p = 0.037).

CONCLUSION

Placement of a gastric tube through the gastric channel of a second-generation laryngeal mask airway, independent of the cuff-type, increases the risk of gastric insufflation. Flow over the gastric channel indicate a higher risk of gastric insufflation and gastric insufflation may increase the risk of postoperative nausea and vomiting.

Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study

BACKGROUND

Postoperative pneumonia is one of the common complications after video-assisted thoracoscopic surgery. There is no related study on the effect of lung isolation with different airway devices on postoperative pneumonia. Therefore, in this study, the propensity score matching method was used to retrospectively explore the effects of different lung isolation methods on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery.

METHODS

This is A single-center, retrospective, propensity score-matched study. The information of patients who underwent VATS in Weifang People 's Hospital from January 2020 to January 2021 was retrospectively included. The patients were divided into three groups according to the airway device used in thoracoscopic surgery: laryngeal mask combined with bronchial blocker group (LM + BB group), tracheal tube combined with bronchial blocker group (TT + BB group) and double-lumen endobronchial tube group (DLT group). The main outcome was the incidence of pneumonia within 7 days after surgery; the secondary outcome were hospitalization time and hospitalization expenses. Patients in the three groups were matched using propensity score matching (PSM) analysis.

RESULTS

After propensity score matching analysis, there was no significant difference in the incidence of postoperative pneumonia and hospitalization time among the three groups (P > 0.05), but there was significant difference in hospitalization expenses among the three groups (P < 0.05).

CONCLUSIONS

There was no significant difference in the effect of different intubation lung isolation methods on postoperative pneumonia in patients undergoing thoracoscopic surgery.

Effect of supraglottic airway devices versus endotracheal intubation general anesthesia on outcomes in patients undergoing mechanical thrombectomy: A prospective randomized clinical trial

BACKGROUND

There are still controversies about the optimal anesthesia protocol for patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The aim of this study was to explore the effect of supraglottic airway device (SAD) versus endotracheal intubation (EI) general anesthesia on clinical and angiographic outcomes in patients with AIS undergoing MT.

METHODS

One hundred sixteen patients with large-vessel occlusion stroke were randomized to receive either SAD or EI general anesthesia. The primary outcome was the rate of occurrence of >20% fall in mean arterial pressure (MAP). Secondary outcomes included hemodynamics, successful recanalization, time metrics, satisfaction score of neurointerventionalist, number of passes performed, the conversion rate from SAD to EI, the National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score before and 24 hours after surgery, length of stay in the stroke unit and hospital, complications and functional independence at discharge, and 90 days after stroke.

RESULTS

Both the lowest systolic blood pressure and lowest diastolic blood pressure were significantly lower in the EI group (P = .001). The consumption of vasoactive agents, the occurrence of >20% reduction in MAP and time spent with >20% fall in MAP were significantly higher in the EI group (P < .05). Compared with the EI group, the time for door-to-puncture was significantly shorter in the SAD group (P = .015). There were no significant differences with respect to puncture-to-reperfusion time, number of passes performed, rates of successful recanalization, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score 24 hours after surgery. The satisfaction score of neurointerventionalist was significantly lower in the EI group (P = .043). Conversion rate from SAD to EI was 7.41%. There were no significant differences with respect to complications, mortality, and mean Modified Rankin Scale scores both at discharge and 90-day after stroke. However, length of stroke unit and hospital stays were significantly shorter in the SAD group (P < .05).

CONCLUSION

AIS patients undergoing MT with SAD general anesthesia led to more stable hemodynamics, higher satisfaction score of neurointerventionalist, shorter door-to-puncture time, length of stroke unit, and hospital stay. However, there were no significant differences between the 2 groups on the angiographic and functional outcomes both at discharge and 90 days after stroke.

Effect of neuromuscular block on surgical conditions during short-duration paediatric laparoscopic surgery involving a supraglottic airway

BACKGROUND

Use of an LMA ProSeal™ laryngeal mask airway (P-LMA; Teleflex) with no neuromuscular block is considered a safe alternative to tracheal intubation in short-duration paediatric laparoscopic surgery. However, few studies have evaluated surgical conditions of short-duration paediatric laparoscopic surgery using this anaesthetic technique. We assessed surgical conditions for paediatric laparoscopic inguinal hernia repair using P-LMA with and without neuromuscular block.

METHODS

Sixty-six patients undergoing laparoscopic inguinal hernia repair were randomised to receive a neuromuscular block (train-of-four 1-2 twitches) using rocuronium or no neuromuscular block with the P-LMA. All operations were performed by the same surgeon who determined the surgical conditions using the Leiden-surgical rating scale (L-SRS). Secondary outcomes included perioperative data, haemodynamics, and adverse events.

RESULTS

Neuromuscular block improved surgical conditions compared with no neuromuscular block: mean (standard deviation) L-SRS 4.1 (0.5) vs 3.5 (0.6), respectively (P<0.0001). Mean rocuronium dose in the neuromuscular block group was 12.7 (4.4-29.7) mg or 0.7 (0.6-0.8) mg kg^-1. The insufflation Ppeak was higher in the no neuromuscular block group than in the neuromuscular block group: mean (standard deviation) Ppeak 17.9 (1.8) cm H₂O vs 16.2 (1.9) cm H₂O, respectively (P=0.0004). Fifteen children (45.5%) in the no neuromuscular block group had adverse events during the surgery and anaesthesia vs four children (12.1%) in the neuromuscular block group (P=0.006).

CONCLUSIONS

Neuromuscular block significantly improved surgical conditions and reduced the incidence of adverse events during surgery and anaesthesia when an LMA Proseal™ was used in short-duration paediatric laparoscopic surgery.

CLINICAL TRIAL REGISTRATION

ChiCTR2000038529.