Evaluation of the insertion parameters and complications of the i-gel Plus airway device for maintaining patent airway during planned procedures under general anaesthesia: a protocol for a prospective multicentre cohort study

INTRODUCTION

Supraglottic airway devices represent a less invasive method of airway management than tracheal intubation during general anaesthesia. Their continued development is focused mainly on improvements in the insertion success rate and minimalisation of perioperative and postoperative complications. The i-gel Plus is a novel, anatomically preshaped supraglottic airway device which achieves a perilaryngeal seal due to a non-inflatable cuff made of a soft thermoplastic elastomer. The purpose of this cohort study is to assess the success rate of the i-gel Plus use during elective procedures under general anaesthesia, its intraoperative performance, and the degree of postoperative complications.

METHODS AND ANALYSIS

This is a multicentre, prospective, interventional cohort study. The enrolment will take place in seven centres in four European countries. We plan to enrol 2000 adult patients in total, who are scheduled for elective surgery under general anaesthesia, and with an indication for use of a supraglottic airway device for management of their airway. The study is projected to run over a period of 18 months. The primary outcome of the study is the total success rate of the i-gel Plus insertion in terms of successful ventilation and oxygenation through the device. Secondary outcomes include perioperative parameters, such as insertion time, seal/leak pressures, number of insertion attempts and postoperative adverse events and complications. Postoperative follow-up will be performed at 1 hour, 24 hours in all patients, and for selected patients at 3 and 6 months.

ETHICS AND DISSEMINATION

The cohort study has received the following ethical approvals: General University Hospital Prague, University Hospital Olomouc, University Military Hospital Prague, University Hospital Barcelona, University Hospital Lodz, Antrim Area Hospital, Craigavon Area Hospital, Office for Research Ethics Committees Northern Ireland. The results will be published in peer-reviewed journals and presented at relevant anaesthesia conferences.

TRIAL REGISTRATION NUMBER

ISRCTN86233693;Pre-results.

Bloodless surgery and gynecological patients among Jehovahs Witnesses

OBJECTIVE

The aim of this research is to present our experiences with the surgical treatment of gynecological patients among Jehovahs Witnesses. Moreover, the medical, moral, and ethical problems in this regard have been highlighted.

METHODS

75 Jehovahs Witnesses patients were operated on for various benign and malignant gynecological diseases between 2007 and 2018. All of these patients were operated on according to the rules of blood-sparing surgery.

RESULTS

The operations were assessed according to the dia-gnosis, mode of surgery, estimated blood loss, and disease outcome. Excessive blood loss did not occur during any of these operations, and the estimated blood loss for the same procedure was 10 to 550 mL.

CONCLUSION

Jehovahs Witnesses gynecological patients is a group of high-risk patients because they refuse to undergo blood transfusion. Nevertheless, the principles of blood-sparing surgery should be applied to not only Jehovahs Witnesses patients but also to all patients in general. Even if a blood transfusion is the last resort to solve issues pertaining to excessive blood loss during complicated operations, the said procedure always carries certain risks. Therefore, blood transfusion should be performed only on rare occasions. Jehovahs Witnesses patients categorically refuse blood transfusion even if it is the only way to save ones life. Even though the legislation of the Czech Republic deals with this problem, there are other moral and ethical aspects that need to be addressed in this regard.

Extracorporeal membrane oxygenation survival: External validation of current predictive scoring systems focusing on influenza A etiology

Despite increasing clinical experience with extracorporeal membrane oxygenation (ECMO), its optimal indications remain unclear. Here, we externally evaluated all currently available ECMO survival-predicting scoring systems and the APACHE II score in subjects undergoing veno-venous ECMO (VV ECMO) support due to acute respiratory distress syndrome (ARDS) with influenza (IVA) and non-influenza (n-IVA) etiologies. Our aim was to find the best scoring system for influenza A ARDS ECMO success prediction. Retrospective data were analyzed to assess the abilities of the PRESERVE, RESP, PRESET, ECMOnet, Roch, and APACHE II scores to predict patient outcome. Patients treated with veno-venous ECMO support for ARDS were divided into two groups: IVA and n-IVA etiologies. Parameters collected within 24 hours before ECMO initiation were used to calculate PRESERVE, RESP, PRESET, ECMOnet, Roch, and APACHE II scores. Compared to the IVA group, the n-IVA group exhibited significantly higher ICU, 28-day, and 6-month mortality (P = .043, .034, and .047, respectively). Regarding ECMO support success predictions, the area under the receiver operating characteristic curve (AUC) was 0.62 for PRESERVE, 0.44 for RESP, 0.57 for PRESET, and 0.67 for ECMOnet, and 0.62 for Roch calculated for all subjects according to the original papers. In the IVA group, APACHE II had the best predictive value for ICU, hospital, 28-day, and 6-month mortality (AUC values of 0.73, 0.73, 0.70, and 0.73, respectively). In the n-IVA group, APACHE II was the best predictor of survival in the ICU and hospital (AUC 0.54 and 0.57, respectively). From all possible ECMO survival scoring systems, the APACHE II score had the best predictive value for VV ECMO subjects with ARDS caused by influenza A-related pneumonia with a cut-off value of about 32 points.

Optical Devices in Tracheal Intubation-State of the Art in 2020

The review article is focused on developments in optical devices, other than laryngoscopes, in airway management and tracheal intubation. It brings information on advantages and limitations in their use, compares different devices, and summarizes benefits in various clinical settings. Supraglottic airway devices may be used as a conduit for fiberscope-guided tracheal intubation mainly as a rescue plan in the scenario of difficult or failed laryngoscopy. Some of these devices offer the possibility of direct endotracheal tube placement. Hybrid devices combine the features of two different intubating tools. Rigid and semi-rigid optical stylets represent another option in airway management. They offer benefits in restricted mouth opening and may be used also for retromolar intubation. Awake flexible fiberoptic intubation has been a gold standard in predicted difficult laryngoscopy for decades. Modern flexible bronchoscopes used in anesthesia and intensive care are disposable devices and contain optical lenses instead of fibers. Endotracheal tubes with an incorporated optics are used mainly in thoracic anesthesia for lung separation. They are available in double-lumen and single-lumen versions. They offer a benefit of direct view to the carina and do not require flexible fiberscope for their correct placement.

General anesthesia or conscious sedation in paroxysmal atrial fibrillation catheter ablation

BACKGROUND

Catheter ablation of paroxysmal atrial fibrillation (AF) can be performed under general anesthesia or conscious sedation. The influence of type of anesthesiology care on procedural characteristics and ablation outcome in patients in whom intracardiac echocardiography (ICE) and elimination of adenosine-mediated dormant conduction (DC) is used is not entirely known.

METHODS

150 patients with paroxysmal AF were randomized to point-by-point radiofrequency catheter isolation of pulmonary veins (PVI) under general anesthesia (n=77) or conscious sedation (n=73). Adenosine-mediated dormant conduction was eliminated in all patients. Antiarrhythmic medication was discontinued after PVI. During twelve months of follow-up, all patients underwent four times 7-day ECG monitorings.

RESULTS

There was no difference between groups in AF recurrence (28.6% vs. 31.5%, P=0.695). Patients in conscious sedation had longer procedure times (160 ± 32.1 vs. 132 ± 31.5 min, P<0.001), longer RF energy application times (40 ± 15 vs. 29 ± 11 min, P<0.001) and longer fluoroscopy times (6.2 min ± 5.3 vs. 4.3 min ± 2.2, P<0.001) with similar complication rates.

CONCLUSION

Conscious sedation is not inferior to general anesthesia in regard to arrhythmia recurrence or complication rates of catheter ablation of paroxysmal atrial fibrillation. However, it is associated with longer procedure times, longer time of radiofrequency energy application and longer fluoroscopy times.

The impact of ECG synchronization during acquisition of left‑atrium computed tomography model on radiation dose and arrhythmia recurrence rate after catheter ablation of atrial fibrillation - a prospective, randomized study

BACKGROUND

The impact of ECG gating during computed tomography (CT) acquisition of left atrium (LA) model on radiation dose, image quality and ablation event-free survival rate after catheter ablation (CA) of atrial fibrillation (AF) is not well defined.

METHODS

Sixty-two patients with paroxysmal atrial fibrillation were randomized for two types of LA CT (with vs without ECG gating) before CA. Pulmonary veins isolation was performed in all patients. Patients were followed for 12 months after CA.

RESULTS

There was no difference between the groups in CA length (131.61±32.57 vs 119.84±33.18 min; p=0.108), CA fluoroscopy time (4.48±2.19 vs 3.89±1.83 min; p=0.251), CA fluoroscopy dose (3.99±2.79 vs 3.91 vs2.91 Gy*cm2; p=0.735), visual data quality (1.77±0.88 vs 2.0±0.63; p=0.102) and registration error (2.42±0.72 vs 2.43±0.46 mm; p=0.612). We found a significant difference in CT Dose index (89.55±5.99 vs 19.19±4.33 mGy; p<0.0001) and Dose Length product (1438.87±147.75 vs 328.21±73.83 mGy*cm; p<0.0001). Twelve months after CA, 25 of 31 patients in the gated group and 24 of 31 patients in the non-gated group were free of AF (80.65 vs 77.42 %; p=0.838).

CONCLUSION

ECG gating of computed tomography of LA before AF ablation burdens patients with a four times higher radiation dose while improving neither the quality of CT model or fusion of CT with the electroanatomic map. As a result, it has no significant impact on arrhythmia recurrence rate after ablation (Tab. 3, Fig. 3, Ref. 25).

Atrial fibrillation inducibility after pulmonary vein isolation under general anaesthesia

AIMS

Atrial fibrillation (AF) inducibility with rapid atrial pacing following AF ablation is associated with higher risk of AF recurrence. The predictive value of AF inducibility in paroxysmal AF patients after pulmonary vein isolation (PVI), done under general anaesthesia (GA), remains questionable since GA might alter AF inducibility and/or sustainability.

METHODS

Consecutive patients (n = 120) with paroxysmal AF without prior catheter ablation (CA) were enlisted in the study. All patients were ablated under GA. We have used a point-by-point CA and elimination of dormant conduction after adenosine in all patients. A predefined stimulation protocol was used to induce arrhythmias after PVI. Regular supraventricular tachycardias were mapped and ablated. Patients were divided into 3 subgroups - noninducible, inducible AF with spontaneous termination in five minutes, inducible AF without spontaneous termination. During 12 months of follow-up, all patients were examined four-times with 7-day ECG recordings.

RESULTS

There was no statistical difference between the three subgroups in a rate of arrhythmia recurrence (11.1 vs. 27.5 vs. 27.3%, P=0.387), despite a clear trend to a better success rate in the non-inducible group. The subgroups did not differ in left atrial (LA) diameter (41.0±6, 43.0±7, 42.0±5 mm, P=0.962) or in any other baseline parameter.

CONCLUSION

AF inducibility as well as presence or absence of its early spontaneous termination after PVI done under general anaesthesia in paroxysmal AF patients were not useful as predictors of procedural failure.

Long-term outcome of paroxysmal atrial fibrillation catheter ablation with and without pulmonary vein dormant conduction after adenosine challenge

OBJECTIVES

The prognostic significance of adenosine-mediated pulmonary vein (PV) dormant conduction is unclear. We prospectively followed patients with adenosine-mediated PV reconduction with a subsequent repeated ablation until there was no reconduction inducible with patients without reconduction after PV isolation.

METHOD AND RESULTS

Consecutive patients (n=179) with paroxysmal atrial fibrillation (AF) without prior catheter ablation (CA) were enlisted in the study. We used a point-by-point CA and general anesthesia in all patients. Twenty minutes after PV isolation we administered adenosine in a dose sufficient to produce an atrioventricular block. If a dormant conduction was present (n=54) we performed additional ablation until there was no adenosine mediated reconduction inducible. During 36 months of follow-up, all patients were examined for eight 7-day ECG recordings. There was no difference in arrhythmia recurrence rate between patients with and without dormant conduction (29.6 vs. 24.8% at 12 months, P=0.500; 31.5 vs. 30.4% at 36 months, P=1.000), for any echocardiographic parameter or any parameter of the ablation procedure.

CONCLUSION

The patients with dormant conduction after adenosine during catheter ablation of paroxysmal atrial fibrillation with complete elimination of the dormant conduction by additional extensive ablation have the same outcome in the long term as patients without a dormant conduction.

ECG non-gated multi-detector computed tomography protocol prior to catheter ablation of atrial fibrillation provides sufficient data quality with lower radiation exposure compared to ECG-gated protocol - results of a prospective, randomized and blinded study

BACKGROUND

The role of ECG-gating in left atrium (LA) computed tomography (MDCT) imaging is not precisely defined.

METHODS AND RESULTS

62 patients were randomized according to ECG gating with prospective evaluation of image quality, Volume CT Dose Index, Dose Length Product, Effective Dose and registration error between anatomical map and MDCT. We found significant difference in all radiation variables, but not in visual quality, registration error, CA duration, CA fluoroscopy time and CA fluoroscopy dose.

CONCLUSION

Helical non-gated MDCT achieved a radiation dose more than four times lower with comparable image quality and course of ablation compared to ECG-gated protocol.