The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care, Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. 

Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis

Difficult tracheal intubation is defined when tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology Most importantly, difficult intubation differs between countries and populations Physicians should be aware of difficult intubation frequencies of their populations Turkey is a transit country between East and West Eastern Turkey reflects the Middle East and Asia, while western Turkey has European features Our objectives were to investigate the frequency of difficult intubation in different regions’ populations, and specificity and sensitivity of predictive values According to the population in the regions, 24 experienced anesthesiologists from 13 hospitals in 7 regions, were included in the study Of 1313 patients, 143 patients (1089%) were detected as difficult intubation Mallampathy (MLP) III-IV were alone (p = 0043), and the combination of thyromental distance <6 cm and MLP III-IV (p: 0018) were statistically significant in difficult and easy intubation patient groups The specificity was 9746% in MLP + thyromental combination, and 9805% in MLP + mouth opening combination Western region had the shortest measurements in sternomental, thyromental and mouth opening (p <005), and had the most difficult intubation frequency compared to the other regions (p: 0001) The positive predictive values were increased with increasing combinations, but further research is needed on the predictors of difficult intubation

/pdf/assessment-of-difficult-intubation-predictors-in-different-ns17s9drlb.pdf

Assessment of Difficult Intubation Predictors in Different Populations of Turkey

Objective A case-control study was conducted to explore the diagnostic efficacy and clinical value of ultrasound in difficult airway assessment. Methods A total of 220 patients undergoing elective surgery under general anesthesia were prospectively enrolled in our hospital from April 2018 to April 2021. General data were collected one day before operation, including sex, age, height, weight, body mass index (BMI), modified Mallampati test (MMT), inter-incisor distance (IID) and thyromental distance (TMD), the upper lip bite test (ULBT), and thyromental height (TMH). DSH, DSE, DSV, HMD, and tongue width and thickness were measured by ultrasound in the supine position before anesthesia induction on the day of operation. The above data were measured by the same anesthesiologist. After anesthesia, the patients were exposed to laryngoscope by the same senior doctor who did not participate in the data analysis, and the Cormack–Lehane (CL) grade was recorded and endotracheal intubation was completed. The relationship between DSE, DSH, DSV, HMD, and tongue width and thickness and laryngoscope exposure difficulty and tracheal intubation difficulty was analyzed. The critical value of each index for predicting laryngoscope exposure difficulty and tracheal intubation difficulty was obtained by the receiver operating characteristic curve (ROC) and Jordan index. According to the critical value, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of each index were calculated. Results On comparing the general conditions of the four groups, this study prospectively included 220 patients undergoing elective surgery under general anesthesia for tracheal intubation in our hospital from April 2018 to April 2021, of which 8 cases were excluded from the study because of loss of incisors, 5 cases were excluded from the study due to unclear development of the anterior vocal cords under ultrasound, 7 cases were excluded from the study, and finally 200 patients were included in the study, including 104 males and 96 females. Among the 200 patients, difficult laryngoscope exposure was found in 26 cases (13.00%) and difficult tracheal intubation in 17 cases (8.50%). Tracheal intubation was performed in 17 patients with a visual laryngoscope and light rod, respectively. The weight and BMI of patients in the DL group were higher than in the NDL group, and the difference was statistically significant (P < 0.05); the weight and BMI of patients in the DI group were higher than in the NDI group, and the difference was statistically significant (P < 0.05); there was no significant difference in sex, age, and height between the DL group and the NDL group and the DI group and the NDI group (P > 0.05). Compared with the NDL group, IID, TMD, and TMH in the DL group were lower, and the difference was statistically significant (P < 0.05); there was no significant difference in ULBT (P > 0.05). DSE, DSH, and DSV were higher than in the NDL group, and the difference was statistically significant (P < 0.05), the HMD was lower than in the NDL group, and the difference was statistically significant (P < 0.05);the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant (P < 0.05). On comparing the DI NDI groups, the IID, TMD, and TMH in group DI were lower than in group NDI, and the difference was statistically significant (P < 0.05), but there was no significant difference in ULBT (P > 0.05); DSE, DSH, and DSV were higher than in the NDI group, and the difference was statistically significant (P < 0.05); the HMD was lower than in the NDI group, and the difference was statistically significant (P < 0.05); the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant (P < 0.05). The AUC of BMI, TMH, DSE, DSV, HMD, and tongue width and thickness all ranged from 0.70 to 0.9. Laryngoscope exposure difficulty diagnostic value was medium. The AUC of TMD, MMT, ULBT, IID, and DSH ranged from 0.5 to 0.7. The diagnostic value of laryngoscope exposure difficulty was low. According to the ROC curve, the AUC value of HMD, DSE, and tongue thickness in ultrasonic indicators was higher than that of traditional indicators and the AUC value of TMH was the highest in traditional indicators. When the HMD cutoff value was 5.29 cm; the accuracy, sensitivity, specificity, PPV, and NPV were 73.6%, 96.7%, 71.6%, 31.8%, and 97.4%, respectively. Compared with tongue width, tongue thickness has a better predictive performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult laryngoscope exposure was lower than HMD and the difference was statistically significant (P < 0.05). The patients in the DI and NDI groups indicated that the AUC of ULBT, TMD, and IID was between 0.5 and 0.7, the diagnostic values of BMI, MMT, TMH, DSE, DSH, DSV, HMD, and tongue width and thickness were between 0.7 and0.9, and the diagnostic value for tracheal intubation difficulty was moderate. According to the ROC curve, HMD, DSE, and tongue thickness in ultrasonic indexes were higher compared to traditional indexes. Among the traditional indexes, the AUC value of TMH is the largest. In ultrasonic indexes, when the critical value of HMD DSE is 4.85 cm, the AUC value is 0.893, and its accuracy, sensitivity, specificity, PPV, and NPV are 81.6%, 93.8%, 80.6%, 30.2%, and 99.5%, respectively. In ultrasonic indexes, the prediction performance is better, followed by the tongue thickness prediction performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult tracheal intubation was lower than in HMD, and the difference was statistically significant (P < 0.05). Conclusion Ultrasonic measurements such as DSH, DSE, DSV, HMD, and tongue width and thickness have predictive value for difficult airway;when the ultrasonic measurement of HMD is ˂5.29 cm, we should pay attention to the difficulty of laryngoscope exposure, and when DSE is ˂4.85 cm, we should watch out for difficult tracheal intubation. In terms of other ultrasound indexes, HMD is more valuable in predicting difficult airway.

/pdf/diagnostic-efficacy-and-clinical-value-of-ultrasonography-in-2qm4ylgi.pdf

Diagnostic Efficacy and Clinical Value of Ultrasonography in Difficult Airway Assessment: Based on a Prospective Cohort Study

Background: Hypotension is the most commonly observed complications with the reported prevalence upto 90% without prophylaxis after spinal anesthesia in obstetric cases. Various methods have been implemented to mitigate spinal induced hypotension. Pharmacological agents as pure α2 adrenoceptor agonist as phenylephrine and 5HT3 antagonists as ondansetron have been used to prevent and treat spinal anesthesia induced hypotension. We aimed to find out whether or not pre-emptive administration of phenylephrine or ondansetron attenuates hypotension in elective cesarean section in healthy parturient under spinal anesthesia.
Methods: This quasi-experimental study was conducted in 120 ASA II parturient scheduled for elective cesarean section under spinal anesthesia with 10 mg 0.5% heavy bupivacaine. Patients in Group O received 4 mg ondansetron and patients in Group P received 100 µg phenylephrine immediately after spinal anesthesia. The occurrence of hypotension, total requirement of mephentermine was compared in both the groups. The complications such as bradycardia, nausea, vomiting were also compared.
Results: Hypotension was present in 31 patients in Group O (51.67%) and 33 patients in Group P (55%) (p=0.71). Consumption of mephentermine were comparable in both the groups (p=0.67) Bradycardia was not seen in any patients of Group O. It was present in five patients in Group P (8.33%) (p=0.02) which was treated with atropine. There were no cases of severe nausea and vomiting requiring treatment in any of the groups.
Conclusions: The pre-emptive administration of phenylephrine or ondansetron was not useful in attenuating intraoperative hypotension in healthy parturient undergoing elective cesarean section under spinal anesthesia.

https://www.jsan.org.np/jsan/index.php/jsan/article/download/288/213

Preemptive administration of ondansetron and phenylephrine for prevention of perioperative hypotension under spinal anesthesia for cesarean section: a quasi-experimental study

BACKGROUND The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not. METHODS This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests. RESULTS The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00). CONCLUSIONS The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.

Assessment of Airway Parameters for Predicting Difficult Laryngoscopy and Intubation in a Tertiary Center in Western Nepal.

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Preemptive administration of ondansetron and phenylephrine for prevention of perioperative hypotension under spinal anesthesia for cesarean section: a quasi-experimental study

Assessment of Airway Parameters for Predicting Difficult Laryngoscopy and Intubation in a Tertiary Center in Western Nepal.