Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies.

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Project for Universal Management of Airways - part 1: concept and methods.

Multiple professional groups and societies worldwide have produced airway management guidelines. These are typically targeted at the process of tracheal intubation by a particular provider group in a restricted category of patients and reflect practice preferences in a particular geographical region. The existence of multiple distinct guidelines for some (but not other) closely related circumstances, increases complexity and may obscure the underlying principles that are common to all of them. This has the potential to increase cognitive load; promote the grouping of ideas in silos; impair teamwork; and ultimately compromise patient care. Development of a single set of airway management guidelines that can be applied across and beyond these domains may improve implementation; promote standardisation; and facilitate collaboration between airway practitioners from diverse backgrounds. A global multidisciplinary group of both airway operators and assistants was assembled. Over a 3-year period, a review of the existing airway guidelines and multiple reviews of the primary literature were combined with a structured process for determining expert consensus. Any discrepancies between these were analysed and reconciled. Where evidence in the literature was lacking, recommendations were made by expert consensus. Using the above process, a set of evidence-based airway management guidelines was developed in consultation with airway practitioners from a broad spectrum of disciplines and geographical locations. While consistent with the recommendations of the existing English language guidelines, these universal guidelines also incorporate the most recent concepts in airway management as well as statements on areas not widely addressed by the existing guidelines. The recommendations will be published in four parts that respectively address: airway evaluation; airway strategy; airway rescue and communication of airway outcomes. Together, these universal guidelines will provide a single, comprehensive approach to airway management that can be consistently applied by airway practitioners globally, independent of their clinical background or the circumstances in which airway management occurs.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts.

Pulmonary aspiration of gastric content is a significant cause of anaesthesia-related morbidity and mortality. High-quality prospective randomised evidence to support prevention strategies, such as rapid sequence intubation, is difficult to generate due to well-described practical, ethical and methodological barriers. We aimed to generate an understanding of worldwide practice through surveying clinically practicing anaesthetists and airway experts. Our survey was designed to assess the influence of: departmental standards; patient factors; socio-economic factors; training; and supervision. We surveyed 10,003 anaesthetists who responded to an invitation to participate on LinkedIn. We then surveyed 16 international airway experts on the same content. When asked about a hypothetical patient with intestinal obstruction, respondents expressed preferences for [OR (95%CI)]: the head-up or -down position 4.26 (3.98-4.55), p < 0.001; nasogastric tube insertion 29.5 (26.9-32.3), p < 0.001; and the use of cricoid force 2.80 (2.62-3.00), p < 0.001, as compared with a hypothetical patient without intestinal obstruction also requiring rapid sequence intubation. Respondents from lower income countries were more likely to prefer [OR (95%CI]: the supine position 2.33 (2.00-2.63), p < 0.001; nasogastric tube insertion 1.29 (1.09-1.51), p = 0.002; and cricoid force application 2.54 (2.09-3.09), p < 0.001 as compared with respondents from higher income countries for a hypothetical patient with intestinal obstruction. This survey, which we believe is the largest of its kind, demonstrates that preferences for positioning, nasogastric tube use and cricoid force application during rapid sequence intubation vary substantially. Achieving agreed consensus may yield better training in the principles of rapid sequence intubation.

When the end is really the end? The extubation in the difficult airway patient.

Difficult airway management remains one of the most important sources of anesthesia related accidents; recent reviews and dedicated guidelines suggest that not only intubation, but extubation too is a critical phase in terms of potential accidents and serious complications. This paper will highlight some fundamental concepts regarding extubation related problems, focusing particularly on epidemiology, risk factors and time course of difficult extubation, suggesting some conceptual points to plan and manage patients in which a difficult extubation might be expected, including parameters and test to be performed to assess and predict such a situation.

Contamination of preservation fluid in kidney transplantation: single-center analysis.

INTRODUCTION: Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients. MATERIALS AND METHODS: We analyzed 62 samples of preservation fluid for microbial and fungal contamination. RESULTS: Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation. CONCLUSION: Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.