Background Patients with BMI ≥35 kg/m2 undergoing laparoscopic bariatric surgery are susceptible to impaired oxygenation and respiratory mechanics, particularly during pneumoperitoneum. Direct comparisons of inverse, equal, and conventional inspiratory-to-expiratory ratios under otherwise standardized ventilation are limited, and the clinical importance of reported physiological differences remains uncertain. Methods In this three-arm, assessor- and analyst-blinded randomized controlled trial, 90 patients with BMI ≥35 kg/m2 undergoing elective laparoscopic bariatric surgery were allocated to volume-controlled inverse ratio ventilation (IRV; I:E 2:1), equal ratio ventilation (ERV; 1:1), or conventional ratio ventilation (CRV; 1:2) (n=30 per group). Tidal volume was 6 mL/kg predicted body weight, set PEEP was 5 cm H2O, and FiO2 was 0.40. The primary outcomes were PaO2 and PaO2/FiO2. Secondary outcomes included airway pressures, driving pressure, dynamic and static compliance, and routine hemodynamic variables at T1, T2, and T3. Results During pneumoperitoneum, PaO2 was higher with IRV than with ERV and CRV (140.4 ± 3.6, 135.4 ± 3.9, and 131.2 ± 4.2 mmHg, respectively; P < 0.001), with an IRV-CRV mean difference of 9.27 mmHg (95% CI 6.76 to 11.78). PaO2/FiO2 showed the same pattern. IRV was also associated with lower plateau and driving pressures and higher static compliance. Heart rate did not differ among groups, while mean arterial pressure showed no persistent between-group difference during or after pneumoperitoneum. Conclusions Prolonged inspiratory time, particularly IRV, was associated with modest improvements in intraoperative oxygenation and respiratory mechanics compared with conventional ventilation. However, it remains unclear whether the statistically significant differences translate into clinically meaningful benefit. Further adequately powered studies assessing postoperative and patient-centred outcomes are needed before a definitive conclusion can be reached.
Nasogastric tube syndrome, also referred to as Sofferman syndrome, is a rare, frequently unrecognized, and underreported complication that can result in life-threatening airway compromise. This syndrome arises in certain patients following the insertion of a nasogastric or nasoenteric tube. It manifests as a triad of nasoenteric tube use, pharyngodynia, and bilateral vocal cord paresis (with occasional unilateral presentations), potentially progressing to critical upper airway obstruction. We present what we believe is the first documented case of failed intubation due to NGTS, necessitating emergency front-of-neck access in a non-operating room anesthesia setting for a patient with an indwelling nasogastric tube. The objective of this report is to increase awareness of this rare syndrome, first described over 35 years ago in association with nasoenteric tubes used for decompression or enteral nutrition. We want to emphasize the importance of prompt recognition and early clinical detection to prevent severe airway compromise and the need for invasive surgical airway interventions.
Background The erector spinae plane block (ESPB) demonstrates variable anterior thoracic dermatomal distribution compared to the paravertebral block (PVB), potentially limiting its clinical reliability. Programmed intermittent bolus (PIB) administration has been proposed to enhance the spread and uniformity of local anesthetic distribution. Objectives To compare dermatomal coverage and analgesic efficacy of PIB-based ESPB and PVB, and to examine determinants of sensory block extent and its relationship with postoperative analgesic outcomes. Methods Sixty adults undergoing lobectomy were included in this predefined sub-study of a randomized controlled trial comparing ultrasound-guided ESPB and PVB with catheter placement. Both groups received a 15-mL bolus of 0.5% ropivacaine followed by programmed intermittent boluses of 0.2% ropivacaine (15 mL every 6 h). The primary outcomes were bidirectional anterior dermatomal extent along the midclavicular line and block success rate at 6 and 24 h postoperatively. Secondary outcomes included postoperative morphine consumption, pain scores, and the proportion of opioid-free patients. Intergroup comparisons, correlation analyses, and mediation analyses were performed. Results At 6 h, ESPB had a lower success rate (76.7% vs. 96.7%, P = 0.052), shorter spread (3.8 vs. 5.0 levels, P = 0.041), and reduced cephalad extension (1.1 vs. 1.7 levels, P = 0.009). These differences were no longer detected at 24 h. ESPB spread correlated with female sex (P = 0.006) and shorter height (ρ = −0.56, P = 0.006). ESPB patients required more morphine (3.0 vs. 1.0 mg, P = 0.004) and had fewer opioid-free recoveries (6.7% vs. 33.3%, P = 0.014). Mediation analysis showed analgesic differences were not explained by dermatomal extent. Conclusions ESPB showed narrower initial sensory spread than PVB but comparable anterior dermatomal coverage at 24 h. Female sex and shorter stature were associated with greater ESPB spread. Better analgesia with PVB despite similar dermatomal coverage suggests contributions from mechanisms beyond sensory mapping, including visceral or paravertebral blockade.
Massive transfusion (MT) and ultra-massive transfusion (UMT) are central to trauma resuscitation, yet clinicians face uncertainty when transfusion requirements escalate despite attempted hemorrhage control. This narrative review synthesizes mortality predictors in adult trauma patients receiving MT or UMT, with emphasis on transfusion burden, physiologic trajectory, hemostatic status, and resuscitation decision-making. PubMed, Embase, Cochrane, and Google Scholar were searched through July 2025. Eligible studies evaluated adult trauma patients receiving MT, UMT, massive transfusion protocol activation, or large-volume blood product resuscitation and reported mortality, transfusion burden, blood product strategy, or mortality-associated predictors. Forty-four studies including 2,153,506 patients were identified. Definitions of MT and UMT varied substantially. Increasing transfusion volume and velocity were associated with mortality, but survival was reported after extreme-volume transfusion and no universal nonsurvivability threshold was identified. Mortality was most strongly associated with high transfusion burden, acidosis, elevated lactate or base deficit, refractory hypotension or arrest, coagulopathy and hemostatic failure, neurologic injury, higher injury severity, older age, and failure to achieve hemorrhage control. Overall, transfusion burden should prompt dynamic multidisciplinary reassessment rather than serve as an isolated criterion for cessation of resuscitation.
Background: Selecting the appropriately sized endotracheal tube (ETT) remains a persistent challenge in paediatric anaesthesia. Age-based formulae do not account for individual anatomical variability, contributing to tube mismatch and necessitating exchange. We evaluated whether pre-intubation ultrasound-derived transverse cricoid diameter (TCD) and distal radial epiphyseal diameter (RED) more accurately predict best-fit cuffed ETT size than age-based formulae. Methods: In this prospective observational study, 105 patients aged 1-12 years scheduled for elective surgery requiring cuffed endotracheal intubation were enrolled consecutively. Initial ETT size was selected by an age-based formula; TCD and RED were measured by a blinded observer after induction and neuromuscular blockade, during bag-mask ventilation prior to intubation. Best-fit ETT was defined as the tube producing an audible tracheal air leak at 10-20 cmH(2)O with the cuff deflated. Spearman correlation, linear regression, and Bland-Altman analysis assessed the strength of association and clinical interchangeability. Results: TCD achieved the highest predictive accuracy (92.4%, 95% CI 85.7-96.1%), followed by RED (91.4%, 95% CI 84.5-95.4%), both significantly outperforming the age-based formula (73.3%, 95% CI 64.2-80.9%; TCD vs formula: p = 0.003; RED vs formula: p < 0.001; Bonferroni-corrected McNemar's test; TCD vs RED: p = 1.000). TCD and RED demonstrated a strong correlation with the best-fit ETT outer diameter (r = 0.98; 95% CI, 0.97-0.99; p < 0.001 for both), with narrow limits of agreement (LoA): TCD, -0.33 to +0.27 mm; RED, -0.37 to +0.34 mm. The age-based formula showed a lower correlation with the best-fit ETT inner diameter (r = 0.96, 95% CI 0.93-0.97, p < 0.001), with a wider LoA (-0.54 to +0.52 mm). First-attempt intubation success was 88.6%; both measurements were acquired in under 40 s. Conclusion: TCD and RED offer accurate, patient-specific ETT size prediction, substantially outperforming age-based formulae. TCD provides the greatest precision; RED is a practical alternative when subglottic ultrasonography is not feasible. Routine pre-intubation airway ultrasound represents a feasible, clinically meaningful step towards personalised paediatric airway management.
Objective Clinical history and physical examination in suspected smoke inhalation injury (SII) are non-specific and correlate poorly with bronchoscopic findings and patient outcomes. Although fibreoptic nasoendoscopy and laryngoscopy are commonly performed during early airway assessment, there is currently no standardised framework for describing acute supraglottic airway findings. This study aimed to: (1) introduce a classification system to standardise the assessment of acute supraglottic airway injury in SII; (2) evaluate its association with clinically relevant inpatient outcomes; and (3) identify clinical variables associated with severe supraglottic injury. Methods A retrospective cohort study of 106 adult patients with suspected SII was conducted at a single quaternary burns centre. SInhale, a classification system for acute supraglottic airway injury, was developed and retrospectively applied to documented endoscopic findings. Associations between SInhale classification, inpatient outcomes, and clinical variables were evaluated. Results Class III injury was significantly associated with intubation lasting more than 24 hours, longer duration of mechanical ventilation, higher frequency of prolonged mechanical ventilation ≥7 days, and increased intensive care unit length of stay compared with Class I injury. After adjustment for age and percentage of total body surface area burned, severe supraglottic injury (Class II-III) remained independently associated with intubation lasting more than 24 hours. Among the clinical variables evaluated, only internal soot within the oral cavity or oropharynx was independently associated with Class II-III injuries. Conclusions The SInhale classification provides a structured descriptive framework for standardising the assessment and documentation of acute supraglottic airway injury in patients with suspected SII. Higher SInhale classes were associated with clinically relevant inpatient outcomes. Prospective multicentre validation, assessment of inter-rater reliability and comparison with established tracheobronchial grading systems are required before routine clinical implementation.
Background: Acute respiratory failure is a common postoperative complication following cardiothoracic surgery, associated with increased morbidity, mortality, and prolonged hospital stay. High-flow nasal cannula (HFNC) delivers heated, humidified gas at high flow rates, improving oxygenation and patient comfort compared with conventional oxygen therapy. Objectives: To synthesize current evidence on HFNC in adult cardiothoracic surgery, focusing on physiological rationale, clinical efficacy, and implementation. Methods: A scoping review was conducted following JBI methodology and PRISMA-ScR guidance, including randomized trials, controlled studies, and meta-analyses evaluating HFNC across perioperative phases. Data were synthesized with outcomes, including oxygenation, reintubation, and escalation of respiratory support. Results: Postoperative evidence suggests that HFNC is associated with reduced reintubation and need for escalation of respiratory support. Several studies show HFNC comparable to non-invasive ventilation in preventing post-extubation respiratory failure, with imporved tolerance. Evidence for preoperative and intraoperative use remains limited and heterogeneous, largely extrapolated from non-cardiothoracic populations. Conclusions: HFNC is a well-tolerated and relevant option for postoperative respiratory support in cardiothoracic surgery. However, optimal indications, patient selection, and titration strategies remain incompletely defined, highlighting the need for well-designed trials.
Purpose Myocardial injury after non-cardiac surgery (MINS) is common and often under detected. Machine learning (ML) has been proposed as a tool for perioperative risk stratification and to support targeted postoperative troponin monitoring. This scoping review summarizes current evidence on ML models developed to predict MINS. Source Five databases were searched in January 2025. Eligible studies applied at least one ML method to predict MINS in adult surgical patients and reported at least one performance metric. Findings were synthesized narratively. Principal Findings Of 2,463 records screened, nine studies met inclusion criteria. Six reported internal validation and three external validation. Median AUROC was 0.777 (IQR 0.770–0.788) for internally validated models and 0.805 (range 0.790–0.821) for externally validated models. Common predictors included age, hemoglobin, renal function markers, perioperative biomarkers, and intraoperative hemodynamic variables. Conclusion Available supervised prediction models for MINS show variable discrimination, but the evidence base is small, heterogeneous, and largely at high risk of bias. Current studies do not establish clinical readiness or superiority of more complex ML approaches over regression-based models. Standardized outcome ascertainment, transparent reporting, clinically meaningful performance evaluation, and robust external validation are needed before implementation can be considered.
Background: Airway management is essential to most anaesthetic procedures but remains associated with significant morbidity and mortality when complications occur. National audits have highlighted the im-portance of system-based approaches to improve airway safety. In response, institutional initiatives such as Difficult Airway Groups (DAG) have been proposed. Methods: We conducted a quality improvement and feasibility study evaluating the implementation of a DAG in a tertiary university hospital. The programme was structured across four domains: organizational, clinical, educational and resource. A retrospective analysis of all DAG consultations over a three-month period (1 July - 30 September 2025) was performed to describe early activity and feasibility. Results: During the study period, 25 cases were managed, predominantly anticipated difficult airways. Most requests originated from the Department of Anaesthesiology (88%), with additional activations from the Intensive Care Unit (8%) and Emergency Department (4%). Awake techniques were favoured, with awake fibreoptic intubation being the most frequently used approach (40%). Airway management was successful in 96% of cases, with no airway-related mortality, unplanned surgical airways or severe complications. These findings primarily reflect early implementation and feasibility outcomes. Conclusions: The implementation of a hospital-wide DAG appears feasible and enables coordinated management of complex airways. Early feasibility indicators of the programme were observed. However, these represent very early implementation data, based on a limited number of cases and a short observation period. Further studies with larger cohorts, longer follow-up and comprehensive outcome metrics are required to evaluate the long-term clinical impact and sustainability of this model.
Purpose: To determine whether vasopressor use prior to intubation is associated with a reduction in the incidence and severity of hypotension in critically ill patients. Materials and methods: We performed a retrospective observational study using two electronic medical record datasets from mixed medical-surgical ICUs in Bern and Amsterdam (HiRiD and UMCDb) between 2003 and 2016. Patients undergoing their first ICU intubation with invasive blood pressure monitoring and >= 15 min of pre-and >= 60 min of post-intubation data were eligible. The primary exposure was continuous vasopressor infusion prior to induction. The primary outcome was the cumulative burden of hypotension, expressed as the area under the curve (AUC) below institutional mean arterial pressure (MAP) targets in the hour following intubation. Propensity score matching and multivariable regression were applied to adjust for confounding. Results: Of 2400 screened episodes, 1507 intubations met inclusion criteria (median age 65 years [IQR 55-75]; 31.9% female). The maximal MAP decrease was-24 mmHg [IQR-37 to-14]. Severe hypotension (MAP <45 mmHg) occurred in 253 patients (16.8%). Median AUC below target was 27.0 mmHg min [IQR 1-82] without vasopressors vs. 50.5 [IQR 5-133] with vasopressors; this difference was not significant after matching (Adjusted Mean Difference 7.82 (95% CI-8.4, 24.0). A MAP <75 mmHg before intubation was associated with a higher probability of severe hypotension post-intubation than baseline. Conclusions: New hypotension is a common occurrence during intubation, and prophylactic vasopressor infusion prior to intubation did not reduce hypotension burden, however the predicted probability of severe hypotension exceeded the overall incidence when the pre-intubation MAP was below 75 mmHg. Prospective randomized trials are needed to evaluate the use of prophylactic vasopressors prior to intubation.
The thalamus has been metaphorically described as the brain’s pacemaker because of its central role in coordinating thalamocortical oscillations. Here, we present the case of a 64-year-old woman with a permanent cardiac pacemaker who was scheduled for a stereotactic biopsy of a high-grade thalamic glioma under total intravenous anesthesia (TIVA). Advanced EEG analyses provide additional information beyond conventional processed indices.
Although videolaryngoscopy (VL) is clearly superior to direct laryngoscopy (DL) for routine tracheal intubation, uncertainty remains regarding which videolaryngoscope (VL) performs better for Double Lumen Tube (DLT) placement. This scoping review summarises the best available evidence on different VLS used for DLT intubation, comparing their performance with DL to confirm that VL improves efficacy, safety, and overall intubation quality. The review was conducted following PRISMA-ScR 2018 guidelines. A comprehensive search of major biomedical databases evaluated airway management techniques used in thoracic anaesthesia. Patients undergoing thoracic surgery are at increased risk for difficult airway management due to the underlying pathology, the physiological vulnerability, and the technical complexity of lung separation. Evidence supports the routine use of enhanced visualisation techniques - particularly VL - to improve first-pass success and reduce complications. The review examines the most used VLS and includes data on video-assisted tools such as flexible endoscopes and stylets. Despite the increasing adoption of VL and promising data supporting its role in DLT placement, current studies remain fragmented and limited by variability in devices, patient characteristics, operator experience, and study design. Large-scale, multicentre, and methodologically robust studies are urgently needed.
Introduction The importance of human factors science within healthcare is increasingly recognised, including during product design. This study assesses the performance of a human factors inspired airway management equipment bag (the StarRoll (TM)) - designed to reduce cognitive load during emergency airway management - against an industry standard bag (SCRAM (TM)), for the purpose of equipment preparation during emergency airway management. Methods 32 participants prepared equipment for a simulated emergency tracheal intubation. Equipment preparation was checked against Difficulty Airway Society (UK) guidelines for omissions. Task duration was timed, video footage captured for ergonomical analysis, and a survey of task performance undertaken using an adapted version of the NASA Task Load Index in order to assess product functionality and user satisfaction. Results Time to readiness for intubation was 115s for StarRoll (TM) versus 99 s for SCRAM (TM) (p < 0.036). There was no statistically significant difference in error commission between the two bags. Ergonomic analysis yielded a median REBA score of 5 for both StarRoll (TM) and SCRAM (TM), indicating a medium risk for both devices. Survey data indicated that the StarRoll (TM) bag was consistently viewed more positively, with no Task Load Index themes resulting in an overall negative response value. Conclusion The StarRoll (TM) bag was found to be favourable during simulated task performance with regards reported stress, effort and cognitive load, suggesting incorporation of human factors into product design can improve clinician experience.
Background: Difficult airway management is a major cause of preventable morbidity and mortality. However, national data on how Portuguese hospitals organize airway governance are lacking. Methods: A multicentre cross-sectional observational study was conducted among Portuguese anaesthesiologists via an electronic survey. The aim was to characterize organizational structures, resources, training activities, and clinicians' perceptions regarding difficult airway management. Results: The response rate was 25.28% (n = 204/807). Fewer than half the respondents reported a formal airway group (43.14%), whose integration into their institutional organograms was inconsistent. Protected working time for airway roles was rare (8.33%). Although most respondents reported that their hospitals had key structural resources (protocols, 83.17%; equipment inventories, 79.41%; and difficult airway carts, 96.06%), the presence of predefined support teams (44.96%), regular training (62.31%), and specialized consultation (23.44%) was much less common and showed marked regional and sectoral heterogeneity. Discussion: This first national characterization reveals a mismatch between structural readiness and organizational preparedness. The findings suggest that Portuguese airway safety depends largely on individual initiatives rather than formal governance, and highlight the need for nationally guided, institutionally supported airway teams or leaders with protected working time, structured training programs, and centralized airway equipment and data systems.
Background Effective postoperative analgesia is essential for enhanced recovery after total knee replacement (TKR). The adductor canal block (ACB) offers predominantly sensory blockade but may not consistently cover the anterior femoral cutaneous nerve (AFCN), resulting in incomplete analgesia. Objective To compare whether the addition of an ultrasound-guided anterior femoral cutaneous nerve block (AFCNB) to ACB improves pain relief and enhances early functional recovery following TKR. Methods Eighty adult patients undergoing unilateral TKR under spinal anaesthesia were randomized in this prospective, single-blind randomized controlled trial (patients and outcome assessors blinded) into two groups. Group A (n = 40) received ACB alone, and Group B (n = 40) received ACB + AFCNB. All blocks were performed postoperatively. Pain scores (numeric rating scale, NRS) on movement at 12 h postoperatively was the primary outcome. Secondary outcomes included Numerical Rating Scale (NRS) pain scores at rest at 6, 12, and 24 h; pain scores on movement at 6 and 24 h; total opioid consumption; time to first rescue analgesia; functional recovery assessed using the Timed Up and Go (TUG) test; and patient satisfaction. Results Both groups were comparable in demographic and perioperative parameters. Compared with ACB alone, the combined block significantly reduced both rest and movement NRS pain scores at all reported postoperative time points (6, 12, and 24 h) (p < 0.05). The AFCNB + ACB group also demonstrated prolonged time to first rescue analgesia (9.75 +/- 0.71 vs 6.05 +/- 1.45 h; p < 0.001) and reduced 24-h fentanyl consumption via PCA (24.18 +/- 4.57 vs 33.15 +/- 6.96 mu g; p = 0.007). Early functional recovery was improved, with faster TUG times (52.05 +/- 12.95 vs 57.95 +/- 10.12 s; p = 0.009), and patient satisfaction scores were higher (6.78 +/- 1.72 vs 4.55 +/- 0.71; p = 0.024) with combined block. Conclusion Ultrasound-guided AFCNB combined with ACB provides superior postoperative analgesia, reduces opioid requirement, and facilitates early mobilisation after unilateral TKR compared with ACB alone. This combined approach is safe and may support ERAS pathways.
