Background Pierre Robin sequence (PRS) syndrome has clinical features of small mandible, tongue drooping, and respiratory obstruction. This study compared the 3-dimensional (3D) reconstruction of the upper airway anatomy based on computed tomography (CT) data between PRS and normal control (NC) children, and analyzed the dynamical changes and airflow field using computer fluid dynamics (CFD) between the two populations. Methods A retrospective study was conducted on 66 PRS and 23 NC children, and all CT data were obtained and used for reconstruction and numerical simulation. 10 anatomical landmarks were used to estimate the mandibular morphology, while the sectional area (SA), pressure, and velocity of five upper airway cross sections (CS) were measured. The measurement results of 3D reconstruction and CFD were subjected to mean processing. The propensity score matching (PSM) method was used to enhance the degree of demographic matching. Results After PSM correction, 21 cases were finally included in each group. The average month age was (5.29 ± 4.26) months, with 52.4% (n = 22) being male. Besides the similar narrowest SA of the tongue base in the anterior-posterior direction, there were differences in other measurement parameters between two groups. Meanwhile, the SA of CS-1 in the PRS group was larger than that in the NC group (P < 0.001); Correspondingly, the pressure and velocity in the PRS group were significantly lower (both P < 0.001). Furthermore, except for similar SA of CS-5, the other three SA in the PRS group were significantly smaller than those in the NC group (all P < 0.001). Conclusions This study identified the abnormal anatomical characteristics in PRS, thereby helping clinicians establish appropriate airway management plans in clinical practice.

This study evaluated the association between preoperative cognitive performance and postoperative delirium (POD) using a multicenter prospective cohort, and explored potential causality using Mendelian randomization (MR) analysis. We analyzed data from 2257 patients aged ≥ 75 years undergoing elective noncardiac and noncranial surgeries across 16 Chinese medical centers. Preoperative cognitive assessment using Mini-Cog revealed 28.4% of patients had cognitive impairment (score ≤ 2). POD occurred in 9.7% of patients, with higher incidence among those with cognitive impairment. Logistic regression demonstrated that cognitive impairment was significantly associated with increased POD risk (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.55-2.74; p < 0.001). This association persisted after adjustment for demographic, preoperative, and intraoperative factors, and was confirmed through propensity score matching and inverse probability treatment weighting analyses. A nearly linear inverse association was observed between Mini-Cog scores and POD incidence. Complementary MR analysis using 139 SNPs from European ancestry data suggested that higher cognitive performance might be associated with decreased delirium risk (inverse-variance weighted OR, 0.74; 95% CI, 0.59-0.93; p = 0.009). Although these results point to a potential link between preoperative cognition and POD, interpretation of causality should be approached with caution, particularly given differences in populations and genetic datasets.

Patients with Pierre Robin sequence (PRS) frequently require multiple attempts for airway stabilization. However, there is currently no standardized algorithm to identify anatomical landmarks that predict the difficulty of tracheal intubation and its clinical impact. This study aimed to determine predictive factors associated with multiple attempts at airway stabilization in PRS patients undergoing mandibular distraction osteogenesis (MDO) and to evaluate their influence on clinical outcomes. A derivation cohort comprising 348 PRS patients who underwent MDO January 2007 and June 2023 was included; An external validation cohort of 87 PRS patients at the same period was analyzed. Machine learning and multivariate regression analyses were employed to examine the relationship between tracheal intubation outcomes and anatomical measurements. Five variables were independently associated with increased risk: Mandibular angle, tongue length, mouth opening, palatopharyngeal flow velocity, and traction length of machine disconnection. The XGBoost model demonstrated superior performance, achieving an area under curve (AUC) of 0.952 after parameter tuning. Decision curve analysis revealed a threshold probability of 84%. Similar results were observed in the external validation cohort (AUC = 0.943). These five-factor model could effectively identify the risk of adverse events in PRS patients undergoing MDO, providing a valuable tool for clinical decision-making.

Background: The main clinical manifestations of patients with Pierre Robin sequence (PRS) include micrognathia, the glossoptosis and dyspnoea. The difficulty of tracheal intubation (TI) in such patients is increased.Objective: The purpose of the study was to evaluate the reliability and efficacy of the PRS simulator.Methods: A PRS simulator was developed by using 3-dimensional (3D) printing technology under computer-aided design. A total of 12 anaesthesiologists each trained 5 times for TI on the PRS Training Simulator-1 and recorded the simulation time. After the training, they were randomly divided into three groups with a total of 12 nontrained anaesthesiologists, and the simulation was completed on PRS Simulator-2, 3 and 4. The simulation time was recorded, and the performance was evaluated by three chief anaesthesiologists. Then, all 24 anaesthesiologists completed the questionnaire.Results: A PRS simulator developed by 3D printing was used to simulate the important aspects of TI. The average number of years worked was 6.3 ± 3.1 years, and 66.7% were female. The time for the 12 anaesthesiologists to complete the training gradually decreased (p < 0.01). Compared with the trained anaesthesiologists, the simulation time of TI in the nontrained anaesthesiologists was much longer (all p < 0.01). In addition, the simulation performance of the trained anaesthesiologists was relatively better (all p < 0.01).Conclusion: The reliability and efficacy of the PRS simulator is herein preliminarily validated, and it has potential to become a teaching and training tool for anaesthesiologists.

INTRODUCTION:Airway management is often a life-saving procedure for patients. However, during airway management, difficult ventilation and difficult intubation are not always predictable. Preoxygenation, a crucial technique to improve oxygen reserves, plays a vital role in preventing hypoxemia during anesthesia induction. Preoxygenation technology and equipment are not monolithic. With the development of preoxygenation equipment and technology, the effect of preoxygenation has been improved, and it can be applied to different clinical settings. EVIDENCE ACQUISITION:We conducted a literature search (PubMed and Scopus) in October 2023 with a starting date of January 1985, repeated in August 2024, to identify relevant articles. Key search terms included: 'preoxygenation,' 'high-flow nasal oxygenation,' 'non-invasive ventilation,' 'obese patients,' 'pediatric patients,' and 'elderly patients.' EVIDENCE SYNTHESIS:The abstracts of identified articles were assessed for relevance, along with screening of their references for further relevant publications. A full-text review of 219 articles was undertaken, of which 77 were included in the final review. CONCLUSIONS:Preoxygenation is really effective, and different preoxygenation equipment and technology can be applied in different clinical settings to improve the oxygen reserve of patients, thereby ensuring patient safety and improving patient outcome.

Objectives:We hope to offer a comprehensive understanding of the advancements and patterns in research on PND. Methods: We performed a thorough search on the Web of Science Core Collection to locate relevant studies published from 1969 to 2022 and utilized four distinct tools, namely VOSviewer (J Data Inf Sci, 2017, 2, 1; J Am Soc Inf Sci, 1973, 24, 265; Amer Doc, 1963, 14, 10 and Scientometrics, 2010, 82, 581), CiteSpace (Scientometrics, 2010, 84, 523), Scimago Graphica, and R-bibliometrix which allowed us to examine various aspects. Results: We included a total of 6787 articles and reviews for analysis which described PND research, the sources, and the subfields; highlighted the significant developments in this field; identified three main directions in PND.Conclusion: This study highlights the rapid growth of research on PND in recent years and provided an overview of previous studies in the field of PND, thereby establishing the overall landscape of PND research and identifying potential avenues for future investigations. Methods:We performed a thorough search on the Web of Science Core Collection to locate relevant studies published from 1969 to 2022. To perform bibliometric analysis and network visualization, we utilized four distinct tools, namely VOSviewer (J Data Inf Sci, 2017, 2, 1; J Am Soc Inf Sci, 1973, 24, 265; Amer Doc, 1963, 14, 10 and Scientometrics, 2010, 82, 581), CiteSpace (Scientometrics, 2010, 84, 523), Scimago Graphica, and R-bibliometrix. These tools allowed us to examine various aspects, including the yearly publication output, the contribution of different countries or regions, the involvement of active journals, co-citation analysis, publication status, keywords, and terms, as well as scientific categories. We hope to offer a comprehensive understanding of the advancements and patterns in research on PND. The insights gained from this study can assist researchers and clinicians in enhancing the management and implementation of their work in this field. Results:In this study, we included a total of 6787 articles and reviews for analysis. First, publication trends and contribution by country analysis described PND research. Second, a historical analysis described PND research, the sources, and the subfields. Third, an analysis of keywords highlighted the significant developments in this field. Fourth, an analysis of research themes identified three main directions in PND. Conclusion:In summary, the research volume exhibits exponential growth over time. Furthermore, the majority of contributions originate from Western countries and China. The interdisciplinary nature of the field is evident, with its roots in biology and medicine and further branching into psychology and social sciences. POCD, delirium-predominant associated clinical management were major research themes about PND.

目的 探讨充气温毯联合液体加温技术预防老年患者围术期低体温的效果.方法 采用前瞻性、随机临床对照研究.选择2016年6月～2017年6月在北京医院择期行全麻下腹部手术的老年患者(≥65岁)37例.采用随机数字表法分为两组,单纯采用充气温毯的20例老年患者为温毯组,充气温毯联合液体加温的17例老年患者为联合组.所有患者自诱导前20～30 min开始向温毯持续吹入经加热的气体直至离开手术室.联合组术中静脉输注由温箱38℃保存8 h以上的加温液体,温毯组输入液体均保持室温水平.记录入室后、诱导前、诱导后15 min、30 min、60 min、90 min、120 min、术毕、出室前患者的核心体温.记录术后寒颤发生情况及观察期间出现的不良反应.结果 从整体分析发现两组患者的核心温度时间、组间、交互作用比较差异均有统计学意义(P＜0.001).联合组在诱导后60 min、90 min、120 min时的核心体温高于温毯组,差异有统计学意义(P＜0.05).联合组术中低体温发生率低于温毯组(P＜0.05).结论 全麻下行腹部手术时,充气温毯联合液体加温技术预防老年患者围术期低体温的效果优于单纯使用充气温毯.

Background: Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety. Methods: Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts. Results: This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway. Conclusions: This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

To compare the potential influences of blind insertion and up-down optimized glottic exposure manoeuvre on the oropharyngeal leak pressure (OPLP) in using SaCoVLM™ video laryngeal mask (VLM) among patients undergoing general anesthesia. A randomized self-control study controlled was conducted to investigate the effect of two insertion techniques on OPLP. A total of 60 patients (male or female, 18–78 years, BMI 18.0–30.0 kg m −2 and ASA I–II) receiving selective surgery under general anesthesia were randomly recruited. After induction of anesthesia, the SaCoVLM™ was inserted by blind insertion manoeuvre. The glottic exposure grading(V1) of the SaCoVLM™ visual laryngeal mask and the OPLP(P1) were recorded. And the glottic exposure grading(V2) and OPLP(P2) of SaCoVLM™ were recorded again when the glottic exposure grading was optimal. The glottis exposure grading and OPLP were compared before and after different insertion manoeuver. The glottic exposure grading (V2) obtained by using up-down optimized glottic exposure manoeuvre was better than that obtained by using blind insertion manoeuvre (V1)(P < 0.001). The OPLP was significantly lower in the blind insertion manoeuvre (P1) than in the up-down optimized glottic exposure manoeuvre (P2) (32.4 ± 5.0 cmH 2 O vs. 36.3 ± 5.2 cmH 2 O, P < 0.001). In using SaCoVLM™, higher OPLP and better glottic exposure grading were achieved through up-down optimized glottic exposure manoeuvre, protecting the airway while real-time monitoring of conditions around the glottis, which significantly improves airway safety. Our results suggests that up-down optimized glottic exposure manoeuver may be a useful technique for SaCoVLM™ insertion. Trial registration : ChiCTR, ChiCTR2000028802. Registered 4 January 2020, http://www.chictr.org.cn/ChiCTR2000028802.

Background: This multicenter prospective, randomized controlled clinical trial compared the clinical performance of supraglottic airway device (SAD) BlockBuster (TM) and laryngeal mask airway (LMA) Supreme for airway maintenance in anesthetized, paralyzed adult patients. Methods: A total of 651 adult patients scheduled for elective surgery in 13 hospitals were randomly allocated into BlockBuster group (n = 351) or Supreme group (n = 300). The primary outcome was oropharyngeal leak pressure (OLP). Duration and ease of insertion, fiberscopic view of positioning, airway manipulations, and complications were also assessed. Results: The OLP was significantly higher in BlockBuster group compared with Supreme group (29.9 +/- 4.2 cmH(2)O vs 27.4 +/- 4.3 cmH(2)O, p < 0.001). Success rate of insertion at the first attempt (90.2% vs 85.1%, p = 0.027), rate of optimal fiberscopic view (p = 0.002) and satisfactory positioning of SAD (p < 0.001) were significantly increased in BlockBuster group. Conclusions: Both SAD BlockBuster (TM) and LMA Supreme are safe, effective, and easy-to-use devices for airway maintenance in anesthetized, paralyzed adult patients, but the SAD BlockBuster (TM) is superior to LMA Supreme in terms of OLP, success rate at the first attempt, and fiber-optic view of positioning.

Abstract Background To preliminary evaluate the application of SaCoVLM™ video laryngeal mask airway in airway management of general anesthesia. Methods We recruited 100 adult patients (ages 18–78 years, male 19, female 81, weight 48–90 kg) with normal predicted airway (Mallampati I ~ II, unrestricted mouth opening, normal head and neck mobility) and ASA I-II who required general anaesthesia. The SaCoVLM™ was inserted after anesthesia induction and connected with the anesthesia machine for ventilation. Our primary outcome was glottic visualization grades. Secondary outcomes included seal pressure, success rate of insertion, intraoperative findings (gastric reflux and contraposition), gastric drainage and 24-h complications after operation. Results The laryngeal inlet was exposed in all the patients and shown on the video after SaCoVLM™ insertion. The status of glottic visualization was classified: grade 1 in 55 cases, grade 2 in 23 cases, grade 3 in 14 cases and grade 4 in 8 cases. The first-time success rate of SaCoVLM™ insertion was 95% (95% CI = 0.887 to 0.984), and the total success rate was 96% (95% CI = 0.901 to 0.989). The sealing pressure of SaCoVLM™ was 34.1 ± 6.2 cmH2O and the gastric drainage were smooth. Only a small number of patients developed mild complications after SaCoVLM™ was removed (such as blood stains on SaCoVLM™ and sore throat). Conclusions The SaCoVLM™ can visualize partial or whole laryngeal inlets during the surgery, with a high success rate, a high sealing pressure and smooth gastroesophageal drainage. SaCoVLM™ could be a promise new effective supraglottic device to airway management during general anesthesia. Trial registration ChiCTR, ChiCTR2000028802 .Registered 4 January 2020.

传统意义上的困难气道多用于描述解剖上存在声门显露困难或气管插管困难的气道。在过去的几十年里，随着辅助通气工具、可视气管插管工具、各种类型气道工具的更新迭代，解剖性困难气道的管理取得了飞速的进步。多个国际气道协会已经为困难气道的管理制定了指南 [1,2,3,4]，显著改善了解剖性困难气道的管理。然而无论使用何种气道管理方式，优化患者气体交换才是气道管理的主要目标 [5]。

Background When a difficult airway is unanticipatedly encountered and the initial laryngoscopic intubation fails, a supraglottic airway device (SAD) may be placed to aid ventilation and oxygenation, and act as a conduit for intubation. SaCoVLM™, as new SAD, can offer a direct vision to guide intubation. However, no study has evaluated the performance of SaCoVLM™ video laryngeal mask (VLM) intubation and i-gel combined with flexible bronchoscopy (FB)-guided intubation in airway management during general anesthesia. Methods A total of 120 adult patients were randomly allocated into the SaCoVLM™ group (Group S) and i-gel group (Group I). After induction of general anesthesia, guided tracheal intubation under direct vision of the SaCoVLM™ was conducted in Group S, while Group I received FB-guided tracheal intubation using the i-gel. The success rate of SAD placement, first-pass success rate of guided tracheal tube placement, and total success rate in both groups were recorded. The time for SAD placement, time for guided tracheal intubation, total intubation time (time for SAD placement and intubation), glottic exposure grading and postoperative intubation complications (i.e., dysphagia, hoarseness, pharyngalgia, etc.) of both groups were also compared. Results The first-time success rate of SAD placement was 98% in two groups. The first-pass success rate of guided endotracheal intubation was 92% in Group S and 93% in Group I (P = 0.74 > 0.05). The total intubation time was 30.8(± 9.7) s and 57.4(± 16.6) s (95% CI = -31.5 to -21.7) in Group S and Group I, respectively (P < 0.01). The total complication rate was 8% in Group S and 22% in Group I (P < 0.05). The laryngeal inlet could be observed in the S group through the visual system of SaCoVLM™. No dysphagia or hoarseness was reported. Conclusion SaCoVLM™ can reveal the position of laryngeal inlet, thus providing direct vision for tracheal intubation. SaCoVLM™ -guided intubation is faster, and does not rely on FB, compared to i-gel combined with FB-guided intubation. Besides, SaCoVLM™ has a lower post-intubation complication rate. Trial registration Chinese Clinical Trials Registry (ChiCTR2100043443); Date of registration: 18/02/2021.

喉罩作为声门上气道管理工具,具有操作简单、血流动力学波动小、术后咽喉疼痛发生率低等优点,已成为气道管理工具中不可或缺的一部分.目前,临床中常用的喉罩有cLMA、Proseal、I-gel等.而 I-gel喉罩采用凝胶状热塑性弹性体材质,无需充气,罩体设计更符合人体解剖结构,同时可置入胃管减少反流误吸.研究[1-4]表明,与cLMA、Proseal比较,I-gel喉罩的口咽部密封压高、置入时间短、首次置入成功率高.但本院在使用I-gel喉罩的过程中发现,本院患儿的口咽部密封压与国外报道的存在一定差异.因此,本研究观察I-gel喉罩在患儿短小手术中的临床应用效果,并探讨影响口咽部密封压的相关因素.

Coronavirus disease 2019 (COVID-19) has caused a dramatic loss of human life worldwide. The rate of tracheal intubation is estimated to be 2.3% in hospitalized patients.[1] As an aerosol-generating procedure, intubation may increase the risk of COVID-19 infection in healthcare workers. Avoiding the generation of aerosol and improving the oxygenation during intubation is sometimes conflicting, which makes the intubation in patients with COVID-19 different from that in other patients with acute respiratory distress syndrome (ARDS). We conducted a survey to collect information on preoxygenation, induction, and intubation procedures in COVID-19 patients. Our study aims to compare the difference in intubation performance between doctors who have ever done tracheal intubation in COVID-19 patients versus those who have never done tracheal intubation in COVID-19 patients. This study was supported by the Airway Management Group of the Chinese Society of Anesthesiology (CSA) and approved by the institutional review board of Beijing Hospital (No. 2020BJYEC-048-01). Written informed consent was waived by the institutional review board of Beijing Hospital. Two versions of the questionnaires were designed: questionnaire A was meant to be filled in by doctors who performed tracheal intubation in COVID-19 patients, and questionnaire B was for doctors without experiences in tracheal intubation in COVID-19 patients. The following information was collected in both questionnaire A and questionnaire B: personal information including basic hospital characteristics, age, gender, and work experience; the number of assistants; methods for airway assessment, preoxygenation, induction, and intubation. Unlike other questions in the questionnaire (both questionnaire A and questionnaire B), the question about the sedative drug has multiple answers, which means more than one kind of sedatives could be selected by doctors during induction. In questionnaire A, numbers of COVID-19 patients intubated were investigated. For doctors who had performed tracheal intubation in COVID-19 patients, they were asked to fill in the questionnaire A according to the situation during tracheal intubation in COVID-19 patients. For those doctors who had never performed tracheal intubation in COVID-19 patients, they were asked to fill in the questionnaire B about what they would do if tracheal intubation was needed in COVID-19 patients. Doctors who filled in questionnaire A were classified as the intubation group and doctors who filled in questionnaire B were classified as the non-intubation group. The questionnaires were uploaded to the Wenjuanxing platform (https://www.wjx.cn) on March 18, 2020, where they remained through March 31, 2020; the links were officially sent to anesthetists in China by the CSA. The questionnaires were designed to ensure that each doctor could submit his or her questionnaire only once. All returned questionnaires were evaluated for validity. For those doctors who have done more than two cases of intubations or who came from a hospital not designated for the treatment of COVID-19 but still have filled in questionnaire A, we do confirm the answers with their department chiefs. If we could not reach the department chief or the number of patients was higher than the number reported by their department chief, the questionnaire would be eliminated from further analysis. At the end of this cross-sectional survey, 3916 responses including 172 responses of questionnaire A and 3744 responses of questionnaire B were received by March 31, 2020. Five responses to questionnaire A from doctors who did not have tracheal intubation cases were excluded. Fourteen responses to questionnaire A were excluded after validation. The proportion of valid responses of questionnaire A and questionnaire B was 89% (153/172) and 100% (3744/3744) respectively. In the 153 copies of questionnaire A included, 633 cases of intubation were completed by 153 doctors. The data analysis was based on questionnaires validated. Categorical data collected were presented as numbers (%) and compared by the χ2 test or Fisher exact test between groups. This study was designed to investigate techniques used by Chinese anesthesiologists when intubating patients with COVID-19. Therefore, no formal hypotheses were implemented to drive the sample size calculation. Statistical analysis was performed with SPSS 24.0 (IBM Corp., Armonk, NY, USA). P < 0.05 was considered statistically significant. Our results showed that 41 of the 153 doctors in the intubation group completed tracheal intubation with no assistant, while 447 of the 3744 doctors in the non-intubation group planned to complete tracheal intubation with no assistant. Modified Mallampati test, which was widely used for airway assessment by anesthetists, was chosen by fewer doctors in the intubation group than in the non-intubation group (46% [71/153] vs. 80% [2977/3744], χ2 = 94.562, P < 0.001). As for anti-fog measures and time used for preoxygenation, no significant difference was found between the intubation group and the non-intubation group (P > 0.05). Noninvasive mechanical ventilation (NIV) was used for preoxygenation by more doctors in the intubation group than in the non-intubation group (58% [89/153] vs. 24% [880/3744], P < 0.001). In comparison with the intubation group, midazolam (47% [1766/3744] vs. 33% [51/153], χ2 = 11.306, P < 0.001) and etomidate (40% [1495/3744] vs. 31% [47/153], χ2 = 5.216, P = 0.022) were used by more doctors in the non-intubation group. During the induction procedure, rocuronium at over 0.9 mg/kg was chosen by more doctors in the intubation group than the non-intubation group (42% [65/153] vs. 25% [942/3744], χ2 = 23.020, P < 0.001), but there was no significant difference in the dosage of succinylcholine chosen by doctors in the two groups (P > 0.05). The instrument used for intubation was similar between the two groups (P > 0.05). In addition, fewer doctors in the intubation group tended to confirm the position of endotracheal tube by auscultation than in the non-intubation group (9% [14/153] vs. 22% [808/3744], χ2 = 13.647, P < 0.001) [Table 1]. Table 1 - Questionnaire survey results of clinical practice on preparation, preoxygenation, induction, and intubation in COVID-19 patients. Items Total (n = 3897) Intubation (n = 153) Non-intubation (n = 3744) χ 2 P values Preparation Working experiences 1.861 0.394 <5 years 752 (19) 23 (15) 729 (19) 5–10 years 915 (23) 38 (25) 877 (23) >10 years 2230 (57) 92 (60) 2138 (57) Modified-Mallampati test 3048 (78) 71 (46) 2977 (80) 94.562 <0.001 Anti-fog measures 3216 (83) 125 (82) 3091 (83) 0.075 0.784 Preoxygenation Time 7.256 0.027 <3 min 611 (16) 35 (23) 576 (15) ≥3 min and <5 min 1436 (37) 46 (30) 1390 (37) ≥5 min 1850 (48) 72 (47) 1778 (48) Methods – <0.001 Bag-mask ventilation 2489 (64) 46 (30) 2443 (65) Nasal cannula 47 (1) 3 (2) 44 (1) HFNC 392 (10) 15 (10) 377 (10) NIV 969 (25) 89 (58) 880 (24) Induction Sedative Etomidate 1542 (40) 47 (31) 1495 (40) 5.216 0.022 Propofol 2868 (74) 116 (76) 2752 (74) 0.405 0.525 Midazolam 1817 (47) 51 (33) 1766 (47) 11.306 <0.001 Ketamine 90 (2) 1 (1) 89 (2) – 0.265 None 34 (1) 4 (3) 30 (1) – 0.042 Neuromuscular blockade – 0.190 Succinylcholine 784 (20) 22 (14) 762 (20) <1 mg/kg 112 (3) 3 (2) 109 (3) ≥1 mg/kg 672 (17) 19 (12) 653 (17) Rocuronium 2129 (55) 96 (63) 2033 (54) ≤0.6 mg/kg 1122 (29) 31 (20) 1091 (29) ≥0.9 mg/kg 1007 (26) 65 (42) 942 (25) Vecuronium/cis-atracurium 892 (23) 32 (21) 860 (23) None 92 (2) 3 (2) 89 (2) Analgesics 25.592 <0.001 Remifentanil 958 (25) 20 (13) 938 (25) Fentanyl 586 (15) 24 (16) 562 (15) Sufentanil 1931 (50) 76 (50) 1855 (50) None 422 (11) 33 (22) 389 (10) Oxygenation during induction – <0.001 Bag-mask ventilation 2348 (60) 63 (41) 2285 (61) HFNC 298 (8) 8 (5) 290 (8) NIV 1249 (32) 80 (52) 1169 (31) None 2 (0) 2 (1) 0 (0) Intubation Video laryngoscope with disposable blades 3307 (85) 128 (84) 3179 (85) 0.178 0.673 Auscultation for ETT position confirmation 822 (21) 14 (9) 808 (22) 13.647 <0.001 Data were presented as n (%). COVID-19: Coronavirus disease 2019; ETT: Endotracheal tube; HFNC: High flow nasal cannula; NIV: Noninvasive mechanical ventilation; –: Not applicable. Our study presented characters of clinical practice on airway management in COVID-19 patients and demonstrated a significant difference between doctors with and without intubation experiences. For tracheal intubation in COVID-19 patients, a consensus guideline suggested experienced assistant should be present to help the intubation.[2] Shortage of doctors and personal protective equipment at the early stages of the COVID-19 outbreak may underlie the difference between the number of assistants recommended by the guideline and that of clinical practice. As a potential aerosol-generating procedure, a modified Mallampati test was suggested to be avoided in the airway assessment in the expert recommendation.[3] Differences between guidelines and clinical practice suggested insufficient understanding of aerosol-generating procedures was not uncommon in doctors, especially for those in the non-intubation group. Hypoxemia worsened after induction in COVID-19 patients with severe lung injury.[3] Therefore, preoxygenation for at least 3 minutes was recommended in COVID-19 patients. COVID-19 patients usually received NIV or high flow nasal cannula (HFNC) oxygen before tracheal intubation. Our results indicated that doctors in the non-intubation group might be unfamiliar with the treatment for COVID-19. In terms of induction, propofol, rocuronium, and sufentanil were the most widely used anesthetics. Attention should be paid to hypotension induced by propofol. Midazolam and etomidate were recommended for hemodynamically unstable patients.[3] Remifentanil or fentanyl was recommended to relieve cardiovascular response. Due to its long onset time, sufentanil was not recommended.[3] Rocuronium at 1.2 mg/kg was recommended during induction by Cook et al.[2] Ethnic differences might underlie the difference between the recommended dose in rocuronium and that used by Chinese doctors. Although ventilation during induction was not suggested in some recommendations based on the potential risk of viral spread, convincing evidence was lacking.[2,4] Tracheal intubation in COVID-19 patients should be done by the best-skilled airway manager. In China, anesthetists performed intubations in most hospitals.[5] There might be some differences between respiratory physicians or doctors from other departments and anesthetists in performing tracheal intubation. Further studies still need to be done to find out these differences. In summary, modified rapid sequence induction and intubation using a video laryngoscope with disposable blades after preoxygenation were recommended for the intubation in COVID-19 patients. Doctors without experience in tracheal intubation in COVID-19 patients were lack of understanding of aerosol generating procedures and the impact of the protective gown on tracheal intubation operations. Thus, doctors should be trained to perform tracheal intubation under a protective gown and to avoid aerosol-generating procedures prior to entering the isolation ward. Conflicts of interest None.

Level III PPE appears to provide healthcare workers with maximum protection against cross infection by aerosolised SARS-CoV-2 viral particles. The highest level of PPE should be considered in the management of patients with COVID-19, especially during performance of AGPs. Global efforts should provide adequate levels of PPE for all healthcare workers during the pandemic and uniform application of environmental controls. Use of HFNO should be considered for management of acute respiratory failure and after tracheal extubation of patients with COVID-19 as long as optimal environmental measures and protective PPE are available for healthcare workers. Noninvasive ventilation is encouraged as the first-line approach before tracheal intubation and mechanical ventilation in critically ill patients with COVID-19 with the aforementioned caveats, although further study of this approach is warranted.

Background: Experimental and observational research suggests that combined epidural–general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural–general anesthesia improves long-term survival in elderly patients. Methods: This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural–general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival. Results: Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural–general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural–general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural–general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural–general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815. Conclusions: In elderly patients having major thoracic and abdominal surgery, combined epidural–general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference. In patients aged 60 to 90 yr having major noncardiac thoracic and abdominal surgery, combined epidural–general anesthesia compared to general anesthesia alone did not improve overall or cancer-specific long-term survival. Combined epidural–general anesthesia also did not improve recurrence-free survival. Supplemental Digital Content is available in the text.

目的 比较肺保护性通气策略与传统通气策略在全身麻醉患者经后腹膜腹腔镜手术中的通气效果.方法 选取2017年1月至2019年6月于北京医院/国家老年医学中心/中国医学科学院老年医学研究院全身麻醉下侧卧折刀位行经后腹膜腹腔镜肾癌手术的患者60例,按照随机数字表法分为两组:传统通气策略组(A组)和肺保护性通气策略组(B组),A组和B组各30例.记录T1(全身麻醉插管后)、T2(侧卧折刀位5min)、T3(气腹30min)、T4(手术结束时)时刻的气道平均压、肺顺应性和呼气末二氧化碳(end-tidal carbon dioxide,EtCO2);记录T0(入手术室)、T2、T3、T4、T5(术后24h)时刻的动脉血pH、动脉血氧分压(arterial partial pressure of oxygen,PaO2)和动脉血二氧化碳分压(arterial partial pressure of carbon dioxide,PaCO2);记录有无术后呼吸衰竭.结果 B组在T1、T2、T3、T4时刻的气道平均压均明显低于A组,B组在T1、T2、T3、T4时刻的肺顺应性和EtCO2均明显高于A组,差异有显著性(P<0.05).B组在T2、T3时刻的PaCO2均明显高于A组,差异有显著性(P<0.05),而T4、T5时两组的PaCO2差异无显著性(P>0.05),其余血气指标差异无显著性(P>0.05).两组患者术后均未发生呼吸衰竭.结论 肺保护性通气策略降低术中气道压,具有更好的肺顺应性,术中PaCO2会有一过性升高但无相关并发症,可安全用于全身麻醉下经后腹膜腹腔镜手术.