Search Results (51)

Background: Maintaining hemodynamic stability is crucial during coil embolization of unruptured intracranial aneurysms. Remimazolam has been suggested to exert less cardiovascular depression than propofol and may therefore provide more stable hemodynamic conditions. This study compared the hemodynamic effects of remimazolam and propofol when used for anesthesia induction and maintenance in patients undergoing coil embolization with I-gel airway management. Methods: In this single-center, randomized study, adults undergoing elective coil embolization for unruptured intracranial aneurysms were assigned to remimazolam or propofol induction followed by I-gel insertion. The primary outcome was the peak-to-nadir systolic blood pressure difference during the peri-induction period. Secondary outcomes included the peak-to-nadir mean arterial pressure difference, lowest systolic and mean arterial pressures, the incidence of hypotension, vasoactive drug requirements, and recovery outcomes. Results: Of the 50 patients randomized, 46 were included in the analysis, including 22 in the remimazolam group and 24 in the propofol group. The peri-induction peak-to-nadir systolic blood pressure difference was smaller with remimazolam than with propofol (38.2 ± 13.2 vs. 51.7 ± 13.4 mmHg, p = 0.001). The peak-to-nadir mean arterial pressure difference was also smaller, while the lowest systolic and mean arterial pressures were higher, with remimazolam. The incidence of hypotension was lower with remimazolam (40.9% vs. 87.5%, p = 0.002), with correspondingly lower requirements for ephedrine and norepinephrine. Conclusions: Remimazolam-based anesthesia was associated with a smaller peri-induction peak-to-nadir systolic blood pressure difference, a lower incidence of hypotension, and less frequent vasoactive drug use than propofol during I-gel-facilitated anesthesia for unruptured intracranial aneurysm coil embolization. These findings suggest a favorable hemodynamic profile in this setting and support further evaluation in larger trials. Full article

Background and Objectives: Gastric insufflation may occur during positive-pressure ventilation through a supraglottic airway when airway pressure exceeds the seal pressure. Because pressure-controlled ventilation (PCV) lowers peak inspiratory pressure compared with volume-controlled ventilation (VCV), it is widely assumed to reduce gastric insufflation—an assumption that remains untested in adults. We therefore compared these two ventilation modes during i-gel ventilation. Materials and Methods: In this single-centre, assessor-blinded randomised controlled trial, 68 adults undergoing elective breast surgery under general anaesthesia with an i-gel and neuromuscular blockade, without a gastric drain tube, were allocated 1:1 to PCV or VCV (tidal volume 8 mL/kg of actual body weight). The primary outcome was the postoperative gastric antral cross-sectional area measured by ultrasonography, an indirect measure of gastric gas. The pre-specified primary analysis was a Student’s t-test. Secondary outcomes included peak inspiratory pressure and oropharyngeal leak pressure; gastric insufflation, defined post hoc as a >30% increase in antral area, was assessed as an exploratory outcome. Results: All 68 participants (34 per group) were analysed. The postoperative antral cross-sectional area did not differ between groups (mean difference, PCV − VCV, −23.7 mm²; 95% CI −73.9 to 26.4; p = 0.347; p = 0.568 after adjustment for baseline); the confidence interval excluded the 100 mm² difference the trial was powered to detect. Gastric insufflation occurred in 2/34 (VCV) versus 3/34 (PCV) (p = 1.000). Peak inspiratory pressure and expiratory tidal volume were lower with PCV (all p ≤ 0.002), whereas oropharyngeal leak pressure was similar; in every patient, peak pressure remained below the leak pressure. No adverse events occurred. Conclusions: In adults ventilated through an i-gel at the low airway pressures this device produces, PCV lowered peak inspiratory pressure but did not reduce the postoperative antral cross-sectional area or the incidence of gastric insufflation compared with VCV. Because delivered tidal volume was also lower with PCV, the peak pressure difference is reported descriptively. Within this low-pressure range, and in this selected population, the ventilation mode did not detectably affect gastric insufflation; the trial does not establish equivalence between the modes or extend to higher airway pressures or obesity. Full article

Background: Airway management in patients with cervical infections remains a major challenge because progressive swelling and distortion of the upper airway may rapidly lead to life-threatening airway obstruction. Despite advances in imaging and advanced intubation techniques, the optimal management strategy remains controversial. This scoping review aimed to evaluate the current evidence on airway assessment and management of adult patients with cervical infections. Methods: A scoping review was conducted according to the PRISMA-ScR recommendations. PubMed/MEDLINE, Scopus, and Embase were systematically searched for English-language studies published between January 2006 and May 2026. Studies evaluating airway management in adult patients with deep neck infections or acute infectious epiglottitis/supraglottitis were included. Data regarding study characteristics, airway management strategies, predictors of airway intervention, and clinical outcomes were extracted and synthesized descriptively. Results: Fourteen studies involving 3297 patients met the inclusion criteria. Endotracheal intubation was the most frequently reported airway management strategy, while tracheostomy remained essential in selected patients with extensive multispace infections, descending necrotizing mediastinitis, severe airway alteration, or anticipated prolonged airway protection. Clinical signs of respiratory compromise, multispace cervical involvement, mediastinal extension, and significant supraglottic edema were the most consistently reported predictors of airway intervention. Across the included studies, airway management strategies varied considerably according to disease severity, anatomical findings, institutional protocols, and operator experience. Conclusions: Current evidence suggests an individualized, multidisciplinary approach to airway management in adults with life-threatening cervical infections. Timely airway assessment integrating clinical evaluation, flexible endoscopy, and contrast-enhanced computed tomography is essential to guide appropriate airway intervention. Full article

Background: Manual bag-valve ventilation is a fundamental intervention in prehospital and emergency care but remains highly operator-related and frequently associated with inappropriate tidal volume delivery. Excessive or insufficient ventilation may adversely affect hemodynamics and clinical outcomes. Although real-time tidal volume monitoring has the potential to improve ventilation quality, its measurement performance across different airway conditions has not been sufficiently evaluated. Methods: This simulation-based repeated-measures study evaluated the measurement agreement and reliability of a newly developed tidal volume monitoring device during manual ventilation using an adult airway management manikin. Twenty emergency medical technicians performed bag-valve ventilation across three airway scenarios: face mask ventilation, endotracheal tube (ETT) intubation, and supraglottic airway (I-gel) insertion. For each scenario, 10 repeated breaths were recorded. Tidal volumes measured by the test device were compared with simulator-derived reference values. Measurement agreement was assessed using paired t-tests, Pearson correlation coefficients, effect sizes, and Bland–Altman analysis, while measurement reliability was evaluated using intraclass correlation coefficients (ICC). Mixed repeated-measures ANOVA was performed to examine interaction effects between airway scenario and operator characteristics. Results: The test device consistently overestimated tidal volume compared with the simulator reference across all airway scenarios (p < 0.001). Correlation between measurements was weak during mask ventilation (r = 0.174) but strong during ETT (r = 0.854) and I-gel (r = 0.709) ventilation, whereas Bland–Altman analysis demonstrated wider limits of agreement in mask ventilation and narrower limits under intubated conditions. ICC analysis revealed airway-dependent reliability, with minimal agreement in normal BVM ventilation but substantially higher agreement during ET-tube and I-gel intubation. Significant effects of airway scenario and operator characteristics (gender, age group, and clinical experience level) were observed, with notable interaction effects between airway scenario and clinical experience. Conclusions: Despite systematic overestimation, the tidal volume monitoring device demonstrated consistent and repeatable performance, particularly under secured airway conditions. Its primary clinical value may lie in reducing operator-related variability and supporting safer manual ventilation through real-time feedback, rather than replacing gold-standard measurement systems. Further algorithm refinement and clinical validation are warranted. Full article

Background and Objective: Out-of-hospital cardiac arrest is associated with high mortality, with prolonged cerebral hypoxia being one of the leading causes of death. The primary objective of this study was to evaluate the probability of survival during hospitalization in OHCA patients and to compare survival outcomes based on the prehospital airway management method—specifically, endotracheal intubation versus supraglottic airway devices. Material and Methods: A retrospective analysis was conducted using medical records of patients admitted to the Emergency Department of the Voivodeship Hospital in Bielsko-Biala between 1 January 2020 and 28 February 2024. The study included 61 OHCA patients who achieved the return of spontaneous circulation and had complete documentation regarding their airway management. Early and definitive survival were evaluated using a logistic regression model (adjusted for age and sex), and survival probabilities over time were estimated using the Kaplan–Meier method. Results: The analysis revealed no statistically significant difference in early survival between patients managed with an endotracheal tube and those managed with an SGA device (RR = 0.80; p = 0.598). Similarly, no significant difference was observed for definitive survival to hospital discharge (RR = 1.13; p = 0.836). Kaplan–Meier survival curves indicated a sharp decline in overall survival probability during the initial days of hospitalization, but the log-rank test (p = 0.600) confirmed the lack of significant differences in survival trajectories between the two airway management groups. Patient age was the only statistically significant factor influencing early survival, with the probability decreasing by an average of 3% for each advancing year. Conclusions: The study did not demonstrate any superiority of the endotracheal tube over supraglottic airway devices regarding the in-hospital survival of OHCA patients. The decision regarding prehospital airway management should be individualized, taking into account the operator’s experience and the critical need to minimize interruptions in chest compressions during advanced life support. Full article

Background: Awake craniotomy is well established in adult neurosurgery for lesions near eloquent cortical areas, but its use in children remains uncommon and presents substantial anesthetic, psychological, and organizational challenges. We report the anesthesiologic management of awake craniotomy in a child with constitutional mismatch repair deficiency (CMMRD). Case Presentation: A 10-year-old boy with CMMRD underwent resection of a recurrent left frontal IDH-mutant astrocytoma, WHO grade 3, located adjacent to eloquent language cortex. Because of the high risk of postoperative language impairment, a structured multidisciplinary pathway was implemented, including neurosurgical, neuropsychological, and anesthesiologic evaluation, preoperative familiarization, and intraoperative language testing. An asleep–awake–asleep strategy was used. After induction with propofol, fentanyl, and rocuronium, the airway was secured with a supraglottic airway device (air-Q) followed by fiberoptic-guided tracheal intubation. During the awake phase, propofol was discontinued, remifentanil reduced, and low-dose dexmedetomidine introduced to preserve cooperation. The patient completed intraoperative language mapping, enabling identification of functional language boundaries and safe resection. No major intraoperative adverse events, airway complications, or seizures occurred. Postoperative pain scores remained below 4 on an age-appropriate Numeric Rating Scale, and the patient showed no new neurological deficits. At 1-month follow-up he remained symptom-free. Conclusions: This case adds to the still limited pediatric experience with awake craniotomy and suggests that, in carefully selected children managed within a structured multidisciplinary perioperative pathway and with a tailored anesthetic strategy, the procedure can be performed safely; confirmation in larger series is nonetheless required. Full article

Introduction: Lightning strikes cause a unique spectrum of cutaneous burn injuries that differ substantially from conventional thermal or high-voltage electrical burns. Despite the well-documented systemic lethality of lightning injuries, the burn-specific sequelae—including airway involvement and its contribution to ventilatory failure—remain underreported in the burn literature. Case Report: We present a 31-year-old woman who sustained multiple cutaneous burns following a lightning strike, including a circumferential necklace-pattern burn to the neck, a large midline torso burn, and burns to the right lower extremity and foot. Following resuscitation from ventricular fibrillation cardiac arrest, she required mechanical ventilation and experienced three sequential extubation failures before ultimately requiring tracheostomy. We propose that direct supraglottic and glottic injury, together with airway mucosal edema from localized thermal and electrical injury of the neck, compounded further by systemic inflammatory and infectious complications, contributed to her inability to sustain independent ventilation. Conclusions: In lightning strike victims with burns involving the neck or thorax, direct upper airway injury should be actively considered, excluded when possible, and closely monitored as a potential cause of extubation failure. A low threshold for early bronchoscopic airway assessment and conservative extubation protocols is warranted. Full article

Background/Objectives: Older adults undergoing surgery for intracranial hemorrhagic lesions after head trauma are clinically heterogeneous, and burr-hole drainage for trauma-related chronic or localized subdural hematoma differs substantially from craniotomy for acute lesions. We evaluated whether a protected-airway local/regional analgesia-dominant strategy (LA), in which airway protection was maintained but continuous maintenance-dose general anesthesia was not planned, was associated with shorter intensive care unit (ICU) stay than conventional general anesthesia (GA). Materials and Methods: In this single-center propensity score-matched retrospective cohort study, 330 patients aged ≥65 years with admission Glasgow Coma Scale (GCS) ≤ 8 who underwent surgery between 2015 and 2024 were analyzed. The LA approach was a pragmatic, jointly selected anesthesiologist–neurosurgeon strategy for carefully selected short burr-hole or localized subdural hematoma procedures; it was not an awake technique and not a protocol of leaving an intubated patient without drugs for airway-device tolerance. A protected airway could include a tracheal tube, supraglottic airway, or preexisting endotracheal tube according to clinical context, and titrated analgesic, sedative, or rescue anesthetic medications were permitted when clinically required. Propensity scores were estimated using age, sex, admission GCS, American Society of Anesthesiologists class, and Charlson Comorbidity Index; lesion category, procedure type, antithrombotic therapy, and intraoperative hypotension were examined as major sources of residual confounding. Results: After matching, the LA group had shorter ICU stay (4 [IQR 2–6] vs. 6 [4–10] days; p < 0.001). Negative binomial regression showed a 28% lower expected ICU stay with LA (incidence rate ratio 0.72, 95% CI 0.58–0.89; p = 0.003), and competing-risk analysis showed faster alive ICU discharge (subdistribution hazard ratio 1.41, 95% CI 1.08–1.84; p = 0.012). Conclusions: In this heterogeneous retrospective cohort, the LA strategy was associated with shorter ICU stay, particularly within selected burr-hole-dominant cases. These findings are hypothesis-generating and should not be interpreted as proof of superiority across acute traumatic brain injury, all lesion types, or all neurosurgical procedures. Full article

Background/Objectives: Prehospital advanced airway management significantly affects patient outcomes. The King Laryngeal Tube (King LT) has been a standard method for managing compromised airways in various emergency medical services (EMSs). However, in-depth analyses of first-attempt success and influencing factors are limited. This study explores the use of the King LT in Saudi Arabia to assess the first-attempt success rate and predictors of successful management. Methods: This retrospective cross-sectional study was conducted to analyze cases requiring the King LT in the main EMS provider in Saudi Arabia between October 2021 and September 2022. A descriptive analysis was employed for categorical data, and Chi-square test, Fisher’s exact test, and a regression analysis were applied to assess the significance of the association. Results: Of the 239 analyzed cases, adults (58.6%) and males (70.7%) were predominant. The highest proportions of cases were medical cases (36.8%) and indoor incidents (69.9%), with a significant association of indoor incidents with female and elderly patients (p = 0.001). The first-attempt success rate reached 82.4%, with significant success likelihood in afternoon incidents (adjusted odds ratio [OR] = 2.92, 95% confidence interval [CI] [0.53–3.57]; p = 0.03). Conclusions: This first nationwide study of King LT outlines advanced airway management characteristics in Saudi Arabia. The high use rates in adults, males, medical cases, and indoor incidents could suggest tailored training strategies. Noted temporal variations may provide insights for policy improvements. While first-attempt success rates are high, reflecting literature findings; performance could improve with further training. Full article

Airway management is central to the care of critically ill patients, yet it remains one of the most challenging interventions in emergency departments and intensive care units. Patients often present with severe physiological instability, limited cardiopulmonary reserve, and high acuity, while clinicians often work under constraints related to time for preparation, equipment availability, trained workforce, monitoring, and access to advanced rescue techniques. These challenges are particularly pronounced in low- and middle-income countries and other resource-limited or austere environments, where the margin for error is narrow and delays or repeated attempts in airway management may rapidly precipitate hypoxemia, hemodynamic collapse, or cardiac arrest. Although contemporary airway guidelines emphasize structured preparation and rescue pathways, many assume resources that are not consistently available in such settings. This narrative review discusses pragmatic, context-adapted strategies for airway management in constrained environments, with emphasis on physiology-first preparation, appropriate oxygenation and induction techniques, simplified rapid-sequence intubation, and the judicious use of basic airway adjuncts, supraglottic devices, and video laryngoscopy, where available. Adapted difficult airway algorithms, front-of-neck access in the absence of surgical backup, human factors, team training, and ethical considerations are also addressed. This review aims to support safer and effective airway management for critically ill patients in resource-limited emergency and intensive care settings. Full article

Over the past two decades, advanced airway management, early coronary angiography, and therapeutic hypothermia have shaped post-out-of-hospital cardiac arrest (OHCA) care. However, recent large randomized trials have challenged these strategies and created substantial uncertainty leading to relevant guideline changes. This review focuses on the trials that ultimately influenced current guideline recommendations by downgrading previous recommendations. We determine how structural limitations may have affected the validity and interpretation of their results. The review critically evaluates the methodological design and execution of those trials. Despite neutral findings from recent randomized trials, use of advanced airway management during resuscitation, coronary angiography in patients with a high likelihood of acute coronary occlusion, and therapeutic hypothermia for comatose OHCA survivors still play a relevant role in post-resuscitation management. Full article

Background: Airway management forms the most important component of pre-hospital trauma patients’ care. In such a setting, the definitive airways may be difficult to establish. This study aimed to evaluate four newer supraglottic airway devices in a simulated condition of an entrapped trauma patient with restricted access. Methods: An intubation manikin with a cervical collar on was placed on the driver’s seat of a passenger car, which was positioned on its left side. The access to the manikin was only allowed from the front. The insertion to successful ventilation (T_iv) time was recorded. First-pass success and the ease of use were also evaluated. Results: The AuraGain device required the shortest median T_iv at 7.5 s (Interquartile Range, IQR 4) vs. 9.5 s (IQR 11), p < 0.001. The AuraGain achieved the highest first-pass success—90%. The Baska mask was the most user-friendly, achieving a mean score of 8.6. Conclusions: The AuraGain outperformed other studied devices concerning the T_iv as well as the first-pass success. The Baska mask was the easiest to use. Full article

Background/Objectives: Supraglottic airway devices are commonly used airway management tools, with various second-generation laryngeal masks available for patients undergoing general anesthesia. These devices offer improved sealing, gastric suction capabilities, and the potential for tracheal intubation. This study compared the recently introduced Singularity^TM Air laryngeal mask with two well-established devices, Ambu^® AuraGain^TM and i-GEL^®, under clinical conditions. Methods: We prospectively included 98 adult patients scheduled for elective surgery requiring general anesthesia. Patients were randomized to one of three laryngeal mask groups, and data on insertion success, ventilation efficiency, and postoperative complications, such as sore throat and dysesthesia, were collected. The primary endpoint was oropharyngeal sealing pressure, with additional assessments of insertion ease and bronchoscopic glottic visibility. Results: Median initial oropharyngeal leak pressure was lowest with i-GEL^® (22 cm H₂O) as opposed to Ambu^® AuraGain^TM (25 cm H₂O) and Singularity^TM Air (25 cm H₂O) [p = 0.0138], but this difference equalized after 15–30 min. I-GEL^® showed higher insertion success (88%, p = 0.001) and shorter time-to-first ventilation (29 s, p = 0.0106). Conversely, the gastric tube insertion rate was lower (70% versus >90% in the other masks). The Ambu^® AuraGain^TM and Singularity^TM Air performed similarly for most parameters. No significant differences were observed in tracheal intubation potential or postoperative adverse events among the three groups. Conclusions: The Singularity^TM Air performed comparably to Ambu^® AuraGain^TM and i-Gel laryngeal masks in oropharyngeal sealing pressure. I-Gel^® had the highest successful insertion rate. Most of the differences detected were not statistically significant, with all three masks providing effective airway management. Full article

Endotracheal intubation in cats carries risks; supraglottic airway devices (SADs) offer a less invasive alternative. This prospective clinical study evaluated the V-gel^® advanced in cats undergoing ovariohysterectomy, with the primary aim of intra-anaesthetic gas leakage; secondary aims were ease of placement, complications, and the effect of device re-use. Spirometric inspired/expired tidal volumes were recorded under predefined ventilatory settings; leakage was calculated and analysed. Of 52 cats enrolled, 47 were analysed. Leakage occurred in 13% during spontaneous breathing and rose to 41.8% with Continuous Positive Airway Pressure (CPAP) 5 cmH₂O; by contrast, controlled mechanical ventilation showed lower leakage, with the smallest values at Peak Inspiratory Pressure (PIP) of 12 cmH₂O and 16 cmH₂O (2.1% and 6.5%, respectively). Re-used devices leaked less than new ones (p = 0.003). Placement by students was straightforward after adequate depth was achieved. Complications included mild regurgitant material in three cats and pulmonary aspiration in two (one euthanised, one discharged after supportive care). The V-gel^® advanced enabled rapid airway management with leakage influenced by ventilation mode, airway pressure, and device re-use. Findings support cautious use during spontaneous breathing or CPAP, attention to fasting and fresh-gas flows, and further controlled comparisons with prior V-gel^® models and endotracheal intubation. Full article

Over time, endoscopic retrograde cholangiopancreatography (ERCP) evolved into the preferred method for both diagnosing and treating diseases of the biliary, pancreatic, and ampullary systems. Traditionally performed under “conscious” sedation, anesthesiological management during ERCP increasingly involves the use of general anesthesia (GA) due to the complexity of procedures and patient comorbidities. This narrative review aims to underscore the current absence of definitive evidence supporting a single airway management strategy during ERCP. In each section, we examine the strengths and limitations of various airway management strategies, including spontaneous breathing, endotracheal intubation, and newer techniques such as high-flow nasal oxygen (HFNO) and supraglottic airway devices (SGAs), tailored for endoscopic procedures. We explore and discuss the multifactorial determinants that influence clinical decision-making, including patient-specific risk factors, procedural complexity, resource availability, and potential complications. Any anesthesiological choice must guarantee the immobility of the patient and the versatility of the position and must be integrated with the preferences and skills of the endoscopist, the available means in the endoscopic suite, and the internal protocols. Spontaneous breathing with sedation may be appropriate for low-risk, short-duration procedures but carries risks of hypoventilation and aspiration, while GA with a device to manage airways improves procedural conditions and perioperative risks. Still, it is resource-intensive and may delay recovery. Transitions between different strategies are inherently fluid, reflecting the need for a flexible, patient-centered approach tailored to the specific clinical context. Rigorous future research is essential to establish evidence-based guidelines that enhance both safety and efficiency of airway management in this setting. Full article