Indian Journal of Anaesthesia最新文献

The All India Difficult Airway Association (AIDAA) methodology document describes the guideline development process and methodology employed for the AIDAA 2025 Guidelines for the management of unanticipated difficult airway in adults, obstetrics, and paediatrics and the management of at-risk extubations. The process for constituting the Steering Committee and Guideline Subcommittees and managing conflicts is described. Patients or Population-Intervention-Comparison-Outcome (PICO) questions were formulated for the respective guidelines. A systematic literature search was performed by a librarian from January 2000 to December 2024. A PRISMA flowchart describing the search process was prepared for each research question. The evidence was summarised and recommendations categorised according to the American Heart Association (AHA) Class of Recommendations and Level of Evidence for clinical strategies, interventions, treatments, or diagnostic testing in patient care. In addition, a Delphi process was conducted by the Steering Committee and a Delphi methodologist to achieve consensus among 24 airway experts for the clinical research questions using Delphi methodology, where the evidence was either lacking or weak. The Steering Committee coordinated the iterative Delphi rounds and refrained from participating in the voting process to prevent potential bias. The Delphi survey results were reported based on the Accurate Consensus Reporting Document (ACCORD) Guidelines. Consensus was established when 75% or more of panellists selected the same option(s) in multiple-choice statements and the seven-point Likert scale statements. Expert consensus statements were drafted from the survey statements that achieved consensus. A plan for guideline dissemination, promotion, integration into clinical practice and revision has also been included.

The All India Difficult Airway Association developed clinical practice statements utilising the Delphi method among experts for specific interventions in the management of unanticipated difficult airways in adult, obstetric, and paediatric populations, as well as for the management of at-risk extubations, where existing evidence was either weak or absent. A Steering Committee consisting of nine airway experts and a Delphi methodologist convened a panel of 24 experts, from whom anonymous responses were collected via an online Delphi survey. Consensus was defined as at least 75% experts voting for a particular option in multiple-choice statements, and agreement (scores of 5-7) or disagreement (scores of 1-3) on a nominal 7-point Likert scale statement. The stability of responses between consecutive rounds was assessed using the Kruskal-Wallis test or Chi-square test, with a P value of greater than or equal to 0.05 indicating stability. Twenty-three experts completed four Delphi rounds conducted from 27 December 2024 to 25 January 2025. Of the 26 statements considered, 23 (88%) achieved both consensus and stability. Of note, the statement regarding the maximum number of attempts permitted for supraglottic airway insertion in adults to mitigate airway management-related complications did not achieve consensus among experts; however, the Steering Committee voted unanimously for a maximum of three attempts. From the 23 statements that achieved expert consensus and the statement that received the maximum vote during the adjudication process by the Steering Committee, 24 expert clinical statements were drafted. Future research is necessary to evaluate the impact of these clinical practice statements and to address the remaining uncertainties.

The paediatric airway differs from the adult airway both anatomically and physiologically. These guidelines are recommended for use in unanticipated difficult airways in children aged 1-12 years. If the initial intubation attempt fails, the anaesthesia team should "Call for help" (Code D) and prioritise providing oxygen to maintain peripheral oxygen saturation (SpO₂) above 95%. While awaiting help, the anaesthesia team may re-attempt tracheal intubation, this time by a more experienced operator, after reoptimising position and considering alternate airway devices. The anaesthesiologist may opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation throughout the period is essential. The current guidelines introduce a circular design for the algorithm, allowing device interchangeability. If satisfactory oxygenation is achieved with either a 2^nd generation SGA device or FM, the decision to continue anaesthesia or wake the child will depend on the urgency of the procedure and the comfort of the anaesthesiologist. If satisfactory ventilation cannot be maintained with a 2^nd generation SGA device or FM or following a failed tracheal intubation, declare "complete ventilation failure" and prepare for an emergency surgical airway. The options for emergency surgical airway depend on the availability of trained surgical help and the age of the child. Post-resuscitation care should address the various steps taken to return the child to normalcy and to discharge. This should include giving an "Airway Alert Card" to the parents to avoid similar life-threatening situations in future.

Background and aims: Supraglottic airway devices (SADs), such as the i-gel^®, are widely used during general anaesthesia but are susceptible to intraoperative displacement. Although clinical methods are commonly employed for confirming placement, they may be unreliable in identifying malposition. Video bronchoscopy (VB) is the gold standard for confirmation of proper SAD placement, but its use is limited by both cost and availability. Ultrasonography (US) is a non-invasive and cost-effective yet underutilised alternative. This study aimed to evaluate the efficacy of US in detecting I-gel^® placement compared with VB.

Methods: In this prospective observational study, 155 female patients undergoing general anaesthesia were assessed. Pre- and post-I-gel^® insertion glottic images were obtained using US, followed by VB to determine I-gel^® positioning. Post I-gel^® insertion US images were graded based on asymmetrical arytenoid cartilage elevation (0-3 scale) relative to the glottic midline and contralateral arytenoid. These grades were then correlated with VB-assessed I-gel^® position and rotation status.

Results: US detected arytenoid displacement in 27% of cases. VB revealed I-gel^® rotation in 63% and malposition in 21.9%. The sensitivity of US in detecting correctly positioned I-gel^® was 77.69% [95% confidence interval (CI): 69.22, 84.75], with a positive predictive value (PPV) of 83.19% (95% CI: 74.99, 89.56). For identifying non-rotated I-gel^®, US showed a sensitivity of 91.07% (95% CI: 80.38, 97.04) but a lower PPV of 45.13% (95% CI: 35.75, 54.77).

Conclusion: US is effective in detecting I-gel^® displacement, but its ability to distinguish malposition from rotation is limited. VB remains the definitive modality for confirming accurate SAD positioning.

Central neuraxial anaesthesia is the preferred approach for caesarean deliveries leading to less frequent use of general anaesthesia. The 2025 guidelines for managing general anaesthesia in obstetrics recommend rapid sequence induction and intubation for parturients requiring general anaesthesia for caesarean delivery. If the initial intubation attempt fails, the team should "Call for help for difficult airway" (Code D) and prioritise oxygenation (SpO₂ > 95%). Tracheal intubation may be attempted by a more experienced operator after re-optimising position and considering alternate airway devices. The primary anaesthesia team can opt for a 2^nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation is critical. If satisfactory oxygenation is achieved with 2^nd generation SGA or FM, the decision to continue will depend upon maternal and fetal condition. If satisfactory ventilation cannot be maintained with 2^nd generation SGA or FM following failed tracheal intubation, the team declares "complete ventilation failure" and proceeds to surgical cricothyroidotomy. Should maternal cardiac arrest occur, proceed to "resuscitative hysterotomy" to improve chances of saving mother and baby. Post-resuscitation care should continue in the ICU to return the parturient to normalcy. Parturients may have a physiologically difficult airway in addition to anatomical reasons for airway difficulty. Specific steps to deal with associated pathophysiological changes constitute an important aspect of airway management in obstetrics. If a difficult airway is encountered, an "Airway Alert Card" must be given to the parturient and her responsible relatives to avoid similar life-threatening situations in future.

The All India Difficult Airway Association (AIDAA) guidelines for 2025 regarding the extubation of "at-risk airways" following anaesthesia emphasise the importance of recognising, preparing for, and executing a planned extubation procedure for these potentially vulnerable airways. AIDAA has reviewed its previous extubation guidelines and developed a new algorithm based on the latest evidence, a Delphi survey, and expert opinions to incorporate necessary changes for patients with "at-risk airways", ultimately aiming to achieve successful extubation. This is articulated through a four-pronged strategy known as SAFE: S-Stratify Risk, A-Assemble and Anticipate, F-Facilitate Extubation, and E-Evaluate and Escalate. This stepwise approach is designed to enhance patient safety during the extubation process. The guidelines emphasise the significance of peri-extubation oxygen (PerEOx) supplementation. Furthermore, it is crucial to quantitatively assess recovery from neuromuscular blockade prior to extubation. A three-limb approach to extubation has been devised to address specific situations: Limb 1 focuses on suppressing the haemodynamic response during extubation in scenarios that require such control but do not pose a risk to the airway, Limb 2 involves a staged sequential extubation, and Limb 3 addresses the need for delayed extubation. Patients at higher risk of airway compromise, collapse, or dependence on the tube may benefit from a staged sequential extubation or delayed extubation strategy rather than a one-step extubation approach. The current guidelines also propose management plans for certain unusual situations, such as a stuck tracheal tube and unexpected extubation failure.

Background and aims: The endotracheal tube (ETT) is commonly used in mechanically ventilated patients to allow for proper ventilation and prevent aspiration of gastropharyngeal contents. Adequate sealing pressures are required to prevent aspiration while being low enough to maintain adequate perfusion of the tracheal mucosa. Multiple techniques exist for inflation of the endotracheal cuff. This study evaluated and compared four different cuff inflation techniques with the primary objective of measuring the volume of air needed to create an effective seal.

Methods: After ethical approval and trial registration, 240 patients scheduled for surgery under general endotracheal tube anaesthesia were enroled, and 228 patients were randomised into four groups (n = 57 per group). The ETT cuff was inflated with air according to the designated group. The techniques were compared for the volume of air required to achieve an adequate seal, cuff pressure post-intubation and just before extubation, cuff-related complications of sore throat, hoarseness of voice, and cough after extubation.

Results: The manual palpation technique had the highest cuff volume, 5.7 mL [interquartile range (IQR): 5.6-5.8], and cuff pressure after inflation, 29.5 (IQR: 29.1-29.9, cmH₂O), whereas the pressure-volume loop (PVL) method had the lowest values [4.3 (IQR: 4.2-4.3) mL; 23.0 (IQR 22.7-23.4) cmH₂O] (P < 0.001). Before extubation, Group 4 (manual palpation) again recorded the highest cuff pressure [31.3 (IQR: 30.9-31.8) cmH₂O] and cuff volume [6.0 (IQR: 5.9-6.1) mL], while the PVL group had the lowest values [24.9 (IQR: 24.6-25.2) cmH₂O; 4.6 (IQR: 4.6-4.7) mL] (P < 0.001).

Conclusion: Cuff inflation guided by the PVL method effectively maintained ETT cuff pressures and volumes within acceptable limits.

The All India Difficult Airway Association 2025 Adult guideline provides guidance for the management of an unanticipated difficult airway under general anaesthesia. The American Heart Association (AHA) Class of Recommendation and Level of Evidence was used. In addition, for interventions where the evidence was absent or weak, a Delphi process among airway experts was convened to generate expert consensus statements. The most significant difference from the 2016 guidelines is providing guidance for a failed supraglottic airway (SGA) insertion, tracheal intubation, face mask ventilation, or other strategies commonly used as part of the primary airway plan under general anaesthesia, not restricting to a failed intubation. Airway assessment should be routinely performed to identify an anatomical as well as the physiologically difficult airway. Peri-intubation oxygenation with pre-oxygenation and apnoeic oxygen with nasal oxygen (10-15 L/min) or high-flow nasal oxygen increases the safe apnoea time. Videolaryngoscopy and adjuncts such as stylets and bougies improve first pass intubation success. Tracheal tube position should be confirmed by waveform capnography. If the primary airway plan fails, activate 'Code D' as the hospital emergency code to call for help. Airway rescue should then be attempted with any of the three devices (tracheal tube, SGA, or face mask), and switching promptly between them as needed, with no hierarchy, until effective ventilation and adequate oxygen saturation (SpO₂) are achieved. Optimise patient position, ensure neuromuscular blockade, and consider changing the tools, technique, or operator. Allow up to three failed attempts with these devices provided the SpO₂ remains ≥95%. Complete ventilation failure (ventilation using a tracheal tube, SGA, and face mask have all failed, even if oxygenation may be maintained) is the trigger to perform an emergency cricothyroidotomy, preferably by a surgical approach. Team debriefing, team support, patient and family counselling, and documentation are paramount after encountering an unanticipated difficult airway.

The All India Difficult Airway Association (AIDAA) guidelines provide a structured framework to ensure safe and effective airway management, with a key emphasis on preparation, timely assistance, and proper documentation. To support these essential elements, AIDAA has introduced a standardised Difficult Airway Cart (DAC), the declaration of "Code D" for summoning trained help, and a dedicated Difficult Airway Alert document for difficult airway management scenarios. Recognising that airway management extends beyond operating theatres, the proposed DAC also suggests a minimal but essential "carry kit." Timely, specific, and reasoned calls for help are encouraged through "Code D" to ensure appropriate personnel respond promptly. Post-event documentation is considered essential, not only for institutional records but also for providing an alert document for future reference. AIDAA's updated recommendations integrate these elements-DAC, Code D, and structured documentation-to improve safety, preparedness, and successful airway management.