Laryngoscopic techniques modulate anaesthesiologists’ perception of halitosis in patients: A randomised controlled trial BACKGROUND Perception of halitosis in patients during intubation is a common and additional stressor for anaesthesiologists and may lead to potential health risks. OBJECTIVES We hypothesised that intubation with videolaryngoscopy could help reduce the anaesthesiologists’ perception of patients’ oral malodor during intubation. DESIGN Randomised, single-blinded, prospective, controlled trial. SETTING Single centre general hospital, Guangdong Province, China. PARTICIPANTS A total of 440 patients who underwent intubation under general anaesthesia for elective surgery, aged 18 to 60 years old, American Society of Anaesthesiologists class I to III, without upper airway abnormality or airway infection were enrolled. INTERVENTION Patients were randomly assigned to receive either UE videolaryngoscopy (UE) or Macintosh's direct laryngoscopy (Macintosh) group. All intubations were performed by one of six very experienced anaesthesiologists. MAIN OUTCOME MEASURES The patient's oral odour score was measured prior to induction of anaesthesia. The anaesthesiologists’ perception of the patient's oral malodor during intubation was recorded. The shortest distance from patient's mouth to the anaesthesiologist's nose (MN distance), the exertion rating and discomfort were also measured. RESULTS The oral malodor score did not differ in the UE and Macintosh groups prior to the induction of anaesthesia. However, the incidence of the anaesthesiologists’ perception of halitosis during intubation was significantly lower in the UE group compared with the Macintosh group (P < 0.001). Similarly, the MN distance was significantly greater in the UE group compared with the Macintosh group (P < 0.001). The first-attempt success rate was higher in the UE group compared to the Macintosh group (P < 0.001). However, the exertion scores were considerably higher in the Macintosh group. After intubation, anaesthesiologists experienced more waist and shoulder discomfort with the Macintosh than the UE technique of intubation. CONCLUSION Compared with direct laryngoscopy, videolaryngoscopy might reduce the anaesthesiologists’ perception of the patients’ oral malodor, help improve first-attempt success rate, as well as alleviate the anaesthesiologists’ waist and shoulder discomfort. TRIAL REGISTRATION Clinicaltrials.gov (ChiCTR-IOR-15007038). Correspondence to Ning Shen, Department of Anaesthesiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, People's Republic of China Tel: +86 13922289000; e-mail: paulshenyh@163.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Laryngeal Mask Airway Supreme™ vs. the Spritztube® tracheal cannula in anaesthetised adult patients: A randomised controlled trial BACKGROUND The Spritztube is a new supraglottic airway device combining the ability to allow extraglottic ventilation of the lungs with the opportunity to perform fibreoptic-assisted intubation. OBJECTIVES To compare the Spritztube tracheal cannula with the Laryngeal Mask Airway Supreme (LMA-S) in anaesthetised adult patients. DESIGN A single-centre, randomised controlled study. SETTING Tertiary hospital. PATIENTS Mechanically ventilated patients undergoing elective surgery in the supine position under general anaesthesia were included. Main exclusion criteria were a history of, or predicted, difficult airway management according to SIAARTI guidelines and absence of written informed consent. INTERVENTIONS Patients received the LMA-S or Spritztube tracheal cannula to facilitate ventilation of the lungs. MAIN OUTCOME MEASURES Successful placement (primary outcome), time required for insertion, number of attempts, subjective assessment of ease of insertion, safety and incidence of complications were recorded. RESULTS One hundred and sixty seven patients were allocated to the LMA-S or Spritztube group, respectively, a total of 334 patients. In the LMA-S group, the device insertion failed in nine patients, compared with none in the Spritztube group (P = 0.002). Spritztube insertion was easy in 100% of cases compared with 94.6% of the cases in the LMA-S group (P = 0.03). The number of attempts was significantly higher with the LMA-S compared with the Spritztube (P = 0.0007), whereas the insertion times were comparable (P = 0.06). Except for the incidence of blood-staining, which was higher in the LMA-S group (P = 0.01), the number of complications was comparable in the two groups. CONCLUSION The Spritztube was as effective as the LMA-S in maintaining the airway with all patients being successfully ventilated without difficulty. The success rate of achieving a patent airway was comparable between the groups, with a similar occurrence of complications. TRIAL REGISTRATION NCT03443219. Correspondence to Massimiliano Sorbello, MD, Anaesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele, Catania, Italy Tel: +39 3496277107; e-mail: maxsorbello@gmail.com © 2019 European Society of Anaesthesiology

Hypoxia, hypercarbia, and mortality reporting in studies of anaesthesia-related neonatal neurodevelopmental delay in rodent models: A systematic review BACKGROUND The concept of anaesthesia-related neonatal neurotoxicity originated in neonatal rodent models, yet prospective clinical studies have largely not supported this concern. OBJECTIVES To determine the frequency and magnitude of hypercarbia, hypoxia and death in rodent models of neonatal anaesthetic toxicity and neurodevelopmental delay. DESIGN Systematic review of published rodent studies of neonatal anaesthesia neurotoxicity. We documented anaesthetic, route, dose, frequency and duration of exposures. We further report ventilation method, documentation of adequacy of ventilation [arterial blood gas (ABG), other], mortality and the reporting of mortality. DATA SOURCES A PubMed literature search from 2003 to 2017 was conducted to identify studies on neurotoxicity in neonatal rodent models. ELIGIBILITY Studies were included when at least one group of animals fell within the postnatal age range of 3 to 15 days. Only English language original studies published as full-length articles in peer reviewed journals were included in the final analysis. RESULTS One hundred and three manuscripts were included. Ninety-eight percent of studies were conducted using spontaneous ventilation (101/103), with ABG monitoring used in only 33% of studies and visual monitoring alone for respiratory distress or cyanosis was employed in 60%. Of the 33% who reported ABG results, there were widely divergent values, with most reporting modest-to-severe hypercarbia. Mortality (median 11%, range of 0 to 40%), which infers severe hypoxia, was documented in only 36/103 (35%) reports. CONCLUSION Hypoxia and hypercarbia have known apoptotic effects on developing brains. Hence, the inadequate control of hypercarbia and hypoxia in neonatal rodent models of anaesthetic exposure during spontaneous ventilation suggests that the evidence for developmental delay and neurotoxicity attributed to anaesthesia may not be valid in humans. Correspondence to Thomas F. Floyd, Department of Anesthesiology and Pain Management, The University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA Tel: +1 469 900 5509; e-mail: thomas.floyd@utsouthwestern.edu © 2019 European Society of Anaesthesiology

Glottic visibility for laryngeal surgery: Tritube: ®: vs. microlaryngeal tube: A randomised controlled trial BACKGROUND Good visibility is essential for successful laryngeal surgery. A Tritube® with outer diameter 4.4 mm, combined with flow-controlled ventilation (FCV), enables ventilation by active expiration with a sealed trachea and may improve laryngeal visibility. OBJECTIVES We hypothesised that a Tritube with FCV would provide better laryngeal visibility and surgical conditions for laryngeal surgery than a conventional microlaryngeal tube (MLT) with volume-controlled ventilation (VCV). DESIGN Randomised, controlled trial. SETTING University Medical Centre. PATIENTS A total of 55 consecutive patients (>18 years) undergoing elective laryngeal surgery were assessed for participation, providing 40 evaluable data sets with 20 per group. INTERVENTIONS Random allocation to intubation with Tritube and ventilation with FCV (Tritube–FCV group) or intubation with MLT 6.0 and ventilation with VCV (MLT–VCV) as control. Tidal volumes of 7 ml kg−1 predicted body weight, and positive end-expiratory pressure of 7 cmH2O were standardised between groups. MAIN OUTCOME MEASURES Primary endpoint was the tube-related concealment of laryngeal structures, measured on videolaryngoscopic photographs by appropriate software. Secondary endpoints were surgical conditions (categorical four-point rating scale), respiratory variables and change of end-expiratory lung volume from atmospheric airway pressure to ventilation with positive end-expiratory pressure. Data are presented as median [IQR]. RESULTS There was less concealment of laryngeal structures with the Tritube than with the MLT; 7 [6 to 9] vs. 22 [18 to 27] %, (P < 0.001). Surgical conditions were rated comparably (P = 0.06). A subgroup of residents in training perceived surgical conditions to be better with the Tritube compared with the MLT (P = 0.006). Respiratory system compliance with the Tritube was higher at 61 [52 to 71] vs. 46 [41 to 51] ml cmH2O−1 (P < 0.001), plateau pressure was lower at 14 [13 to 15] vs. 17 [16 to 18] cmH2O (P < 0.001), and change of end-expiratory lung volume was higher at 681 [463 to 849] vs. 414 [194 to 604] ml, (P = 0.023) for Tritube–FCV compared with MLT–VCV. CONCLUSION During laryngeal surgery a Tritube improves visibility of the surgical site but not surgical conditions when compared with a MLT 6.0. FCV improves lung aeration and respiratory system compliance compared with VCV. TRIAL REGISTRY NUMBER DRKS00013097. Correspondence to Dr Johannes Schmidt, Department of Anaesthesiology and Critical Care, Medical Centre – University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany Tel: +49 761 270 26390; e-mail: johannes.schmidt@uniklinik-freiburg.de This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2019 European Society of Anaesthesiology

Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial BACKGROUND Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE. OBJECTIVE To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation. DESIGN Randomised controlled trial. SETTING Single-centre study based at a tertiary care centre in Shanghai, China. PATIENTS A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation. INTERVENTIONS Children were randomised to receive either intranasal DEX 1.5 μg kg−1 (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction. MAIN OUTCOME MEASURES The incidence of PRAE. RESULTS Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left–right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted. CONCLUSION Administration of intranasal DEX 1.5 μg kg−1 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation. TRIAL REGISTRATION chictr.org.cn identifier: ChiCTR-RRC-17012519. Correspondence to Jijian Zheng, MD, PhD, Department of Anaesthesiology, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Tel: +86 18964853803; fax: +86 021 38626161; e-mail: zhengjijian626@sina.com © 2019 European Society of Anaesthesiology

Anaesthesiology: a problem-based learning approach No abstract available

The role of goal-directed therapy in the prevention of acute kidney injury after major gastrointestinal surgery: Substudy of the OPTIMISE trial BACKGROUND Acute kidney injury (AKI) is an important adverse outcome after major surgery. Peri-operative goal-directed haemodynamic therapy (GDT) may improve outcomes by reducing complications such as AKI. OBJECTIVE To determine if GDT was associated with a reduced incidence of postoperative AKI according to specific renal biomarkers. DESIGN Prospective substudy of the OPTIMISE trial, a multicentre randomised controlled trial comparing peri-operative GDT to usual patient care. SETTING Four UK National Health Service hospitals. PATIENTS A total of 287 high-risk patients aged at least 50 years undergoing major gastrointestinal surgery. OUTCOME MEASURES The primary outcome measure was AKI defined as urinary neutrophil gelatinase-associated lipase (NGAL) at least 150 ng ml−1 24 and 72 h after surgery. Secondary outcomes were between-group differences in NGAL measurements and NGAL : creatinine ratios 24 and 72 h after surgery and AKI stage 2 or greater according to Kidney Disease Improving Global Outcomes (KDIGO) criteria within 30 days of surgery. RESULTS In total, 20 of 287 patients (7%) experienced postoperative AKI of KDIGO grade 2 or 3 within 30 days. The proportion of patients with urinary NGAL at least 150 ng ml−1 24 or 72 h after surgery was similar in the two groups [GDT 31/144 (21.5%) patients vs. usual patient care 28/143 (19.6%) patients; P = 0.88]. Absolute values of urinary NGAL were also similar at 24 h (GDT 53.5 vs. usual patient care 44.1 ng ml−1; P = 0.38) and 72 h (GDT 45.1 vs. usual patient care 41.1 ng ml−1; P = 0.50) as were urinary NGAL : creatinine ratios at 24 h (GDT 45 vs. usual patient care 43 ng mg−1; P = 0.63) and 72 h (GDT 66 vs. usual patient care 63 ng mg−1; P = 0.62). The incidence of KDIGO-defined AKI was also similar between the groups [GDT 9/144 (6%) patients vs. usual patient care 11/143 (8%) patients; P = 0.80]. CONCLUSION In this trial, GDT did not reduce the incidence of AKI amongst high-risk patients undergoing major gastrointestinal surgery. This may reflect improving standards in usual patient care. TRIAL REGISTRATION OPTIMISE Trial Registration ISRCTN04386758 Correspondence to Neil MacDonald, Department of Peri-operative Medicine and Pain, Royal London Hospital, London E1 1BB, UK Tel: +44 20 3594 0346; e-mail: n.macdonald2@nhs.net © 2019 European Society of Anaesthesiology

A comparison between the flexor hallucis brevis and adductor pollicis muscles in atracurium-induced neuromuscular blockade using acceleromyography: A prospective observational study BACKGROUND Neuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative. OBJECTIVE The aim of our study was to compare NMB onset and recovery at both sites. DESIGN Prospective observational study. SETTING Operating rooms at the University Hospital of Poitiers, France. PATIENTS Sixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia. INTERVENTION After atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously. MAIN OUTCOME MEASURES The time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF = 4, T4/T1 ratio = 0.75 and T4/T1 ratio more than 0.90. RESULTS NMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4 ± 1.5 versus 3.7 ± 1.2 min at adductor pollicis (P = 0.0001). Recovery to TOF = 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF = 4. The full recovery of NMB (T4/T1 > 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ± 9.9 versus 64.5 ± 10.7 min at adductor pollicis (P < 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0 ± 12.2 min at flexor hallucis brevis versus 54.0 ± 12.4 min at adductor pollicis (P = 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients. CONCLUSION Flexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis. TRIAL REGISTRATION ClinicalTrials.gov (NCT02825121). Correspondence to Matthieu Boisson, Service d’anesthésie-réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86021 Poitiers Cedex, France E-mail: matthieu.boisson@chu-poitiers.fr © 2019 European Society of Anaesthesiology

Thermochromic nail polish as a novel indicator to predict infraclavicular brachial plexus block success: A prospective cohort study BACKGROUND Skin temperature measurements after peripheral nerve block can be used as an easy and objective method to help predict block success. Thermochromic nail polishes are popular cosmetic products especially among young women. The colour change of nail polish is based on a thermochromic reaction as the temperature changes. OBJECTIVE The aim of this study was to test the hypothesis that the success of infraclavicular brachial plexus blocks (IBPBs) can be predicted by the colour change in thermochromic nail polish, which depends on skin temperature changes. DESIGN A prospective cohort study. SETTING Training and research hospital from December 2018 to March 2019. PATIENTS A total of 50 patients who received IBPB for forearm, wrist or hand surgery were included. MAIN OUTCOME MEASURES Thermochromic nail polish was applied to the nails of both hands of all patients before the block. Reaction of the nail polish in both hands was photographed immediately after application of nail polish and at 30 min after performing the block. The digital photographs of each patient were evaluated by observers. To evaluate the validity of the colour change in nail polish in predicting a successful IBPB, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios were estimated. RESULTS The positive predictive value for colour change in thermochromic nail polish predicting a successful IBPB was 96% [95% confidence interval (CI) 90 to 98] and sensitivity was 94% (95% CI 87 to 97). Fleiss kappa value showed substantial agreement (0.76; 95% CI 0.59 to 0.93) in the assessment of interobserver agreement. CONCLUSION The current study demonstrates that the colour change in thermochromic nail polish is a valid and reliable indicator for the prediction of block success. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03767868. Correspondence to Ali S. Kavakli, MD, Department of Anaesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, Antalya Egitim ve Arastirma Hst, Varlik Mh. Kazim Karabekir Cd., 07100 Antalya, Turkey Tel: +90 505 6775121; fax: +90 242 2494462; e-mail: alisaitkavakli@hotmail.com © 2019 European Society of Anaesthesiology

Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: A retrospective analysis BACKGROUND Viscoelastic techniques have made it possible to describe specific fibrinolytic phenotypes (physiological, hyperfibrinolysis and shutdown) and to establish a relationship of these phenotypes with outcome. However, there remains a debate as to whether shutdown is a state of hypercoagulability or rather a coagulopathy with moderate fibrinolysis and fibrinogen consumption. OBJECTIVES Our objectives were to describe the relationship between fibrinolytic phenotypes and outcomes, and to report the effects of tranexamic acid (TXA) administration. DESIGN This was a retrospective analysis of prospectively acquired data from a trauma registry. SETTING An academic level 1 trauma centre in the Lyon Region, from March 2011 to December 2016. PATIENTS We included all injured patients who had a rotational thromboelastometry analysis at admission. Fibrinolytic phenotypes were determined according to the maximum lysis: shutdown less than 3%, physiological 3 to 15%, hyperfibrinolysis more than 15%. MAIN OUTCOME MEASURE Mortality at 24 h and at hospital discharge. RESULTS During the study period, 473 patients were included with the following phenotypes: physiological (344 patients, 73%), shutdown (107 patients, 23%) and hyperfibrinolysis (22 patients, 5%). There was an increase in injury severity, prothrombin time ratio, fibrin degradation products and transfusion requirements from the physiological to the shutdown and hyperfibrinolysis phenotypes. Prehospital TXA administration increased the rate of shutdown and decreased the maximum lysis value at admission. After adjustment, multivariate analysis showed that fibrinolytic phenotypes, but not TXA, were independently associated with an increased risk of early death and death before hospital discharge: shutdown [odds ratio (95% confidence interval)] 2.4 (1.2 to 4.8) and hyperfibrinolysis 67.9 (7.4 to 624.2). CONCLUSION The results of the current study suggest that shutdown, which is associated with injury severity and mortality, probably reflects a moderate form of coagulopathy and fibrinolysis rather than a hypercoagulopathy. Therefore, the observation of shutdown fibrinolysis on thromboelastography/rotational thromboelastometry should not lead to withholding but rather to the administration of TXA. Correspondence to Jean-Stephane David, Département d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, F-69495 Lyon, France E-mail: js-david@univ-lyon1.fr © 2019 European Society of Anaesthesiology