Pre-operative transnasal endoscopy as a predictor of difficult airway: A prospective cohort study BACKGROUND Consequences of failed endotracheal intubation can be catastrophic and predicting difficulty is therefore a critical issue. There is no consensus on the best way to predict difficulty. OBJECTIVE To evaluate the role of transnasal flexible endoscopic laryngoscopy (TFEL), a minimally invasive procedure, in the prediction of difficult intubation. DESIGN Prospective cohort study. SETTING San Raffaele Hospital, Milan, a tertiary university hospital. PATIENTS One hundred and sixty nine adults scheduled for elective ear, nose and throat surgery under general anaesthesia with pre-operative TFEL. INTERVENTION In addition to routine pre-operative evaluation by an anaesthesiologist, glottis exposure during TFEL was assessed with a scoring system similar to the modified Cormack–Lehane (MCL). MAIN OUTCOME MEASURES The extent to which TFEL improves the prediction of difficult direct laryngoscopy, measured with the MCL score, and of difficult intubation, measured with the intubation difficulty scale score. RESULTS When added to bedside evaluation, TFEL performed during tongue protrusion significantly (P = 0.005) improved the prediction of MCL. The area under the receiver operating characteristics curve was 0.75 [95% confidence interval (CI) 0.67 to 0.83] vs. 0.65 (95% CI 0.58 to 0.74). For the intubation difficulty scale (P = 0.049), the area under the receiver operating characteristics curve was 0.70 (95% CI 0.61 to 0.80) vs. 0.66 (95% CI 0.58 to 0.74). CONCLUSION TFEL is a useful tool in predicting difficult intubation, improving predictability of routine bedside evaluation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02671877. Correspondence to Luca Buratti, Department of Anaesthesiology, Vita-Salute University, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy Tel: +39 0226432656; e-mail: buratti.luca@hsr.it © 2019 European Society of Anaesthesiology

The effect of ropivacaine concentration on common peroneal nerve block duration using a fixed dose: A randomised, double-blind trial in healthy volunteers BACKGROUND The effect of local anaesthetic concentration on peripheral nerve block duration is unclear. Recent clinical trials found nerve blocks of equivalent duration despite changing local anaesthetic concentration but with a fixed local anaesthetic dose. A criticism of these studies is that the local anaesthetic doses used were above the proposed local anaesthetic dose-duration ceiling level, masking any potential effect of different local anaesthetic concentrations on nerve block duration. OBJECTIVE We investigated the effect of local anaesthetic concentration on nerve block duration using a fixed local anaesthetic dose below the local anaesthetic dose-duration ceiling level. We hypothesised that changing local anaesthetic concentration would affect nerve block duration. DESIGN Randomised, double-blind trial. SETTING Single-centre, academic hospital. PARTICIPANTS Healthy volunteers. INTERVENTIONS Each participant received an ultrasound-guided common peroneal nerve block with a fixed dose of 10 mg of ropivacaine dissolved in either 2.5, 5, 10, 15 or 20 ml of 0.9% saline according to group allocation, yielding local anaesthetic concentrations of 4, 2, 1, 0.67 and 0.5 mg ml−1. MAIN OUTCOME MEASURES The primary outcome was duration of sensory block defined as altered or no sensitivity to a cold stimulus. The secondary outcome was duration of motor block defined as either paresis or paralysis. Intergroup differences were tested using one-way Analysis of variance . RESULTS All participants had sensory block, and 56 out of 60 participants had motor block. From the highest to the lowest concentration groups, mean ± SD sensory block durations were 13.1 ± 2.7, 13.4 ± 3.3, 12.6 ± 3.9, 10.4 ± 2.9 and 11.0 ± 2.1 h (P = 0.073), and mean ± SD motor block durations were 8.5 ± 2.0, 7.9 ± 3.0, 6.1 ± 3.1, 5.9 ± 3.5, 4.0 1.9 h (P = 0.002). CONCLUSION In contrast to our hypothesis, we found no changes in mean sensory nerve block duration. However, local anaesthetic dilution resulted in reduced motor block duration. TRIAL REGISTRATION ClinicalTrials.gov, NCT03326609. Correspondence to Claus Behrend Christiansen, Department of Anaesthesiology, Nordsjællands Hospital, Dyrehavevej 29, Building 52B, 4th floor, DK-3400 Hillerød, Denmark Tel: +45 4829 6680; fax: +45 4829 4213; e-mail: claus.behrend.christiansen@dadlnet.dk 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). © 2019 European Society of Anaesthesiology

An ultrasound assessment of gastric emptying following tea with milk in pregnancy: A randomised controlled trial BACKGROUND Peri-operative fasting guidelines allow clear fluids including tea without milk to be consumed up to 2 h before surgery. Recent evidence has shown that a modest amount of milk consumed with clear fluids does not significantly slow gastric emptying. OBJECTIVES The aim of this study was to compare the gastric emptying of tea with milk versus water using ultrasonography in fasted pregnant patients. DESIGN A randomised controlled trial quantifying gastric emptying in two groups using ultrasonography by an operator blinded to the group allocation. SETTING Department of Anaesthesia and Peri-operative Medicine, Coombe Women and Infants University Hospital, Dublin. The study was conducted between October 2018 and June 2019. PARTICIPANTS Total 50 nonlabouring pregnant women, more than 36 weeks gestation. INTERVENTIONS After a standard overnight fast, women were randomised to either 250 ml of water or 250 ml of tea with milk. All patients underwent a gastric ultrasound assessment at regular intervals for 2 h after consumption of their drink. MAIN OUTCOME MEASURE The primary outcome was the difference in gastric antrum cross-sectional area (CSA) at 2 h. RESULTS A total of 50 women were recruited to the study. There was no significant difference in the median [IQR] gastric antrum CSA in either group at 2 h: 3.2 cm2 [2.3 to 3.7] vs. 3.1 cm2 [2.6 to 3.9]; P = 0.720. The gastric antrum CSA had returned to its baseline measurement in both groups by 90 min. CONCLUSION The change of gastric antrum CSA after 250 ml of tea with milk is similar to a corresponding volume of water in fasted pregnant patients. This study could help inform future peri-operative fasting guidelines regarding the use of a modest volume of milk with clear fluids. TRIAL REGISTRY NUMBER NCT 03694509 ClinicalTrials.gov. Correspondence to Ruairi Irwin, Department of Anaesthesia and Perioperative Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland E-mail: r.irwin1987@gmail.com © 2019 European Society of Anaesthesiology

An arrow pointing somewhere: Qualitative study of the Helsinki declaration on patient safety and its role in European anaesthesiology No abstract available

European Society of Anaesthesiology academy multimedia platform: An easy way to learn No abstract available

Spontaneous recovery of neuromuscular blockade is an independent risk factor for postoperative pulmonary complications after abdominal surgery: A secondary analysis of the individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery (iPROVE) randomised controlled trial BACKGROUND In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven. OBJECTIVE To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs). DESIGN The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data. SETTING Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016. PATIENTS Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases. INTERVENTIONS The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery. MAIN OUTCOME MEASURES The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed. RESULTS From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82). CONCLUSION Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02158923. Correspondence to Carlos L. Errando, Department of Anaesthesiology, Consorcio Hospital, General Universitario de Valencia, 2 Av. Tres Cruces, 46014 Valencia, Spain E-mail: errando013@gmail.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). © 2019 European Society of Anaesthesiology

Peri-operative serum lactate level and postoperative 90-day mortality in a surgical ICU: A retrospective association study BACKGROUND There is inadequate information on the association of pre-operative and postoperative peak level of lactate with mortality of surgical ICU patients. OBJECTIVE To investigate the association between peri-operative lactate level and 90-day mortality in patients admtted to the surgical ICU. DESIGN Retrospective cohort study. SETTING ICUs in single tertiary academic hospital. PATIENTS Adult patients postoperatively admitted to the ICU between January 2012 and December 2017. INTERVENTION None. MAIN OUTCOME MEASURES Hazard ratios of 90-day mortality according to the following serum lactate levels were assessed: pre-operative lactate level; peak lactate levels on postoperative day (POD) 0 to 3; and delta values of the lactate level on POD 0 to 3 from pre-operative lactate level. Multivariable Cox regression and receiver operating characteristic analyses were used. RESULTS Overall 9248 patients were included, among whom 2511, 8690 and 1958 had measured pre-operative lactate levels, lactate levels within POD 0 to 3, and lactate levels measured at both timepoints, respectively. When the peak lactate level on POD 0 to 3 and delta lactate level all increased by 1 mmol l−1, 90-day mortality increased by 15% [hazard ratio: 1.15; 95% confidence interval (CI) 1.11 to 1.19; P < 0.001] and 14% (hazard ratio: 1.14; 95% CI 1.11 to 1.18; P < 0.001), respectively; the pre-operative lactate level was not significantly associated with 90-day mortality (P = 0.069). The area under the curve for peak level of lactate on POD 0 to 3 (0.72, 95% CI 0.70 to 0.74) was higher than that of pre-operative lactate level (0.58, 95% CI 0.56 to 0.60) in the receiver operating characteristic analysis. CONCLUSION In patients admitted postoperatively to the ICU, higher peri-operative lactate levels were associated with increased 90-day mortality. The peak level of lactate during POD 0 to 3 showed the most significant contribution to this association. Correspondence to Young-Tae Jeon, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, South Korea Tel: +82 31 787 7499; fax: +82 31 787 4063; e-mail: ytjeon@snubh.org 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). © 2019 European Society of Anaesthesiology

Predicting postoperative complications with the respiratory exchange ratio after high-risk noncardiac surgery: A prospective cohort study BACKGROUND The respiratory exchange ratio (RER), defined as the ratio of CO2 production (VCO2) to O2 consumption (VO2), is reported to be a noninvasive marker of anaerobic metabolism. The intubated, ventilated patient's inspired and expired fractions of O2 and CO2 (FiO2, FeO2, FiCO2 and FeCO2) are monitored in the operating room and can be used to calculate RER. OBJECTIVE To investigating the ability of the RER to predict postoperative complications. DESIGN An observational, prospective study. SETTING Two French university hospitals between March 2017 and September 2018. PATIENTS A total of 110 patients undergoing noncardiac high-risk surgery. MAIN OUTCOME MEASURES The RER was calculated as (FeCO2 − FiCO2)/(FiO2 − FeO2) at five time points during the operation. The primary endpoint was at the end of the surgery. The secondary endpoints were systemic oxygenation indices (pCO2 gap, pCO2 gap/arteriovenous difference in O2 ratio, central venous oxygen saturation) and the arterial lactate level at the end of the surgery. Complications were classified according to the European Peri-operative Clinical Outcome definitions. RESULTS Postoperative complications occurred in 35 patients (34%). The median [interquartile range] RER at the end of surgery was significantly greater in the subgroup with complications, 1.06 [0.84 to 1.35] than in the subgroup without complications, 0.81 [0.75 to 0.91], and correlated significantly with the arterial lactate (r = 0.31, P < 0.001) and VO2 (r = −0.23, P = 0.001). Analysis of the area under the receiver operating characteristic curve for the predictive value of RER for postoperative complications revealed a value of 0.77 [95% confidence interval (CI) 0.69 to 0.88, P = 0.001]. The best cut-off for the RER was 0.94, with a sensitivity of 71% (95% CI 54 to 85) and a specificity of 79% (95% CI 68 to 88). CONCLUSION As a putative noninvasive marker of tissue hypoperfusion and anaerobic metabolism, the RER can be used to predict complications following high-risk surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03471962. Correspondence to Stéphane Bar, Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, F-80054 Amiens, France Tel: +33 621841562; e-mail: stephane.bar.sb@gmail.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). © 2019 European Society of Anaesthesiology

Preventive effect of dexmedetomidine on postictal delirium after electroconvulsive therapy: A randomised controlled study BACKGROUND Postictal delirium (PID) is a relatively common complication following electroconvulsive therapy (ECT). OBJECTIVE We investigated whether prophylactic dexmedetomidine administration would safely decrease the incidence of PID in psychiatric patients after ECT. DESIGN A randomised, double-blind, placebo-controlled trial. PATIENTS A total of 223 patients undergoing ECT were randomly allocated to two groups. INTERVENTIONS Patients received 0.5 μg kg−1 dexmedetomidine (Dex group, n=111) or 0.9% sodium chloride (Con group, n=112) before ECT. Propofol was used for anaesthesia and succinylcholine for muscle relaxation. The incidence of PID was measured using the Confusion Assessment Method for the Intensive Care Unit. MAIN OUTCOME MEASURES The percentage of patients who were diagnosed with PID at any ECT session during the whole treatment. RESULTS PID occurred in 76 (67.9%) of 112 patients given saline (0.9% sodium chloride), and in 49 (44.1%) of 111 patients given dexmedetomidine during the whole treatment. There was a significant difference in the incidence of PID between two groups (P < 0.001). Post hoc analyses showed that the incidence of PID was significantly lower in the Dex group than in the Con group from the first to the seventh ECT session (P < 0.005). There were no significant differences in seizure duration or recovery time between the two groups. Heart rate and mean arterial pressure in the Dex group were significantly lower than in the Con group at 0, 5 and 15 min after electrical stimulation. No patients developed bradycardia, hypotension or respiratory depression during recovery. CONCLUSION Pretreatment with dexmedetomidine leads to a significant reduction in the incidence of PID with no respiratory depressant effect. Dexmedetomidine might be considered an effective method for the prevention of PID post-ECT. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-IOR-17012306. Correspondence to Xiang Li, PhD, Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, No. 600, Tianhe Road, Tianhe Sistrict, 510630 Guangzhou, China Tel: +86 20 85253132; e-mail: lixiang27@mail.sysu.edu.cn 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). © 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