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J Clin Pathol ; 56 : — A volcanic explosion of autoantibodies in systemic lupus erythematosus: a diversity of different antibodies found in SLE patients. Autoimmun Rev ; 14 : 75— Ann Rheum Dis ; 65 : — Arthritis Rheum ; 41 : — Walport MJ. Second of two parts. N Engl J Med ; : — Systemic lupus erythematosus, complement deficiency, and apoptosis. Adv Immunol ; 76 : — Links between complement abnormalities and systemic lupus erythematosus.

Rheumatology ; 39 : — Clinical presentation of human C1q deficiency: how much of a lupus? Mol Immunol ; 67 : 3— Clin Immunol ; : — Flierman R, Daha MR. Mol Immunol ; 44 : — Lupus ; 5 : — Plasma C4d as marker for lupus nephritis in systemic lupus erythematosus. Arthritis Res Ther ; 19 : Arthritis Rheum ; 31 : — Clin Immunol Immunopathol ; 61 : — Front Immunol ; 12 : Arthritis Rheum ; 64 : — IgG autoantibodies against C1q are correlated with nephritis, hypocomplementemia, and dsDNA antibodies in systemic lupus erythematosus.

J Rheumatol ; 18 : — Changes in antibodies to C1q predict renal relapses in systemic lupus erythematosus. Am J Kidney Dis ; 26 : — Predictive value of IgG autoantibodies against C1q for nephritis in systemic lupus erythematosus. Ann Rheum Dis ; 52 : — Am J Kidney Dis ; 37 : — Mannik M, Wener MH.

Arthritis Rheum ; 40 : — C1q: a fresh look upon an old molecule. Mol Immunol ; 89 : 73— J Clin Invest ; : — Clin Exp Immunol ; : 32— Emerging and novel functions of complement protein C1q.

Front Immunol ; 6 : Front Immunol ; 10 : J Immunol ; : — C1q differentially modulates phagocytosis and cytokine responses during ingestion of apoptotic cells by human monocytes, macrophages, and dendritic cells. C1q and mannose binding lectin engagement of cell surface calreticulin and CD91 initiates macropinocytosis and uptake of apoptotic cells.

J Exp Med ; : — Thanei S, Trendelenburg M. Human T cells express specific binding sites for C1q. J Leukoc Biol ; 97 : — Cell Immunol ; : 62— Clin Exp Immunol ; : 61— Science ; : — Monoclonal antibody identification of infiltrating mononuclear leukocytes in lupus nephritis. Kidney Int ; 30 : — Nephrol Dial Transpl ; 25 : — The regulatory roles of C1q. Immunobiology ; : — Toubi E, Shoenfeld Y. The role of CD40—CD interactions in autoimmunity and the benefit of disrupting this pathway.

Autoimmunity ; 37 : — Stimulation of CD40 with purified soluble gp39 induces proinflammatory responses in human monocytes.

Int Immunol ; 13 : — A PCA of transcriptome data showed overall gene expression patterns. B Factor loading for PC2 ranked genes that contributed to PC2 values positively top half; Mt1 , most significant and negatively bottom half. MT-I has been shown to be a secreted protein Supplemental Fig. Treatment of mice with MT-I markedly attenuated the inflammatory response vs.

Among the many potential regenerative medicine strategies tailored toward cerebral injury repair, SC-based therapeutics have shown the most promise. This was observed by decreased adherent leukocytes, which is consistent with the cerebral effects observed in other models [ e.

Our results are in line with experimental and clinical findings supporting the use of SCs as a therapeutic in IS. Route of administration of SCs for treatment has long been under debate. Recent studies have shown that there is little or no difference in benefit between cells administered either intravenously or intraarterially. In addition, we administered HSPCs 24 h after stroke to represent a treatment regimen that can be applied to patients i.

In this study, although HSPCs were found to be present in both the contralateral and ipsilateral infarcted hemispheres, considerably greater numbers were found in the ipsilateral hemisphere of experimental mice. Differences in the integrity and pathophysiologic status of the blood—brain barrier 2 may facilitate HSPCs into the ischemic hemisphere more selectively 38 , while some studies have shown that cells fail to localize to an infarct at all although in some cases are still protective In addition, with respect to HSPC migration, we were able to achieve efficient migration when administering cells intravenously Clinical trials have commonly opted for intraarterial administration via the common carotid artery ipsilateral to the infarct because intuitively it is the most efficient way to deliver the largest number of cells rapidly to the infarct area while avoiding the considerable invasiveness of intracerebroventricular injection.

Preclinically, recent work has shown little or no improvement when using intraarterial; and intracerebroventricular approaches compared to intravenous 40 , with cells able to migrate in significant numbers to an infarct region having been administered intravenously [although some studies describe large numbers of cells becoming lodged in the lungs 39 , 41 ].

This less invasive route is preferable in a clinical setting when dealing with patients who are both frail and immunocompromised after stroke. Moreover, intraarterial; administration may be additionally deleterious because of the potential formation of microemboli and decreased cerebral blood flow The homing and migratory ability of HSPCs in our study is perhaps unsurprising, as hematopoietic progenitors ultimately differentiate into blood cells that themselves have migratory abilities, as the machinery with which to respond to chemokine and cytokine gradients.

Interestingly, our findings demonstrated a vast improvement between HSPC- and saline-treated mice just 24 h after administration, suggesting that the protective mechanism of the cells was unlikely to involve direct replacement of infarcted brain tissue. In fact, it has yet to be observed in humans that any type of SCs applied as a therapy replace lost neuronal circuitry 47 , Despite many studies focusing on the clarification of which signaling molecules attract SCs and direct their migration to damaged areas, little is known regarding what HSPCs do in the brain after stroke.

We have demonstrated here that transcriptome in naive HSPCs vs. RNA-Seq analyses also uncovered increases in inflammation-associated transcripts and other transcripts. Because the factors released by HSPCs are broad, we have not ruled out the notion that these factors may also be changeable depending on the evolving microenvironment within the brain.

Further experiments will shed light on this. Notably, they are highly inducible, and dramatically increased transcription is observed during ischemia Various proinflammatory mediators such as IL-6 and reactive oxygen species 53 promote growth and angiogenesis, neurogenesis, and expression of antiinflammatory cytokines While few studies investigate MT activity, those that do indicate their protective effects: in one study, therapeutic effects of MT administered i.

In summary, our results demonstrate that administration of HSPCs leads to neuroprotection in stroke. It is likely that the mechanisms providing therapeutic benefit in this study are multidimensional. Furthermore, this was confirmed by the administration of MT-I, which was able to successfully protect against stroke.

Therefore, this study demonstrates that HSPCs are an attractive treatment option for patients with stroke, and we urge the establishment of further larger-scale clinical trials investigating their therapeutic potential. This article includes supplemental data. The authors thank R. Cvek Louisiana State University for her help with statistical analysis, and P. The authors declare no conflicts of interest.

Smith, S. Omura, F. Becker, E. Senchenkova, G. Kaur, I. Tsunoda, and F. Gavins designed and performed research, analyzed data, and wrote the article; S. Vital performed research and wrote the article; and S. Europe PMC requires Javascript to function effectively.

Search life-sciences literature 41,, articles, preprints and more Search Advanced search. This website requires cookies, and the limited processing of your personal data in order to function. By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Recent Activity. The snippet could not be located in the article text. This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article.

Published online Jan 8. PMID: Helen K. Peirce , and Felicity N. Shantel A. Elena Y. Shayn M. Felicity N. Author information Article notes Copyright and License information Disclaimer. Received Jul 31; Accepted Dec 4. This article has been cited by other articles in PMC. Associated Data Supplementary Materials fj. Abstract Stroke continues to be a leading cause of death and disability worldwide, yet effective treatments are lacking.

Keywords: brain, cerebrovascular disease, neuroprotectants, ischemia—reperfusion injury. Open in a separate window. Figure 1. Cerebral intravital fluorescence microscopy Intravital fluorescence microscopy IVM was performed as previously described 2. Mortality rate Mortality rate was a binary evaluation, calculated as the percentage of animals alive in each group after MCAo 24 h after treatment with either HSPCs or vehicle.

TABLE 1. Eighteen-point neurologic score 1 point where any of the following apply. Bone marrow extraction Four to 5 wk old male mice 15—17 g were humanely killed, and femurs and tibias were removed. RNA-Seq data analyses Exon read count data of 12 samples given by the company were normalized with 2 methods using R software 22 : read counts per kilobase and tag count comparison.

Volcano plot A volcano plot was drawn using OriginPro 8. Principal component analysis Principal component analysis PCA can reduce the dimensionality of a data set e. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Supplementary Material This article includes supplemental data.

Hilary P. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Canadian Journal of Anaesthesia. Can J Anaesth. Published online Jun 8. Wong , MD, 17 Philip M. Adam Law. Laura V. Orlando R. Kathryn Sparrow 16 Discipline of Anesthesia, St. Timothy P. David T. Philip M. Author information Article notes Copyright and License information Disclaimer. Adam Law, Email: ac. Corresponding author. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material.

If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Keywords: guidelines, airway management, anticipated, difficult, intubation, tracheal.

Disclaimer These recommendations seek to reflect the latest published evidence regarding airway management. Introduction Significant morbidity related to airway management continues to be reported, with the failure to plan for difficulty a recurrent theme.

Methods The methods presented here are identical to those described in the companion part 1 article 5 and are reproduced here for the benefit of the reader.

Definitions The following definitions are used throughout the manuscript. Anticipated difficult airway. Awake tracheal intubation. Awake tracheal intubation ATI refers to tracheal intubation of a patient who is sufficiently conscious to maintain a patent airway unassisted, to maintain adequate gas exchange by spontaneous ventilation, and to protect the airway against the aspiration of gastric contents or other foreign material.

Awake tracheal intubation can occur via the nasal, oral, or front of neck routes, and is facilitated by topical, regional, or local infiltrative airway anesthesia. At-risk tracheal extubation. The at-risk tracheal extubation is defined by the patient anticipated to be intolerant of tracheal extubation or who might be potentially difficult to re-intubate. Difficult re-intubation might be anticipated based on pre-existing or de novo conditions e. Prediction of difficulty with airway management Predicting difficulty underlies the planning for safe airway management.

Table 1 Published predictors of difficult tracheal intubation using direct laryngoscopy. Open in a separate window. Table 2 Published predictors of difficult tracheal intubation using video laryngoscopy.

Table 3 Published predictors of difficult tracheal intubation using other devices. Table 4 Published predictors of difficulty with face-mask ventilation and difficult face-mask ventilation combined with difficult direct laryngoscopy. Table 5 Published predictors of difficult supraglottic airway use in the adult patient. Table 6 Presumptive predictors of difficulty with front of neck airway access.

Table 7 Physiologic and contextual issues that may impact airway management. Published predictors of difficult airway management Predictors of difficult tracheal intubation by DL and VL and other devices appear in Tables 1 — 3.

The enhanced airway evaluation Patients with obstructing airway pathology may have distortions of upper or lower airway anatomy that cannot be identified by regular bedside screening tests. Decision-making when difficult tracheal intubation is predicted Few published studies or guidelines specifically address which patients with predictors of difficult tracheal intubation can safely be managed after the induction of general anesthesia. Can the patient cooperate with ATI and is there time?

Implementation of the planned strategy when difficult tracheal intubation is predicted When difficult tracheal intubation is predicted, the following principles are common to implementing the plan, whether by ATI or after induction of general anesthesia: An additional experienced airway manager should be sourced.

For more challenging situations, having this individual standing by in the room is advisable;. The airway manager should brief the assembled team on the intended strategy for securing the airway;. The briefing should include the planned response to failure of the intended technique;. An SGA must be available for use as a rescue technique in the event of failed tracheal intubation;.

During the briefing, the airway manager should include triggers for declaring failure of one technique and proceeding to the next. At this time, all members of the team should be explicitly empowered to state when they believe a trigger has occurred.

Awake tracheal intubation in the patient with anticipated difficult tracheal intubation When performed by experienced airway managers, high success and low complication rates have been reported with ATI. Adjunctive systemic medications during awake tracheal intubation Systemic medications should complement topical airway anesthesia and should not be used to compensate for its ineffective application.

Choice of device to facilitate awake tracheal intubation ATI has traditionally been accomplished using a flexible bronchoscope FB. Failed awake intubation Awake tracheal intubation may fail 59 - 61 for a number of reasons, including inadequate topical anesthesia, excess sedation, adverse anatomy, or a lack of patient cooperation. Awake tracheotomy or awake cricothyrotomy Elective FONA by tracheotomy or cricothyrotomy is a good option as a planned primary technique when great difficulty is predicted with airway management—e.

Requiring patient cooperation, local infiltrative anesthesia, and most often performed by a surgeon, this option might be chosen in the following situations, among others: For the patient presenting with advanced obstructing upper airway pathology that might cause significant technical difficulties during attempted awake oral or nasal intubation e.

When the glottic opening is very small e. When both oral and nasal routes are not available e. When a surgeon elects to do awake tracheotomy as an alternative to awake oral or nasal intubation if the airway manager is not confident that ATI is a feasible option. Management of the patient with anticipated difficult tracheal intubation after the induction of general anesthesia If difficulty with management is predicted but the airway manager has elected to proceed with tracheal intubation after the induction of general anesthesia, close attention must be paid to details of implementation.

Guiding principles are as follows: Position the patient optimally for the planned technique;. Prepare an appropriately sized second-generation SGA for rescue ventilation and oxygenation;. Brief the team on the planned progression of techniques, with objective triggers for transitioning to the next technique;. Review and communicate the exit strategy 5 to be used if tracheal intubation fails;.

Patient positioning Appropriate patient positioning can help with technical aspects of airway management and by increasing safe apnea time. Positioning for laryngoscopy and intubation. The patient positioned in the neutral position with cervical spine immobilization is sub-optimally positioned for DL and Mac-VL, so that an experienced airway manager and alternate devices such as an HA-VL should be available.

Positioning for FMV. Although the evidence is sparse, the sniffing position appears to be beneficial for improving upper airway patency and facilitating FMV. Positioning for SGA insertion. Product monographs for SGAs typically espouse a sniffing position for insertion, with head extension and lower neck flexion. Conversely, compared with the neutral position, the extended position worsened the device seal but had no effect on ventilation effectiveness or endoscopic view.

These findings suggest that after insertion, SGAs should generally be used with the head and neck in the neutral position. Positioning for eFONA. Although published evidence is lacking, full extension of the head and neck is likely the optimal position for eFONA. Pre-oxygenation The American Society of Anesthesiologists and Canadian Medical Protective Association closed claims publications revealed that many patients who sustained airway-related morbidity were healthy and presenting for elective surgery.

There is evidence that safe apnea time can be further extended with efforts to increase FRC, e. This is particularly applicable to morbidly obese patients and term parturients. Moderate to high risk of oxygen desaturation: For the patient at higher risk of oxygen desaturation with the onset of apnea, such as those with lower FRC and increased shunt fraction, the optimal pre-oxygenation strategy likely involves use of positive end-expiratory pressure or non-invasive positive pressure ventilation NIV during pre-oxygenation, - together with back up or reverse Trendelenburg positioning.

The concurrent use of standard nasal cannulae with NIV can augment pre-oxygenation and subsequently provide apneic oxygenation during laryngoscopy and intubation, although to avoid hazardous gastric insufflation, airway patency must be assured.

Use of high-flow nasal oxygenation HFNO devices running high flows under a tightly sealed mask should be avoided, e. High risk of oxygen desaturation due to refractory hypoxemia: The critically ill patient with substantial lung parenchymal disease and high shunt fraction is often refractory to pre-oxygenation and apneic oxygenation techniques, resulting in severely limited safe apnea time. The use of awake intubation and HFNO while maintaining spontaneous ventilation is one option to help address this scenario, if feasible.

Apneic oxygenation The use of apneic oxygenation can be beneficial in prolonging the safe apnea time during airway management. Maintenance or ablation of spontaneous ventilation? Assessing for FMV efficacy prior to administration of a neuromuscular blocking agent After the induction of general anesthesia, a trial of FMV prior to administering neuromuscular blocking agents NMBAs has been advocated, with a view to potentially allowing the patient to awaken if FMV is unsuccessful.

Use of short or intermediate-acting neuromuscular blockade When difficulty with tracheal intubation is anticipated, the CAFG could not find evidence of an outcome benefit to justify recommending use of succinylcholine over an intermediate-acting non-depolarizing NMBA. Considerations in choosing a NMBA include the following: Pharmacologic modelling studies have indicated that succinylcholine may not necessarily wear off in time to allow resumption of spontaneous ventilation before hypoxemia occurs in the CVCO situation.

Similarly, a proportion of patients given sugammadex for reversal of rocuronium or vecuronium would also critically desaturate during the time required to draw up and administer the drug and for it to work, particularly if apnea intolerant. Therefore, the immediate availability of sugammadex is recommended in all airway management locations.

It should be noted that sugammadex will not necessarily reverse CVCO situations related to obstructing airway pathology. In critically ill patients where airway management is being performed as part of a resuscitation, expectations of a return to effective spontaneous ventilation is unrealistic when the clinical trajectory is rapidly deteriorating. Use of succinylcholine or a plan to reverse rocuronium if difficulty occurs is not a reliable plan if it is the only difficult airway strategy being deployed.

Use of an intermediate-acting NMBA to facilitate tracheal intubation will optimize conditions for the duration of airway management should more than one attempt be required, including change of device or operator.

Choice of equipment Resources allowing, the CAFG advocates for the routine use of VL with appropriately selected blade type for tracheal intubation, with or without anticipated difficulty.

Difficulty encountered with a first attempt at tracheal intubation Difficulty with tracheal intubation after the induction of general anesthesia will inevitably occur from time to time, whether predicted or not. Difficult tracheal intubation predicted—other options When difficult tracheal intubation is predicted, most patients will be intubated either awake or after the induction of general anesthesia with additional preparation and precautions. Nevertheless, in some circumstances, the following options may be considered: Avoiding predicted difficult tracheal intubation—use of regional or local anesthesia for a surgical case When difficult tracheal intubation is predicted, some surgical cases may be amenable to regional or local anesthesia, with the following caveats: As complications from the surgical procedure itself, administered local anesthetic or sedative medications could all present the need for airway management despite the use of a regional technique, a complete airway evaluation must still occur, and a management strategy determined.

The surgical procedure must be of a predictable duration, and the block must be shown to be effective before proceeding. Deferring management of the patient with predicted difficult tracheal intubation Occasionally, it might be appropriate to defer airway management when difficult tracheal intubation is predicted. Examples of this include: Transferring an elective surgical patient to a more fully equipped hospital;. Transferring a pediatric surgical patient with known facial dysmorphism to a specialized pediatric hospital for management;.

Rescheduling a semi-urgent surgical procedure from overnight hours until daytime staff have arrived;. Deferring tracheal intubation of a critically ill patient by temporizing with the use of non-invasive ventilation or HFNO while additional expertise and equipment is sourced, or until the patient is transferred to a different location e. Use of an SGA in the patient with known or predicted difficult tracheal intubation For the patient with predictors or a history of difficult tracheal intubation, the use of an SGA requires careful consideration.

Three scenarios that might be considered include: For the case normally undertaken with tracheal intubation, electively choosing to proceed with an SGA simply to avoid a difficult tracheal intubation situation has been shown to be hazardous.

For a case where an SGA would normally be used, using an SGA in a patient with anticipated difficult tracheal intubation is often successful, although the airway manager must recognize that the fallback option of defaulting to tracheal intubation should the SGA fail may not easily succeed.

This might suggest consideration of initial tracheal intubation as the safer plan when general anesthesia is required. If using an SGA regardless, at the very least, there should be a pre-determined plan for airway management should SGA ventilation fail.

Despite the above, SGA use is often appropriately recommended as a fallback option after failed tracheal intubation in the induced patient.

In an urgent situation e. Special situations The patient with a known or suspected highly infectious respiratory pathogen Airway management guidelines for patients with known or suspected highly transmissible infections should follow core principles, with some modification.

The risk of transmission of a highly infectious pathogen such as SARS-CoV-2 to a healthcare worker in the immediate peri-intubation period depends on the pathogen and precautions taken. Whether it is an elective surgical patient who has tested positive for a highly infectious pathogen, a critically ill patient with unknown status, or a patient requiring tracheal intubation because of primary respiratory disease caused by a highly infectious pathogen, airway manager and team safety is paramount.

Hastening to manage one of these patients without considering team safety may result in healthcare worker infections. The number of people in the room should be kept to a minimum, with a pre-assigned primary airway manager, an airway assistant, and ideally a third clinical support practitioner. Personal protective equipment PPE. Airborne, contact, and droplet precaution PPE for practitioners directly performing or assisting in airway management includes an N95 respirator, eye shield, Association for the Advancement of Medical Instrumentation level 3 gown, neck cover, and gloves.

Table 10 Airway management considerations for the patient with known or suspected respiratory infectious disease spread by droplet or aerosol. The patient with obstructing airway pathology or a traumatized airway The patient with known or suspected obstructing airway pathology, or with airway trauma, requires careful and skilled evaluation and planning.

The morbidly obese patient The obese patient is at elevated risk during airway management. Canadian Airway Focus Group recommendations for airway management of the obese and morbidly obese patient are as follows: The potential for technical difficulty with both tracheal intubation and other modes of ventilation, coinciding with likely apnea intolerance, suggests that the airway manager should carefully consider whether ATI might confer a safety benefit Fig.

Apneic oxygenation is recommended during laryngoscopy and intubation of all morbidly obese patients when managed after the induction of general anesthesia. Given the anticipated short apnea time and potential for difficulty with fallback ventilation options, primary use of VL with appropriately selected blade type is recommended for tracheal intubation to help maximize first-pass success.

Careful planning and documentation should occur before embarking on airway management of the obese patient. The team should be briefed on the strategy in the event that difficulty is encountered; this should include the triggers for moving to the next step in the plan. Given the potential for rapid oxygen desaturation, the airway manager should consider having a second experienced airway manager stand by for assistance if required.

The patient with an increased risk of aspiration In the NAP4 audit, aspiration was the most common cause of airway management-related death and brain damage. Canadian Airway Focus Group recommendations for airway management of the patient with an anticipated difficult airway and an increased risk of aspiration are as follows: There may still be a role for correctly applied CP in some settings e.

Given the limited data available, the ultimate decision to use CP is at the discretion of the airway manager;. When a significantly elevated risk of aspiration coincides with an anticipated difficult airway, performing ATI with minimal sedation may confer a safety benefit;. If the airway manager decides to intubate the at-risk patient after the induction of general anesthesia, practical advice includes suctioning a nasogastric tube if already present consider inserting one if not before induction, placing the patient in the back up or reverse Trendelenburg position, and having two suction devices immediately available for oropharyngeal suctioning.

Before induction, an in situ nasogastric tube should be attached to continuous low-pressure suction to prevent intra-gastric pressure accumulation following induction ;. Use of VL allows airway team members to assess the laryngeal view, the impact of CP if used on the view of the glottis, and provides heightened situational awareness during a critical time.

Nevertheless, should massive regurgitation occur, the camera may be obscured. Thus, unless difficulty in glottic visualization is anticipated, use of Mac-VL is preferable in the patient at high risk of regurgitation, to allow direct, eye-to-glottis visualization if necessary;.

If CP is deemed to be impeding either laryngoscopy or tracheal intubation, it should be removed;. The use of FMV with low inspiratory pressure during RSI, before or between attempts at tracheal intubation, can extend safe apnea time without oxygen desaturation;. If the planned tracheal intubation attempts fail, a second-generation SGA should be inserted, and the integrated drainage port used to drain the esophagus.

The patient with a bleeding upper airway Bleeding in the upper airway and subsequent problems with airway management are important causes of airway-related morbidity and death. Tracheal extubation Published audits and closed legal claims continue to document the risks associated with tracheal extubation. The at-risk tracheal extubation The patient may be deemed at risk at the time of tracheal extubation in one or both of two ways: 1 failure to tolerate tracheal extubation, where the patient is at risk of failing to maintain gas exchange, airway patency, or airway protection after extubation; and 2 if tracheal re-intubation might be difficult, either because the patient was originally difficult to intubate, or because of an interval event Table Table 11 Potential causes of an at-risk extubation.

Table 12 Strategies to address the at-risk patient upon tracheal extubation. Supplemental oxygen delivery should occur during transportation of all recently extubated patients to high-dependency nursing units including postanesthesia care units.

Pulse oximetry monitoring should also be used. Handover should routinely detail the type and ease of airway management. Extubation over an airway exchange catheter AEC If tracheal intubation was or might now be challenging, short-term use of an AEC can be considered at extubation to assist re-intubation should it be required.

Human factors and the anticipated difficult airway The NAP4 study 1 and published closed legal claims 2 , 3 have indicated that airway management misadventure was often associated with inadequate evaluation and lack of a pre-determined airway strategy. Table 13 Potential human factor issues during patient evaluation and airway management decision-making, with suggested mitigation strategies. Maintenance of competence. Use of ATI is decreasing When difficulty is predicted, lack of recent experience, confidence, or skills in ATI might tempt the airway manager to avoid its use despite indicators of it being the safest approach.

Lack of suitable equipment might also be a factor in some cases. Summary and key recommendations Informed by publications of airway-related morbidity, 1 - 3 guidelines should not only address management techniques for the difficult airway when encountered in the unconscious patient but also emphasize the need for detailed patient evaluation, planning, and communication. Briefly summarized, our guiding principles and recommendations are as follows: Airway evaluation of the patient should always occur before embarking on airway management;.

Review of previous airway management records, databases, and imaging studies will contribute to a complete evaluation. Nasopharyngoscopy or VL under local anesthesia can add useful information about the patient with known or suspected glottic or supraglottic pathology;.

Information gleaned from the airway evaluation must be synthesized into the safest decision on how to proceed with airway management.

It is also useful if difficulty is predicted with more than one mode of airway management e. Awake tracheal intubation can proceed via oral, nasal, or front of neck routes. In some cases, oral or nasal ATI can be facilitated by a variety of devices e. A second airway manager should be sourced, the team briefed, and the required equipment brought to the room.

Attention should be paid to patient positioning, pre-oxygenation, and apneic oxygenation;. Regardless of the chosen approach when difficulty is predicted, the airway manager must clearly communicate the planned management strategy to the team, including the triggers for moving from one technique to the next;.

Extra care should be used in the planning and implementation of care for the patient with head and neck pathology, obesity, or increased aspiration risk;. Tracheal extubation of the at-risk patient must be carefully planned in terms of assessing whether the patient can tolerate extubation and whether re-intubation might be difficult;. As unanticipated difficulty with airway management can occur despite none being predicted, the airway manager must be ready with a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available and easily accessible;.

As pandemic conditions add complexity to both routine and difficult airway decision-making and management, individual and institutional preparedness should be mandated. Author contributions See Appendix. Disclosures See Appendix. Funding None. Editorial responsibility This submission was handled by Dr. Adam Law, MD Focus Group chair; data acquisition, analysis and interpretation; writing and critically revising article; final approval of version to be published.

Work supported by the Department of Anesthesia, Dalhousie University. Laura Duggan, MD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published. Editor of the journal Anaesthesia and co-creator of The Airway App Mathieu Asselin, MD Data acquisition, analysis and interpretation; writing and critically revising article; final approval of version to be published.

None Andrew Downey, MBBS Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published. None Orlando R. Hung, MD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published.

Co-authored a textbook: Management of the Difficult and Failed Airway. Jones, MD, MSc Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published. No industry conflicts to declare. None Rudiger Noppens, MD PhD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published.

Recipient of equipment for clinical trial from Karl Storz, Germany. Recipient of honoraria from Medtronic and Karl Storz for lectures at Euroanesthesia. Matteo Parotto, MD, PhD Data acquisition, analysis and interpretation; writing and critically revising article; final approval of version to be published.

None Nick Sowers, MD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published. Received one prior honorarium for attending an expert input forum from Merck Canada Inc. Turkstra, MD, MEng Data acquisition, analysis and interpretation; writing and critically revising article; final approval of version to be published. None David T. Wong, MD Data acquisition, analysis and interpretation; critically revising article; final approval of version to be published.

Board of Directors, Society for Airway Management. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Major complications of airway management in the United Kingdom.

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J Anaesthesiol Clin Pharmacol. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of , cases. Incidence and predictors of difficult nasotracheal intubation with airway scope.

Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2, Glidescope intubations, complications, and failures from two institutions. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope.

Br J Anaesth ; Predictors of difficult intubation with the Bonfils rigid fiberscope. Patient factors associated with difficult flexible bronchoscopic intubation under general anesthesia: a prospective observational study.

 

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By using our site, you agree to our collection of information through the use of cookies. To learn more, view our Privacy Policy. To browse Academia. Jan Simoni. Ulrich Goebel. Marvin Romeo Illescas Rojas. Gustavo Fabregat. Ayse Mizrak. Chin-Han LinMeei-shyuan Lee. Anesthetic techniques can login usajobs gov 443 account confirmed cases login usajobs gov account to reduction of anesthesia-controlled time to improve operating room OR efficiency.

However, little is known about the difference in anesthesia-controlled time between propofol-based total IV anesthesia TIVA and desflurane anesthesia DES techniques for ophthalmic surgery under general anesthesia. The various time intervals surgical time, incision to surgical completion and application of dressings; anesthesia time, start of anesthesia weather vancouver bc canada 75 day trendelenburg test internet extubation; extubation time, surgery complete and dressings applied to extubation; time in OR, arrival in the OR to departure from the OR; postanesthetic care unit PACU stay time, arrival in the PACU to discharge fro KehletPaul White.

Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with and we'll email you a reset link. Need an account? Click here to sign up. Download Free PDF. Related Papers. Current Opinion in Anaesthesiology The perioperative use of nitrous oxide. Ambulatory Outpatient Anesthesia.

European Journal of Anaesthesiology Role of the aquaporin channels 1 and 5 on weather vancouver bc canada 75 day trendelenburg test internet ventilator-induced lung injury.

Clinical Ophthalmology Ketamine versus propofol for strabismus surgery in children. Anesthesia and analgesia An analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in ophthalmic surgery: a retrospective study.

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