BackgroundPreviously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. MethodsNineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.ConclusionsThe clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.

BackgroundAppropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.MethodsTo review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.Principal findingsPreviously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician’s experience, must also be considered in deciding the appropriate strategy.ConclusionsWith an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

Among adults undergoing major surgery, complete handover of intraoperative anesthesia care compared with no handover was associated with a higher risk of adverse postoperative outcomes. These findings may support limiting complete anesthesia handovers.

ContextNecrotizing enterocolitis (NEC) is the most frequent gastrointestinal emergency in neonates. The microbiome of the preterm gut may regulate the integrity of the intestinal mucosa. Probiotics may positively contribute to mucosal integrity, potentially reducing the risk of NEC in neonates.ObjectiveTo perform an updated systematic review and meta-analysis on the efficacy and safety of probiotics for the prevention of NEC in premature infants.Data SourcesStructured searches were performed in: Medline, Embase, and the Cochrane Central Register of Controlled Trials (all via Ovid, from 2013 to January 2015). Clinical trial registries and electronically available conference materials were also searched. An updated search was conducted June 3, 2016.Study SelectionRandomized trials including infants less than 37 weeks gestational age or less than 2,500 g on probiotic vs. standard therapy.Data ExtractionData extraction of the newly-identified trials with a double check of the previously-identified trials was performed using a standardized data collection tool.ResultsThirteen additional trials (n = 5,033) were found. The incidence of severe NEC (RR 0.53 95% CI [0.42–0.66]) and all-cause mortality (RR 0.79 95% CI [0.68–0.93]) were reduced. No difference was shown in culture-proven sepsis RR 0.88 95% CI [0.77–1.00].LimitationsHeterogeneity of organisms and dosing regimens studied prevent a species-specific treatment recommendation from being made.ConclusionsPreterm infants benefit from probiotics to prevent severe NEC and death.

CAN J ANESTH 54: 1 www.cja-jca.org Januar y, 2007Purpose: The GlideScope® videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords is sometimes difficult. The goal of the study was to determine which of two ETT angles (60° vs 90°) and cambers (forward vs reverse) was better, as determined by time to intubation (TTI). Methods:Two hundred patients requiring orotracheal intubation for elective surgery were randomly allocated to one of four groups: A) 90° angle, forward camber; B) 90° angle, reverse camber; C) 60° angle, forward camber; D) 60° angle, reverse camber. Time to intubation was assessed by a blinded observer. Operators were blinded until the point of intubation. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were recorded. Results: The angle of the ETT had an impact on TTI but camber did not. The 90° angle demonstrated a 13% faster TTI than the 60° angle (47.1 ± 21.2 sec vs 54.4 ± 28.2 sec, P = 0.042), and it resulted in easier intubation (VAS 16.4 ± 14.2 mm vs 27.3 ± 23.5 mm, P = 0.0001). The overall incidence of a grade 1 or 2 Cormack-Lehane glottic view was 99%. Conclusions: In a heterogeneous group of operators and patients intubated with the GlideScope®, a 90° ETT angle provided the best result and should be the initial configuration. The camber of the ETT does not affect the time to intubation. 'avec une angulation de 60° (47,1 ± 21,2 sec vs 54,4 ± 28,2 sec, P = 0,042), et l' intubation était plus facile (VAS 16,4 ± 14,2 mm vs 27,3 ± 23,5 mm, P = 0,0001