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Tracheal intubation in patients at risk for cervical spinal cord injury: A systematic review


Cabrini, Luca; Baiardo Redaelli, Martina; Filippini, Martina; Fominskiy, Evgeny; Pasin, Laura; Pintaudi, Margherita; Plumari, Valentina P; Putzu, Alessandro; Votta, Carmine D; Pallanch, Ottavia; Ball, Lorenzo; Landoni, Giovanni; Pelosi, Paolo; Zangrillo, Alberto (2020). Tracheal intubation in patients at risk for cervical spinal cord injury: A systematic review. Acta anaesthesiologica Scandinavica, 64(4):443-454.

Abstract

BACKGROUND
Tracheal intubation in patients at risk for secondary spinal cord injury is potentially difficult and risky.
OBJECTIVES
To compare tracheal intubation techniques in adult patients at risk for secondary cervical spinal cord injury undergoing surgery. Primary outcome was first-attempt failure rate. Secondary outcomes were time to successful intubation and procedure complications.
DESIGN
Systematic review and meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis (TSA).
DATA SOURCES
Databases searched up to July 2019.
ELIGIBILITY
Randomized controlled trials comparing different intubation techniques.
RESULTS
We included 18 trials enrolling 1972 patients. Four studies used the "awake" approach, but no study compared awake versus non-awake techniques. In remaining 14 RCTs, intubation was performed under general anesthesia. First-attempt failure rate was similar when comparing direct laryngoscopy or fiberoptic bronchoscopy versus other techniques. A better first-attempt failure rate was found with videolaryngoscopy and when pooling all the fiberoptic techniques together. All these results appeared not significant at TSA, suggesting inconclusive evidence. Intubating lighted stylet allowed faster intubation. Postoperative neurological complications were 0.34% (no significant difference among techniques). No life-threatening adverse event was reported; mild local complications were common (19.5%). The certainty of evidence was low to very low mainly due to high imprecision and indirectness.
CONCLUSIONS
Videolaryngoscopy and fiberoptic-assisted techniques might be associated with higher first-attempt failure rate over controls. However, low to very low certainty of evidence does not allow firm conclusions on the best tracheal intubation in patients at risk for cervical spinal cord injury.

Abstract

BACKGROUND
Tracheal intubation in patients at risk for secondary spinal cord injury is potentially difficult and risky.
OBJECTIVES
To compare tracheal intubation techniques in adult patients at risk for secondary cervical spinal cord injury undergoing surgery. Primary outcome was first-attempt failure rate. Secondary outcomes were time to successful intubation and procedure complications.
DESIGN
Systematic review and meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis (TSA).
DATA SOURCES
Databases searched up to July 2019.
ELIGIBILITY
Randomized controlled trials comparing different intubation techniques.
RESULTS
We included 18 trials enrolling 1972 patients. Four studies used the "awake" approach, but no study compared awake versus non-awake techniques. In remaining 14 RCTs, intubation was performed under general anesthesia. First-attempt failure rate was similar when comparing direct laryngoscopy or fiberoptic bronchoscopy versus other techniques. A better first-attempt failure rate was found with videolaryngoscopy and when pooling all the fiberoptic techniques together. All these results appeared not significant at TSA, suggesting inconclusive evidence. Intubating lighted stylet allowed faster intubation. Postoperative neurological complications were 0.34% (no significant difference among techniques). No life-threatening adverse event was reported; mild local complications were common (19.5%). The certainty of evidence was low to very low mainly due to high imprecision and indirectness.
CONCLUSIONS
Videolaryngoscopy and fiberoptic-assisted techniques might be associated with higher first-attempt failure rate over controls. However, low to very low certainty of evidence does not allow firm conclusions on the best tracheal intubation in patients at risk for cervical spinal cord injury.

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Additional indexing

Item Type:Journal Article, refereed, further contribution
Communities & Collections:04 Faculty of Medicine > Cardiocentro Ticino
Dewey Decimal Classification:610 Medicine & health
Scopus Subject Areas:Health Sciences > Anesthesiology and Pain Medicine
Language:English
Date:1 April 2020
Deposited On:22 Jan 2020 13:07
Last Modified:14 Dec 2020 01:00
Publisher:Wiley-Blackwell Publishing, Inc.
ISSN:0001-5172
OA Status:Hybrid
Publisher DOI:https://doi.org/10.1111/aas.13532
PubMed ID:31837227

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