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The purpose of this study was to determine if laryngoscopy using a Miller blade with a paraglossal approach would yield an improved view of the larynx compared to that obtained with a Macintosh blade using the standard approach.One-hundred and sixty-one patients, scheduled for elective surgery requiring tracheal intubation, voluntarily participated in this study. Patients were randomly assigned to one of the two groups (Miller vs. Macintosh). A standard general anaesthetic was administered. Comparisons were made of the percentage of the vocal cords visible at laryngoscopy. The view of the airway was also graded using the Cormack and Lehane scale. Statistical analysis using Fisher's exact test was performed. A P value <0.05 was considered statistically significant. The time required to complete intubation and complications if any, were also recorded. Laryngoscopy using the Miller blade allowed 100% of the vocal cords to be viewed in 78% of cases, whereas this was achievable in only 53% with the Macintosh blade (P=0.0014). The Miller blade enabled greater than 25% of the vocal cords to be seen in 95% of the cases, whereas this was achievable in only 80% with the Macintosh laryngoscope (P=0.003). A grade 1 Cormack and Lehane view of the larynx was obtained in 96.5% of cases in the Miller group compared with 85% in the Macintosh group (P=0.02).Direct laryngoscopy using the Miller blade and paraglossal approach, afforded a much-improved view of the larynx in the majority of cases. For this reason trainees should learn laryngoscopy using both blades.

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypassassociated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial. Methods As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding. Results E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P &lt; 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained. Conclusions Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.