The unanticipated difficult airway with recommendations for managementPurpose: To review the current literature and generate recommendations on the role of newer technology in the management of the unanticipated difficult airway. Methods: A literature search using key words and filters of English language and English abstracted publications from contained in the Medline, Current Contents and Biological Abstracts databases was carried out. The literature was reviewed and condensed and a series of evidence-based recommendations were evolved. Conclusions: The unanticipated difficult airway occurs with a low but consistent incidence in anaesthesia practice. Difficult direct laryngoscopy occurs in 1,5 -8.5% of general anaesthetics and difficult intubation occurs with a similar incidence. Failed inubation occurs in 0.13-0.3% general anaesthetics. Current techniques for predicting difficulty with laryngoscopy and intubation are sensitive, non-specific and have a low positive predictive value. Assessment techniques which utilize multiple characteristics to derive a risk factor tend to be more accurate predictors. Devices such as the laryngeal mask, lighted styler and rigid fibreoptic laryngoscopes, in the setting of unanticipated difficult airway, are effective in establishing a patent airway, may reduce morbidity and are occasionally lifesaving. Evidence supports their use in this setting as either alternatives to facemask and bag ventilation, when it is inadequate to support oxygenation, or to the direct laryngoscope, when tracheal intubation has failed, Specifically, the laryngeal mask and Combitube TM have proved to be effective in establishing and maintaining a patent airway in "cannot ventilate" situations. The lighted stylet and Bullard (rigid) fibreoptic scope are effective in many instances where the direct laryngoscope has failed to facilitate tracheal intubation. The data also support integration of these devices into strategies to manage difficult airway as the new standard of care. Training programmes should ensure graduate physicians are trained in the use of these alternatives. Continuing medical education courses should allow physicians in practice the opportunity to train with these alternative devices.Objectif : Passer en revue la documentation courante et fournir des recommandations sur le r61e de la nou velle technologie dans la conduite ~ tenir Iors d'une intubation difficile. M~thodes : On a procEdE ~ une recherche documentaire selon des mots-clEs et des filtres de langue anglaise et des publications de rEsumEs anglais de 1990 ~ 1996, contenus dans les bases de donnEes de Medline, Current Contents et Biolo~colAbstracts.La littErature a ErE revue et r&umEe et une sErie de recommandations basEes sur les fairs ont ErE ElaborEes. Conclusion : Les dit~cultEs d'intubation non prEvues surviennent selon une incidence faible, mais constante, clans la pratique de I'anesthEsie, Des probl~mes de laryngoscopie directe et des difficult& d'intubation ont lieu dans 1,5 -8,5 % des anesth&ies gEnErales. E&hec de I'...

P Pu ur rp po os se e: : During liver transplantation, excessive blood losses are correlated with increased morbidity and mortality. Blood losses are particularly high in the case of urgent liver transplantation for fulminant hepatic failure (FHF). Recombinant activated factor VII (rFVIIa) has shown promise in treating the coagulopathy of liver disease. We review our experience with the use of rFVIIa in treating the coagulopathy of FHF during urgent liver transplantation.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : We report four patients with FHF who met King's College criteria for liver transplantation and in whom rFVIIa was used after conventional means for treating the associated coagulopathy had failed. In all patients, the coagulation defect was corrected by rFVIIa. However, thrombotic complications occurred in two patients (myocardial ischemia and portal vein thrombosis) and the implication of rFVIIa cannot be excluded.

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