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

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 firstattempt 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.

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence

“…This was in part due to the ability to undertake this with the patient awake, thereby allowing neurological assessment after tracheal intubation and before induction of general anaesthesia. A systematic review from 2019 was unable to identify any study that had compared awake vs. non‐awake tracheal intubation [28]. A more recent randomised controlled trial compared awake tracheal intubation in patients with upper cervical spine instability using a flexible bronchoscope with the McGrath videolaryngoscope [29].…”

“…A meta‐analysis identified nine studies that reported neurological complications after tracheal intubation in patients at risk of cervical cord injury (definitions varied between different studies) [28]. Overall, there were 4/1177 (0.34%) cases of postoperative neurological deterioration: one case involved upper limb numbness which spontaneously resolved; and there were no details provided as to the nature, severity and duration of the symptoms for the other cases.…”

“…This was in part due to the ability to undertake this with the patient awake, thereby allowing neurological assessment after tracheal intubation and before induction of general anaesthesia. A systematic review from 2019 was unable to identify any study that had compared awake vs. non-awake tracheal intubation [28]. successful in all patients and subjective ease of intubation was the same in both groups.…”

Factors influencing lower respiratory tract infection in older patients after general anesthesia

“…3 Lower respiratory tract infections are usually caused by bacteria and viruses. 4,5 The wide application of antibacterial drugs has changed the types of pathogenic bacteria that can invade the lower respiratory tract; the number of drugresistant pathogen strains has gradually increased together with the level of drug resistance, and multidrug-resistant strains have appeared, bringing great challenges to clinical treatment. 6 In recent years, with accelerated growth of the global aging population, the number of older patients undergoing surgical treatment has been increasing each year.…”