José Alfonso Sastre

Acquired haemophilia A is a severe and rare coagulation disorder caused by autoantibodies (inhibitors) against factor VIII. We present a case of acquired haemophilia A diagnosed during preoperative evaluation for lung tumour resection. Laboratory evaluation showed prolonged activated partial thromboplastin time (aPTT), reduced factor VIII activity, and detectable factor VIII inhibitors. Immunosuppressive therapy with oral prednisone led to normalisation of coagulation parameters and elimination of factor VIII inhibitors within 4 weeks. Surgical resection was performed without haemorrhagic complications. This case highlights the importance of early diagnosis and timely intervention in acquired haemophilia A to enhance clinical outcomes and mitigate the risk of haemorrhagic complications. Late identification of the disorder can have potentially catastrophic consequences in patients undergoing thoracic surgery.

Background: Epidural obstetric analgesia is the standard of care for labor pain relief; however, its impact on neonatal cerebral oximetry remains debated. Objective: We aimed to evaluate whether epidural analgesia modifies cerebral regional oxygen saturation (CrSO₂), measured by near-infrared spectroscopy (NIRS), in term neonates from low-risk deliveries. Methods: We conducted a prospective comparative observational cohort study, including 48 term newborns: 25 delivered under epidural analgesia (EA) and 23 without epidural analgesia (NE). CrSO₂ was monitored using NIRS (INVOS 5100C, Somanetics/Medtronic, Troy, MI, USA; OxyAlert NIRSensor Cerebral/Somatic Infant–Neonatal Sensor CNN/SNN) during the neonatal transition up to 15 min after birth (primary outcome), and its relationship with neonatal well-being parameters (umbilical cord pH, Apgar score, and other analytical and obstetric indicators) was explored. Results: Median CrSO₂ at 15 min was 79.52 [76.40–82.64] in the EA group and 78.65 [74.21–83.09] in the NE group. Both groups exhibited a similar temporal pattern characterized by a progressive increase, a peak at 10 min, and stabilization by 15 min. Mean (SD) CrSO₂ in EA/NE were: 2 min, 57.64 (14.8)/60.04 (14.4); 5 min, 79.56 (10.9)/79.39 (12.2); 10 min, 82.28 (8.1)/81.13 (9.7); 15 min, 79.52 (7.6)/78.65 (10.3). No significant between-group differences were detected at any time point using a linear mixed model (p-values: 2 min, 0.57; 5 min, 0.96; 10 min, 0.66; 15 min, 0.74). Conclusions: These findings indicate that epidural obstetric analgesia does not alter cerebral oximetry parameters in term neonates from low-risk deliveries during the early transitional period.

BACKGROUND: Traditionally, diabetics have been considered patients with a high risk of aspiration due to having delayed gastric emptying; However, the evidence concerning residual gastric volume (GV) in fasting diabetic patients is inconsistent. This study aimed to compare the fasting GV of diabetic patients with or without dysautonomia with control patients scheduled for elective surgery using gastric ultrasound. METHODS: This bicentric prospective single-blinded case-control study was conducted at 2 university hospitals in Spain. Patients aged over 18 years, classified as American Society of Anesthesiologists (ASA) physical statuses I to III and having similar fasting statuses, were included in the study. The primary outcome was to compare the prevalence of risk stomach using the Perlas gastric content grading scale evaluated by ultrasound in the 3 groups. Secondary outcomes included the measurement of cross-sectional area (CSA) and GV in the right lateral decubitus (RLD) position, as well as the prevalence of solid gastric residue. RESULTS: A total of 289 patients were recruited for the study, comprising 145 diabetic patients (83 of whom had dysautonomia) and 144 patients in the control group. The percentage of patients classified as Perlas grade 2 was 13.2% in the control group, 16.1% in diabetic patients without dysautonomia, and 22.9% in diabetic patients with dysautonomia (P = .31). Antral CSA was significantly higher in diabetic patients with dysautonomia (6.5 [4.8–8.4]) compared to the control group (5.4 [4.0–7.2]; P = .04). However, no significant differences were observed between groups in residual GV. Among diabetic patients with dysautonomia, 12% exhibited solid gastric residue, which was twice the percentage observed in diabetic patients without dysautonomia (4.8%) and 3 times higher than that in the control group (3.5%; P = .03). The presence of dysautonomia was associated with an increased odds ratio of solid gastric residue (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.28–8.87; P = .01) after adjusting for confounding factors. CONCLUSIONS: This study offers insights into the relationship between dysautonomia in patients with diabetes mellitus and the presence of full stomach, underscoring the significance of preoperative gastric ultrasound evaluation in managing perioperative risks in this population.

This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD -0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD -4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD -5.38 sec; p < 0.00001). Heterogeneity was high. Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. CRD42023472122.

A wide range of airway devices and techniques have been created to enhance the safety of airway management. However, airway management remains a challenge. All techniques are susceptible to failure. Therefore, it is necessary to have and know the greatest number of alternatives to treat even the most challenging airway successfully. The aim of this narrative review is to describe some new devices, such as video laryngeal masks, articulated stylets, and non-standard techniques, for laryngeal mask insertion and endotracheal intubation that are not applied in daily practice, but that could be highly effective in overcoming a difficulty related to airway management. Artificial intelligence and 3D technology for airway management are also discussed.