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(B) Chest radiograph showing displacement of the electrode, which is coiled around the device (Reel syndrome).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Navarro-Suay, E. López-Soberón, S. Álvarez-Antón, R. Puchades-Rincón de Arellano" "autores" => array:4 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Navarro-Suay" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "López-Soberón" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Álvarez-Antón" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Puchades-Rincón de Arellano" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301986" "doi" => "10.1016/j.redar.2017.07.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301986?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300131?idApp=UINPBA00004N" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300131/v3_201803240409/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Neuromuscular blockade in the management of the difficult airway" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "176" "paginaFinal" => "178" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Á. Pérez Fernández-Escandón, A.I. Fernández Díez, R. Pérez Blanco, N. Guadalupe Fernández" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Á." "apellidos" => "Pérez Fernández-Escandón" "email" => array:1 [ 0 => "alviescandon@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A.I." "apellidos" => "Fernández Díez" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Pérez Blanco" ] 3 => array:2 [ "nombre" => "N." "apellidos" => "Guadalupe Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología, Reanimación y tratamiento del dolor, Complejo Asistencial Universitario de León, León, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueantes neuromusculares en el manejo de la vía aérea difícil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1815 "Ancho" => 2346 "Tamanyo" => 172453 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study flow chart.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">GA: general anaesthesia; LA: local anaesthesia; AT: Airtraq; SAD: supraglottic airway device; FOB: fibreoptic bronchoscope; DL: direct laryngoscopy; MG: MacGrath; DA: difficult airway; VL: videolaryngoscopy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">According to the recommendations of the SEDAR expert committee, neuromuscular blocking agents (NBA) should only be used in potentially difficult intubation when the feasibility of face mask ventilation has been confirmed.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The 4th National Audit Project (NAP4), meanwhile, reminds us that when face or laryngeal mask ventilation is complicated, the early administration of other anaesthetic agents or NBAs to prevent or treat laryngospasm should be considered, and that anaesthesiologists should never permit airway obstruction and hypoxia requiring a surgical airway without first having administered an NBA.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study has been to evaluate the utility of NBAs in the management of the anticipated or unanticipated difficult airway (DA) during 2016 in a tertiary hospital.</p><p id="par0020" class="elsevierStylePara elsevierViewall">All patients receiving general anaesthesia and requiring airway manipulation during the period from January 1 to December 31, 2016 were included. Patients undergoing all type of surgeries, except thoracic surgery, were included. Of these, we selected patients diagnosed with DA. In the ASA's 2013 Airway Algorithm and the Canadian Airway Society's 2013 guidelines on Difficult Airway with Recommendations for Management, difficult airway is defined as the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> To this, the Canadians add the difficulty of performing direct or indirect laryngoscopy, or the use of supraglottic devices or surgical airway.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> In order to standardise data collection, we defined DA as patients diagnosed with Han 3-4<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> or Cormack-Lehane 2e and 3a, 3b and 4.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Difficult mask ventilation (Han 3) was defined as the inability to deliver adequate ventilation due to poor adaptation or sealing, leakage or excessive resistance.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Clinical criteria for DA, clinical signs of DA, clinical tests of difficult intubation, DA-related disease, Han scale, Cormack-Lehane classification, use of inhalation induction or NBAs were noted in a data collection sheet. Airway management was performed by trained anaesthesiologists.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We evaluated the extent to which the use of NBAs affected DA management. Whenever NBAs were used, they were administered before the use of the face mask. The NBA was chosen on the basis of the patient's clinical status and the strategy chosen by the operating room anaesthesiologist. Non-depolarizing NBAs were used, both aminosteroid and benzylisoquinoline derivatives.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 12,153 patients received general anaesthesia during the 12-month study period; of these, 110 presented DA, which gives an incidence of DA of 0.9% in our setting.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Over 30% of DAs were unanticipated (39); 71 DAs were anticipated, 23 were already known, and 48 were diagnosed by clinical tests in the preoperative workup. Another 60 patients diagnosed with DA on the basis of clinical tests were later found to have normal airways (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In total, 69% of DAs were resolved at the first attempt, 21% at the second and 9% at the third. We encountered no major complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The most widely used rescue device for both anticipated and unanticipated DA was the Airtraq video laryngoscope. There were 10 cases of intubation failure with the Airtraq, which were resolved as follows: in 4 cases using Airtraq plus frova introducer; in 5 cases using a fibrobronchoscope; and in 1 case using a supraglottic device. We performed 19 awake intubations, all using a fibreoptic bronchoscope.</p><p id="par0055" class="elsevierStylePara elsevierViewall">All patients with unanticipated DAs had received neuromuscular blockade; there was only 1 case of difficult face mask ventilation (Han 3). Two cases of Han 3 were recorded among patients with anticipated DA that had received neuromuscular blockade. The NBA was always administered without checking ventilation with a face mask. Intubation was uneventful in all patients. Only 1 patient in our series was diagnosed with Han 4. This patient did not receive neuromuscular blockade and a supraglottic device was used. This resulted in inadequate ventilation that required early termination of surgery.</p><p id="par0060" class="elsevierStylePara elsevierViewall">NBAs were used in the 60 patients diagnosed with DA using clinical tests and who later did not meet study criteria for DA. Ventilation difficulties were not encountered in any of these patients, and all were intubated with direct laryngoscopy at the first attempt.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In an editorial published in 2008, Calder<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> proposed abolishing the rule of confirming the possibility of face mask ventilation before administering NBAs. Since then, numerous articles have been published for<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> and against<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> this proposal. Ketherpal went as far as to classify anaesthesiologists into 2 groups according to their approach to these patients – checkers and non-checkers, depending on whether facial mask ventilation is confirmed before administering an NBA.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In our experience, NBAs can maintain or improve, but never worsen, ventilation. The 3 Han 3 cases were resolved uneventfully with videolaryngoscope. As far as the case of Han 4 is concerned, we believe that the patient should have received muscle relaxants, as recommended by the guidelines, particularly in view of the fact that optimal laryngeal mask ventilation was not achieved and the surgery had to be concluded early. Used discerningly, NBAs can provide more solutions than problems. This does not mean that NBAs should be used in all DAs; however, there may be a subgroup of patients with DA in which the use of NBAs can optimise airway management. Identifying this subgroup of patients in which the benefit of NBAs outweights the risks may be a promising topic for future research.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Our findings are not specific enough to enable us to recommend one particular NBA over another, as this was not the aim of our study. We set out merely to evaluate the general use of NBAs as an aid to DA management. Guidelines in the use of supraglottic airway devices include the use of NBAs to optimise the first attempt at laryngoscopy, in addition to adequate preoxygenation and patient positioning. The availability of drugs capable of rapidly reversing deep aminosteroidal blocking agents will probably result in more anaesthesiologists using steroidal non-depolarizing muscle relaxants in patients with anticipated DA.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study has shown that the approach to DA in clinical anaesthesiology is changing and calls for a review of existing protocols.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Fernández-Escandón Á, Fernández Díez AI, Pérez Blanco R, Guadalupe Fernández N. Bloqueantes neuromusculares en el manejo de la vía aérea difícil. Rev Esp Anestesiol Reanim. 2018;65:176–178.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1815 "Ancho" => 2346 "Tamanyo" => 172453 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study flow chart.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">GA: general anaesthesia; LA: local anaesthesia; AT: Airtraq; SAD: supraglottic airway device; FOB: fibreoptic bronchoscope; DL: direct laryngoscopy; MG: MacGrath; DA: difficult airway; VL: videolaryngoscopy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Empleo clínico de bloqueantes neuromusculares y su reversión. Recomendaciones del grupo de expertos de la Sociedad Española de Anestesiología, Reanimación y Tratamiento del Dolor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.A. Álvarez Gómez" 1 => "J.J. Ariño Irujo" 2 => "C.L. Errando Oyonarte" 3 => "F. Martínez Torrente" 4 => "J. Roigé i Solé" 5 => "F. Gilsanz Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2009" "volumen" => "56" "paginaInicial" => "34" "paginaFinal" => "45" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0070" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fourth National Audit Project. 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