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Respiration and the Airway British Journal of Anaesthesia 103 (2): 283–90 (2009) doi:10.1093/bja/aep124 Advance Access publication May 20, 2009 RESPIRATION AND THE AIRWAY Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103 812 consecutive adult patients recorded in the Danish Anaesthesia Database L. H. Lundstrøm12*, A. M. Møller1, C. Rosenstock3, G. Astrup4,M.R.Ga¨tke1 and J. Wetterslev2 and the Danish Anaesthesia Database 1Department of Anaesthesia and Intensive Care, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark. 2Copenhagen Trial Unit, Copenhagen Centre of Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. 3Department of Anaesthesia, Hillerød Hospital, Hillerød, Denmark. 4Department of Anaesthesia A˚ rhus Sygehus, A˚ rhus University Hospital, A˚ rhus, Denmark *Corresponding author. E-mail: [email protected] Background. Previous studies indicate that avoiding neuromuscular blocking agents (NMBAs) may be a risk factor for difficult tracheal intubation (DTI). We investigated whether avoiding NMBA was associated with DTI. Methods. A cohort of 103 812 consecutive patients planned for tracheal intubation by direct laryngoscopy was retrieved from the Danish Anaesthesia Database. We used an intubation score based upon the number of attempts, change from direct laryngoscopy to a more advanced technique, or intubation by a different operator. We retrieved data on age, sex, ASA physical status classification, priority of surgery, time of surgery, previous DTI, modified Mallampati score, BMI, and the use of NMBA. Using logistic regression, we assessed whether avoiding NMBA was associated with DTI. Results. The frequency of DTI was 5.1 [95% confidence interval (CI): 5.0–5.3]%. In a univari- ate analysis, avoiding NMBA was associated with DTI, odds ratio (OR) 1.52 (95% CI: 1.43– 1.61)%, P,0.0001. Using multivariate analysis, avoiding NMBA was associated with DTI, OR 1.48 (95% CI: 1.39–1.58), P,0.0001. Among patients intubated using NMBA, a multivariate analysis identified patients anaesthetized with only non-depolarizing NMBA to be more at risk for DTI than those anaesthetized with depolarizing NMBA alone. Conclusions. Avoiding NMBA may increase the risk of DTI. However, confounding by indi- cation may be a problem in this observational study and systematic reviews with meta-analysis or more randomized clinical trials are needed. Br J Anaesth 2009; 103: 283–90 Keywords: anaesthetic techniques, laryngoscopy; complications, intubation tracheal; neuromuscular block Accepted for publication: March 5, 2009 Difficult airway management including difficult tracheal risk of difficult intubation.67In addition to patient factors, intubation (DTI) may be a major cause of severe successful airway management is determined by the anaes- perioperative morbidity and mortality related to anaesthe- thetist’s technical skills, non-technical skills, the facilities sia.1–4 Predicting DTI enables the anaesthesiologist to take available, and the local environment.89The results of pre- precautions to reduce the risks associated with tracheal vious randomized trials, although small and with surrogate intubation.5 Several studies have focused on one or more outcome measures, indicate that avoiding neuromuscular factors related to the patient which may identify those at blocking agents (NMBAs) may be associated with # The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected] Lundstrøm et al. increased risk of difficult intubation and more post- 374 308 operative discomfort to the patients.10 – 18 records An evaluation of the use of neuromuscular blocking 55 270 records of regional anaesthesia alone were excluded drugs during anaesthesia of patients recorded in the 319 038 Danish Anaesthesia Database from January 2005 to records December 2007 demonstrated a decrease in the use of 12 261 records of sedation alone patients were excluded these drugs for general anaesthesia including intubation. In 306 777 light of this change of practice, the aim of this study was records to evaluate whether avoiding the use of neuromuscular 158 231 records of patients undergoing general or combined anaesthesia without any attempts of tracheal blocking drugs for general anaesthesia including intubation intubation were excluded 148 546 by direct laryngoscopy is a risk factor for difficult intuba- records tion and failed tracheal intubation (FTI). Also, the use of 441 records of duplicates excluded non-depolarizing drugs was compared with depolarizing 148 105 drugs as a risk factor for difficult intubation. records 4097 records of intubations of patients already intubated when arriving in the operating theatre excluded 144 008 Methods records 14 267 records of children aged <15 yr excluded Fourteen Danish anaesthesia departments in 2005 and 25 129 741 in 2006–7 prospectively and consecutively reported data records on patients undergoing anaesthesia and surgery to the 3308 records of intubations in patients undergoing Danish Anaesthesia Database version 2. The Danish rigid or flexible fibreoptic intubation excluded Anaesthesia Database contains specific quantitative anaes- 126 433 records thetic and surgical indicators describing the perioperative 22 621 records of intubation other than the last for each period. This information is recorded immediately after patient excluded each operation by the anaesthesiologist. The departments 15 512 (Appendix I) are connected online, via the Internet, to a 103 812 records of a penultimate records of the last intubation in central server. intubation of patients intubated each patient from the study more than once in the study cohort The Danish National Board of Health and The Danish cohort used to generate data on Data Protection Agency approved the registration in the previous difficult intubation Danish Anaesthesia Database of all patients undergoing Fig 1 Selection of the study cohort. About 374 308 records of patients anaesthesia. The steering committee of the Danish undergoing anaesthesia were identified in the Danish Anaesthesia Anaesthesia Database approved this study and provided Database. Excluding records of anaesthesia other than patients access to the data. undergoing general or combined anaesthesia who were primarily We retrieved 148 546 records of patients undergoing undergoing tracheal intubation, the cohort included 148 546 records. general or combined anaesthesia with tracheal intubation Recorded intubations were excluded as explained in the figure. The subgroup of 15 512 records representing the penultimate intubations of from January 1, 2005, to December 31, 2007 (Fig. 1). patients intubated more than once was merged to the corresponding last We excluded patients aged ,15 yr, those already intu- intubation for the specific patient, and thereby information for the bated, and those primarily undergoing rigid and flexible covariate PDI was created. Thus, 88 265 patients were only tracheal fibreoptic intubation. We included 103 812 patients, who intubated once, 15 512 patients were intubated two or more times, while were intubated 126 433 times in this study. About 15 512 information was missing for 35. patients were anaesthetized and undergoing intubation by direct laryngoscopy on more than one occasion, for these departments may differ in their recommendations for patients only the last record was included. Thus, the final airway management. cohort includes 103 812 patients each represented by only one session of attempted tracheal intubation by direct laryngoscopy. Of these patients, 84 had missing records of an intubation score (Table 1). About 12 850 Intubation score and covariates recorded in the patients had missing records for one or more covariates, Danish Anaesthesia Database whereas 90 962 patients had complete records without International consensus defining a DTI does not exist. any missing data. All types of surgery are represented in Often, difficult laryngoscopy is used as a surrogate for the Danish Anaesthesia Database except for cardiothor- difficult intubation,19 whereas others suggest a specific defi- acic surgery. nition of DTI.520We devised an intubation score based on There is no national recommendation for the evaluation fields in the Danish Anaesthesia Database (DTI score, and handling of the airway in patients undergoing tracheal Table 1) and recorded this score for all patients in whom intubation in Denmark. Therefore, participating anaesthetic tracheal intubation by direct laryngoscopy was attempted 284 Neuromuscular block hampers tracheal intubation Table 1 The Danish Anaesthesia Database tracheal intubation score. DTI was defined as an intubation score .1. Consequently, the definition of DTI includes FTI All patients in whom the primary airway management plan was tracheal intubation by direct laryngoscopy were scored as follows Score¼1 Intubated by direct laryngoscopy by the first anaesthetist and in two attempts maximally Score¼2 Intubated by direct laryngoscopy by the first anaesthetist but with more than two attempts or intubated by a supervising anaesthetist after one or more failed attempts at intubation Score¼3 Intubated by a method other than direct laryngoscopy Score¼4 Intubation failed after multiple attempts, no tracheal tube was inserted and was the primary strategy planned for airway NMBA’ and ‘avoidance of NMBA’. For our assessments, management.
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