BJA
Correspondence
Declaration of interest None declared. H.-T. Hsu C.-H. Lin K.-Y. Tseng Y.-C. Shen C.-H. Chen W.-M. Chuang K.-I. Cheng* Kaohsiung, Taiwan *E-mail: [email protected]
1 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105– 11 2 Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the
complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290– 7 3 Hirabayashi Y. GlideScope videolaryngoscope facilitates nasotracheal intubation. Can J Anaesth 2006; 53: 1163–4 4 Jones PM, Armstrong KP, Armstrong PM, et al. A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg 2008; 107: 144– 8
doi:10.1093/bja/aeu334
b-Blockers and cardiac protection Editor—We were interested to read the editorial by Pierre Foex and John Sear on the cardioprotective effect of b-blockers in the perioperative period.1 While citing their original work and the seminal study of Mangano and colleagues,2 they fail to highlight the unsound nature of that publication. As we have pointed out, several major flaws exist in this study, which led Devereaux and colleagues to exclude the results from their meta-analysis justifying the POISE study.3 – 6 First, patients in the Mangano study were randomized to receive either atenolol or placebo irrespective of existing treatment with b-blockers, thus exposing the placebo group to a higher baseline risk of perioperative major adverse cardiac events (MACE) as a result of sudden cessation of b-blocker therapy.7 Secondly, the results were not analysed on an ‘intention to treat’ basis with the 2 yr Kaplan–Meier survival curve restricted to an analysis of post-discharge mortality when the number of patients in the atenolol treated group who had died in hospital was higher than the placebo group.3 – 5 Furthermore, Foex and Sear continue to cite the Decrease II and Decrease IV studies, which have been found to be ‘negligent’ and ‘scientifically incorrect’ by the Erasmus University committee that was asked to investigate Professor Polderman’s scientific integrity.8 In support of the use of b-blockers to prevent MACE in the perioperative period, Foex and Sear continue to refer to the Guidelines of the European Society of Cardiologists (ESC) without referring to the fact that the ESC Guideline Writing Committee was chaired by none other than Professor Polderman, who had considerable influence in the content of those guidelines.5 Similarly, the American College of Cardiologists/ American Heart Association Guidelines, which are endorsed by the ASA, have also been questioned.9 With respect to the choice of dose and formulation of b-blocker used in the POISE study, it is important to bear in mind that failure to reduce heart rate or arterial pressure enough may explain the negative effect of b-block in those studies that did not identify a beneficial perioperative effect of b-blockers.10 – 14 Given the mounting evidence of lasting harm to patients that could accrue from injudicious use of perioperative b-blockade and the high likelihood of ineffective treatment, we would reiterate our advice that ‘patients already receiving beta-blockers or statins before surgery should continue with treatment. Only patients who need heart rate or blood pressure control, or both, in the perioperative period should start treatment with beta-blockers’.5 15 16
721
Downloaded from http://bja.oxfordjournals.org/ at Seton Hall on September 26, 2014
Epistaxis was assessed anteriorly by nostril bleeding and posteriorly by grading of blood in the oropharynx (0, none; 1, minimal; 2, slight; 3, moderate; 4, severe). MNIDS scored intubation conditions were assessed as follows: N1, additional intubation attempts; N2, number of supplementary operators, directly but not assisted; N3, alternative intubation techniques such as change of head position, cuff inflation, or Magill forceps intervention; N4, glottic exposure grading as Cormack–Lehane1 minus 1; N5, lifting force; N6, glottic exposure with BURP manoeuvre; N7, vocal cords position. The MNIDS scores were categorized as easy (0), minor difficulty (0,scores≤5), major difficulty (5,scores), and impossible intubation or failed intubation (scores¼1).2 There were no statistical differences between the groups on patient characteristic data, haemodynamic responses to intubation, and side-effects. One patient unexpectedly failed intubation and one tube advancement into retropharyngeal mucosa in the laryngoscope group were excluded from the final analysis. The total intubation time and T2 time spent were significantly shorter in the Trachway group (Table 1). In the laryngoscope group, six patients were considered as major difficulty in intubation. The median score of MNIDS was three in the laryngoscope group and zero in the Trachway group. Some patients in the laryngoscope group needed cuff inflation or BURP manoeuvre during intubation, but none in the Trachway group. In this study, the Trachway-tube assembly provided a smooth advancement from selected nostril through the nasopharynx into trachea and needed no opening of the patient’s mouth. By using the Macintosh laryngoscope, the mean total intubation time spent took nearly 2 min for trainees3 and around 1 min for experienced intubators with Magill forceps.4 This is in line with our findings. In the Trachway group, however, a mean total intubation time was 32.3 s along with easy intubation conditions. Using the Trachway technique to establish a nasal airway with a preformed double-curved nasotracheal tube is feasible and an efficient technique.
BJA Declaration of interest None declared. S. N. Bolsin* A. Marsiglio M. Colson Geelong, Australia *E-mail: [email protected]
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9 Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med 2012; 125: 953– 5 10 Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. Br Med J 2006; 332: 1482–9 11 Yang H, Raymer K, Butler R, Parlow J, Roberts R. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006; 152: 983–90 12 Brady AR, Gibbs JSR, Greenhalgh RM, Powell JT, Sydes MR. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg 2005; 41: 602–9 13 Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Can Med Assoc J 2005; 173: 627– 34 14 Devereaux PJ, Yang H, Guyatt GH, et al. Rationale, design, and organization of the PeriOperative ISchemic Evaluation (POISE) trial: a randomized controlled trial of metoprolol versus placebo in patients undergoing noncardiac surgery. Am Heart J 2006; 152: 223–30 15 Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery. Heart 2013; 100: 456–64 16 Messori A, Fadda V, Maratea D, Trippoli S. Sequential analysis shows that beta-blockade in non-cardiac surgery is ineffective and may even be harmful. Br Med J 2013; 347, doi:10.1136/bmj.f6296
doi:10.1093/bja/aeu288
Downloaded from http://bja.oxfordjournals.org/ at Seton Hall on September 26, 2014
1 Foex P, Sear JW. b-Blockers and cardiac protection: 5 yr on from POISE. Br J Anaesth 2014; 112: 206– 10 2 Mangano DT, Layug EL, Wallace A, Tateo I, The Multicenter Study of Perioperative Ischemia Research Group. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713– 21 3 Bolsin S, Colson M. Beta-blockers for patients at risk of cardiac events during non-cardiac surgery. Br Med J 2005; 331: 919– 20 4 Bolsin S, Colson M, Conroy M. Beta-blockers and statins in noncardiac surgery. Br Med J 2007; 334: 1283–4 5 Bolsin SN, Colson M, Marsiglio A. Perioperative beta-blockade. Br Med J 2013; 347: 9 6 Devereaux PJ, Beattie WS, Choi PT-L, et al. How strong is the evidence for the use of perioperative beta-blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. Br Med J 2005; 331: 313– 21 7 Wallace AW, Au S, Cason BA. Association of the pattern of use of perioperative beta-blockade and postoperative mortality. Anesthesiology 2010; 113: 794–805 8 Erasmus Medical Centre Follow-up Investigation Committee. Report of 2012 Follow Up Investigation of Possible Breaches of Academic Integrity. Rotterdam: Erasmus Medical Centre, 2012; 26
Correspondence
Correspondence
Declaration of interest None declared. H.-T. Hsu C.-H. Lin K.-Y. Tseng Y.-C. Shen C.-H. Chen W.-M. Chuang K.-I. Cheng* Kaohsiung, Taiwan *E-mail: [email protected]
1 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105– 11 2 Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the
complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290– 7 3 Hirabayashi Y. GlideScope videolaryngoscope facilitates nasotracheal intubation. Can J Anaesth 2006; 53: 1163–4 4 Jones PM, Armstrong KP, Armstrong PM, et al. A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg 2008; 107: 144– 8
doi:10.1093/bja/aeu334
b-Blockers and cardiac protection Editor—We were interested to read the editorial by Pierre Foex and John Sear on the cardioprotective effect of b-blockers in the perioperative period.1 While citing their original work and the seminal study of Mangano and colleagues,2 they fail to highlight the unsound nature of that publication. As we have pointed out, several major flaws exist in this study, which led Devereaux and colleagues to exclude the results from their meta-analysis justifying the POISE study.3 – 6 First, patients in the Mangano study were randomized to receive either atenolol or placebo irrespective of existing treatment with b-blockers, thus exposing the placebo group to a higher baseline risk of perioperative major adverse cardiac events (MACE) as a result of sudden cessation of b-blocker therapy.7 Secondly, the results were not analysed on an ‘intention to treat’ basis with the 2 yr Kaplan–Meier survival curve restricted to an analysis of post-discharge mortality when the number of patients in the atenolol treated group who had died in hospital was higher than the placebo group.3 – 5 Furthermore, Foex and Sear continue to cite the Decrease II and Decrease IV studies, which have been found to be ‘negligent’ and ‘scientifically incorrect’ by the Erasmus University committee that was asked to investigate Professor Polderman’s scientific integrity.8 In support of the use of b-blockers to prevent MACE in the perioperative period, Foex and Sear continue to refer to the Guidelines of the European Society of Cardiologists (ESC) without referring to the fact that the ESC Guideline Writing Committee was chaired by none other than Professor Polderman, who had considerable influence in the content of those guidelines.5 Similarly, the American College of Cardiologists/ American Heart Association Guidelines, which are endorsed by the ASA, have also been questioned.9 With respect to the choice of dose and formulation of b-blocker used in the POISE study, it is important to bear in mind that failure to reduce heart rate or arterial pressure enough may explain the negative effect of b-block in those studies that did not identify a beneficial perioperative effect of b-blockers.10 – 14 Given the mounting evidence of lasting harm to patients that could accrue from injudicious use of perioperative b-blockade and the high likelihood of ineffective treatment, we would reiterate our advice that ‘patients already receiving beta-blockers or statins before surgery should continue with treatment. Only patients who need heart rate or blood pressure control, or both, in the perioperative period should start treatment with beta-blockers’.5 15 16
721
Downloaded from http://bja.oxfordjournals.org/ at Seton Hall on September 26, 2014
Epistaxis was assessed anteriorly by nostril bleeding and posteriorly by grading of blood in the oropharynx (0, none; 1, minimal; 2, slight; 3, moderate; 4, severe). MNIDS scored intubation conditions were assessed as follows: N1, additional intubation attempts; N2, number of supplementary operators, directly but not assisted; N3, alternative intubation techniques such as change of head position, cuff inflation, or Magill forceps intervention; N4, glottic exposure grading as Cormack–Lehane1 minus 1; N5, lifting force; N6, glottic exposure with BURP manoeuvre; N7, vocal cords position. The MNIDS scores were categorized as easy (0), minor difficulty (0,scores≤5), major difficulty (5,scores), and impossible intubation or failed intubation (scores¼1).2 There were no statistical differences between the groups on patient characteristic data, haemodynamic responses to intubation, and side-effects. One patient unexpectedly failed intubation and one tube advancement into retropharyngeal mucosa in the laryngoscope group were excluded from the final analysis. The total intubation time and T2 time spent were significantly shorter in the Trachway group (Table 1). In the laryngoscope group, six patients were considered as major difficulty in intubation. The median score of MNIDS was three in the laryngoscope group and zero in the Trachway group. Some patients in the laryngoscope group needed cuff inflation or BURP manoeuvre during intubation, but none in the Trachway group. In this study, the Trachway-tube assembly provided a smooth advancement from selected nostril through the nasopharynx into trachea and needed no opening of the patient’s mouth. By using the Macintosh laryngoscope, the mean total intubation time spent took nearly 2 min for trainees3 and around 1 min for experienced intubators with Magill forceps.4 This is in line with our findings. In the Trachway group, however, a mean total intubation time was 32.3 s along with easy intubation conditions. Using the Trachway technique to establish a nasal airway with a preformed double-curved nasotracheal tube is feasible and an efficient technique.
BJA Declaration of interest None declared. S. N. Bolsin* A. Marsiglio M. Colson Geelong, Australia *E-mail: [email protected]
722
9 Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med 2012; 125: 953– 5 10 Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. Br Med J 2006; 332: 1482–9 11 Yang H, Raymer K, Butler R, Parlow J, Roberts R. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006; 152: 983–90 12 Brady AR, Gibbs JSR, Greenhalgh RM, Powell JT, Sydes MR. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg 2005; 41: 602–9 13 Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Can Med Assoc J 2005; 173: 627– 34 14 Devereaux PJ, Yang H, Guyatt GH, et al. Rationale, design, and organization of the PeriOperative ISchemic Evaluation (POISE) trial: a randomized controlled trial of metoprolol versus placebo in patients undergoing noncardiac surgery. Am Heart J 2006; 152: 223–30 15 Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery. Heart 2013; 100: 456–64 16 Messori A, Fadda V, Maratea D, Trippoli S. Sequential analysis shows that beta-blockade in non-cardiac surgery is ineffective and may even be harmful. Br Med J 2013; 347, doi:10.1136/bmj.f6296
doi:10.1093/bja/aeu288
Downloaded from http://bja.oxfordjournals.org/ at Seton Hall on September 26, 2014
1 Foex P, Sear JW. b-Blockers and cardiac protection: 5 yr on from POISE. Br J Anaesth 2014; 112: 206– 10 2 Mangano DT, Layug EL, Wallace A, Tateo I, The Multicenter Study of Perioperative Ischemia Research Group. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713– 21 3 Bolsin S, Colson M. Beta-blockers for patients at risk of cardiac events during non-cardiac surgery. Br Med J 2005; 331: 919– 20 4 Bolsin S, Colson M, Conroy M. Beta-blockers and statins in noncardiac surgery. Br Med J 2007; 334: 1283–4 5 Bolsin SN, Colson M, Marsiglio A. Perioperative beta-blockade. Br Med J 2013; 347: 9 6 Devereaux PJ, Beattie WS, Choi PT-L, et al. How strong is the evidence for the use of perioperative beta-blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. Br Med J 2005; 331: 313– 21 7 Wallace AW, Au S, Cason BA. Association of the pattern of use of perioperative beta-blockade and postoperative mortality. Anesthesiology 2010; 113: 794–805 8 Erasmus Medical Centre Follow-up Investigation Committee. Report of 2012 Follow Up Investigation of Possible Breaches of Academic Integrity. Rotterdam: Erasmus Medical Centre, 2012; 26
Correspondence
