CORRESPONDENCE

Xue et al. had a particular question about the definition of intubation rescue techniques after failed direct laryngos-
copy in adults: A retrospective comparative analysis from the
of a failed direct laryngoscopy attempt. They are correct Multicenter Perioperative Outcomes Group. ANESTHESIOLOGY
that we cannot confirm that the initial direct laryngos- 2016; 125:656–66
copy attempt was optimized through patient positioning 2. Cook TM, Woodall N, Frerk C; Fourth National Audit Project:
or laryngeal manipulation. However, all intubations were Major complications of airway management in the UK:
Results of the Fourth National Audit Project of the Royal
supervised or performed by anesthesiologists with suf- College of Anaesthetists and the Difficult Airway Society. Part
ficient experience. Furthermore, we did describe alterna- 1: Anaesthesia. Br J Anaesth 2011; 106:617–31
tion of direct laryngoscopy blade types (see table 4 of our 3.
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath
R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I; Difficult
article1). We agree that often an inadequate laryngeal view Airway Society Intubation Guidelines Working Group:
with direct laryngoscopy can be overcome with optimiza- Difficult Airway Society 2015 guidelines for management
tion maneuvers or when utilizing a gum-elastic bougie. of unanticipated difficult intubation in adults. Br J Anaesth
2015; 115:827–48
These cases were a priori excluded from analysis as we were
4. Timmermann A, Chrimes N, Hagberg C: Need to consider
interested in the mechanisms of rescue after direct laryn- human factors when determining first-line technique for
goscopy has failed by whatever means. We cannot deter- emergency front-of-neck access. Br J Anaesth 2016; 117:5–7
mine why direct laryngoscopy was abandoned after one 5. Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink
AM: Routine clinical practice effectiveness of the GlideScope
attempt and/or if tube placement was actually attempted in difficult airway management: An analysis of 2,004
along with that failed direct laryngoscopy. Certainly, the GlideScope intubations, complications, and failures from two
providers who performed direct laryngoscopy first aimed institutions. ANESTHESIOLOGY 2011; 114:34–41
to intubate the patient but simply could not, even though (Accepted for publication April 9, 2017.)
such appropriate adjuncts were available and/or used. So,
we did not describe failed intubation via direct laryngos-
copy per se, but we do believe we appropriately described
failed direct laryngoscopy.
Maslow and Panaro had some questions about the valid-
ity of the data set that we believe represent a misunderstand- Calculating Ideal Body Weight: Keep It
ing that should be clarified. They question the high exclusion Simple
rate from the primary query. The automated query identified
7,259 cases that involved multiple laryngoscopy attempts To the Editor:
and notations of device(s) of interest in an effort to “screen” We read with much interest the editorial on protective
the electronic record for potential cases as only the narrative ventilation by Hedenstierna and Edmark in the December
could describe the actual sequence of events. These were not issue of ANESTHESIOLOGY.1 We agree with most of the ideas
necessarily failed direct laryngoscopy attempts but a trigger put forward. However, as thoracic anesthesiologists, we
to further evaluate the record. The final analysis included strongly believe in the importance, during one-lung venti-
1,427 failed direct laryngoscopy cases from 346,861 intu- lation, of low tidal volume based on ideal body weight.2,3
bation records (0.4%). Also, our data do not address the Many authors still recommend using the gender-specific
primary success rate of either direct laryngoscopy or video Acute Respiratory Distress Syndrome Network (ARDSnet)
laryngoscopy. The data set only speaks to the success rate formulas to calculate ideal body weight.4 Ideal body weight
of various techniques after direct laryngoscopy has failed. is computed in men as 50 + (0.91 × [height in centime-
So, the primary success rate of video laryngoscopy is not ters − 152.4]) and in women as 45.5 + (0.91 × [height in
reported. However, we did publish such findings in a dif- centimeters − 152.4]). A simple alternative would be to
ferent study and observed a 98% success rate with video compute ideal body weight as the weight corresponding to
laryngoscopy as the primary technique despite early clinical an ideal body mass index of 22 kg/m2. Ideal body weight is
experience with the device.5 then simply calculated as 22 × ([the actual patient’s height
in meters]^2) or by using body mass index charts available
Competing Interests on our anesthesia cart.5 We chose 22 kg/m2 as the ideal body
The authors declare no competing interests. mass index after comparing the ideal body weight corre-
sponding to body mass indices ranging from 20 to 25 to
Michael F. Aziz, M.D., David W. Healy, M.D., M.R.C.P., ideal body weight calculated from ADRSnet formulas. For
F.R.C.A., Ansgar M. Brambrink, M.D., Ph.D., Sachin example, a 1.75-m man would have an ideal body weight of
Kheterpal, M.D., M.B.A. Oregon Health and Science 67 kg (22 × [1.75^2]) compared to 71 kg if using ARDSnet;
­University, Portland, Oregon (M.F.A.). [email protected] a 1.60-m woman would have an ideal body weight of 56 kg
(22 × [1.60^2]) compared to 52 kg if using ARDSnet.
References The method we propose is simple and easy to remember.
1. Aziz MF, Brambrink AM, Healy DW, Willett AW, Shanks A,
Tremper T, Jameson L, Ragheb J, Biggs DA, Paganelli WC, The same computation applies for both men and women
Rao J, Epps JL, Colquhoun DA, Bakke P, Kheterpal S: Success and involves simple arithmetic.

Anesthesiology 2017; 127:194-207 203 Correspondence

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 Correspondence

Competing Interests Evaluation of Nitrous Oxide in the Gas

The authors declare no competing interests. Mixture for Anesthesia II (ENIGMA II)
Olivier Moreault, M.D., Yves Lacasse, M.D., F.R.C.P.C., Revisited: Patients Still Vomiting
Jean S. Bussières, M.D., F.R.C.P.C. Institut universitaire
de cardiologie et de pneumologie de Québec - Université To the Editor:
Laval, Québec City, Québec, Canada ( J.S.B.). jbuss@criucpq. We read the secondary analysis of the Evaluation of Nitrous
ulaval.ca Oxide in the Gas Mixture for Anesthesia II (ENIGMA II)
trial for severe postoperative nausea and vomiting (PONV)
References with great interest.1 Because PONV remains an often-cited
1. Hedenstierna G, Edmark L: Protective ventilation during anes- risk in using nitrous oxide,2 the investigation of methods to
thesia: Is it meaningful? ANESTHESIOLOGY 2016; 125:1079–82
2. Brassard CL, Lohser J, Donati F, Bussières JS: Step-by-step
mitigate PONV using existing data generated from random-
clinical management of one-lung ventilation: Continuing pro- ized controlled trials is an important undertaking. We wish
fessional development. Can J Anaesth 2014; 61:1103–21 to respond to this thorough reanalysis.
3. Lohser J, Slinger P: Lung injury after one-lung ventilation: The authors used a retrospective propensity score
A review of the pathophysiologic mechanisms affecting
the ventilated and the collapsed lung. Anesth Analg 2015; approach to investigate the effects of antiemetic prophy-
121:302–18 laxis on the nitrous oxide and non-nitrous oxide arms. The
4. Acute Respiratory Distress Syndrome Network. Ventilation
well-recognized limitations of this approach were openly
with lower tidal volumes as compared with traditional tidal acknowledged in the publication, including the inability
volumes for acute lung injury and the acute respiratory dis-
tress syndrome. N Engl J Med 2000; 342:1301–8 to control for hidden covariates and the need to truncate
5. Moreault O, Lacasse Y, Bussières J: Body mass index chart 2016. available data.3 In the abstract, the authors conclude that
Available at: http://bit.ly/2ikOtch. Accessed March 31, 2017 the emetogenic effects of nitrous oxide are near eliminated
by the addition of antiemetics. However, the results from
(Accepted for publication April 8, 2017.) the propensity score-matched analysis do not seem to sup-
port this conclusion, as the nitrous/antiemetic group had
statistically higher odds of PONV compared with the non-
nitrous/nonantiemetic group. In addition, administration
In Reply: of antiemetic prophylaxis among participants who did not
We appreciate the important comment by Moreault et al. receive nitrous oxide counterintuitively increased the odds
on our article, “Protective Ventilation during Anesthesia: Is of PONV. Although various clinical and scientific reasons
It Meaningful?”1 We agree fully with the opinion that a low may be hypothesized to explain this phenomenon, perhaps
tidal volume should be based on ideal body weight to avoid the simplest hypothesis is the presence of hidden covariates.
harmful stress and strain to the lungs during anesthesia. This Therefore, it is our opinion that the conclusion of negating
is even more important during one-lung ventilation. Ideally, PONV with antiemetics when nitrous is used is not sup-
the tidal volume should be adjusted to the size of the venti- ported by the results of this retrospective analysis, and the
lated lung, but without a simple recording of lung volume, use of propensity score matching in this instance may not
ideal body weight is a reasonable alternative. However, we have resulted in a balanced comparison.
also believe that an appropriate positive end-expiratory pres- In light of the aforementioned results, another statis-
sure is a prerequisite when using a low tidal volume, whatever tic (risk ratio, 0.74 [95% CI, 0.63 to 0.84]; P < 0.001) is
the calculation method of ideal body weight. We find the quoted in the report1 to support the conclusion that PONV
method proposed by the authors commendable and indeed is not increased when antiemetics are used in conjunction
easy to remember as most anesthesiologists already are famil- with nitrous oxide. This risk ratio does not appear among the
iar with the method for calculating body mass index. results generated by propensity score matching but appears
to be the result of a subgroup analysis for the PONV out-
Competing Interests
come in the original ENIGMA II report for patients who
The authors declare no competing interests.
received antiemetic prophylaxis.4 However, the lack of
blinding of attending anesthesiologists to treatment allo-
Göran Hedenstierna, M.D., Ph.D., Lennart Edmark,
M.D., Ph.D. Uppsala University, Sweden (G.H.). goran.­ cation may have introduced selection bias into antiemetic
[email protected] prophylaxis, a possibility supported by the statistically sig-
nificant difference in antiemetic administration between the
References nitrous and non-nitrous arms. If selection bias were present
1. Hedenstierna G, Edmark L: Protective ventilation during anes- in antiemetic administration, the efficacy of this originally
thesia: Is it meaningful? ANESTHESIOLOGY 2016; 125:1079–82 randomized subgroup analysis to equalize hidden covariates
may have been compromised.5
(Accepted for publication April 8, 2017.)
Although this secondary analysis1 of antiemetic prophy-
laxis on PONV has important limitations, we believe that

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