Background/Objectives: Unanticipated difficult airway remains a critical patient safety concern in perioperative care. Despite routine preoperative assessment, difficult intubation may still occur in patients without obvious high-risk findings. This study aimed to evaluate perioperative factors associated with unanticipated difficult intubation and to examine the relationship between preoperative assessment and intraoperative intubation difficulty in routine clinical practice. Methods: This retrospective case–control study included adult patients undergoing general anesthesia with tracheal intubation between 2015 and 2020 at a tertiary care hospital. Unanticipated difficult intubation was defined as requiring ≥3 intubation attempts without documented preoperative suspicion of difficult airway. Patients with anticipated difficult airway or preoperative mechanical ventilation were excluded. A total of 95 cases and 429 controls were analyzed. Associations were explored using multivariable logistic regression. Results: Among 524 patients, cases more frequently had ASA physical status III and airway/neck/oral deformity. Notably, intubation difficulty became evident only at laryngoscopy, characterized by poorer visualization, increased intubation attempts (median 4 vs. 1), and frequent escalation to video laryngoscopy. Severe laryngoscopic views (Cormack–Lehane grade III–IV: 74.8% vs. 3.0%) were markedly overrepresented among cases. In multivariable analysis, ASA III and airway deformity remained independently associated with unanticipated difficult intubation. The model demonstrated modest discrimination (AUC 0.685). Conclusions: Unanticipated difficult intubation was uncommon but clinically important and frequently became apparent only during airway management. Although several associated factors were identified, routine bedside airway assessment alone may not reliably predict all cases of intraoperative difficult intubation. These findings highlight the limitations of routine bedside airway assessment in identifying all patients who subsequently experience difficult intubation and support the need for improved strategies to identify patients at risk.

Background Unanticipated difficult airways are a major cause of perioperative morbidity. Existing bedside airway assessments often fail to predict difficulty when anatomical predictors are absent, highlighting the need for a pragmatic tool that integrates physiological, procedural, and demographic factors to flag patients at risk for unanticipated difficult intubation. Results In this retrospective case–control study of 62,111 anesthetized patients between 2015 and 2020, we identified 98 unanticipated difficult airway events and matched them 1:3 to 294 controls. The incidence of unanticipated difficult airways was 0.16%. Multivariate logistic regression determined four independent predictors: coagulopathy or hypocalcaemia, female sex, potentially difficult airway on physical exam, and intubation by a less-experienced resident. These variables were combined into the CLAIR score which demonstrated an area under the receiver operating characteristic curve of 0.633, with high sensitivity (98%) despite low specificity (16%). A cutoff of 0 effectively stratified patients into high (≥ 1), and low (≤-1) risk groups to airway management strategies while a web-based risk calculator and QR code enhanced accessibility for real-time clinical applications. Conclusion The CLAIR score, based on routinely available preoperative and procedural data, provides a high-sensitivity screening tool to identify patients at risk of unanticipated difficult airway. Although external validation is required, its simplicity and reliance on routine information make it a valuable tool in routine anesthetic practice to prompt preparedness and risk mitigation.

Neuromuscular blocking agents (NMBAs) are widely used in the intensive care unit (ICU) to facilitate mechanical ventilation; however, excessive or prolonged blockade increases the risk of complications such as ICU-acquired weakness. Quantitative train-of-four (TOF) monitoring remains the standard for assessing depth of neuromuscular blockade, although it is often underutilized in ICU practice. Indirect methods including capnography, ventilator waveform analysis, and respiratory effort indices provide complementary but nonspecific information. Integration of quantitative and physiologic monitoring supports safer and more individualized NMBAs management in critically ill patients. This review summarizes current neuromuscular monitoring strategies in the ICU and discusses the clinical utility, limitations, and practical integration of quantitative and indirect monitoring modalities during NMBAs administration.

Background/Objectives: Unanticipated difficult airways remain a significant challenge in anesthesia practice and are associated with increased severe complication risk. This study developed and validated a novel predictive tool for identifying unanticipated difficult airways. Methods: This retrospective case-control study analyzed data from 62,111 patients who underwent general anesthesia between 2015 and 2020. Among them, 98 unanticipated difficult airways were identified and matched in a 1:3 ratio with 294 controls. Multivariate logistic regression was utilized to determine key predictors for developing the CLAIR score, which integrates coagulopathy, hypocalcemia, laryngoscopic view, potential airway difficulty, and the presence of inexperienced residents. Results: The incidence of unanticipated difficult airways was 0.16%. The CLAIR score exhibited excellent discriminative performance, with an area under the receiver operating characteristic curve of 0.93. At an optimal cutoff of 4, the score achieved a sensitivity of 86% and a specificity of 90%. Patients were stratified into high (≥6), intermediate (1–5), and low (≤0) risk categories, facilitating tailored airway management strategies. A web-based risk calculator, accessible via a QR code, further enhances its utility in real-time clinical applications. Conclusions: Implementing the CLAIR score holds significant promise for enhancing preoperative risk assessment, optimizing resource allocation, and improving patient safety in diverse anesthesia settings. Future prospective studies and robust external validation are essential to establishing the generalizability of the CLAIR score and confirming its efficacy in reducing airway-related complications. This novel tool represents a paradigm shift in airway management, addressing a longstanding challenge in anesthesia practice with a practical and actionable solution.

Background: High-flow nasal cannula (HFNC) therapy is increasingly utilized following extubation in patients undergoing cardiac surgery, due to its potential benefits in preventing pulmonary complications such as atelectasis, pleural effusion, and pneumonia. However, the comparative efficacy of HFNC versus conventional oxygen therapy (COT) in elderly patients remains unclear. This study aims to compare post-extubation pulmonary outcomes between HFNC and COT in elderly patients following cardiac surgery. Methods: We conducted a retrospective cohort study at a tertiary care hospital in Southern Thailand, including patients aged 65 and older who underwent elective cardiac surgery between December 2018 and January 2024. The primary outcome was the incidence of post-extubation pulmonary complications (PPCs) within 72 hours. Secondary outcomes included the length of intensive care unit (ICU) and hospital stays, all-cause in-hospital mortality, and atelectasis scores. Results: A total of 424 patients were included, with 212 patients in each group. HFNC therapy was associated with a significant reduction in the odds of bronchospasm (7.5% vs. 24.5%; adjusted OR = 0.22, 95% CI = 0.12–0.41). There were no significant differences between the groups in terms of reintubation rates, tracheostomy, ICU stay, hospital stay, or all-cause mortality. However, atelectasis scores were significantly improved on day 5 post-extubation. Conclusion: HFNC therapy may reduce the incidence of bronchospasms in elderly patients after cardiac surgery and significant improvement of atelectasis score at day 5. While these findings suggest a potential benefit of HFNC in postoperative care, further research is warranted to explore its long-term effects and implications for patient outcomes.

Background: Active learning, particularly through serious and analog serious games, is effective for increasing participant engagement, fostering learners’ motivation, and promoting dynamic knowledge acquisition. In this study, we developed the “Basic Pharmacology for Anesthesia” card game to teach about anesthetic drug to first- to third-year anesthesiology residents and assessed its effectiveness and the residents’ satisfaction with game-based learning. Methods: Nineteen anesthesiology residents participated in this cross-sectional observational study conducted at the Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University. A game-based learning was introduced to the participants. The objective of the game was for participants to collect a complete set of five cards for a specific anesthetic drug. The deck comprised 55 cards representing 11 anesthetic drugs, each of which detailed the drug’s name, dosage, onset and duration, contraindications, side effects, and metabolism or pharmacology. Pre- and posttests (total score: 20 points) were administered before and after the game-based learning, respectively. Pre- and posttest knowledge scores were compared, and the participants’ satisfaction with the activity was assessed using a five-point Likert scale. Results: A comparison of the pre- and posttest scores revealed improvements across all categories: 5.00 vs. 7.47 ( p < 0.001) for induction drugs, 2.59 vs. 3.92 ( p < 0.001) for volatile anesthetics, and 6.67 vs. 7.51 ( p < 0.001) for neuromuscular agents. The total score significantly increased from 14.26 (pretest) to 18.91 (posttest) ( p < 0.001). The overall satisfaction level was 4.84 (standard deviation = 0.37). Conclusions: Game-based learning using a serious card game could effectively improve anesthesiology residents’ knowledge of anesthetic drugs and was associated with a high learner satisfaction. To achieve a more comprehensive evaluation of this educational intervention, future studies should include additional assessment methods, such as measuring learner engagement and comparing game-based learning with traditional methods used to teach anesthetic drugs to anesthesiology residents.