Showing papers in "Anaesthesia in 2004"
TL;DR: The Difficult Airway Society (DAS) developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction as discussed by the authors.
Abstract: Summary Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flowcharts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. Disclaimer: It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.
987 citations
TL;DR: Dantrolene is not only used for the treatment of malignant hyperthermia, but also in the management of neuroleptic malignant syndrome, spasticity and Ecstasy intoxication, and its main disadvantage is its poor water solubility, and hence difficulties are experienced in rapidly preparing intravenous solutions in emergency situations.
Abstract: Human malignant hyperthermia is a life-threatening genetic sensitivity of skeletal muscles to volatile anaesthetics and depolarizing neuromuscular blocking drugs occurring during or after anaesthesia. The skeletal muscle relaxant dantrolene is the only currently available drug for specific and effective therapy of this syndrome in man. After its introduction, the mortality of malignant hyperthermia decreased from 80% in the 1960s to < 10% today. It was soon discovered that dantrolene depresses the intrinsic mechanisms of excitation-contraction coupling in skeletal muscle. However, its precise mechanism of action and its molecular targets are still incompletely known. Recent studies have identified the ryanodine receptor as a dantrolene-binding site. A direct or indirect inhibition of the ryanodine receptor, the major calcium release channel of the skeletal muscle sarcoplasmic reticulum, is thought to be fundamental in the molecular action of dantrolene in decreasing intracellular calcium concentration. Dantrolene is not only used for the treatment of malignant hyperthermia, but also in the management of neuroleptic malignant syndrome, spasticity and Ecstasy intoxication. The main disadvantage of dantrolene is its poor water solubility, and hence difficulties are experienced in rapidly preparing intravenous solutions in emergency situations. Due to economic considerations, no other similar drugs have been introduced into routine clinical practice.
481 citations
TL;DR: Serum β‐tryptase measurements can be used to distinguish mast cell‐dependent reactions from other systemic disturbances such as cardiogenic shock, which can present with similar clinical manifestations and patients without increased mast cell tryptase levels should be investigated for an allergic cause.
Abstract: Mast cells, which are granulocytes found in peripheral tissue, play a central role in inflammatory and immediate allergic reactions. beta-Tryptase is a neutral serine protease and is the most abundant mediator stored in mast cell granules. The release of beta-tryptase from the secretory granules is a characteristic feature of mast cell degranulation. While its biological function has not been fully clarified, mast cell beta-tryptase has an important role in inflammation and serves as a marker of mast cell activation. beta-Tryptase activates the protease activated receptor type 2. It is involved in airway homeostasis, vascular relaxation and contraction, gastrointestinal smooth muscle activity and intestinal transport, and coagulation. Serum mast cell beta-tryptase concentration is increased in anaphylaxis and in other allergic conditions. It is increased in systemic mastocytosis and other haematological conditions. Serum beta-tryptase measurements can be used to distinguish mast cell-dependent reactions from other systemic disturbances such as cardiogenic shock, which can present with similar clinical manifestations. Increased beta-tryptase levels are highly suggestive of an immunologically mediated reaction but may also occur following direct mast cell activation. Patients with increased mast cell beta-tryptase levels must be investigated for an allergic cause. However, patients without increased mast cell tryptase levels should be investigated if the clinical picture suggests severe anaphylaxis.
276 citations
TL;DR: Ultrasonography offers faster sensory and motor responses and a longer duration of sensory blockade than nerve stimulation in children undergoing infraclavicular brachial plexus blocks, and the pain associated with nerve stimulation due to muscle contractions at the time of insertion is eliminated.
Abstract: Summary
Ultrasonography may offer significant advantages in regional anaesthesia of the upper and lower limbs. It is not known if the same advantages demonstrated in adults also apply to children. We therefore performed a prospective, randomised study comparing ultrasound visualisation to conventional nerve stimulation for infraclavicular brachial plexus anasesthesia in children. Forty children scheduled for arm and forearm surgery underwent infraclavicular brachial plexus blocks with ropivacaine 0.5 ml.kg−1 guided by either nerve stimulation or ultrasound visualisation. Evaluated parameters included sensory block quality, sensory block distribution and motor block. All surgical procedures were performed under brachial plexus anaesthesia alone. Direct ultrasound visualisation was successful in all cases and was associated with significant improvements when compared with the use of nerve stimulation: lower visual analogue scores during puncture (p = 0.03), shorter mean (median) sensory onset times (9 (5–15) min vs. 15 (5–25) min, p < 0.001), longer sensory block durations (384 (280–480) min vs. 310 (210–420) min, p < 0.001), and better sensory and motor block scores 10 min afrter block insertion. Ultrasound visualisation offers faster sensory and motor responses and a longer duration of sensory blockade than nerve stimulation in children undergoing infraclavicular brachial plexus blocks. In addition, the pain associated with nerve stimulation due to muscle contractions at the time of insertion is eliminated.
271 citations
TL;DR: A total of 34 ‘N of 1’ studies were undertaken using this novel therapy for patients with chronic, mainly neuropathic, pain and associated symptoms to explore efficacy, tolerability, safety and dosages of CBME.
Abstract: Summary Three Cannabis Based Medicinal Extracts (CBMEs) for sublingual use became available in 2000. A total of 34 ‘N of 1’ studies were undertaken using this novel therapy for patients with chronic, mainly neuropathic, pain and associated symptoms to explore efficacy, tolerability, safety and dosages. Three CBMEs (D9 Tetrahydrocannabinol (THC), Cannabidiol (CBD) and a 1 : 1 mixture of them both) were given over a 12-week period. After an initial open-label period, the CBMEs were used in a randomised, double-blind, placebo controlled, crossover trial. Extracts which contained THC proved most effective in symptom control. Regimens for the use of the sublingual spray emerged and a wide range of dosing requirements was observed. Side-effects were common, reflecting a learning curve for both patient and study team. These were generally acceptable and little different to those seen when other psycho-active agents are used for chronic pain. These initial experiences with CBME open the way to more detailed and extensive studies.
260 citations
TL;DR: It is shown that during surgical procedures identical to those described here, S100b levels increases are consistent with early damage to the cerebral vasculature, and was evident only when non-specific binding to non-S100b protein was taken into account and subtracted from the readout.
Abstract: work, we have shown that these exorbitant levels do not derive from cardiac (or other non-CNS) tissue, but rather reflect a cross-reactivity between the antibodies employed for the study [1]. This is an important issue, since it also addresses the question of why putative increases in peripheral S100b occur in the absence of neuronal or cerebrovascular damage. Since the offending antigens belong to a family of high molecular weight protein, serum filtration prevents false reading of peripheral levels of S100b. We have shown that during surgical procedures identical to those described here, S100b levels increases are consistent with early damage to the cerebral vasculature. This was evident only when non-specific binding to non-S100b protein was taken into account and subtracted from the readout.
245 citations
TL;DR: Recommendations that systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia and the label on any drug ampoule or syringe should be read carefully are developed.
Abstract: We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.
230 citations
TL;DR: It is important to consider drug therapy as a contributing factor to this adverse experience, which patients perceive as particularly stressful, and to consider withdrawal reactions to prescribed and occasionally recreational drugs as possible triggers for sleep disruption.
Abstract: Sleep disturbances are common in critically ill patients and contribute to morbidity. Environmental factors, patient care activities and acute illness are all potential causes of disrupted sleep. Additionally, it is important to consider drug therapy as a contributing factor to this adverse experience, which patients perceive as particularly stressful. Sedative and analgesic combinations used to facilitate mechanical ventilation are among the most sleep disruptive drugs. Cardiovascular, gastric protection, anti-asthma, anti-infective, antidepressant and anticonvulsant drugs have also been reported to cause a variety of sleep disorders. Withdrawal reactions to prescribed and occasionally recreational drugs should also be considered as possible triggers for sleep disruption. Tricyclic antidepressants and benzodiazepines are commonly prescribed in the treatment of sleep disorders, but have problems with decreasing slow wave and rapid eye movement sleep phases. Newer non-benzodiazepine hypnotics offer little practical advantage. Melatonin and atypical antipsychotics require further investigation before their routine use can be recommended.
195 citations
TL;DR: The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.
Abstract: Neurological assessment is an essential component of early warning scores used to identify seriously ill ward patients. We investigated how two simple scales (ACDU - Alert, Confused, Drowsy, Unresponsive; and AVPU - Alert, responds to Voice, responds to Pain, Unresponsive) compared to each other and also to the more complicated Glasgow Coma Scale (GCS). Neurosurgical nurses recorded patients' conscious level with each of the three scales. Over 7 months, 1020 analysable measurements were collected. Both simple scales identified distinct GCS ranges, although some overlap occurred (p < 0.001). Median GCS scores associated with AVPU were 15, 13, 8 and 6 and for ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.
168 citations
TL;DR: Propofol anaesthesia attenuated the surgical stress‐induced adverse immune response better than isoflurane anaesthesia and may inhibit the decrease in the Th1/Th2 ratio.
Abstract: There are two major subpopulations of peripheral helper T lymphocytes: T helper 1 (Th1) and T helper 2 (Th2) cells. Surgical stress increases the number of Th2 cells, and decreases that of Th1 cells, resulting in a decrease in the Th1/Th2 ratio, and, consequently, in suppressed cell-mediated immunity. Since anaesthesia can suppress the stress response to surgery, it may inhibit the decrease in the Th1/Th2 ratio. Using flow cytometry, we studied whether propofol anaesthesia (n = 9) or isoflurane anaesthesia (n = 9) had more effect on the decrease in the Th1/Th2 ratio after surgery in patients undergoing craniotomy. The Th1/Th2 ratio decreased significantly after isoflurane anaesthesia (p = 0.011), while it did not change after propofol anaesthesia. The ratio was significantly lower with isoflurane than propofol (p = 0.009). Propofol anaesthesia attenuated the surgical stress-induced adverse immune response better than isoflurane anaesthesia.
152 citations
TL;DR: Ultrasound guidance used in central venous cannulation procedures saves NHS resources even with conservative modelling assumptions, and the results of modelling appear robust to the central assumptions used.
Abstract: We compared the economics of using two-dimensional ultrasound locating devices and more traditional landmark methods for central venous cannulation in the National Health Service (NHS). The evaluation consisted of a systematic review of randomised controlled trials and an economic evaluation using decision analytic cost-effectiveness modelling. Incremental costs per complication avoided associated with landmark and ultrasound central venous cannulation were modelled for patients scheduled for central venous cannulation. The marginal economic cost of using ultrasound for central venous cannulation was less than 10 pounds sterling per procedure, assuming that a machine is used for 15 procedures each week. The base case scenario implied that 2000 pounds sterling worth of resource savings result for every 1000 procedures undertaken and 90 avoided complications. Sensitivity analysis indicated that the results of modelling appear robust to the central assumptions used. Ultrasound guidance used in central venous cannulation procedures saves NHS resources even with conservative modelling assumptions.
TL;DR: The physiology and pharmacology of vasopressin are reviewed and its efficacy and safety in clinical trials and its subsequent therapeutic use are summarised.
Abstract: Vasopressin and its analogue, terlipressin, are potent vasopressors that may be useful therapeutic agents in the treatment of cardiac arrest, septic and catecholamine-resistant shock and oesophageal variceal haemorrhage. The aim of this article is to review the physiology and pharmacology of vasopressin and summarise its efficacy and safety in clinical trials and its subsequent therapeutic use. Recent studies indicate that the use of vasopressin during cardiopulmonary resuscitation may improve the survival of patients with asystolic cardiac arrest. Vasopressin deficiency can contribute to refractory shock states associated with sepsis, cardiogenic shock and cardiac arrest. Low doses of vasopressin and terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in reducing bleeding and mortality associated with oesophageal variceal haemorrhage. The long-term outcome of the use of these drugs is not known.
TL;DR: Prediction using surgical site or patient's history alone was poor while the simplified risk score provided clinically useful sensitivity and specificity, which were used to quantify predictive properties.
Abstract: Although site of surgery and previous occurrence of postoperative nausea and vomiting are often used to decide whether prophylactic anti-emetic drugs are indicated, the value of these predictors is unclear. We compared these two risk factors against a simplified four-factor risk score. We analysed data from 1566 adult inpatients who received balanced anaesthesia without prophylactic anti-emetics. Sensitivity, specificity, predictive value and area under the receiver operating characteristic curve were used to quantify predictive properties. Nausea and vomiting occurred in 600 (38.3%) patients within 24 h. Sensitivity and specificity were, respectively, 47% and 59% for surgical site; 47% and 70% for history of postoperative nausea and vomiting; and 58% and 70% for risk score with three or more factors. The area under the curve for surgical site was 0.53 (95% CI 0.50-0.56); that for patient's history was 0.58 (95% CI 0.56-0.61) while for risk score it was 0.68 (95% CI 0.66-0.71; P < 0.001). Prediction using surgical site or patient's history alone was poor while the simplified risk score provided clinically useful sensitivity and specificity.
TL;DR: The clinical features of the more common causes of thrombocytopenia associated with pregnancy are discussed, and an overview of the anaesthetic considerations are provided.
Abstract: Thrombocytopenia in pregnant women can be associated with substantial maternal and neonatal morbidity. It may result from a range of conditions and early implementation of some specific treatment may improve both maternal and neonatal outcome. In this review we discuss the clinical features of the more common causes of thrombocytopenia associated with pregnancy, and provide an overview of the anaesthetic considerations.
TL;DR: The pressure within the abdominal cavity is normally little more than atmospheric pressure, however, even small increases in intra‐abdominal pressure can have adverse effects on renal function, cardiac output, hepatic blood flow, respiratory mechanics, splanchnic perfusion and intracranial pressure.
Abstract: The pressure within the abdominal cavity is normally little more than atmospheric pressure. However, even small increases in intra-abdominal pressure can have adverse effects on renal function, cardiac output, hepatic blood flow, respiratory mechanics, splanchnic perfusion and intracranial pressure. Although intra-abdominal pressure can be measured directly, this is invasive and bedside measurement of intra-abdominal pressure is usually achieved via the urinary bladder. This cheap, easy approach has been shown to produce results that correlate closely with directly measured abdominal pressures. Significant increases in intra-abdominal pressure are seen in a wide variety of conditions commonly encountered in the intensive care unit, such as ruptured aortic aneurysm, abdominal trauma and acute pancreatitis. Abdominal compartment syndrome describes the combination of increased intra-abdominal pressure and end-organ dysfunction. This syndrome has a high mortality, most deaths resulting from sepsis and multi-organ failure. Detection of abdominal compartment syndrome requires close surveillance of intra-abdominal pressure in patients thought to be at risk of developing intra-abdominal hypertension. The only available treatment for established abdominal compartment syndrome is decompressive laparotomy. Prevention of abdominal compartment syndrome after laparotomy by adoption of an open abdomen approach may be preferable in the patient at significant risk of developing intra-abdominal hypertension, but this has not been demonstrated in any large trials. Most surgeons prefer to adopt a 'wait and see' policy, only intervening when clinical deterioration is associated with a significant increase in intra-abdominal pressure.
TL;DR: The use of a nerve stimulator‐guided technique appears to enhance the likelihood of achieving the more desirable longitudinal spreading pattern of a paravertebral injection.
Abstract: The factors responsible for the spreading pattern of a single paravertebral injection are still uncertain. In this study, 28 patients were randomly assigned to receive a paravertebral injection of radio-opaque dye (10 ml, with or without co-administration of 20 ml of local anaesthetics) either dorsal or ventral to the endothoracic fascia. The point of injection was determined by use of a nerve-stimulator and the radiographic distribution pattern was assessed blindly by a radiologist. Injections made in the more ventral part of the thoracic paravertebral space, supposedly anterior to the endothoracic fascia, resulted in a multisegmental longitudinal spreading pattern, whereas injections made dorsal to the endothoracic fascia resulted in a less predictable cloud-like spreading pattern, with only limited distribution over adjacent segments. The use of a nerve stimulator-guided technique appears to enhance the likelihood of achieving the more desirable longitudinal spreading pattern.
TL;DR: Although prescription rates (and error rates) in critical care appear higher than elsewhere in hospital, the number of potentially serious errors is similar to other areas of high‐risk practice.
Abstract: Drug prescription errors are a common cause of adverse incidents and may be largely preventable. The incidence of prescription errors in UK critical care units is unknown. The aim of this study was to collect data about prescription errors and so calculate the incidence and variation of errors nationally. Twenty-four critical care units took part in the study for a 4-week period. The total numbers of new and re-written prescriptions were recorded daily. Errors were classified according to the nature of the error. Over the 4-week period, 21,589 new prescriptions (or 15.3 new prescriptions per patient) were written. Eighty-five per cent (18,448 prescriptions) were error free, but 3141 (15%) prescriptions had one or more errors (2.2 erroneous prescriptions per patient, or 145.5 erroneous prescriptions per 1000 new prescriptions). The five most common incorrect prescriptions were for potassium chloride (10.2% errors), heparin (5.3%), magnesium sulphate (5.2%), paracetamol (3.2%) and propofol (3.1%). Most of the errors were minor or would have had no adverse effects but 618 (19.6%) errors were considered significant, serious or potentially life threatening. Four categories (not writing the order according to the British National Formulary recommendations, an ambiguous medication order, non-standard nomenclature and writing illegibly) accounted for 47.9% of all errors. Although prescription rates (and error rates) in critical care appear higher than elsewhere in hospital, the number of potentially serious errors is similar to other areas of high-risk practice.
TL;DR: There was a 100% success rate of achieving an adequate airway within acceptable time limits using the ‘Quiktrach’ and ‘Melker’ sets, with good airway patency and ease of ventilation.
Abstract: Summary
This study used a patient simulator to study the ease of use and efficacy of four currently available cricothyroidotomy sets. We assessed the success of insertion of each piece of equipment and measured the subsequent adequacy of oxygenation and ventilation. We also examined the complications encountered using each set. We found that there was a 100% success rate of achieving an adequate airway within acceptable time limits using the ‘Quiktrach’ and ‘Melker’ sets, with good airway patency and ease of ventilation. There was an unacceptably high failure rate in achieving a patent airway when using the ‘Transtracheal airway catheter with ENK-flow modulator’ and ‘Patil's airway'. The pre-assembled and user-friendly ‘Quiktrach’ set provided the fastest and most effective means of oxygenation in the simulated patient requiring an emergency surgical airway.
TL;DR: This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme.
Abstract: Cervical spine injury occurs in 5-10% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. In addition, many studies are limited in their application to the obtunded or unconscious trauma victim. This review will provide the clinician managing unconscious trauma victims with an assessment of the actual performance of clinical examination and imaging modalities in detecting cervical spine and isolated ligamentous injury, a review of existing guidelines in light of the available evidence, relative risk estimates and a proposed management scheme.
TL;DR: The impact of transoesophageal echocardiography on haemodynamic management during elective noncardiac surgery was assessed during this observational prospective database analysis and showed a significant impact on drug therapy in patients with pre‐operative systolic wall motion abnormalities.
Abstract: The impact of transoesophageal echocardiography on haemodynamic management during elective noncardiac surgery was assessed during this observational prospective database analysis. Ninety-nine consecutive patients were studied, who were at risk of intra-operative myocardial ischaemia or haemodynamic instability (Class II indications) and were undergoing vascular, visceral or chest surgery. A total of 165 new echocardiographic findings were recorded. Based on these findings changes in drug therapy were made in 47% and changes in fluid therapy in 24% of patients. Left ventricular wall motion abnormalities were seen in 32% and other relevant diagnoses made in 10%. Echocardiography showed a significant impact on drug therapy in patients with pre-operative systolic wall motion abnormalities (vasodilators: OR = 7.1, CI 95% = 2.1/24.0; vasopressors: OR = 3.3, CI 95% = 1.2/9.1) and patients with a history of left heart failure (vasodilators: OR = 5.2, CI 95% = 1.0/31.4). Fluid therapy was significantly influenced by echocardiographic findings during liver and lung transplantation (50% compared with 24% during other surgical interventions, p < 0.05).
TL;DR: A 62‐year‐old male underwent off‐pump coronary artery grafting surgery while cerebral function was monitored with bispectral index (BIS), during which time the patient experienced a cardiopulmonary arrest.
Abstract: A 62-year-old male underwent off-pump coronary artery grafting surgery while cerebral function was monitored with bispectral index (BIS). The BIS monitoring was continued into the immediate postoperative period, during which time the patient experienced a cardiopulmonary arrest. The changes in the BIS values helped the resuscitating team in assessing the cerebral response to the cardiopulmonary resuscitation.
TL;DR: The discovery of tissue factor pathway inhibitor further supports the revised theory of coagulation and shows that blood‐borne tissue factor has an important procoagulant function in sepsis, atherosclerosis and cancer, and other functions beyond haemostasis such as immune function and metastases.
Abstract: The classical 'cascade/waterfall' hypothesis formulated to explain in vitro coagulation organised the amplification processes into the intrinsic and extrinsic pathways. Recent molecular biology and clinical data indicate that tissue factor/factor-VII interaction is the primary cellular initiator of coagulation in vivo. The process of blood coagulation is divided into an initiation phase followed by a propagation phase. The discovery of tissue factor pathway inhibitor further supports the revised theory of coagulation. Tissue factor is also a signalling receptor. Recent evidence has shown that blood-borne tissue factor has an important procoagulant function in sepsis, atherosclerosis and cancer, and other functions beyond haemostasis such as immune function and metastases.
TL;DR: This randomised, placebo‐controlled, patient and observer blinded trial was conducted to determine whether acupuncture at the acupuncture point P6 is effective in preventing postoperative nausea and vomiting (PONV) compared to placebo acupuncture.
Abstract: This randomised, placebo-controlled, patient and observer blinded trial was conducted to determine whether acupuncture at the acupuncture point P6 is effective in preventing postoperative nausea and vomiting (PONV) compared to placebo acupuncture. Female patients (n = 220) scheduled for gynaecological or breast surgery were randomly assigned to two groups receiving either acupuncture (n = 109) or placebo acupuncture (n = 111). Each group was stratified for type of surgery and included two subgroups receiving intervention either before or after induction of anaesthesia. The incidence of PONV and/or antiemetic rescue medication within 24 h after surgery was the main outcome measure which showed no statistically significant difference between groups (43.7% acupuncture, 50.9% placebo, p = 0.27). The differences were more pronounced for patients having gynaecological surgery (48.9% acupuncture, 67.6% placebo, p = 0.07) than for those having breast surgery (38.7% acupuncture, 40.3% placebo, p = 0.86). The secondary outcome, vomiting, was significantly reduced by acupuncture from 39.6% to 24.8% (p = 0.03). Subgroup analysis showed no difference between applications of acupuncture before compared to after induction of anaesthesia.
TL;DR: It is concluded that the application of positive airway pressure during induction of anaesthesia in adults prolongs the non‐hypoxic apnoea duration by > 2 min.
Abstract: Positive end-expiratory pressure (PEEP) applied during induction of anaesthesia may prevent atelectasis formation in the lungs This may increase the duration of non-hypoxic apnoea by increasing the functional residual capacity We studied the benefit of PEEP applied during the induction of anaesthesia on the duration of apnoea until the SpO2 reached 90% Forty ASA I-II patients were randomly allocated to one of two groups In the PEEP group (n = 20) patients were pre-oxygenated using 100% O2 administered using a CPAP device (6 cmH2O) for 5 min Following induction of anaesthesia, patients were mechanically ventilated (PEEP 6 cm H2O) for a further 5 min In the ZEEP group (n = 20), no CPAP or PEEP was used The duration of apnoea until SpO2 reached 90% was measured Non-hypoxic apnoea duration was longer in the PEEP group compared to ZEEP group (599 +/- 135 s vs 470 +/- 150 s, p = 0007) We conclude that the application of positive airway pressure during induction of anaesthesia in adults prolongs the non-hypoxic apnoea duration by > 2 min
TL;DR: There was no evidence that the prophylactic use of fresh frozen plasma affected peri‐operative blood loss in cardiac surgery, and there was some evidence that it may improve platelet count and fibrinogen concentration.
Abstract: Summary Fresh frozen plasma is commonly used in cardiac surgery in an attempt to replace clotting factors and to decrease bleeding. Despite this, there has been no previous review of the available literature to support this practice. The aim of this review was to study the effect of prophylactic peri-operative transfusion of fresh frozen plasma on bleeding and coagulopathy in patients undergoing cardiac surgery. A comprehensive literature search was performed and all randomised controlled trials of the use of fresh frozen plasma in cardiac surgery were included. Six small trials were found that included a total of 363 participants with six different dose regimens of fresh frozen plasma. The overall quality of the studies was poor due to small patient numbers and lack of allocation concealment. There was no evidence that the prophylactic use of fresh frozen plasma affected peri-operative blood loss in cardiac surgery. There was some evidence that it may improve platelet count and fibrinogen concentration.
TL;DR: Patients in the Bonfils group suffered less sore throat and hoarseness than those in the other group, as well as a subjective assessment of the handling of the device and the incidence of postoperative sore throats andHoarseness.
Abstract: Tracheal intubation with the intubating laryngeal mask airway or the Bonfils intubation fibrescope was performed in 80 patients with predicted difficult airways. Mallampati score, thyromental distance, mouth opening and mobility of the atlanto-occipital joint were used to predict difficult airways. The overall success rate, time to the first adequate lung ventilation and time taken for the successful placement of the tracheal tube were recorded, as well as a subjective assessment of the handling of the device and the incidence of postoperative sore throat and hoarseness. The median [range] time to the first adequate ventilation was significantly shorter with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (28 [6-85] s vs. 40 [23-77] s, p < 0.005). Tracheal intubation was significantly slower with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (76 [45-155] s vs. 40 [23-77] s, p < 0.0001. Patients in the Bonfils group suffered less sore throat and hoarseness than those in the other group.
TL;DR: The results show that the more intense the anaesthetists' belief that the violations were important, the less likely they were to violate, except for the case of alarm silencing, which suggests that there may be a basic lack of confidence in the reliability of audible alarms that undermines their utility.
Abstract: The Theory of Planned Behaviour has been used to investigate the likelihood that anaesthetists will routinely perform three violations of safety guidelines. The three violations were: failing to visit patients before surgery, failure to perform pre-anaesthetic equipment checks and the silencing of alarms during anaesthesia. These suggested violations arose from discussions with the Medical Defence Union. In forming the intention not to perform these violations, anaesthetists are most influenced by their normative beliefs about the violation, i.e. the opinion they believe a group of peers and other significant other people would hold about them performing the violation. The next most influential factor is their personal norms, i.e. beliefs that the individual has about whether the violation is really right or wrong, followed by behavioural beliefs, i.e. beliefs about the consequences of performing the violation, and control beliefs, i.e. beliefs about how much control they have over performing the violation. The results show that the more intense the anaesthetists' belief that the violations were important, the less likely they were to violate, except for the case of alarm silencing. This result suggests that there may be a basic lack of confidence in the reliability of audible alarms that undermines their utility.
TL;DR: Tracheal intubation using the Bonfils Intubation fibrescope appears to be a simple and effective technique for the management of a difficult intubations.
Abstract: Failed tracheal intubation due to a difficult airway is an important cause of anaesthetic morbidity and mortality This study was undertaken to evaluate the effectiveness of the Bonfils intubation fibrescope for tracheal intubation after failed direct laryngoscopy Twenty-five patients undergoing coronary artery bypass grafting were enrolled in the study after two attempts at conventional laryngoscopy by a board certified anaesthetist had failed Intubation with the Bonfils fibrescope was successful on the first attempt in 22 patients (88%) and on the first or second attempt in 24 patients (96%); in one patient intubation was impossible Median (IQR [range]) time to intubation using the Bonfils intubation fibrescope was 475 (30-80 [20-200]) s Tracheal intubation using the Bonfils intubation fibrescope appears to be a simple and effective technique for the management of a difficult intubation
TL;DR: The procedure can be performed safely and it seems unacceptable to uphold an age restriction, but it is believed that it is the individual level of development of the child that determines suitability for this type of surgery.
Abstract: We report the pre-operative preparation and anaesthetic management for resection of an intracerebral tumour during awake craniotomy in a 9-year-old boy. We believe this is the youngest patient reported to have undergone this procedure. The challenges of sedation and psychological care throughout the procedure are discussed. We conclude that the procedure can be performed safely and that it seems unacceptable to uphold an age restriction. We believe that it is the individual level of development of the child that determines suitability for this type of surgery.