Anesthesiology
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Randomized Controlled Trial Comparative Study
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.
Accurately identifying the cricothyroid membrane is foundational for front-of-neck rescue of airway misadventure. Yet the very patients who are at risk of a cannot intubate, cannot oxygenate scenario (eg. obese, neck pathology) are also likely to make identifying the cricothyroid membrane (CTM) difficult.
Naveed and co. compared the accuracy of CTM palpation to ultrasound in a single-blinded randomized trial of 223 patients, with poorly defined landmarks, undergoing CT neck.
The ultrasound group showed a 10-time greater success in identifying the CTM (correct within 5 mm of actual; 81% vs 8%), along with a 5-times smaller mean distance from actual to estimated, than did the palpation group.
So what's the take home?
Given the wide-availability of ultrasound and it's acceptability to patients, any pre-induction marking of the CTM in an anticipated difficult airway should employ neck ultrasound in all but the most obviously-palpable necks.
In an emergent CICO situation, neck ultrasound likely has utility, though at the potential cost of procedural complexity and delay.
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Randomized Controlled Trial
Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis.
Optimal intraoperative PEEP varies among patients. Individualizing PEEP reduces post-operative atelectasis.
pearl -
Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. ⋯ In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.