Anaesthesia and intensive care
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Anaesth Intensive Care · Jul 2021
Transtracheal jet ventilation in a general tertiary hospital: A 7-year audit.
Airway management in patients presenting with severe airway obstruction can present a challenge to the anaesthetist, as conventional difficult airway pathways are often inappropriate. The use of a transtracheal jet cannula is an alternative means of airway securement, but lack of familiarity has limited its use in general tertiary hospitals. We report a retrospective audit of the use of transtracheal jet ventilation in a general tertiary healthcare centre over the past seven years, with a total of 50 patients with severe airway compromise undergoing pharyngolaryngeal surgery. ⋯ We conclude that transtracheal jet ventilation for high-risk pharyngolaryngeal surgery can be performed using a high frequency jet ventilator, with a high rate of success and only minor complications. Cannulation of the trachea below the cricothyroid membrane is feasible but more challenging. Low-flow apnoeic oxygenation through the transtracheal jet ventilation cannula maintains oxygenation during initial surgical airway manipulation.
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Anaesth Intensive Care · Jul 2021
ReviewAirway management in the adult patient with COVID-19: High flow nasal oxygen or not? A summary of evidence and local expert opinion.
The use of high flow nasal oxygen in the care of COVID-19-positive adult patients remains an area of contention. Early guidelines have discouraged the use of high flow nasal oxygen therapy in this setting due to the risk of viral spread to healthcare workers. However, there is the need to balance the relative risks of increased aerosol generation and virus transmission to healthcare workers against the role high flow nasal oxygen has in reducing hypoxaemia when managing the airway in high-risk patients during intubation or sedation procedures. ⋯ However, given the limited safety data, we recommend a cautious approach. For intubation in the COVID-positive or suspected COVID-positive patient we support the use of high flow nasal oxygen to extend time to desaturation in the at-risk groups, which include the morbidly obese, those with predicted difficult airways and patients with significant hypoxaemia, ensuring well-fitted high flow nasal oxygen prongs with staff wearing full personal protective equipment. For sedation cases, we support the use of high flow nasal oxygen when there is an elevated risk of hypoxaemia (e.g. bariatric endoscopy or prone-positioned procedures), but recommend securing the airway with a cuffed endotracheal tube for the longer duration procedures when theatre staff remain in close proximity to the upper airway, or considering the use of a surgical mask to reduce the risk of exhaled particle dispersion.
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Anaesth Intensive Care · Jul 2021
Risk factor identification and predictive models for central line requirements for patients on vasopressors.
Vasopressors are ubiquitous in intensive care units. While central venous catheters are the preferred route of infusion, recent evidence suggests peripheral administration may be safe for short, single-agent courses. Here, we identify risk factors and develop a predictive model for patient central venous catheter requirement using the Medical Information Mart for Intensive Care, a single-centre dataset of patients admitted to an intensive care unit between 2008 and 2019. ⋯ A logistic regression model predicting the composite endpoint had an area under the receiver operating characteristic curve (standard deviation) of 0.747 (0.013) and an accuracy of 0.691 (0.012). This retrospective study reveals a high prevalence of short vasopressor courses in intensive care unit settings, a majority of which were administered using central venous catheters. We identify several important risk factors that may help guide clinicians deciding between peripheral and central venous catheter administration, and present a predictive model that may inform future prospective trials.
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Anaesth Intensive Care · Jul 2021
Early intubation versus late intubation for COVID-19 patients: An in situ simulation identifying factors affecting performance and infection control in airway management.
COVID-19 poses an infectious risk to healthcare workers especially during airway management. We compared the impact of early versus late intubation on infection control and performance in a randomised in situ simulation, using fluorescent powder as a surrogate for contamination. Twenty anaesthetists and intensivists intubated a simulated patient with COVID-19. ⋯ There was no difference in performance measured by intubation time and incidence of first attempt success. Late intubation, especially when resources are limited, may be a valid approach. However, strict infection control and appropriate personal protective equipment usage is recommended in such cases.