Anaesthesia
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The term 'dedicated airway' was first used in connection with nasal fibreoptic intubations using the cuffed nasopharyngeal airway. Since that time, the concept has developed and the term has been extended to include fibreoptic intubation techniques involving both the laryngeal mask airway and cuffed oropharyngeal airway. 'Dedicated airway' can now be defined as: 'An upper airway device dedicated to the maintenance of airway patency while other major airway interventions are anticipated or are in progress. ⋯ As well as promoting safe conditions for training fibreoptic intubation in general, there is the particular advantage of being able to train using these techniques in patients known to be difficult to intubate. The authors' evolved clinical experiences in promoting the concept and the relevant literature are reviewed.
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This study aimed to evaluate whether cricoid pressure is associated with a high risk of gastro-oesophageal reflux. Fifteen awake, fasted volunteers were studied. ⋯ Using continuous oesophageal pH monitoring, no volunteer had gastro-oesophageal reflux during cricoid pressure, although one subject had a reflux spike soon after relieving cricoid pressure. We conclude with 95% confidence that the incidence of gastro-oesophageal reflux during cricoid pressure is not more than 20%.
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Case Reports
Intubating laryngeal mask and rapid sequence induction in patients with cervical spine injury.
The Intubating Laryngeal Mask (FastrachTM), a modified conventional laryngeal mask airway, and its prototype cuffed silicone tube, continue to be an appropriate intubating tool in combination with fibreoptic bronchoscopy in the emergency situation. This is an account of two patients with suspected cervical spine fracture admitted to our emergency room in a haemodynamically unstable condition and requiring a rapid sequence induction of anaesthesia, in whom we successfully applied this newly developed intubating device for the first time. Provided that there are no intubation difficulties, direct laryngoscopy is still the fastest method of securing an airway; however, this procedure leads to an extension of the cervical spine, which may be hazardous in the case of a cervical spine injury. Intubation by means of the Intubating Laryngeal Mask avoids dangerous hyperextension of the occipito-atlanto-axial complex, a fact that we were able to verify by lateral cervical spine fluoroscopy during intubation.
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Case Reports
Acromegaly and papillomatosis: difficult intubation and use of the airway exchange catheter.
We describe the anaesthetic management of a patient with acromegaly scheduled for transsphenoidal resection of a pituitary tumour who was found at intubation to have coexisting laryngeal papillomatosis. Oral intubation was impossible using both direct and fibreoptic techniques. Nasal fibreoptic intubation was successful but precluded the transsphenoidal approach to surgery. A Cook Airway Exchange Catheter [Cook (UK) Ltd, Monroe House, Letchworth SG6 1LN] was used with a Negus bronchoscope to convert to oral intubation and allow completion of surgery without resort to tracheostomy.
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A study published in 1992 highlighted wide variations in the provision of training in pain management. In this survey, data were collected from both pain clinicians and Programme Directors of the Schools of Anaesthesia to see if there had been any changes in training patterns since the introduction of the Calman training scheme. There did not seem to be a uniform improvement in the provision of training in pain management for Specialist Registrars and many may reach their Certificate of Completion of Specialist Training without a basic knowledge of chronic pain. It is thought that at the present time there will be few Specialist Registrars with sufficient training to take up consultant posts in pain management unless they compete for the much sought after, and often not fully funded, pain fellowships outside their rotations.