Anaesthesia
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Cancellation of scheduled surgery is undesirable for patients and an inefficient use of resources. We prospectively collected data for 52 consecutive months in a public general hospital to estimate the prevalence and causes. ⋯ The commonest specific causes within these categories were respectively: infections/fever (18%), patient did not attend (20%) and lack of theatre time (23%). This data will help direct resources to target prevention of cancellations as a result of these main problems.
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We previously defined surgical list 'efficiency' as: maximising theatre utilisation, minimising over-running, and minimising cancellations. 'Efficiency' maximises output for input; 'productivity' emphasises total output. We define six criteria that any measure of productivity (better termed 'quantitative performance') needs to satisfy. We then present a theoretical analysis that fulfils these by incorporating: 'speed' of surgery (with reference to average speeds), 'patient contact' (synonymous with minimising gaps between cases), and 'efficiency' (as previously defined). 'Speed' and 'patient contact' together constitute a 'productive potential'. Our formula satisfies the pre-set criteria and yields plausible results in both hypothetical and real data sets, To be productive in these quantitative terms, teams in any specialty need to achieve minimum quality standards defined by their sub-specialty; to plan their lists to utilise the time available with no cancellations or over-runs and to work at least as fast as average with minimal gaps between cases. 'Productive potential' combined with 'efficiency' yielding 'actual productivity' in our theoretical analysis more completely describes quantitative surgical list performance than any other single measure.
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In rapid sequence induction of anaesthesia in the emergency setting in shocked or hypotensive patients (e.g. ruptured abdominal aortic aneurysm, polytrauma or septic shock), prior resuscitation is often suboptimal and comorbidities (particularly cardiovascular) may be extensive. The induction agents with the most favourable pharmacological properties conferring haemodynamic stability appear to be ketamine and etomidate. ⋯ Ketamine has been traditionally contra-indicated in the presence of brain injury, but we argue in this review that any adverse effects of the drug on intracranial pressure or cerebral blood flow are in fact attenuated or reversed by controlled ventilation, subsequent anaesthesia and the greater general haemodynamic stability conferred by the drug. Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised patients.
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Randomized Controlled Trial Comparative Study
Tracheal intubation and alternative airway management devices used by healthcare professionals with different level of pre-existing skills: a manikin study.
The classic Laryngeal Mask Airway (cLMA), ProSeal Laryngeal Mask Airway (PLMA), Intubating Laryngeal Mask Airway (ILMA), Combitube (CT), Laryngeal Tube (LT) and tracheal intubation (TI) were compared in a manikin study. Nurses, anaesthetic nurses, paramedics, physicians and anaesthetists inserted the devices three times in a randomised sequence. Time taken for successful insertion, success rates and ease of insertion were evaluated. ⋯ All non-anaesthetists were able to insert the cLMA, PLMA and LT within two attempts with a > 90% success rate on the first attempt. The ILMA and TI were the only devices where more than one subject experienced some difficulty in insertion. The cLMA, PLMA and LT should be evaluated for use in situations where only limited airway training is possible.