Anaesthesia
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Although videolaryngoscopy can provide excellent views of the laryngeal structures as both the primary method of tracheal intubation and as a rescue technique for difficult direct laryngoscopy, the existing literature is inadequate to define expertise or even competence. We observed the performance of nine trainees during 890 intubations, with an additional 72 intubations performed by expert anaesthetists used as a control group. ⋯ Optimal performance was predicted by single laryngoscope insertion (p < 0.001) and a Cormack and Lehane grade-1 view (p < 0.001), and not by normal lifting force applied to the device (p = 0.15), with expertise reached after 76 attempts. These results indicate that expertise in videolaryngoscopy requires prolonged training and practice.
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Cranial nerve injuries are unusual complications of supraglottic airway use. Branches of the trigeminal, glossopharyngeal, vagus and the hypoglossal nerve may all be injured. We performed a systematic review of published case reports and case series of cranial nerve injury from the use of supraglottic airway devices. ⋯ Contributing factors may include: an inappropriate size or misplacement of the device; patient position; overinflation of the device cuff; and poor technique. Injuries other than to the recurrent laryngeal nerve are usually mild and self-limiting. Understanding the diverse presentation of cranial nerve injuries helps to distinguish them from other complications and assists in their management.
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The clinical value of the estimation of systolic pulmonary artery pressure, based on Doppler assessment of peak tricuspid regurgitant velocity using transoesophageal echocardiography, is unclear. We studied 109 patients to evaluate the feasibility of obtaining adequate Doppler recordings, and compared Doppler estimates with values measured using a pulmonary artery catheter in a subset of 33 patients. Tricuspid regurgitation was evaluated at the mid-oesophageal level at 0-120° using Doppler echocardiography. ⋯ Doppler estimates by transoesophageal echocardiography were within 10 mmHg and 15% of values recorded with the pulmonary artery catheter in 28/33 (75%) patients and 22/31 (55%) patients, respectively. In 7 (21%) patients, the echocardiographic Doppler measurement exceeded the measured systolic pulmonary artery pressure by more than 30%. Our study indicates that estimation of the systolic pulmonary artery pressure using transoesophageal Doppler echocardiography is not a reliable and clinically useful method in anaesthetised patients undergoing mechanical ventilation.