Anaesthesia
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Randomized Controlled Trial
Standard and flexible tip bougie for tracheal intubation using a non-channelled hyperangulated videolaryngoscope: a randomised comparison.
Bougie impingement during tracheal intubation can increases the likelihood of prolonged intubation time, failed intubation and airway trauma. A flexible tip bougie may overcome this problem, which can occur when using a non-channelled, hyperangulated videolaryngoscope with a standard bougie. This randomised controlled study compared standard and flexible tip bougies using a non-channelled videolaryngoscope (C-MAC® D-blade) in 160 patients. ⋯ There was no significant differences in laryngoscopy time, total tracheal intubation time, first attempt success rate and postoperative sore throat between the two groups. Both the flexible tip and standard bougies can be used with a high first attempt success rate for tracheal intubation using a C-MAC D-blade videolaryngoscope. The flexible tip bougie demonstrated a significantly better modified intubation difficulty scale score and lower incidence of bougie impingement.
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Review
Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults.
Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. ⋯ After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.
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Average pre-operative fasting times for clear liquids are many times longer than those specified in national and international guidelines. We sought to decrease fasting times by applying a quality management tool aimed at continuous improvement. Through the application of iterative 'plan-do-study-act' cycles, tools to reduce pre-operative liquid fasting times were developed and applied, the effects measured, analysed and interpreted and the conclusions used to inform the next plan-do-study-act cycle. ⋯ The third cycle included lectures for ward staff, putting up information posters throughout the hospital, revision of all written materials and provision of screencasts on the homepage for staff and patients. This decreased median liquid fasting time to 2.1 (1.2-3.8 [0.4-18.8]; p < 0.0001) h, with inpatients having the shortest fasting time of 1.4 (1.1-3.8 [0.4-18.8]) h. Repeated quality improvement cycles, adapted to local context, can support sustained reductions in pre-operative liquid fasting times.
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Randomized Controlled Trial
Ease and comfort of pre-oxygenation with high-flow nasal oxygen cannulae vs. facemask: a randomised controlled trial.
The Difficult Airway Society recommends that all patients should be pre-oxygenated before the induction of general anaesthesia, but this may not always be easy or comfortable and anaesthesia may often be induced without full pre-oxygenation. We tested the hypothesis that high-flow nasal oxygen cannulae would be easier and more comfortable than facemasks for pre-oxygenation. We randomly allocated 199 patients undergoing elective surgery aged ≥ 10 years to pre-oxygenation using either high-flow nasal oxygen or facemask. ⋯ There was no significant difference between groups in the number of patients with hypoxaemia (Sp O2 < 90%) or severe hypoxaemia (Sp O2 < 85%) lasting ≥ 1 min or ≥ 2 min; in the proportion of patients with an end-tidal oxygen fraction < 87% in the first 5 min after tracheal intubation (52.2% vs. 58.9% in facemask and high-flow nasal oxygen groups, respectively; p = 0.31); or in time taken to secure an airway (11.6 vs. 12.2 min in facemask and high-flow nasal oxygen groups, respectively; p = 0.65). In conclusion, we found pre-oxygenation with high-flow nasal oxygen to be easier for anaesthetists and more comfortable for patients than pre-oxygenation with a facemask, with no clinically relevant differences in end-tidal oxygen fraction after securing a definitive airway or time to secure an airway. The differences in ease and comfort were modest.