Anaesthesia
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Observational Study
Ultrasound assessment of gastric contents in children undergoing elective ear, nose and throat surgery: a prospective cohort study.
Ultrasound examination of the gastric antrum allows reliable assessment of gastric contents and volume. Postoperative assessment of gastric contents before recovery from anaesthesia could help the physician to choose the most appropriate extubation technique after surgery in children. In this prospective observational study, we assessed whether significant changes occurred in gastric contents during the intra-operative period in children undergoing elective ear, nose and throat (ENT) surgery. ⋯ The mean (SD) gastric volume was 0.28 (0.30) ml.kg-1 before surgery and 0.27 (0.30) ml.kg-1 after surgery, p = 0.82. No solid contents were identified in the antrum, and the gastric volume was < 1.5 ml.kg-1 in all patients during both ultrasound examinations. Our results suggest that, after elective ENT surgery, children are not at risk of a full stomach before tracheal extubation, and that pulmonary aspiration of blood that may occur after elective ENT surgery is probably not related to regurgitation of ingested blood from the stomach.
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Surgery under apnoeic conditions with the use of high-flow nasal oxygen is novel. Between November 2016 and May 2017, 28 patients underwent tubeless laryngeal or tracheal surgery under apnoeic conditions with high-flow nasal oxygen as the sole method of gas exchange. Patients received total intravenous anaesthesia and neuromuscular blocking agents for the duration of their surgery. ⋯ Mean (SD) pH was 7.40 (0.03) at baseline and 7.23 (0.04) after 15 min of apnoea. Mean (SD) standard bicarbonate was 26.7 (1.8) mmol.l-1 at baseline and 25.4 (1.8) mmol.l-1 at 15 min. We conclude that high-flow nasal oxygen under apnoeic conditions can provide satisfactory gas exchange in order to allow tubeless anaesthesia for laryngeal surgery.
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Observational Study
Change of transfusion and treatment paradigm in major trauma patients.
Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005-2007) and after (2012-2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. ⋯ Compared to 2005-2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012-2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012-2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.
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Capnography (ETCO2 ) is routinely used as a non-invasive estimate of arterial carbon dioxide (PaCO2 ) levels in order to modify ventilatory settings, whereby it is assumed that there is a positive gap between PaCO2 and ETCO2 of approximately 0.5 kPa. However, negative values (ETCO2 > PaCO2 ) can be observed. We retrospectively analysed arterial to end-tidal carbon dioxide differences in 799 children undergoing general anaesthesia with mechanical ventilation of the lungs in order to elucidate predictors for a negative gap. ⋯ The intercept model revealed PaCO2 to be the strongest predictor for a negative PaCO2 -ETCO2 difference. A decrease in PaCO2 by 1 kPa resulted in a decrease in the PaCO2 -ETCO2 difference by 0.23 kPa. This study demonstrates that ETCO2 monitoring in children whose lungs are mechanically ventilated may paradoxically lead to overestimation of ETCO2 (ETCO2 > PaCO2 ) with a subsequent risk of unrecognised hypocarbia.
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Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. ⋯ We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0-10.0 [4.0-12.0]) kg and 15.4 (12.1-23.2 [3.3-49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.