Anaesthesia
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Review Meta Analysis
Meta-analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy.
Controversy exists regarding the best choice of anaesthesia for carotid endarterectomy. We aimed to evaluate the peri-operative outcomes of local vs. general anaesthesia for carotid endarterectomy. We conducted a systematic search of electronic information sources and applied a combination of free text and controlled vocabulary searches adapted to thesaurus headings, search operators and limits in each of the electronic databases. ⋯ On trial sequential analysis of the randomised trials, the Z-curve did not cross the α-spending boundaries or futility boundaries for stroke, mortality and transient ischaemic attack, suggesting that more trials are needed to reach conclusive results. Our meta-analysis of observational studies suggests that local anaesthesia for carotid endarterectomy may be associated with lower peri-operative morbidity and mortality compared with general anaesthesia. Although randomised studies have not confirmed any advantage for local anaesthesia, this may be due to a lack of pooled statistical power in these trials.
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Observational Study
Using middle finger length to determine the internal diameter of uncuffed tracheal tubes in paediatrics.
The selection of an appropriately-sized tracheal tube is of critical importance in paediatric patients to reduce both the risk of subglottic stenosis from a tracheal tube that is too large, and inadequate ventilation or poor end-tidal gas monitoring from a tracheal tube that is too small. Age formulae are widely used, but known to be unreliable, often resulting in a need to change the tracheal tube. Previous work has shown that the length of the middle finger and the internal diameter can both be used to guide depth of tracheal tube insertion. ⋯ We found a linear relationship between uncuffed tracheal tube internal diameter and median middle finger length for each size of tracheal tube. Relationship between middle finger length and cuffed tracheal tube internal diameter was less clear. We propose that the formula: 'middle finger length (cm) (round up to nearest 0.5) = internal diameter of uncuffed tracheal tube (mm)' may be an improvement compared with age formulae for selecting uncuffed tracheal tubes in children, although this requires formal testing.
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Multicenter Study Observational Study
A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning.
Cricoid pressure is employed during rapid sequence induction to reduce the risk of pulmonary aspiration. Correct application of cricoid pressure depends on knowledge of neck anatomy and precise identification of surface landmarks. Inaccurate localisation of the cricoid cartilage during rapid sequence induction risks incomplete oesophageal occlusion, with potential for pulmonary aspiration of gastric contents. ⋯ There were also no significant differences in error between male and female patients. Identification of cricoid position using a landmark technique has a high degree of variability and has little correlation with age, sex or body mass index. These findings have significant implications for the safe application of cricoid pressure in the context of rapid sequence induction.
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Comparative Study
Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study.
Although different injection locations for retrolaminar and erector spinae plane blocks have been described, the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. ⋯ The number of stained thoracic spinal nerves was greater with erector spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique, the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of dye and with limited spread to the paravertebral space.
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Complications during pregnancy are not frequent, but may occur abruptly. Point-of-care ultrasound is a non-invasive, non-ionising diagnostic tool that is available at the bed-side when complications occur. This review covers the use of ultrasound in various clinical situations. ⋯ Combined echocardiography and lung ultrasound can be combined with ultrasound of the leg veins to differentiate between the various causes of acute respiratory failure, and guide treatment in this situation. Finally, as shown in the general population, multi-organ point-of-care ultrasound allows early diagnosis of the main causes of circulatory failure and cardiac arrest at the bed-side. As the importance of point-of-care ultrasound in critical patients is increasingly recognised, it is emerging as an important tool in the therapeutic armoury of obstetric anaesthetists.