Anaesthesia
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The Difficult Airway Society 2015 guidelines recommend and describe in detail a surgical cricothyroidotomy technique for the can't intubate, can't oxygenate (CICO) scenario, but this can be technically challenging for anaesthetists with no surgical training. Following a structured training session, 104 anaesthetists took part individually in a simulated can't intubate, can't oxygenate event using simulation and airway models to evaluate how well they could perform these front-of-neck access techniques. Main outcomes measures were: ability to correctly perform the technical steps; procedural time; and success rate. ⋯ Mean (SD) procedural time was 44 (16) s and 65 (17) s for the palpable and impalpable cricothyroid membrane models, respectively (p ≤ 0.001). First-pass tracheal tube placement was obtained in 103 out of the 104 palpable cricothyroidotomies and in 101 out of the 104 impalpable cricothyroidotomies (p = 0.31). We conclude that anaesthetists can be trained to perform surgical front-of-neck access to an acceptable level of competence and speed when assessed using a simulator.
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Randomized Controlled Trial
A triple-blind, placebo-controlled randomised trial of the ilioinguinal-transversus abdominis plane (I-TAP) nerve block for elective caesarean section.
This study investigated the efficacy of a new ilioinguinal-transversus abdominis plane block when used as a component of multimodal analgesia. We conducted a prospective, triple-blind, placebo-controlled randomised study of 100 women undergoing elective caesarean section. All women had spinal anaesthesia with hyperbaric bupivacaine, 15 μg fentanyl and 150 μg morphine, as well as 100 mg diclofenac and 1.5 g paracetamol rectally. ⋯ Post-hoc analysis showed that the ilioinguinal-transversus abdominis group was less likely to use ≥ 1000 μg fentanyl compared with the control group (2% vs. 16%; p = 0.016). There were no differences in opioid-related side-effects or maternal satisfaction with analgesia. The addition of the ilioinguinal-transversus abdominis plane block provides superior analgesia to our usual multimodal analgesic regimen.
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Although target-controlled infusion has been in use for more than two decades, its benefits are being obscured by anomalies in clinical practice caused by a number of important problems. These include: a variety of pharmacokinetic models available in open target-controlled infusion systems, which often confuse the user; the extrapolation of anthropomorphic data which provokes anomalous adjustments of dosing by such systems; and the uncertainty of regulatory requirements for the application of target-controlled infusion which causes uncontrolled exploitation of drugs and pharmacokinetic models in target-controlled infusion devices. ⋯ However, a specific behaviour of a model in a target-controlled infusion system that is neither intended nor supported by scientific data can be considered an artefact or anomaly. Several of these anomalies can be identified in the current commercially available target-controlled infusion systems and are discussed in this review.
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Randomized Controlled Trial
The effect of anaesthetic technique during primary breast cancer surgery on neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and return to intended oncological therapy.
Inflammation and immunosuppression contribute to the pathogenesis of cancer. An increased neutrophil-lymphocyte ratio reflects these processes and is associated with adverse cancer outcomes. Whether anaesthetic technique for breast cancer surgery influences these factors, and potentially cancer recurrence, remains unknown. ⋯ Pre-operative neutrophil-lymphocyte ratio was similar in the propofol-paravertebral 2.3 (95%CI 1.8-2.8) and inhalational agent-opioid anaesthesia 2.2 (1.9-3.2) groups, p = 0.72. Postoperative neutrophil-lymphocyte ratio was lower (3.0 (2.4-4.2) vs. 4.0 (2.9-5.4), p = 0.001) in the propofol-paravertebral group. Propofol-paravertebral anaesthesia attenuated the postoperative increase in the neutrophil-lymphocyte ratio.
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Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. ⋯ Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.