Anaesthesia
-
Observational Study
Impact of change in head and neck position on ultrasound localisation of the cricothyroid membrane: an observational study.
The ideal position for performing surgical cricothyroidotomy is with full neck extension. Some authors have recommended marking the cricothyroid membrane before general anaesthesia, typically with the patient's head and neck in a neutral position. The primary aim of this observational study was to determine whether skin marks made over the centre of the cricothyroid membrane with the head and neck in the neutral position moved outside the boundaries of the membrane when the neck was subsequently extended. ⋯ The initial skin mark moved to lie outside the boundary of the cricothyroid membrane in 12 of 22 subjects after extending the neck. The height of the cricothyroid membrane increased by 30% with the neck extended. We recommend that marking the skin in preparation for cricothyroidotomy should be performed with the neck extended, not with the head and neck in the neutral position as previously suggested.
-
Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. ⋯ Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.
-
Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. ⋯ There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.