Anaesthesia
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Randomized Controlled Trial Clinical Trial
The use of the McCoy laryngoscope in patients with simulated cervical spine injuries.
We studied the laryngoscopic view in 167 patients with their head and necks held in the neutral position with manual in-line stabilisation and cricoid pressure to simulate the patient with a suspected cervical spine injury. Each patient underwent laryngoscopy using both a McCoy and a Macintosh laryngoscope. The best view obtained by each larngoscope was graded according to standard guidelines. ⋯ It improved the Macintosh grade by 1 grade in 41% and by 2 grades in 8% (p < 0.001). Difficult laryngoscopy, defined as the inability to see the glottis (grade 3 or 4), was found in 56 (33%) with the Macintosh laryngoscope and only eight (5%) (P < 0.001) with the McCoy laryngoscope. We suggest that patients with a suspected cervical spine injury and a full stomach should be intubated using a McCoy in preference to a Macintosh laryngoscope.
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The triggering of phantom limb pain by subarachnoid or epidural anaesthesia has been well described leading to the suggestion that neuraxial regional anaesthesia is relatively contraindicated in lower limb amputees. We report our experience of the provision of anaesthesia for repeat Caesarean section on two occasions in such a patient. Intrathecal fentanyl and morphine supplementation of bupivacaine successfully abolished peri-operative phantom limb pain, whereas epidural anaesthesia was associated with recurrence of phantom limb pain upon regression of the block.
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An analysis of 1500 laryngeal mask airway uses by one anaesthetist using the standard insertion technique was conducted to determine successful insertion rates, position by fibreoptic larynoscopy, complication rates and whether there is a long-term learning curve. The correlation between laryngeal mask airway placement and modified Mallampati grade was also determined. The first time insertion rate was 95.5% with an overall failure rate after three attempts of 0.4%. ⋯ The vocal cords were visible from the mask aperture bars in 97.1%. Comparison of insertion rates, fibreoptic position and complications for the first and second 750 insertions provides evidence for a 'long' term learning curve. These data could be used as a guide for 'optimal' or expected successful laryngeal mask airway insertion rates in adults undergoing routine anaesthesia.
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Recent published data suggest that despite apparently satisfactory recovery from nondepolarising block (train-of-four ratios in excess of 0.90), even very small doses of additional relaxant may re-establish significant paralysis. We sought to verify this observation and quantify its magnitude. Twelve adult patients were studied under nitrous oxide-propofol-opioid anaesthesia and neuromuscular block was monitored electromyographically. ⋯ The control ED50 of mivacurium (calculated from the initial dose of mivacurium) averaged 43 micrograms.kg-1. When the same dose of drug was given at 95% recovery of the train-of-four ratio, the ED50 was reduced to 19 micrograms.kg-1 (p < 0.0001). Hence, there remains a considerable reduction in the neuromuscular margin of safety even at a train-of-four ratio of 0.95.
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Comparative Study
A practical evaluation of four human-powered portable airway aspirators.
The establishment of a clear airway is a vital part of basic life support and mechanical devices are available to assist the clearance of the upper airway during resuscitation. The performances of four human-powered devices, currently available in the United Kingdom, were compared with the relevant British Standard. The ease of use of the devices by 20 experienced and 20 novice resuscitators was assessed. ⋯ However, two devices ('Res-Q-Vac' and 'Ambu Maxi Suction Pump') were more user friendly. The incidence of airway contamination during resuscitation and the current recommended resuscitation protocols suggest that there is a need for increased emphasis on these airway adjuncts in life-support training. Wider access to basic life support equipment inside and outside hospital premises may improve resuscitation outcome.