Effect of palpable vs. impalpable cricothyroid membranes in a simulated emergency front-of-neck access scenario.

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. Outcomes were compared between palpable and impalpable cricothyroid membrane scenarios. Anaesthetists' technical abilities were good, as assessed by a video analysis checklist score. 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.

Anaesthesia for electroconvulsive therapy: a comparison of sevoflurane with propofol.

This study was a prospective audit of patients receiving either intravenous induction of anaesthesia with propofol 2 mg/kg or inhalational induction using 8% sevoflurane for patients undergoing electroconvulsive therapy (ECT). All patients received inhaled 50% nitrous oxide. The anaesthetic agent was determined by psychiatrist preference. Each psychiatrist nominated only one induction technique for all his or her patients. Seventy treatments were studied in each group. Induction time was longer in the sevoflurane group. The time from commencing induction to loss of verbal contact was [mean (SD)] 64 (29.9) seconds for sevoflurane and 36 (33.6) seconds for propofol (P=0.001). Time to loss of eyelash reflex was 82 (32.6)s for sevoflurane and 44 (17.9)s for propofol (P<0.001). The duration of seizure activity was longer in sevoflurane patients, 35 (17.8)s, compared with 20 (9.8)s in the propofol group (P< 0.001). Discharge times were similar Minor adverse effects occurred in three patients, all in the sevoflurane group (one bradycardia and two episodes of post-procedural nausea). There were no major adverse events in either group. Propofol and sevoflurane both appear to be suitable agents for induction of anaesthesia for ECT.

Prediction of readmission to acute psychiatric units.

BACKGROUND: Many factors are known to influence readmission to psychiatric wards, and readmission rates have been suggested as proxy outcome indicators of quality. METHOD: Korner returns were used to ascertain readmission rates for all psychiatric admissions to acute wards in North Staffordshire, 1987-1993. Predictor variables were derived from Korner returns or obtained from the 1991 Census data. Survival analysis techniques were used to examine which variables predicted readmission. RESULTS: A predictive model was derived using Cox regression, which followed the observed data at greater than chance probability (chi2=48.5, df=4, P < 0.001). A psychotic diagnosis was the most influential predictor of readmission. CONCLUSION: Length of stay is not predictive in the Cox regression model, which suggests patients are not being prematurely discharged. The derived models may have value in service planning, audit and resource allocation.

Effect of cricoid pressure on the success of endotracheal intubation with a lightwand.

BACKGROUND: The lightwand may be useful as an alternative for tracheal intubation during a rapid-sequence induction of anesthesia in the presence of a full stomach. This study was undertaken to assess the effect of application of cricoid pressure on the success of lightwand intubation. METHODS: Sixty adult female patients presenting for abdominal hysterectomy were randomly allocated to lightwand intubation with and without cricoid pressure. The time to successful intubation and number of attempts were recorded. RESULTS: All 30 patients allocated to intubation without cricoid pressure were intubated successfully at the first attempt within a median time of 28 s (95% confidence interval, 18-77 s). Lightwand intubation with cricoid pressure was successful in 26 of 30 patients at the first attempt, but the median time to successful intubation was significantly longer at 48.5 s (95% confidence interval, 36-78 s; P = 0.001). Three patients required two attempts for successful intubation, and one could not be intubated with the lightwand while cricoid pressure was being applied. CONCLUSIONS: The lightwand cannot be recommended for the first attempt at intubation where cricoid pressure is being applied because the time to successful intubation is significantly prolonged, and the failure rate for the first attempt at lightwand intubation is 13%.

Congenital diaphragmatic hernia repair--impact of delayed surgery and epidural analgesia.

This study was undertaken to assess the impact on mortality and the need for postoperative ventilation of intra- and postoperative epidural analgesia and delayed surgery in neonates with congenital diaphragmatic hernia. The study was a retrospective chart review of 35 neonates with congenital diaphragmatic hernia treated in Durban between 1988 and 1993. The mortality rate was 30%, with too few patients having delayed surgery to demonstrate a benefit from this policy. Mortality and the requirement for postoperative ventilation were reduced in the epidural group. However, the patients with the worst prognosis all received general anaesthesia. The benefit of delaying surgery for congenital diaphragmatic hernia repair could not be demonstrated because of small numbers. Epidural analgesia appears to be a useful technique to reduce the need for postoperative ventilation following repair in lower-risk patients.

North Staffordshire Community Beds Study: longitudinal evaluation of psychiatric in-patient units attached to community mental health centres. I: Methods, outcome and patient satisfaction.

BACKGROUND: This study evaluates two in-patient units attached to community mental health centres (CMHCs) that were designed to supplement acute in-patient care and to integrate with community-based after-care services. AIM: To examine the comparative outcome of patients with severe mental illness (SMI) admitted to the two units. METHOD: All patients with SMI admitted to the acute psychiatric wards serving the two CMHCs, those transferred to the community in-patient units and those admitted directly to these units (n = 110) were compared with patients (n = 67) admitted to acute wards serving two similar catchment areas without associated community beds. Baseline clinical and social measures were made and repeated at six and 12 months. Satisfaction with services was assessed at 12 months. RESULTS: The experimental group showed significantly better outcomes, significant reduction in unmet need and better satisfaction with services. CONCLUSIONS: The use of the community beds appears to have significant benefits for patients with SMI.

Mivacurium for caesarean section in hypertensive parturients receiving magnesium sulphate therapy.

The interaction between mivacurium and magnesium sulphate was investigated in a group of parturients undergoing caesarean section under general anaesthesia. Thirty parturients were studied; 10 normotensive controls (group NT), 10 hypertensive controls (group HT) and 10 hypertensives who received magnesium sulphate (group HTM). At induction group HT received 30 microg/kg of alfentanil and group HTM 10 microg/kg of alfentanil and 30 or 60 mg/kg of magnesium sulphate. Neuromuscular function was monitored by electromyography. Mivacurium 0.15 mg/kg was given after 60% recovery of T1 following succinylcholine. Magnesium concentrations and plasma cholinesterase activity were significantly elevated in group HTM (1.57 +/- 0.53 mmol/1 and 4.60 +/- 1.27 kU/1) compared with group HT (0.71 +/- 0.18 mmol/1 and 3.44 +/- 0.97 kU/1) and group NT (0.60 +/- 0.07 mmol/1 and 2.86 +/- 0.82 kU/1) (P < 0.005). Time to maximal recovery, and time from 25-75% of maximal recovery from mivacurium, were significantly prolonged in group HTM (60.9 +/- 15.3 min and 16.8 +/- 5.6 min) compared with group HT (34.9 +/- 7.6 min and 7.6 +/- 3.6 min) and group NT (37.4 +/- 14.4 min and 8.5 +/- 3.4 min) (P < 0.01). Time to 25% recovery was prolonged in group HTM (35.1 +/- 7.4 min) compared with the other two groups (HT: 21.6 +/- 6.4 min and NT: 22.8 +/- 10.2 min) (P < 0.01). Whilst the duration of action of mivacurium, determined by electromyography, is prolonged by subtherapeutic serum magnesium concentrations, of the available non-depolarizing relaxants mivacurium would seem to be most appropriate for caesarean section.

De facto gatekeeping and informed consent in intensive care.

Medical decision-making is based on the doctrine of informed consent which is, in turn, based on autonomy, which represents one of four pillars of medical ethics, the others being beneficence, non-malfeasance and social justice. Decision-making in intensive care with respect to the withdrawal of treatment, in particular ventilator therapy, is often extremely difficult for patients or their relatives and they would rather not make any decision other than to insist on the maintenance of therapy in spite of sound, reasonable medical advice that such therapy is of no value to the patient. Aside from issues of a dignified death, this is likely to be to the detriment of other patients who might be refused admission to intensive care and thus is counter to the dictates of social justice. Under these circumstances, there would appear to be a need to give authority to the reasonable medical decision to discontinue resuscitation.

Social indicators and the prediction of psychiatric admission in different diagnostic groups.

BACKGROUND: Recent findings indicate that the established association between social indicators of deprivation and psychiatric admission rates may not hold across all diagnoses. METHOD: Admission rates in individuals aged 16-64 years for 71 electoral wards in North Staffordshire were calculated for six diagnostic groups using data from the Korner Episode System for 1987-1993. These were correlated with selected individual census variables, Townsend and Jarman indices. The ability of regression models to predict admission rates was tested. RESULTS: The strongest correlations were found for total admissions (r 0.44-0.79). Strong correlations were found for neurotic disorders/depression (r 0.29-0.62), schizophrenia (r 0.24-0.59), all non-psychotic disorders combined (r 0.41-0.71) and all psychotic disorders combined (r 0.33-0.67). Predicted admission rates for total admissions, psychotic and non-psychotic admissions using regression models showed strong positive correlations with observed admission rates. CONCLUSIONS: The strong correlations between social indicators of deprivation and total psychotic admission rates are consistent with the results of previous studies. The strong associations between social indicators and admissions for non-psychotic disorders is contrary to previous findings and may be partly explained by the relatively high admission rates for neurotic disorders.

Immunisation against hepatitis B viral infection--a study of South African anaesthesiologists.

INTRODUCTION: The practice of anaesthesia involves exposure to blood or bloodstained secretions which may be contaminated with transmissible pathogens including the hepatitis B virus (HBV). This study was undertaken to assess the impact of freely available hepatitis B vaccine and applications of universal precautions against blood exposure on the uptake of immunisation and prevalence of HBV markers in South Africa anaesthesiologists. METHODS: Anaesthesiologists from the Department of Anaesthesia of the University of Natal and those attending a continuing medical education course in Cape Town in March 1993 participated in the study. Each participant completed a questionnaire giving details of previous exposure to HBV, immunisation status and details of immunisation. Blood samples were obtained on a voluntary basis for determination of HBV serology. RESULTS: One hundred and twenty-one anaesthesiologists participated in the study; 36 were unimmunised, of whom 18 (50%) were seropositive for HBV markers. More experienced anaesthesiologists (> 10 years) tended both not to be immunised and to be seropositive, indicating previous exposure to HBV. Eighty-five participants were immunised. Intradermal immunisation caused significantly less seroconversion than the intramuscular route (35% v. 81%; P < 0.05). Of 7 non-responders to intradermal immunisation, 5 responded to a single intramuscular booster injection. DISCUSSION: Exposure to HBV is common in anaesthetic practice, as evinced by the 50% seropositivity in unimmunised anaesthesiologists, which means that routine serological testing before immunisation is warranted. Intramuscular immunisation provides the best protection against HBV. Post-immunisation serological testing should be performed to demonstrate an adequate antibody response. The intradermal route may save cost with similar efficacy if combined with post-immunisation testing and a single intramuscular booster injection for non-responders.