AAGBI guidelines: the use of blood components and their alternatives 2016.

Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.

Axillary brachial plexus block for perioperative analgesia in 250 children.

A cannula technique for axillary brachial plexus block in combination with general anaesthesia has been in use since 1994 for children undergoing surgical correction of congenital hand anomalies. During a 4-year period data were collected on 250 procedures in 185 patients of median age 3 years detailing the block technique and the intraoperative and postoperative analgesic requirements. Fifteen patients (6%) required supplemental intravenous opioid intraoperatively and this is taken as a marker of failure of the block. Ninety-five patients (38%) required postoperative codeine phosphate with a mean time to receiving codeine phosphate of 9 h. Postoperative pain was controlled in this series with oral analgesia in all but six patients who received parenteral codeine. It is proposed that a cannula technique is an effective and safe method of producing axillary brachial plexus block in children.

Increasing the effectiveness and efficiency of academic advising through computerization.

Academic advising is an essential part of any university degree program and becomes especially important in programs where there is competitive and limited admission to professional courses. This requires that academic advisors have ready access to student scholastic and demographic data for counseling and statistical purposes. The use of computers in creating a database for student records has become routine in most universities and colleges. Computerization of these records through the registration process creates a university database with the potential for many different applications. This article describes the development of a computer software program for a baccalaureate science of nursing program that makes use of a university's database to provide the foundation of a computer software program used in the nursing academic advising office. Identifying the special needs and requirements of the nursing advising program and developing a close working relationship with the computer programmer were essential in the development and implementation process. The result was an increase in the effectiveness and efficiency of the advising process, better record keeping, and better use of available student data for statistical purposes.

Craniodiaphyseal dysplasia; another cause of difficult intubation.

A nine-year-old boy with craniodiaphyseal dysplasia (CDD) presented for mandibular reduction. Patients with CDD present problems to the anaesthetist, specifically difficulties with airway management and tracheal intubation. This child was managed using laryngeal mask airway (LMA) guided fibreoptic intubation. Spontaneous respiration was maintained throughout intubation, following which ventilation was controlled and anaesthesia was provided using nitrous oxide, isoflurane and fentanyl. The perioperative management is described.

Lessons from a case of kleeblattschädel. Case report.

The authors describe the clinical, radiological, and postmortem findings of a case of cloverleaf skull syndrome. The presence of hindbrain herniation, abnormal cervical segmentation, and atlantoaxial subluxation illustrate the anatomical complexity of the skull base and the craniocervical junction that may coexist in this condition. Unavoidable division of occipital emissary veins during elevation of the skin flap at the time of vault remodeling surgery led to an acute and, ultimately, fatal rise in intracranial pressure. Postmortem examination and review of magnetic resonance imaging revealed an anomalous pattern of venous drainage of the intracranial structures that appeared to have developed in response to venous obstruction, secondary to intraosseous venous sinuses and stenosis of the jugular foramina. The relationship between venous hypertension, hindbrain herniation, and hydrocephalus in this situation is reviewed, and the implications for evaluation and management of this vexing disorder are discussed.

Complications in paediatric craniofacial surgery: an initial four year experience.

107 children undergoing transcranial craniofacial surgery in a paediatric hospital have been reviewed to assess the incidence and type of complications which arose. This represents the first 4 years' experience of the craniofacial team. There were no deaths or permanent adverse sequelae of surgery. A total of 53 complications were seen in 42 patients. In 9.3% of patients they were potentially life-threatening, serious in 12.1% and of a minor nature in 28%. The more serious complications were related either to haemorrhage and/or vasovagal shock at operation or to infection post-operatively. Infants undergoing monoblock frontofacial advancements and those with tracheostomies were at particular risk.

The Humphrey ADE system: evaluation in paediatric use.

The Humphrey ADE single lever parallel form breathing system was evaluated in 17 children whose lungs were ventilated mechanically, mean age 28 (range 9-58) months, weight 13.3 (8.3-18.0) kg and in 10 spontaneously breathing children, age 50.7 (18-99) months and weight 17.5 (10.9-24.3) kg. During controlled ventilation in the E mode, the ADE behaved in a manner similar to the Jackson-Rees modification of Ayre's T-piece with the fresh gas flows (FGF) set either according to weight or at a standard 3 litre min-1. After 5 min hand ventilation in the A mode with FGF 3 litre min-1 the mean end-tidal partial pressure of carbon dioxide was 5.3 (SD 0.8) kPa (range 4.1-7.7 kPa). Whilst breathing spontaneously in the A mode, no patient experienced rebreathing at FGF 3 litre min-1; rebreathing started at 124 (31.6) ml kg-1 min-1. The ADE circuit performed satisfactorily in all three modes. During controlled ventilation in the E mode, FGF should be adjusted according to the standard formulae recommended for the T-piece circuit. During hand ventilation in the A mode, an FGF greater than 3 litre min-1 should be used.

Sedation in children scanned with high-field magnetic resonance; the experience at the Hospital for Sick Children, Great Ormond Street.

Patient movement is the most common cause of image degradation when performing magnetic resonance scans in children. This is a particular problem scanning at high field, as noise levels of up to 90 dB may be reached. Movement can be reduced by adequate sedation. We present the results of two sedation protocols when scanning with a 1.5T Magnetom scanner. Optimal scan quality can be achieved in up to 85% of scans using Pethco combined with triclofos in children aged 1 month-2 years, and trimeprazine combined with papaveretum in children over 2 years. When heavy sedation is used, patient selection must be cautious, and there is a minimum acceptable level of monitoring including close physical observation, electrocardiographic and apnoea monitoring.

The laryngeal mask airway in children.

The laryngeal mask airway was used in 200 children during a variety of surgical procedures. Some problem with the use of the device was encountered in 47 cases (23%), but in only five cases (2.5%) were the problems serious enough to warrant abandonment of its use. A clear airway was ultimately achieved in 191 children. Downfolding of the epiglottis over the laryngeal inlet was identified in eight out of 24 patients where flexible laryngoscopy was performed, clinically all these had unobstructed airways. The mask was used in 16 children with known airway problems. It is concluded that the size 2 laryngeal mask airway can be successfully used within the weight range 6-30 kg.

Comparison of two ventilators used with the T-piece in paediatric anaesthesia.

The Nuffield 200 ventilator was compared with a new valveless ventilator (CW 200) in 20 children undergoing general anaesthesia for paediatric surgery. The new ventilator incorporates design features which overcome the main disadvantages of the Nuffield 200 and make it an inherently safer machine. At identical ventilator settings it produced a significantly greater tidal volume with a reduction in end-tidal carbon dioxide partial pressure. This may have advantages in avoiding pulmonary barotrauma in children.

Endotracheal compared with intravenous administration of atropine.

Endotracheal and intravenous administration of atropine were compared in two groups of 10 children. No differences were found between the groups in effect on heart rate or speed of onset of the effect. We conclude that the two methods are equally effective.

Continuous EEG and ICP monitoring as a guide to the administration of althesin sedation in severe head injury.

The effects of 142 intravenous boluses of althesin (0.05 ml/kg) on cerebral perfusion pressure (CPP) were studied in twelve head injured comatose patients. The data were divided into those where the mean pre-bolus intracranial pressure (ICP) was above or below 20 mmHg and then subdivided into those where the minimum pre-bolus voltage of the cerebral function monitor (CFM) was above or below 5 microV (representing marked reduction in cortical electrical activity). The pre-bolus ICP influenced the extent of the fall in ICP and thus the direction of the resulting change in CPP. A mean reduction in CPP was observed in both groups in which ICP was below 20 mmHg irrespective of the CFM voltage. In the subgroups with high ICP, CPP increased when CFM was not depressed and fell when CFM was below 5 microV. The effects of individual boluses varied within and between the subgroups and, occasionally, severe and unpredictable hypotension occurred. If althesin administration had been restricted to the high CFM and high ICP group, 90% of the episodes of reduced CPP would have been avoided. In fact, when cortical electrical activity is already severely depressed, further administration of hypnotic anaesthetic agents produces only small reductions in ICP and usually a fall in CPP. These findings suggest that the minimum voltage of the CFM trace is a clinically useful guide to the administration of intravenous anaesthetic agents and offers a relevant prediction of their effects on CPP.

Influence of bolus doses of phenoperidine on intracranial pressure and systemic arterial pressure in traumatic coma.

The effects of bolus doses of phenoperidine 1-2 mg i.v. either alone, or combined with pancuronium 2-4 mg, were investigated in seven patients in traumatic coma. Phenoperidine alone significantly reduced mean arterial pressure (MAP) by a mean (+/- SEM) of 13.2 (+/- 2.8) mm Hg. Overall there was no significant change in intracranial pressure (ICP) despite the decreases in MAP and, consequently, cerebral perfusion pressure (CPP) decreased (14.0 +/- 2.4 mm Hg) on all but one occasion. In some instances these decreases were considerable (maximum 38 mm Hg). Similar results were obtained when phenoperidine was combined with pancuronium. These findings suggest that the bolus administration of phenoperidine and probably other opiates should be avoided in traumatic coma.

Assisted ventilation and the Servo ventilator in infants. An assessment of three systems used for CPAP/IMV.

A laboratory assessment was made of systems used for Continuous Positive Airway Pressure/Intermittent Mandatory Ventilation (CPAP/IMV) with the Servo 900B and 900C ventilators. Pressure-volume loops recorded during sine wave oscillation using an external CPAP/IMV system were similar to those found during normal respiration. Pressure-volume loops using the systems based on the ventilator's inbuilt trigger mechanism were very different, particularly for the 900B. The results were confirmed by measurements in two infants. The implications of these findings with reference to the weaning of infants from mechanical ventilation are discussed.