A clinical evaluation of four non-Luer spinal needle and syringe systems.

We performed an evaluation of non-Luer spinal devices supplied by four manufacturers or suppliers: Polymedic; Pajunk; Sarstedt; and Smiths. For each supplier, 100 evaluations were performed using a 25-G 90-mm spinal needle, 3-ml syringe, 5-ml syringe and filter needle; for comparison, 100 evaluations were performed with our standard Luer equipment. The non-Luer devices were associated with more qualitative problems compared with the Luer devices, for example, poor feel of dural puncture (9-32% vs 10%, respectively), poor observation of cerebrospinal fluid in the hub (3-27% vs 0%), and connection problem of the syringe to the spinal needle (7-33% vs 0%). There was also more frequent failure to achieve the spinal injection due to equipment-related causes (4-7% vs 0%, respectively). Median (IQR [range]) numeric satisfaction scores for the spinal needles were: Luer 10 (9-10 [7-10]); Polymedic 7 (4-8 [0-10]; Pajunk 7 (5-8 [0-10]); Sarstedt 7 (6-8 [0-10]); and Smiths 9 (7-10 [0-10]) (p<0.0001). Satisfaction scores for all spinal equipment were: Luer 10 (9-10 [5-10]); Polymedic 8 (6-8 [0-10]); Pajunk 7 (5-7 [1-9]); Sarstedt 8 (6-8 [0-10]); and Smiths 8 (8-9 [2-10]) (p<0.0001). Between 21% and 75% of non-Luer evaluations were rated with satisfaction worse than the usual Luer needle compared with 0-10% rated better, depending on the needle type. Between 22% and 76% of non-Luer evaluations were rated with satisfaction worse than the usual Luer equipment compared with 0-14% rated better. Specific concerns included poor feel of tissue planes and observation of cerebrospinal fluid (Polymedic), difficulty with connection of the syringe to the spinal needle and trocar removal (Pajunk), poor feel of tissue planes and needle flexibility (Sarstedt) and difficulty with connection of the syringe to the spinal needle (Smiths). We could not demonstrate a short-term learning curve for the new devices. Decisions on purchasing and implementation of the new non-Luer equipment will have to acknowledge that clinicians may have greater technical problems and reduced satisfaction compared with the current equipment.

Selection of baseline blood pressure to guide management of hypotension during spinal anaesthesia for caesarean section.

INTRODUCTION: Recommendations on vasopressor management during caesarean section under spinal anaesthesia suggest maintaining systolic arterial pressure ≥90% of an accurately measured baseline value. The baseline is often taken as the first reading in the operating room. We hypothesise that this reading may not reflect an accurate baseline value. METHODS: A retrospective case note review of 300 non-hypertensive women undergoing caesarean section with neuraxial anaesthesia, including spinal anaesthesia for elective delivery (n=100), and spinal (n=100) and epidural top-up anaesthesia (n=100) for emergency delivery. Systolic arterial pressure values recorded at various time points between the last antenatal visit and the first blood pressure value recorded in the operating room were compared. RESULTS: There was a stepwise and significant increase in systolic arterial pressure over three time points (last antenatal clinic, morning of surgery, operating room) before elective caesarean section (all P <0.001). In women having emergency caesarean under spinal anaesthesia, a stepwise increase over four time points (last antenatal clinic, first reading in labour, final reading in labour, operating room) was observed. A similar trend was seen over these time points for women having emergency caesarean under epidural top-up, although the systolic blood pressure did not rise during labour. CONCLUSIONS: Using the initial blood pressure reading in the operating room as the baseline value may lead to unnecessary vasopressor use and hypertension. Prospective research is required to clarify which reading represents the most accurate baseline to maintain homeostasis and reduce the hypotensive sequelae of neuraxial anaesthesia for both the mother and fetus.

LMA Supreme insertion by novices in manikins and patients.

The LMA Supreme has been suggested for use in emergency situations by medical personnel with no experience in endotracheal intubation. We evaluated the LMA Supreme when inserted by non-anaesthetists, firstly in a manikin and then in patients. Fifty airway novices inserted a LMA Supreme in a manikin without any complications so we proceeded to the patient phase. Fifty airway novices inserted the LMA Supreme in anaesthetised patients undergoing elective surgery. First time insertion success rate was 86% and overall insertion success rate was 100%. Mechanical ventilation was successful in all cases. Median (IQR [range]) time to establish an airway was 34 s (26-40 [18-145] s). Median (IQR [range]) pharyngeal seal pressure was 23 cmH(2)O (19-28 [13-40] cmH(2)O). There were no important complications. Results are consistent with previous studies of use of the LMA Supreme by airway experts. We conclude that the LMA supreme is suitable for use by airway novices. Further research is needed before it may be recommended for cardiopulmonary resuscitation and emergency airway use.

I-gel insertion by novices in manikins and patients.

The i-gel, a novel supraglottic airway, has been proposed for use during cardiopulmonary resuscitation. We evaluated the performance of this device in manikins and anaesthetised patients when used by novices: medical students, non-anaesthetist physicians and allied health professionals all unfamiliar with the i-gel. Fifty i-gels were placed in manikins. Eighty-eight percent (44/50) were placed on the first attempt with a median insertion time of 14 s (range 7-45). I-gels were placed in 40 healthy anaesthetised patients. Success on the first attempt was 82.5% (33/40) and on the second attempt 15% (6/40). After three attempts there were no failures. Median insertion time was 17.5 s (range 7-197). Median airway seal was 20 cmH(2)O (range 13-40). One case of regurgitation and partial aspiration occurred. Our results suggest the i-gel is rapidly inserted in both manikins and patients by novice users and compares favourably to other supraglottic airways available. Further work determining safety and efficacy during cardiopulmonary resuscitation is required.