Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists.

BACKGROUND: Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. METHODS: We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. RESULTS: In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. CONCLUSIONS: The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Emphysematous gastritis in a patient with neutropenic sepsis: A case report and literature review with comment on management.

Emphysematous gastritis is a severe form of gastritis caused by gas-forming infectious organisms and is most frequently encountered in critically unwell patients. Diagnosis rests on the radiographic appearances of air within the gastric wall, which may extend into the portal venous system. Not previously described in the context of neutropenic sepsis, our case involves a 77-year-old patient with emphysematous gastritis who was admitted to the intensive care unit with a neutrophil count of 0.1 × 109/L and managed successfully with conservative treatment. Presenting complaints usually include abdominal pain, nausea, vomiting and occasionally haematemesis, in the context of systemic upset. Predisposing factors may include diabetes and immunosuppression, ingestion of corrosive substances, alcohol abuse, and abdominal surgery. The historical approach to management which previously involved urgent exploratory laparotomy with gastrectomy, has largely been replaced with conservative therapy, including broad-spectrum antimicrobials, gut rest and parenteral nutrition, with improved outcomes. Previously considered a commonly terminal diagnosis with mortality rates as high as 60%, this recent shift in approach to management has contributed to mortality rates being halved. The role of oesophago-gastro-duodenoscopy has not been established and is unlikely to be indicated in every case. Longterm complications may be of concern and include fibrosis and gastric contractures.

Can endoscopic follow-up after acute diverticulitis be rationalised?

BACKGROUND: Acute diverticulitis (AD) is a common cause of presentation to emergency surgical services. Follow-up with endoluminal investigation to exclude colorectal cancer (CRC) remains controversial. Guidelines are increasingly moving to a more restrictive follow-up based on severity of disease and age. The purpose of this observational study was to assess the prevalence of CRC in AD patients and the impact of follow-up on endoscopy services. METHODS: Patients admitted with a diagnosis of AD over a 2-year period were reviewed. The proportion of patients undergoing endoscopic follow-up and the CRC detection rate were recorded. The potential impact of a more conservative approach to follow-up was evaluated. RESULTS: There were 484 patients with AD presenting 546 times (M:F = 198:286; median age = 63 years). 80% of admissions were aged 50 or older. There were 43 emergency interventions in 39 patients (10 percutaneous drain; 33 surgery). The remainder were managed conservatively. 28 patients (5.1%) underwent colonic resection with cancer found in one specimen (3.6%). 287 patients underwent endoluminal follow-up with cancer diagnosed in 3 cases (1.0%). There was no significant difference in the prevalence of CRC between patients requiring emergency surgery and those managed conservatively, or between patients with complicated versus uncomplicated diverticulitis. CONCLUSION: CRC masquerading as acute diverticulitis is rare. The incidence of neoplasia both at endoscopic follow-up and in patients requiring emergency intervention is low. Conservative follow-up strategies appear safe, but their effectiveness in reducing the burden on endoscopy services may be limited by current age-based recommendations. Restricting follow-up to those with complicated AD would reduce the number of patients requiring endoluminal investigation by 70%.

Preventing unrecognised oesophageal intubation.

Major harm from unrecognised oesophageal intubation continues, despite the 2018 Royal College of Anaesthetists' 'no trace, wrong place' campaign. It is likely that publicly reported cases represent a fraction of real occurrences. This article summarises a 2022 consensus guideline on the prevention of unrecognised oesophageal intubation from the Project for Universal Management of Airway and international airway societies. The guideline is written for all airway operators and assistants, in any clinical setting, and readers are advised to deepen their understanding by studying the original guideline. The recommendations include how to avoid and recognise oesophageal intubation as well as a set of logical actions to take when it is a plausible possibility, even if it is not suspected. The guideline emphasises the importance of videolaryngoscopy, capnography and oxygen saturation monitoring for all tracheal intubations, wherever performed. It introduces the concept of sustained exhaled carbon dioxide, which is central to identifying oesophageal intubation, and acting to prevent progression to unrecognised oesophageal intubation. In the absence of sustained exhaled carbon dioxide, the default action is to remove the tube. This will mean some tracheal placed tubes are removed but based on a risk-benefit analysis, this is desirable. The tube should only be left in place if there is clear danger in removing it and in this event, its position should be confirmed, using repeat videolaryngoscopy plus one other of bronchoscopy, skilled ultrasound or use of an oesophageal detector device. The importance of human factors is underlined; for instance, the value of a shared and vocalised report of videolaryngoscopy view and trained assistants working with the operator to confirm whether the criteria for sustained exhaled carbon dioxide are met, to minimise error and improve team working.

Developing sustainable patient and public involvement in mesothelioma research: multi-method exploration with researchers, patients, carers, and patient organisations.

BACKGROUND: Rare diseases where prognosis is poor provide limited scope for patient and public involvement (PPI). One such disease is mesothelioma, a cancer of the lung pleura or of the peritoneum caused by exposure to asbestos, where PPI is poorly documented. We undertook to explore how PPI could be facilitated in mesothelioma research. METHODS: An online survey with mesothelioma researchers (n = 23) assessed the perceived benefits and challenges of PPI in mesothelioma. Six online workshops and thirteen in-depth interviews with patients and the public explored their views on how PPI could be increased in mesothelioma and their motivations to become PPI representatives in the future. The survey data were analysed using descriptive statistics and the interviews, using Thematic Analysis. RESULTS: In the survey, 26% (n = 6) of the researchers did not include PPI in their research, while 74% (n = 17) did, finding it most beneficial at the stages of applying for funding and dissemination. The main perceived benefits of PPI were clarifying the research question and outcome measures, making research more credible and relevant to patients' needs, and increasing its impact. The main perceived challenges to PPI were the general poor prognosis in mesothelioma, and funding timescales which hindered timely recruitment of PPI representatives. The analysis of the interviews with the patients and public revealed three main themes: "Motivations to become a PPI representative in the future", "Understanding the nature of PPI during the project", and "Perceived challenges to PPI in mesothelioma". Altruism and the need for hope were the main reasons to wish to become involved in PPI in the future. For many participants, the project proved to be a journey of understanding the nature of PPI, a concept that was not easy to grasp from the start. The participants perceived certain barriers to PPI such as high symptom burden in mesothelioma, the abstract concept of PPI, and the use of scientific language. CONCLUSIONS: The present research provides a detailed picture of the benefits and challenges of PPI in mesothelioma. We recommend long-term engagement with mesothelioma support groups so that researchers achieve meaningful and sustainable PPI in mesothelioma research.

Patient and public involvement (PPI) in research means research that is done 'with' or 'by' the public, not 'to', 'about', or 'for' them. Involving patients, family caregivers or the public (e.g. coordinators of patient organisations) in research activities means that they contribute to how research is designed, conducted, or disseminated. However, some diseases where patients have a short prognosis after diagnosis make it harder for patients or their family members to get involved. In this project we explored the perspectives of patients, public, and researchers on how PPI could be increased and maintained in research on mesothelioma­a rare cancer of the lining of the lung or of the peritoneum caused by exposure to asbestos. We conducted an online survey with mesothelioma researchers, and they indicated a number of PPI benefits but also challenges such as finding people living with mesothelioma well enough to participate. We also conducted six online workshops and thirteen interviews with patients, family members and coordinators of mesothelioma patient organisations­these were not PPI representatives but participants in research. All participants in the project were motivated by the wish to enhance outcomes for other patients. Their understanding of PPI improved during the project and they saw a number of challenges to others becoming involved in PPI, such as its abstract nature and the use of scientific language. We recommend that researchers engage long-term with mesothelioma support groups so that they have opportunities to explain what PPI means and involve people affected by mesothelioma in research.

Has the time really come for universal videolaryngoscopy?

Recent evidence, highlighted in this editorial, creates a strong argument for universal use of videolaryngoscopy in anaesthesia to improve efficiency and safety of tracheal intubation. In a recent study published in the British Journal of Anaesthesia, the authors implemented widespread (66%) use of videolaryngoscopy as first choice in one hospital and compared this with a control hospital, in which this was not implemented. Increased videolaryngoscopy use was associated with a significant fall in the rate of difficult airways, use of airway rescue techniques, and operator-reported difficulty, whilst in the control hospitals no such changes were seen. Locations outside the operating theatre might also benefit from universal laryngoscopy, but the evidence base is less robust, most notably in pre-hospital emergency medicine. The extent to which variation in results in different locations is attributable to different patient factors or organisational and operator factors is considered.

BSACI guideline for the set-up of penicillin allergy de-labelling services by non-allergists working in a hospital setting.

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de-labelling service for their patients. It is intended to supplement the BSACI 2015 guideline "Management of allergy to penicillin and other beta-lactams" and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta-lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non-allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update.

BACKGROUND: Tracheal intubation is a commonly performed procedure that can be associated with complications and result in patient harm. Videolaryngoscopy (VL) may decrease this risk as compared with Macintosh direct laryngoscopy (DL). This review evaluates the risk and benefit profile of VL compared with DL in adults. METHODS: We searched MEDLINE, Embase, CENTRAL, and Web of Science on February 27, 2021. We included RCTs comparing VL with DL in patients undergoing tracheal intubation in any setting. We separately compared outcomes according to VL design: Macintosh-style, hyperangulated, and channelled. RESULTS: A total of 222 RCTs (with 26 149 participants) were included. Most studies had unclear risk of bias in at least one domain, and all were at high risk of performance and detection bias. We found that videolaryngoscopes of any design likely reduce rates of failed intubation (Macintosh-style: risk ratio [RR]=0.41; 95% confidence interval [CI], 0.26-0.65; hyperangulated: RR=0.51; 95% CI, 0.34-0.76; channelled: RR=0.43, 95% CI, 0.30-0.61; moderate-certainty evidence) with increased rates of successful intubation on first attempt and better glottic views across patient groups and settings. Hyperangulated designs are likely favourable in terms of reducing the rate of oesophageal intubation, and result in improved rates of successful intubation in individuals presenting with difficult airway features (P=0.03). We also present other patient-oriented outcomes. CONCLUSIONS: In this systematic review and meta-analysis of trials of adults undergoing tracheal intubation, VL was associated with fewer failed attempts and complications such as hypoxaemia, whereas glottic views were improved. SYSTEMATIC REVIEW REGISTRATION: This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2022, Issue 4, DOI: 10.1002/14651858.CD011136.pub3 (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the CDSR should be consulted for the most recent version of the review.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.

BACKGROUND: Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016. OBJECTIVES: To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings. SEARCH METHODS: We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation. MAIN RESULTS: We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit.  We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%). AUTHORS' CONCLUSIONS: VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.

Identification of the source events for aerosol generation during oesophago-gastro-duodenoscopy.

OBJECTIVE: To determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events. DESIGN: A prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient's mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject. RESULTS: Patients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L-1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L-1). Aerosol recording during OGD showed an average particle number concentration of 595 L-1 with a wide range (3-4320 L-1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient's reference voluntary coughs (11 710 vs 2320 L-1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered. CONCLUSION: Coughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.

Capnography use in the critical care setting: why do clinicians fail to implement this safety measure?

Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Project (NAP4) was identification of waveform capnography as the single intervention with the highest potential for reducing morbidity and mortality during tracheal intubation and maintenance of an artificial airway. In the INTUBE study, penetration of capnography into ICUs was low, and was not in use in 70% of the episodes of oesophageal intubation. To reduce harm and avoidable death, there is a need for a global initiative to increase access to and use of capnography in ICUs.

The safety of anaesthetists and intensivists during the first COVID-19 surge supports extension of use of airborne protection PPE to ward staff.

A key controversy in the COVID-19 pandemic has been over staff safety in health and social care settings. Anaesthetists and intensivists were anticipated to be at the highest risk of work-related infection due to involvement in airway management and management of critical illness and therefore wear the highest levels of personal protective equipment (PPE) in the hospital. However, the data clearly show that those working in anaesthesia and critical care settings are at lower risk of infection, harm and death from COVID-19 than colleagues working on the wards. The observed safety of anaesthetists and intensivists and increased risk to those in other patient-facing roles has implications for transmission-based infection control precautions. The precautionary principle supports extending training in and use of airborne precaution PPE to all staff working in patient-facing roles who have close contact with coughing patients. This will both reduce their risk of contracting COVID-19, maintain services and reduce nosocomial transmission to vulnerable patients. The emergence of a new variant of the SARS-CoV-2 virus with significantly higher transmissibility creates urgency to addressing this matter.