Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE: To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS: A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS: Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS: Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Vasopressors to treat postoperative hypotension after adult noncardiac, non-obstetric surgery: a systematic review.

BACKGROUND: Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults. METHODS: We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes. RESULTS: A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5-74.7%). Norepinephrine was the most common vasopressor used. CONCLUSIONS: The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making.

Reducing Preoperative Fasting Through Technology and Education in an Acute General Surgical Adult Cohort.

BACKGROUND: Despite widespread support for reduced fasting protocols prior to anesthesia, the traditional "fast from midnight" (FFMN) remains widely employed. This study implemented a pilot preoperative fasting reduction program for patients booked for acute surgery in the Department of General Surgery at a busy metropolitan tertiary hospital, including use of an electronic health record (EHR)-based solution, aiming to measure effect on fasting times and use of intravenous fluid (IVF). METHODS: A pilot program was implemented in August 2021 in the Emergency General Surgery (EGS) unit at the Royal Melbourne Hospital, Australia. This included a new smart phrase within the EHR (EU2WU6: Eat until 2, drink water until 6) and an education campaign. Adult patients who underwent preoperative fasting between September 1 and December 31, 2021, were screened. Uptake of the protocol was recorded. Further, total fasting times (TFT) and IVF use were recorded. Potential impact with varying levels of protocol uptake was modeled. RESULTS: Uptake of EU2WU6 increased from 0% to 80%. TFT and total time on IVF (TT-IVF) were lower using EU2WU6 (TFT 7 hours vs. 13 hours, p < 0.001; TT-IVF 3 hours vs. 8 hours, p < 0.001). Proportion of patients requiring fluid overnight when using EU2WU6 was lower (18/45 vs. 34/50, p = 0.0062). Hospitalwide yearly savings, with 100% application of EU2WU6, were projected at 2,050 bags of IVF (at a cost savings of A$2,296), 10,251 minutes for physicians, and 20,502 minutes for nurses. CONCLUSION: The pilot preoperative fasting reduction program successfully reduced disparity between evidence and clinical practice.

Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review.

STUDY OBJECTIVES: To describe the epidemiological factors of mental health presentations in young people to emergency medical services (EMS) and define those experiencing acute severe behavioral disturbance by reviewing parenteral sedation use. METHODS: We performed a retrospective review of records of EMS attendance for young people (aged <18 years) with mental health presentations between July 2018 and June 2019 to a statewide EMS system in Australia of a population of 6.5 million persons. In addition, epidemiological data and information about parenteral sedation for acute severe behavioral disturbance and any adverse events were extracted from the records and analyzed. RESULTS: A total of 7,816 patients had mental health presentations with a median age of 15 years (IQR 14-17). The majority (60%) were female. These presentations accounted for 14% of all pediatric presentations to EMS. Out of them, 612 (8%) received parenteral sedation for acute severe behavioral disturbance. A number of factors were associated with increased odds of parenteral sedative medication being used, including autism spectrum disorder (odds ratio [OR] 3.3; confidence interval [CI], 2.7 to 3.9), posttraumatic stress disorder (OR 2.8; CI, 2.2 to 3.5) and intellectual disability (OR 3.6; CI, 2.6 to 4.8). The majority (460, 75%) of young people received midazolam as their first-line medication, with the remaining patients being provided ketamine (152, 25%). No serious adverse events were noted. CONCLUSION: Mental health conditions were a common presentation to EMS. A history of autism spectrum disorder, posttraumatic stress disorder, or an intellectual disability increased the odds of receiving parenteral sedation for acute severe behavioral disturbance. Sedation appears generally safe in the out-of-hospital setting.

Triggers for medical emergency team activation after non-cardiac surgery.

Deterioration after major surgery is common, with many patients experiencing a medical emergency team (MET) activation. Understanding the triggers for MET calls may help design interventions to prevent deterioration. We aimed to identify triggers for MET activation in non-cardiac surgical patients. A retrospective cohort study of adult patients who experienced a postoperative MET call at a single tertiary hospital was undertaken. The trigger and timing of each MET call and patient characteristics were collected.Four hundred and one MET calls occurred after 23,258 surgical procedures, a rate of 1.7% of all non-cardiac surgical procedures, accounting for 11.7% of all MET calls over the study period. Hypotension (41.4%) was the most common trigger, followed by tachycardia (18.5%), altered conscious state (11.0%), hypoxia (10.0%), tachypnoea (5.7%), 'other' (5.7%), clinical concern (4.0%), increased work of breathing (1.5%) and bradypnoea (0.7%). Cardiac and/or respiratory arrest triggered 1.2% of MET activations. Eighty-six percent of patients had a single MET call, 10.2% had two, 1.8% had three and one patient (0.3%) had four. The median interval between post-anaesthetic care unit (PACU) discharge and MET call was 14.7 h (95% confidence interval 4.2 to 28.9 h). MET calls resulted in intensive care unit (ICU) admission in 40 patients (10%), while 82% remained on the ward, 4% had a MET call shortly after ICU discharge and returned there, 2% returned to theatre, and 2% went to a high dependency unit.Hypotension was the most common trigger for MET calls after non-cardiac surgery. Deterioration frequently occurred within 24 h of PACU discharge. Future research should focus on prevention of hypotension and tachycardia after surgery.

Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting.

INTRODUCTION: Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment.PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. METHODS AND ANALYSIS: Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery.Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. ETHICS AND DISSEMINATION: This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER: ACTRN12620001295932.

Do Physiological Variables Predict the Need for Transport to Hospital From Music Festivals? An Analysis of Australian Festival Data.

OBJECTIVE: Using physiological markers to detect patients at risk of deterioration is common. Deaths at music festivals in Australia prompted scrutiny of tools to identify critically unwell patients for transport to hospital. This study evaluated initial physiological parameters to identify patients selected for transport to hospital from a music festival. METHODS: A retrospective audit of 2045 presentations at music festivals in Victoria, Australia, was performed. Presentation heart rate, systolic blood pressure, respiratory rate, oxygen saturation, temperature, and Glasgow Coma Scale were assessed using area under the receiver operating characteristic curve (AUROC) analysis, with a prespecified threshold of 0.7. RESULTS: The only measured variable to exceed the prespecified cutpoint was initial systolic blood pressure, with an AUROC of 0.72 and optimal cutpoint of 122 mmHg. Using commonly accepted cutpoints for variables did not improve detection performance to acceptable levels, nor did using combination systems of cutpoints. CONCLUSIONS: Initial physiological variables are poor predictors of the decision to transport to hospital from music festivals. Systolic blood pressure was significant, but only at a clinically insignificant value. Decisions on which patients to transport from an event site should incorporate more information than initial physiology. Senior clinicians should lead decision-making about hospital transport from music festivals.

Real-world estimate of the value of one metabolic equivalent in a population of patients planning major surgery.

BACKGROUND: One metabolic equivalent (MET) is equal to resting oxygen consumption. The average value for one MET in humans is widely quoted as 3.5 mL/kg/min. However, this value was derived from a single male participant at the end of the 19th century and has become canonical. Several small studies have identified varied estimates of one MET from widely varying populations. The ability of a patient to complete 4 MET (or 14 mL/kg/min) is considered an indicator of their fitness to proceed to surgery. AIMS: To define a typical value of one MET from a real-world patient population, as well as determine factors that influenced the value. METHODS: A database of cardiopulmonary exercise testing (CPET) was interrogated to find a total of 1847 adult patients who had undergone CPET testing in the previous 10 years. From this database, estimates of oxygen consumption (VO2 ) at rest and at the anaerobic threshold and several other variables were obtained. The influence of age, body mass index (BMI), sex and the use of beta-blockers was tested. RESULTS: The median resting VO2 at rest was 3.6 mL/kg/min (interquartile range (IQR): 3.0-4.2). Neither sex, age >65 years or the use of beta-blockers produced a significant difference in resting VO2 , while those with a BMI >25 kg/m2 had a significantly lower VO2 at rest (3.4 mL/kg/min vs 4.0 mL/kg/min; P < 0.001). CONCLUSIONS: The estimate of 3.6 mL/kg/min for resting VO2 presented here is consistent with the previous literature, despite this being the first large study of its kind. This estimate can be safely used for pre-operative risk stratification.

Feasibility of pulse oximetry after water immersion.

OBJECTIVE: This study aimed to determine if pulse oximetry could reliably be used after immersion in water, and if so, which of the finger, earlobe or nose most reliably produced a functional waveform. METHOD: Pulse oximetry data was recorded from the ear, nose and finger before and after 30 min of immersion in water. The primary outcome was the ability to measure pulse oximetry at any of the sites. RESULTS: A total of 119 participants were enrolled (with a median age of 16 years, 55% male). A useful pulse oximetry waveform was obtained after immersion from at least one of the measurement sites in 118 (99.2%) participants. Waveforms were usable after immersion in 96% of participants at the nostril, compared to 92% at the finger, and 41% at the ear lobe. The likelihood of success at the ear was significantly lower than either the finger or the nose (41% vs 92% and 96% respectively, p < 0.0001 for both comparisons). The finger and nostril were similar. Oxygen saturations were not significantly different after immersion at the nostril (100% vs 100%, p = 0.537) and finger (100% vs 100%, p = 0.032) sites but were different at the ear (100% vs 96%, p < 0.0001). CONCLUSION: This study demonstrates that pulse oximetry is feasible and reliable in a large cohort of participants who have been immersed in water for 30 min. The results support the nostril as the most reliable location. Only pulse oximeters registered for clinical use should be employed for patient care.

Perioperative gabapentinoid use lowers short-term opioid consumption following lower limb arthroplasty: Systematic review and meta-analysis.

BACKGROUND: The management of post-operative pain and high levels of acute and chronic opioid use following total knee arthroplasty (TKA) and total hip arthroplasty (THA) remain challenges to the perioperative team. We performed a system-atic review and meta-analysis to determine the opioid sparing effects, analgesic effects, and safety profile of perioperative gabapentinoid usage in lower limb arthroplasty. METHODS: We searched multiple databases from inception until May 2019 and included randomized controlled trials (RCT) on perioperative gabapentinoids in lower limb arthroplasty. The primary outcome was cumulative opioid con-sumption (oral morphine equivalents) at 24 and 48 hours, and the secondary outcomes were pain scores, time to hospi-tal discharge, and adverse events including nausea, vomiting, pruritus, and sedation. Methodological quality was as-sessed using the Cochrane tool. The grading of recommendations assessment, development, and evaluation method-ology for the certainty of evidence was also used. RESULTS: We included 19 RCT involving 2,455 patients undergoing lower limb arthroplasty. The overall methodological quality of included studies was good. Gabapentinoid use was associated with a significant reduction in opioid consump-tion at 24 hour (mean difference (MD) 22.81 mg [95 percent Confidence Interval (CI) 13.64-31.98]) and 48 hour (MD 44.03 mg [95 percent CI 16.92-71.14]). We found no meaningful difference in pain scores at rest between gabapenti-noid and placebo groups at 24 or 48 hours. Gabapentinoid use reduced the risk of post-operative nausea (risk ratio (RR) 0.69 [95 percent CI 0.57-0.82]), vomiting (RR 0.65 [95 percent CI 0.47-0.91]), and pruritus (RR 0.60 [0.37-0.98]), but not sedation (RR 1.25 [0.76-2.06]). There was no effect on time to discharge from hospital (MD-0.05 days [95 per-cent CI -0.31 to 0.20]. CONCLUSIONS: The addition of gabapentinoids to perioperative multimodal analgesia decreases opioid consumption fol-lowing lower limb arthroplasty, while also lowering rates of nausea, vomiting, and pruritus. Further study is required to evaluate the effect of gabapentinoid use on long-term opioid use and dependence.

Surgical caps displaying team members' names and roles improve effective communication in the operating room: a pilot study.

BACKGROUND: Teamwork in the operating theatre is a complex emergent phenomenon and is driven by cooperative relationships between staff. A foundational requirement for teamwork is the ability to communicate effectively, and in particular, knowing each other's name. Many operating theatre staff do not know each other's name, even after formal team introductions. The use of theatre caps to display a staff member's name and role has been suggested to improve communication and teamwork. METHODS: We hypothesized that the implementation of scrub hats with individual team members' names and roles would improve the perceived quality and effectiveness of communication in the operating theatre. A pilot project was designed as a pre-/post-implementation questionnaire sent to 236 operating room staff members at a general hospital in suburban Melbourne, Victoria, Australia, between November 6 to December 18, 2018. Participants included medical practitioners (anaesthetists, surgeons, obstetricians and gynaecologists), nurses (anaesthetic, scrub/scout and paediatric nurses), midwives and theatre technicians. The primary outcome was a change in perceived teamwork score, measured using a five position Likert scale. RESULTS: Of 236 enrolled participants, 107 (45%) completed both the pre and post intervention surveys. The median perceived teamwork response of four did not change after the intervention, though the number of low scores was reduced (p = 0.015). In a pre-planned subgroup analysis, the median perceived teamwork score rose for midwives from three to four (p < 0.001), while for other craft groups remained similar. The median number of staff members in theatre that a participant did not know the name of reduced from three to two (p < 0.001). Participants reported knowing the names of all staff members present in the theatre more frequently after the intervention (31% vs 15%, p < 0.001). The reported rate of formal team introductions was not significantly different after the intervention (34.7% vs 47.7% p = 0.058). CONCLUSIONS: In this study, we found that wearing caps displaying name and role appeared to improve perceived teamwork and improve communication between staff members working in the operating theatre.

Prognostic Significance of Preoperative Neutrophil-Lymphocyte Ratio in Vascular Surgery: Systematic Review and Meta-Analysis.

OBJECTIVE: The global burden of surgical vascular disease is increasing and with it, the need for cost-effective, accessible prognostic biomarkers to aid optimization of peri-operative outcomes. The neutrophil-lymphocyte ratio (NLR) is emerging as a potential candidate biomarker for perioperative risk stratification. We therefore performed this systematic review and meta-analysis on the prognostic value of elevated preoperative NLR in vascular surgery. METHODS: We searched Embase (Ovid), Medline (Ovid), and the Cochrane Library database from inception to June 2019. Screening was performed, and included all peer-reviewed original research studies reporting preoperative NLR in adult emergent and elective vascular surgical patients. Studies were assessed for bias and quality of evidence using a standardized tool. Meta-analysis was performed by general linear (mixed-effects) modelling where possible, and otherwise a narrative review was conducted. Between-study heterogeneity was estimated using the Chi-squared statistic and explored qualitatively. RESULTS: Fourteen studies involving 5,652 patients were included. The overall methodological quality was good. Elevated preoperative NLR was associated with increased risk of long-term mortality (HR 1.40 [95%CI: 1.13-1.74], Chi-squared 60.3%, 7 studies, 3,637 people) and short-term mortality (OR: 3.08; 95%CI: 1.91-4.95), Chi-squared 66.59%, 4 studies, 945 people). Outcome measures used by fewer studies such as graft patency and amputation free survival were assessed via narrative review. CONCLUSIONS: NLR is a promising, readily obtainable, prognostic biomarker for mortality outcomes following vascular surgery. Heterogeneity in patient factors, severity of vascular disease, and type of vascular surgery performed renders direct comparison of outcomes from the current literature challenging. This systematic review supports further investigation for NLR measurement in pre-vascular surgical risk stratification. In particular, the establishment of a universally accepted NLR cut-off value is of importance in real-world implementation of this biomarker.

Systematic review and meta-analysis of postoperative troponin as a predictor of mortality and major adverse cardiac events after vascular surgery.

BACKGROUND: The prognostic value of asymptomatic perioperative troponin rise in vascular surgery is unclear. We conducted this systematic review and meta-analysis to determine the significance of clinical and subclinical troponin elevation after vascular surgery. METHODS: We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library, without language restriction, from inception to May 2019 and included studies that reported associations between elevated postoperative troponin and short-term mortality, major adverse cardiac events (MACEs), or long-term mortality in a vascular surgery cohort. We synthesized study-level data on the maximally adjusted estimates using mixed effects modeling to generate summary odds ratios (ORs) for fixed-interval outcomes and summary hazard ratios for long-term mortality. Between-study heterogeneity was assessed with meta-regression. Methodologic quality and publication bias were formally assessed. RESULTS: We included 24 studies involving 11,657 participants. Postoperative troponin was found to have a strong, positive association with short-term mortality (OR, 4.95; 95% confidence interval [CI], 2.87-8.52; 7 studies; 2661 people) and MACEs (OR, 5.33; 95% CI, 1.59-17.82; 12 studies; 5047 people) independent of meeting the criteria for myocardial infarction. Subclinical postoperative troponin elevation was further demonstrated to be associated with greater long-term mortality (hazard ratio, 1.94; 95% CI, 1.56-2.42; 13 studies; 7630 people; median follow-up, 24 months). Time to troponin sampling, hypertension, and type of surgery partially accounted for between-study heterogeneity. The methodologic quality of included studies was variable, and publication bias was not detected. CONCLUSIONS: Elevated postoperative troponin is strongly prognostic of worse survival and greater likelihood of MACEs after vascular surgery, regardless of whether symptoms of myocardial ischemia are present. These data support the benefit of postoperative troponin monitoring in identifying patients at increased risk of worse outcomes and who may be candidates for personalized preventive interventions.

Performance of First Aid Trained Staff using a Modified START Triage Tool at Achieving Appropriate Triage Compared to a Physiology-Based Triage Strategy at Australian Mass Gatherings.

INTRODUCTION: Triage at mass gatherings in Australia is commonly performed by staff members with first aid training. There have been no evaluations of the performance of first aid staff with respect to diagnostic accuracy or identification of presentations requiring ambulance transport to hospital. HYPOTHESIS: It was hypothesized that triage decisions by first aid staff would be considered correct in at least 61% of presentations. METHODS: A retrospective audit of 1,048 presentations to a single supplier of event health care services in Australia was conducted. The presentations were assessed based on the first measured set of physiological parameters, and the primary triage decision was classified as "expected" if the primary and secondary triage classifications were the same or "not expected" if they differed. The performance of the two triage systems was compared using area under the receiver operating characteristic curve (AUROC) analysis. RESULTS: The expected decision was made by first aid staff in 674 (71%) of presentations. Under-triage occurred in 131 (14%) presentations and over-triage in 142 (15%) presentations. The primary triage strategy had an AUROC of 0.7644, while the secondary triage strategy had an AUROC of 0.6280, which was significantly different (P = .0199). CONCLUSION: The results support the continued use of first aid trained staff members in triage roles at Australian mass gatherings. Triage tools should be simple, and the addition of physiological variables to improve the sensitivity of triage tools is not recommended because such an approach does not improve the discriminatory capacity of the tools.

Safety and Efficacy of an On-Site Intensive Treatment Protocol for Mild and Moderate Sympathomimetic Toxicity at Australian Music Festivals.

INTRODUCTION: Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals. PROBLEM: The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST. METHODS: The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques. RESULTS: One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital. CONCLUSIONS: On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.

Ice Water Immersion - Practicalities for Monitoring Hyperthermic Patients in the Prehospital Context.

Immersion of patients in a body bag filled with ice and water is recommended as prehospital management of severe hyperthermia. Experienced paramedics have raised a number of concerns about the use of this technique; particularly, whether cardiac monitoring equipment would remain functional once immersed. This test showed that monitoring equipment does remain functional and provides advice about safety considerations. The test should reassure practitioners that such an approach is feasible.

Competence in the use of supraglottic airways by Australian surf lifesavers for cardiac arrest ventilation in a manikin.

OBJECTIVES: Lifesavers in Australia are taught to use pocket mask (PM) rescue breathing and bag valve mask (BVM) ventilation, despite evidence that first responders might struggle with these devices. Novices have successfully used the Laryngeal Mask Airway (LMA) Supreme and iGel devices previously, but there has been no previous comparison of the ability to train lifesavers to use the supraglottic airways compared to standard techniques for cardiac arrest ventilation. METHODS: The study is a prospective educational intervention whereby 113 lifesavers were trained to use the LMA and iGel supraglottic airways. Comparisons were made to standard devices on plastic manikins. Successful ventilation was defined as achieving visible chest rise. RESULTS: The median time to first effective ventilation was similar between the PM (16 s, 95% confidence interval 16-17 s), BVM (17 s, 16-17 s) and iGel devices (18 s, 16-20 s), but longer for the LMA (36 s, 33-38 s). The iGel frequently failed to achieve ventilation (10%) compared with the PM (1%, P < 0.01) and LMA (3%, P < 0.01) but was not worse than the BVM (3%, P < 0.57). Hands-off time was similar between the BVM, LMA and iGel (10 s for each device), but worse for the PM (13 s, P = 0.001). CONCLUSION: Lifesavers using the PM and BVM perform ventilation for cardiopulmonary resuscitation well. There appears to be a limited role for supraglottic airway devices because of limitations in terms of time to first effective ventilation and reliability. Clinical validation of manikin data with live resuscitation performance is required.