Emergence characteristics comparing endotracheal tube to reinforced laryngeal mask airway during endoscopic sinus surgery - A randomised controlled study.

Background and Aims: During endoscopic sinus surgery, anaesthetic conditions significantly impact the intraoperative surgical field and bleeding during emergence. While the endotracheal tube (ETT) has been traditionally used in sinus surgery, a reinforced laryngeal mask airway (RLMA) that produces less upper airway stimulation may result in smoother emergence. Methods: A randomised controlled trial of 72 patients undergoing elective sinus surgery was conducted, with the allocation of airway technique to either ETT with a throat pack or RLMA. The primary outcome measure was emergence time, measured by time to opening eyes on commands at the cessation of anaesthesia, and the secondary outcomes were time to removal of airway device, remifentanil use, procedure times, mean arterial pressure (MAP) and the RLMA grade of blood contamination. The continuous variables were analysed using Student's t-tests and discrete variables, count tables were analysed using Fisher's exact tests. Results: There was no significant difference in the emergence time between the ETT and RLMA groups (P = 0.83). Remifentanil use was significantly higher in the ETT group than in the RLMA group (P = 0.022). The ETT group showed a significantly increased total anaesthetic time (P = 0.01). MAP was not significant during preinduction, maintenance or post-RMLA removal. The highest grade of contamination was grade 2 in RLMA. RLMA had lower rates of postoperative adverse events. Conclusions: RLMA comparable to ETT in terms of emergence time. The RMLA group had lower remifentanil use, anaesthesia duration and fewer postoperative adverse events such as cough and throat pain.

Basophil activation test in the diagnostic workup of perioperative anaphylaxis due to neuromuscular blocking agents: A case series and implications for practice.

In Australia, neuromuscular blocking agents are the leading cause of perioperative anaphylaxis. Current investigation of suspected anaphylaxis includes tryptase levels, serum immunoglobulin E (IgE) levels, and skin testing, including intradermal testing and skin prick testing. The gold standard for the diagnosis of a hypersensitivity reaction is a challenge test, but this poses a risk to patient safety. An alternative test, known as the basophil activation test (BAT) is a form of cellular in vitro testing using flow cytometry to measure the degree of basophil degranulation within a sample of blood following exposure to an allergen. This acts as a surrogate marker for mast cell and basophil activation, thereby identifying IgE-mediated allergy. It is most commonly used to supplement equivocal findings from initial in vitro testing to assist in confirming the diagnosis of a hypersensitivity reaction and identify the causative agent. We present a case series in which five patients with suspected anaphylaxis underwent a BAT, demonstrating its role and limitations in allergy testing within Australia.

SGLT2 Inhibitor-Associated Ketoacidosis vs Type 1 Diabetes-Associated Ketoacidosis.

This cohort study examines the natural history and response to treatment of sodium glucose cotransporter 2 (SGLT2) inhibitor­associated ketoacidosis compared with that of type 1 diabetes­associated ketoacidosis.

Effectiveness of erector spinae plane block for rib fracture analgesia: a systematic review protocol.

OBJECTIVE: This systematic review will investigate the effectiveness of the ultrasound-guided erector spinae plane block as an analgesic technique for patients with rib fractures compared with all other standard management techniques. Comparisons will be made with both nerve blocks (neuraxial techniques and peripheral nerve blocks) and systemic treatment (with patient-controlled analgesia and/or per required need analgesia for breakthrough pain). INTRODUCTION: Erector spinae plane block is a well-established rescue analgesia option for patients with rib fractures. The use of ultrasound-guided erector spinae plane block in clinical practice has been largely based on observational data, with recent randomized controlled trials examining it against several other options for analgesic management. This review will compare the erector spinae against all other management techniques used in practice for rib fractures to determine whether this is the most effective analgesic technique. INCLUSION CRITERIA: The review will include all randomized controlled and pseudo-randomized controlled trials examining ultrasound-guided erector spinae plane block for the analgesic management of traumatic rib fractures. All other study designs will be excluded. METHODS: MEDLINE (PubMed), Embase (Ovid), CINAHL (EBSCOhost), the Cochrane Central Register of Controlled Trials, the Australian and New Zealand Clinical Trials Registry (ANZCTR), ClinicalTrials.gov, and the ISRCTN registry will be searched to identify all relevant ongoing clinical trials. Study selection, critical appraisal, and data extraction will be performed by 2 independent reviewers. Data will be extracted into software for statistical analysis (including meta-analysis where possible). REVIEW REGISTRATION: PROSPERO CRD42023414849.

Effectiveness of high-flow nasal cannula oxygen in apneic oxygenation during intubation in high-risk surgical patients: a systematic review protocol.

OBJECTIVE: This review will investigate the effectiveness of high-flow nasal oxygen in apneic oxygenation through safe apnea time and other ventilation parameters in patients at high risk of oxygen desaturation during induction and tracheal intubation for anesthesia management. INTRODUCTION: High-risk surgical patient groups include obese patients, those with suspected or known obstructive sleep apnea, and critically ill patients, who are at risk of rapid oxygen desaturation during intubation. Conventional oxygen administration in induction and intubation of patients undergoing general anesthesia include nasal cannulas, simple face masks, Venturi, buccal oxygenation, bag-valve mask ventilation, and non-invasive ventilation. High-flow nasal oxygen has emerged as a novel technique, and is advantageous because it increases positive end-expiratory pressure and oxygen delivered. INCLUSION CRITERIA: Eligible studies will include high-risk surgical patients aged 18 or above requiring endotracheal intubation in both emergency and elective anesthetic settings. High-risk patients are defined as those with suspected or known obstructive sleep apnea, obesity (BMI > 35), or critically ill patients (scored the American Society of Anesthesiologists classification as 3 or above). METHODS: The review will follow the JBI methodology for systematic reviews of effectiveness. Databases to be searched include MEDLINE, Embase, and Scopus. Reference lists of selected studies will then be hand-searched for additional eligible studies. The primary outcome will be safe apnea time, with secondary outcomes including oxygen and carbon dioxide parameters, and adverse events (eg, gastric distension). Studies will, where possible, be pooled in statistical meta-analyses with data heterogeneity assessed using the standard χ2 and I2 tests. REVIEW REGISTRATION: PROSPERO CRD42022312145.

Peri-colonoscopy Implications of Sodium-Glucose Cotransporter-2 Inhibitor Therapy: A Mini-review of Available Evidence.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of oral glucose-lowering agents commonly used for the treatment of type 2 diabetes. With increased use, there has been an increase in the incidence of the rare but life-threatening complication of euglycemic diabetic ketoacidosis. A common but underappreciated precipitant is colonoscopy. In this work, we outline the pathophysiology of the interaction between colonoscopy and SGLT2i use, the evidence regarding SGLT2i use in the periprocedural setting and Australian Diabetes Society guidelines.

Incidence and factors impacting PTSD following the 2005 Eyre Peninsula bushfires in South Australia - A 7 year follow up study.

OBJECTIVES: To identify the incidence and factors impacting post-traumatic stress disorder (PTSD) at 6 months, 2 and 7 years following the 2005 Eyre Peninsula bushfires in South Australia. METHODS: A questionnaire was used to assess symptoms. DESIGN AND SETTING: A longitudinal follow-up study with responses collected from a self-report booklet. PARTICIPANTS: 179 respondents were present at 6 months post bushfires, with 103 and 87 participants at 2 and 7 years, respectively. MAIN OUTCOME MEASURES: PTSD rates and its precipitating factors. RESULTS: The proportion of PTSD cases at times 1, 2 and 3 were 13.4% (24/179), 10.7% (11/103), and 4.8% (4/87), respectively. At 6 months, terrifying experience of fire reduced odds of developing PTSD (Odds Ratio [OR]: 0.45; 95% CI 0.21-0.96) while relocation increased odds (OR: 2.93; 95% CI 1.06-8.08). At 2 years, relocation (OR: 6.81; 95% CI 1.07-43.41) was a positive predictor. At 7 years, personal loss from the fires (OR: 2.82; 95% CI 1.17-6.77) positively predicted PTSD. CONCLUSION: PTSD rates declined over time. Relocation may be a proxy measure of high levels of emotional trauma. Those most traumatised probably decided to relocate, and hence, relocation should be considered a trigger for PTSD in the aftermath of bushfire.

The application of a surgical face mask over different oxygen delivery devices; a crossover study of measured end-tidal oxygen concentrations.

BACKGROUND: The application of a surgical face mask over oxygen delivery devices is now a widespread recommendation in the setting of the Coronavirus disease pandemic. This addition is designed to reduce droplet spread, but this also changes the nature of these devices, and may alter the amount of oxygen delivered to a patient. This research investigated how placing a surgical face mask over both a simple plastic mask ("Hudson mask") and nasal cannula altered the concentration of available oxygen measured at the nares. METHODS: We measured the inspired and end-tidal oxygen concentrations of five healthy non-smoking volunteers. Oxygen was delivered via nasal cannula and also a simple plastic face mask, at flow rates of 2, 4, 6 and 8 l per minute, with and without an overlying surgical face mask. RESULTS: Adding a surgical mask over nasal cannula caused an appreciable rise in the end-tidal oxygen concentrations at all the measured oxygen flow rates 2, 4, 6, 8 L/minute. With the Hudson mask, there was a rise in oxygen concentration at 4 and 6 L/minute. For example, at a flow rate of 4 l/min via nasal cannula, available oxygen concentration increased from 24 to 36%, and via the Hudson mask the concentration rose from 27 to 38%. CONCLUSIONS: The addition of a surgical face mask over both nasal cannula and a Hudson mask resulted in an increased available oxygen concentration. This may be valuable where more advanced oxygen devices are not available, or alternatively providing adequate supplemental oxygen at lower flow rates and thus making critical savings in oxygen usage.

Airway emergency from megaoesophagus: A rare complication of an adjustable gastric band.

A 77-year-old lady with a laparoscopic adjustable gastric band (LAGB), implanted 12 years earlier for obesity, developed an unusual but almost fatal complication, characterised by dysphonia and stridor within minutes and a tensely swollen anterior neck. The condition mimicked haemorrhage into the subcutaneous tissues of the neck, and the airway was secured with an awake fibreoptic intubation. Subsequent computed tomography imaging of the abdomen and chest revealed megaoesophagus with dilatation up to 7 cm, proximal to the gastric band. The band was then deflated percutaneously with immediate resolution of the neck swelling. In patients with LAGB in situ, fluid should be removed from the band for any suspected device-associated symptoms such as severe vomiting, severe gastro-oesophageal reflux or neck swelling and respiratory distress. When there is radiological evidence of gross oesophageal dilatation or a high likelihood of an obstructive pathology at the level of the band, a careful nasogastric tube decompression may also resolve reflux, neck swelling or respiratory distress. A complication associated with LAGB should be considered in a patient with unexplained neck swelling or other features of airway obstruction who has an LAGB in situ.

Underused approach: subarachnoid block for a laparoscopic cholecystectomy? A case report and discussion of anaesthetic and surgical considerations.

We present a case of laparoscopic cholecystectomy with subarachnoid block (SAB) in an opioid-tolerant patient with chronic obstructive pulmonary disease (COPD). A 64-year-old woman presented to the emergency department with acute abdominal pain of biliary colic. Surgery was delayed in favour of conservative management given that she was considered high risk for general anaesthesia. Due to refractory pain, she successfully proceeded to have laparoscopic cholecystectomy with SAB. This case is a timely reminder that SAB is feasible and safe in patients with severe COPD, with the added benefit of increased analgesic effects, fewer postoperative pulmonary complications and quick recovery time.