Emergency biventricular assist device implantation in a patient with suspected COVID-19 disease.

Severe coronavirus disease 2019 (COVID-19) is a multisystem inflammatory disorder and knowledge and experience with severe acute respiratory failure in infected patients has grown considerably since reports of the first few cases. Little is known about the effect of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus on the heart, and it has been suggested that fulminant cardiac failure, with or without respiratory failure, may occur several weeks following infection. A young man presented after a recent viral illness. He was in severe cardiogenic shock and was implanted with an emergency biventricular assist device, which also incorporated an extracorporeal membrane oxygenator. He stabilised soon after and, despite an intracerebral haemorrhage which resolved and bleeding into the trachea following percutaneous tracheostomy, he survived to explant and was successfully stepped down to a rehabilitation unit on postoperative day 50. He tested positive for SARS-CoV-2 antibodies when the test became available on postoperative day 33. We envisage there will be many more such presentations of acute COVID-19-associated cardiogenic shock and we recommend clinicians consider this diagnosis when presented with an acutely unwell patient with an unclear diagnosis following a viral illness. These patients should be discussed as early as possible with a transplant/mechanical circulatory support team.

Survey of airway skills of surgeons in Western Australia.

Our objective was to survey all consultant surgeons, including obstetricians/gynaecologists, in the State of Western Australia to assess their experience with, and readiness to assist anaesthetists with a difficult or failed airway. Survey questionnaires were mailed to all surgeons registered in Western Australia (n = 445). A total of 238 responses (53%) were received, mostly from general surgeons, obstetrician/gynaecologists and orthopaedic surgeons. Forty percent had provided non-surgical assistance with a difficult airway and 60% had assisted with a surgical airway. All ear nose and throat surgeons who responded to the survey had assisted with an emergency surgical airway and 47 surgeons reported having performed six or more surgical airways. However 26% of respondents had never performed a surgical airway and 37% did not feel confident in performing an urgent surgical airway Seven percent of respondents reported witnessing a failed airway that resulted in death or neurological damage. Seventy percent of respondents had undergone formal training in tracheostomy and 26% had advanced trauma life support or early management of severe trauma training. These findings indicate that surgeons in Western Australia perform surgical airways infrequently and only occasionally assist anaesthetists with difficult airway management. However, some surgeons lack confidence and training in surgical airway management. Because anaesthetists cannot always rely on their surgical colleagues to provide a surgical airway during a crisis, we recommend that anaesthetists discuss airway management with their surgical colleagues for all patients with identified difficult airways and that anaesthesia training should include surgical airway management.

Neonatal illicit drug screening practices in Iowa: the impact of utilization of a structured screening protocol.

OBJECTIVE: The purpose of the study was to determine the neonatal illicit drug screening practices of Iowa birthing hospitals. STUDY DESIGN: Cross-sectional survey design was implemented. The impact of structured screening protocols on the numbers of neonates screened and positive testing in 2004 was reviewed. RESULTS: Of 81 birthing hospitals, 53 (65%) participated in the study. Screening and positive test rates were higher in hospitals utilizing a structured screening protocol compared to those not utilizing one (10.9 versus 2.1% and 0.9 versus 0.2%, respectively, P < 0.0001). Hospitals with higher population, numbers of outpatients, inpatients, deliveries, and availability of drug abuse treatment services utilized a structured screening protocol more often. CONCLUSION: Utilization of a structured screening protocol increases the number of neonates screened for illicit drugs and positive testing rate regardless of urbanization. Regional standardization of structured screening protocols may improve the recognition of perinatal illicit drug exposure and provision of treatment services.

A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fiberoptic intubation.

BACKGROUND: The design of an endotracheal tube has been shown to influence the passage of the tube through the glottis during fiberoptic intubation. Difficulty in passing the endotracheal tube can occur if the aryepiglottic folds obstruct the passage of the bevel. The relevant aspects of endotracheal tube design include the shape of the bevel, the material used by the manufacturer, and the ability of the tube to conform to the shape of the fiberscope. The aim of the current study was to compare the ease of passage through the glottis of two different tubes. One tube was a wire reinforced polyvinyl chloride tube with a standard bevel and the other was a newly designed tube with a bevel of different shape and made of silicone rubber. The new design is for use with the a commerical intubating laryngeal mask. METHODS: The authors studied a population of 30 patients who received a standard anesthetic. In all cases, oral fiberoptic intubation was attempted. Anesthetic was administered to each patient using both tubes, and before the study the order of the tubes was randomized. The difficulty in passing the tube was assessed by a blinded observer and graded using a three-point scale (grade 1: no difficulty passing the tube; grade 2: obstruction to passing the tube relieved by withdrawal and a 90 degrees anticlockwise rotation; grade 3: obstruction necessitating more than one manipulation or external laryngeal manipulation). RESULTS: In 27 patients, no difficulty was shown by use of the silicone-tipped tube. In only three patients was there difficulty that necessitated a 90 degrees anticlockwise twist. With the wire-reinforced tube, no difficulty was experienced on 14 occasions. Grade 1 difficulty was experienced eight times and difficulty necessitating more than one maneuver, head movement, or external laryngeal manipulation was seen on eight occasions. Statistical significance was achieved at P = 0.0002 (Wilcoxon signed rank test). CONCLUSIONS: The authors conclude that the use of the silicone-tipped tube with the new bevel design may provide an advantage in the clinical situation of fiberoptic intubation.

Airway management for carinal tumour resection.

We describe the airway management during resection of a right main bronchial and carinal "pseudotumour" in a 16-year-old patient. Two 5 mm microlaryngoscopy tubes (Mallinckrodt) were inserted side by side in the trachea, with one positioned in the left main bronchus and the other just below the larynx. Independent ventilation of both lungs, with suctioning and fibreoptic inspection of the lower trachea, could easily be carried out. Current airway devices used to isolate lung ventilation are reviewed and their limitations considered.

A comparison of two airway aids for emergency use by unskilled personnel. The Combitube and laryngeal mask.

Many non-anaesthetists find airway control and intubation difficult. The laryngeal mask has been advocated for use by non-anaesthetists at cardiorespiratory arrests, whilst the Combitube is said to provide protection from aspiration. We wished to determine which device was easiest for unskilled staff to use. Staff not previously trained in airway support were briefly taught insertion of each device. Twenty-six ASA 1 or 2 adults, requiring muscle relaxation and tracheal intubation for surgery, were recruited to this randomised crossover study. Both devices were inserted in random order and the time to successful ventilation of the lungs recorded. Both devices were successfully placed in 24/26 patients. The median times to insertion were 40 s and 45 s for the laryngeal mask and Combitube, respectively, with two failures, both with the Combitube (p > 0.05); these were due to faulty operator technique. The Combitube may be a suitable alternative to the laryngeal mask for use in resuscitation by unskilled staff.

Training in anaesthesia: the US perspective.

In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Specialist training in anaesthesia, supervision and assessment', there is currently much debate concerning the future of anaesthesia training in the UK. We present a description of anaesthesia training in the US for discussion and comparison. US residency training is short and seamless. It is highly structured, but retains a capacity for specialisation. It may offer ideas for the future direction of training in the UK.

Monitoring neuromuscular block by acceleromyography: comparison of the Mini-Accelograph with the Myograph 2000.

The precision of the compact Mini-Accelograph (M-A) was compared with the Myograph 2000 (MYO). Neuromuscular block resulting from atracurium was measured simultaneously by the MYO and the M-A applied to contralateral thumbs. During onset, the M-A frequently underestimated the extent of block (maximal at approximately 50% twitch depression). The M-A control train-of-four (TOF) ratio was characteristically > 1.0 and remained greater than the MYO ratio during the onset of atracurium. During recovery, the difference between the MYO and the M-A was maximal at approximately 50% twitch depression, but the M-A frequently overestimated the extent of block. The mean differences between the MYO and the M-A were small in respect of the recovery index (RI) and the TOF. However, the limits of agreement were unacceptably wide for both TOF and RI. When the MYO TOF was 0.7, the corresponding M-A TOF varied between 0.4 and 1.0. The M-A was more susceptible to drift than the MYO.

Anaesthetic log books. How are they being used?

Since 1989, the Royal College of Anaesthetists has encouraged trainees to keep log books, although there is little information about the benefits of this practice as a part of anaesthetic training. A postal survey of all grades of trainee anaesthetist in the North West Region of England was conducted to obtain information about the present use of log books. The survey showed that log books are only used diligently by the more junior grades of anaesthetic staff. Although the practice of keeping a log resulted in an increased ability of the trainee to describe his clinical experience, the subsequent exploitation of this information to monitor or correct deficiencies in training was disappointingly low.

Does the laryngeal mask airway compromise cricoid pressure?

The laryngeal mask airway was inserted in 10 cadavers. At postmortem the chest was opened and an infusion set primed with a dilute barium solution was inserted into the oesophagus and ligated in place. A cricoid force of 43 N was then applied and the infusion set was positioned so that when the clamp was opened it generated a pressure of 7.8 kPa within the oesophagus. The cricoid pressure was able to stop the flow of fluid into the oesophagus. This demonstrates that cricoid pressure is effective in preventing reflux at intragastric pressures which are encountered clinically and the presence of the laryngeal mask airway does not compromise this.