Cannula cricothyroidotomy and rescue oxygenation with the Rapid-O2™ oxygen insufflation device in the management of a can't intubate/can't oxygenate scenario.

We describe the successful use of cannula cricothyroidotomy and the Rapid-O2™ oxygen insufflation device (Meditech Systems Ltd, Dorset, UK) for rescue of a can't intubate/can't oxygenate (CICO) scenario in a patient with severe airway haemorrhage post-debridement of laryngeal amyloidosis. This case highlights the practical utility of a cannula technique for CICO rescue when appropriate equipment is used and when institutional measures are taken to prepare for this rare anaesthetic crisis.

A survey of the sequelae of memorable anaesthetic drug errors from the anaesthetist's perspective.

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist's perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.

Effectiveness of superior versus inferior subconjunctival anaesthesia for cataract surgery.

This study compared the efficacy of two different injection sites for subconjunctival anaesthesia (SCA) in cataract surgery. One-hundred-and-three eyes of 99 consecutive patients undergoing routine cataract surgery were randomised to receive SCA either to the superior bulbar conjunctiva (n = 52) or the inferior bulbar conjunctiva (n = 51). Pain experienced during anaesthetic administration and at various stages of the perioperative period was assessed using a simplified scale. Assessment of subconjunctival haemorrhage and chemosis was made by the surgeon. The percentage of patients reporting any pain on administration of superior SCA was 46% compared to 67% with inferior SCA (P = 0.036). Moderate to severe pain on SCA injection was experienced by 15% and 18% of those in the superior and inferior SCA groups respectively. The cataract procedure was well tolerated in both groups. There was no difference between the groups for duration of surgery (P = 0.25), anaesthetic related complications including chemosis (P = 0.28), subconjunctival haemorrhage (P = 0.38) or intraoperative complications (P = 0.50). We found that subconjunctival anaesthesia is effective for routine cataract surgery. There was no difference in block efficacy between superiorly and inferiorly delivered SCA. However, superior SCA appeared to be less painful on injection compared to inferiorly delivered SCA.

Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine.

OBJECTIVES: (a) To measure gastric tonometry values in critically ill patients with peritonitis and to assess the impact of epidural analgesia on these values. (b) To assess the impact of epidural analgesia on gastro-intestinal motility by abdominal ultrasound and paracetamol absorption. (c) To observe any change in clinical outcome that may result from the use of epidural analgesia in such patients. DESIGN: A double-blinded, prospective, randomised and controlled study of general intensive therapy unit (ITU) patients. PATIENTS: Twenty-one patients admitted with peritonitis and adynamic small bowel following abdominal surgery were randomly allocated to receive either intravenous morphine or epidural bupivacaine for analgesia. MEASUREMENTS AND RESULTS: Gastric intramucosal pH (pHig) and the mucosal:arterial PCO2 gradient (Pg-PaCO2) were measured at admission and after 24 h of analgesia. Analysis of mean changes in tonometry values showed a rise in Pg-PaCO2 and a fall in pHig in the morphine group and a significant difference between groups in the Pg-PaCO2 trends (p = 0.024). Significant improvements in the ultrasound appearance of the small bowel were observed in the epidural group (p = 0.0037, Mann-Whitney U test of median changes in a locally developed scoring system). There were no significant differences between the groups in any of the variables derived from the paracetamol absorption test (n = 10); both groups showed persistently delayed gastric outflow throughout the study period. CONCLUSIONS: Epidural analgesia resulted in improvements in gastric mucosal perfusion and the ultrasound appearance of the small bowel, indicating potential clinical benefit in a group of patients in whom epidural catheterisation is traditionally contraindicated.

Further localization of midbrain neurones mediating the defence reaction in the cat by microinjections of excitatory amino acids.

Microinjections (0.05 microliter) of L-glutamic acid, L-aspartic acid and DL-homocysteic acid were made in the midbrain at the same sites from which a defence reaction had been elicited previously by electrical stimulation. It was found that injections made at sites within the midbrain periaqueductal grey region (PAG) consistently elicited the facio-vocal signs of the defence reaction, whereas injections made at sites in the tegmentum bordering the PAG did not. As injections of excitatory amino acids depolarize cell bodies but not axons, the results indicate that the midbrain PAG but not the adjacent tegmentum contains a population of neurones whose excitation elicits these reactions. Furthermore, the data suggested that such neurones may be located preferentially within the caudal half of the midbrain PAG.