Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study.

OBJECTIVE: Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. METHODS: Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. RESULTS: From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. CONCLUSIONS: Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.

The prevalence of cognitive impairment in emergency general surgery.

OBJECTIVES: Rates of all surgical procedures are increasing at a faster rate than the population is ageing. However, this encouraging statistic, necessitates a robust evidence base. The epidemiological evidence base in acute general surgery in the older person is sparse. This is the first assessment of the prevalence of cognitive impairment measured using the Montreal Cognitive Assessment tool (MoCA) in acute general surgery. METHODS: In three sites in Wales, England and Scotland comprising rural and urban populations, we studied consecutive patients aged over 65 years. We considered any older person admitted to the acute general surgical unit. We assessed them for baseline demographic data. They each underwent a MoCA assessment. RESULTS: We collected data on 245 people, mean age 76.9 years (8.1, standard deviation), 136 (55.5%) were women. Of these 201 completed the MoCA test, mean score of 18.9 and median score 20 (range 0-30). There were 37 (15.1%) MoCA scores in the normal range (≥26) and 44 (18%) people were unable to attempt (or complete) the MoCA. Increasing age (p < 0.01) but not sex (p = 0.14) predicted an abnormal MoCA. Considering only the 44 people who were unable to attempt the MoCA assessment, 11 (25%) were known to have a diagnosis of dementia, 9 (20.5%) were too unwell and the remainder unable to complete the assessment to due pre-existing disability. CONCLUSIONS: In a representative UK wide population, a high proportion of older people admitted with an acute general surgical problem had cognitive impairment when assessed using the MoCA.

Improving the accessibility of trust guidelines for junior doctors at North Bristol NHS Trust.

Medicine is becoming increasingly protocol driven. This provides a standardised format for doctors to deliver best practice, especially in the acute setting. 40 junior doctors were asked to locate three Trust guidelines: venous thromboembolism (VTE) prophylaxis; antibiotic prescribing; and management of upper gastrointestinal bleed (UGIB). For each doctor the time taken and number of mouse clicks to access each guideline was recorded. Following successful redesign of the Trust intranet we completed a re-audit. Initial results showed 48% of doctors were unable to locate the UGIB or the VTE guidelines within 5 min. For those who were able to locate the guidelines it took an average of 111 sec and 17 mouse clicks. 100% of doctors were able to locate the antibiotic guidelines in 12 sec and with two clicks. These are accessible via a single port of access. Following our redesign of the Trust intranet 100% of doctors located all three guidelines in an average time of 7.2 sec and in 2.1 clicks. Improvement in access to VTE prophylaxis and UGIB was statistically significant (p=0.001). Redesigning our Trust intranet homepage has significantly improved the accessibility of acute surgical and medical guidelines.