Diagnostic findings in sinonasal aspergillosis in dogs in the United Kingdom: 475 cases (2011-2021).

OBJECTIVES: To describe the diagnostic tests used and their comparative performance in dogs diagnosed with sinonasal aspergillosis in the United Kingdom. A secondary objective was to describe the signalment, clinical findings and common clinicopathologic abnormalities in sinonasal aspergillosis. MATERIALS AND METHODS: A multi-centre retrospective survey was performed involving 23 referral centres in the United Kingdom to identify dogs diagnosed with sinonasal aspergillosis from January 2011 to December 2021. Dogs were included if fungal plaques were seen during rhinoscopy or if ancillary testing (via histopathology, culture, cytology, serology or PCR) was positive and other differential diagnoses were excluded. RESULTS: A total of 662 cases were entered into the database across the 23 referral centres. Four hundred and seventy-five cases met the study inclusion criteria. Of these, 419 dogs had fungal plaques and compatible clinical signs. Fungal plaques were not seen in 56 dogs with turbinate destruction that had compatible clinical signs and a positive ancillary test result. Ancillary diagnostics were performed in 312 of 419 (74%) dogs with observed fungal plaques permitting calculation of sensitivity of cytology as 67%, fungal culture 59%, histopathology 47% and PCR 71%. CLINICAL SIGNIFICANCE: The sensitivities of ancillary diagnostics in this study were lower than previously reported challenging the clinical utility of such tests in sinonasal aspergillosis. Treatment and management decisions should be based on a combination of diagnostics including imaging findings, visual inspection, and ancillary testing, rather than ancillary tests alone.

Bilateral Thyroid Carcinosarcoma in a Cat.

A neutered female domestic shorthaired cat was presented for a rapidly growing left cervical mass and a 6-month history of primary hyperthyroidism. Cytological examination of the mass was consistent with a sarcoma. Due to poor clinical response the cat was humanely destroyed and a post-mortem examination was performed. This revealed a markedly enlarged, irregularly shaped left thyroid gland with signs of infiltration of the trachea. The contralateral (right) thyroid was also moderately enlarged and irregularly shaped. Histopathological examination of the cervical masses indicated bilateral thyroid carcinosarcomas, evidenced by positive immunohistochemical labelling for vimentin, pan-cytokeratin and thyroid transcription factor-1 of the appropriate cell populations. The cat also had a concurrent pulmonary adenocarcinoma (papillary-lepidic type), unrelated to the thyroid neoplasm. Thyroid carcinosarcoma is an uncommonly recorded canine and human neoplasm and this is the first case of this entity to be reported in a cat.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.

Failed tracheal intubation during obstetric general anaesthesia: a literature review.

We reviewed the literature on obstetric failed tracheal intubation from 1970 onwards. The incidence remained unchanged over the period at 2.6 (95% CI 2.0 to 3.2) per 1000 anaesthetics (1 in 390) for obstetric general anaesthesia and 2.3 (95% CI 1.7 to 2.9) per 1000 general anaesthetics (1 in 443) for caesarean section. Maternal mortality from failed intubation was 2.3 (95% CI 0.3 to 8.2) per 100000 general anaesthetics for caesarean section (one death per 90 failed intubations). Maternal deaths occurred from aspiration or hypoxaemia secondary to airway obstruction or oesophageal intubation. There were 3.4 (95% CI 0.7 to 9.9) front-of-neck airway access procedures (surgical airway) per 100000 general anaesthetics for caesarean section (one procedure per 60 failed intubations), usually carried out as a late rescue attempt with poor maternal outcomes. Before the late 1990s, most cases were awakened after failed intubation; since the late 1990s, general anaesthesia has been continued in the majority of cases. When general anaesthesia was continued, a laryngeal mask was usually used but with a trend towards use of a second-generation supraglottic airway device. A prospective study of obstetric general anaesthesia found that transient maternal hypoxaemia occurred in over two-thirds of cases of failed intubation, usually without sequelae. Pulmonary aspiration occurred in 8% but the rate of maternal intensive care unit admission after failed intubation was the same as that after uneventful general anaesthesia. Poor neonatal outcomes were often associated with preoperative fetal compromise, although failed intubation and lowest maternal oxygen saturation were independent predictors of neonatal intensive care unit admission.

"Mouth to mouth ventilation": a comparison of the laryngeal mask airway with the Laerdal Pocket Facemask.

Ten nurses with basic airway management experience were formally trained to use a classic laryngeal mask airway (LMA) and a Laerdal Pocket Facemask (LPFM) for oxygen enriched expired air ventilation (EEAV). They then used both of these devices for EEAV in a randomised fashion in 100 anaesthetised ASA I/II patients for elective surgery. EEAV was considered successful if the patient's arterial oxygen saturation was maintained above 93% on room air for 3 min. EEAV success rates for the LMA and LPFM were 95% and 51% respectively (P=0.03). There was no apparent learning curve for either apparatus. Mean time in seconds (s) for first successful ventilation from picking up the apparatus was 26.8s and 15.1s, for the LMA and LPFM respectively (P<0.005). Although the LMA took significantly longer time to insert, it proved to be more successful and easier to use than the LPFM for EEAV.

A national survey of safe practice with epidural analgesia in obstetric units.

The National Patient Safety Agency (NPSA) identified practice improvements with regard to epidural injections and infusions and released a patient safety alert on 28th March 2007. Prior to this, the Obstetric Anaesthetists' Association had considered the draft document and wished to assess current compliance in UK obstetric units. A postal survey of consultant-led obstetric anaesthetic units in the UK was performed in September 2006 to look at practice prior to the release of the safety alert. The response rate was 89%. Many units are already following the guidance from the NPSA but nearly one in four units have experience of wrong route drug errors related to confusion between systems for intravenous and regional drug administration.

The laryngeal mask airway and the tracheal route for drug administration.

We undertook a study to observe if a preformed curved plastic cannula, the Trachojet, could be passed blindly down a laryngeal mask airway into the trachea in 100 anaesthetized patients. Using air aspiration and a fibreoptic scope to confirm placement of the cannula, it passed into the trachea in only 27% of patients. The air aspiration technique used for detecting tracheal cannulation was 100% successful when the cannula was inserted fully. We conclude that it may not be possible to gain access to the trachea with a Trachojet for drug administration if a laryngeal mask airway is used to maintain the patient's airway.