Point of care ultrasound: a clinical decision support tool for COVID-19

The COVID-19 global pandemic has overwhelmed health services with large numbers of patients presenting to hospital, requiring immediate triage and diagnosis. Complications include acute respiratory distress syndrome, myocarditis, septic shock, and multiple organ failure. Point of care ultrasound is recommended for critical care triage and monitoring in COVID-19 by specialist critical care societies, however current guidance has mainly been published in webinar format, not a comprehensive review. Important limitations of point of care ultrasound include inter-rater variability and subjectivity in interpretation of imaging findings, as well as infection control concerns. A practical approach to clinical integration of point of care ultrasound findings in COVID-19 patients is presented to enhance consistency in critical care decision making, and relevant infection control guidelines and operator precautions are discussed, based on a narrative review of the literature.

Trauma-induced coagulopathy: Mechanisms and clinical management

INTRODUCTION@#Trauma-induced coagulopathy (TIC) is a form of coagulopathy unique to trauma patients and is associated with increased mortality. The complexity and incomplete understanding of TIC have resulted in controversies regarding optimum management. This review aims to summarise the pathophysiology of TIC and appraise established and emerging advances in the management of TIC.@*METHODS@#This narrative review is based on a literature search (MEDLINE database) completed in October 2020. Search terms used were "trauma induced coagulopathy", "coagulopathy of trauma", "trauma induced coagulopathy pathophysiology", "massive transfusion trauma induced coagulopathy", "viscoelastic assay trauma induced coagulopathy", "goal directed trauma induced coagulopathy and "fibrinogen trauma induced coagulopathy'.@*RESULTS@#TIC is not a uniform phenotype but a spectrum ranging from thrombotic to bleeding phenotypes. Evidence for the management of TIC with tranexamic acid, massive transfusion protocols, viscoelastic haemostatic assays (VHAs), and coagulation factor and fibrinogen concentrates were evaluated. Although most trauma centres utilise fixed-ratio massive transfusion protocols, the "ideal" transfusion ratio of blood to blood products is still debated. While more centres are using VHAs to guide blood product replacement, there is no agreed VHA-based transfusion strategy. The use of VHA to quantify the functional contributions of individual components of coagulation may permit targeted treatment of TIC but remains controversial.@*CONCLUSION@#A greater understanding of TIC, advances in point-of-care coagulation testing, and availability of coagulation factors and fibrinogen concentrates allows clinicians to employ a more goal-directed approach. Still, hospitals need to tailor their approaches according to available resources, provide training and establish local guidelines.

Skin-to-epidural distance in the Southeast Asian paediatric population: multiethnic morphometrics and international comparisons

INTRODUCTION@#Paediatric epidurals can present technical challenges due to wide variations in age and weight among children, ranging from neonates to teenagers. This study evaluated the skin-to-epidural distance in the thoracic and lumbar regions to determine the relationship between age, weight and ethnicity and depth to the epidural space in our Singapore paediatric population.@*METHODS@#Data from the Acute Pain Service was prospectively collected over 16 years. Details included patient demographics, level of epidural performed and distance from skin to epidural space. Multivariable regression analysis was performed to determine the association of weight, age, ethnicity and gender with the depths to the thoracic and lumbar epidural spaces. A simple linear regression was calculated to predict the depth to both thoracic and lumbar epidural spaces based on body weight. Equations were formulated to describe the relationship between weight and depth of epidural space.@*RESULTS@#A total of 616 midline epidurals were studied. Regression analysis was performed for 225 thoracic epidurals and 363 lumbar epidurals. Our study revealed a clear correlation between skin-to-lumbar epidural distance and weight in children. The best correlation was demonstrated between skin-to-lumbar epidural distance and body weight (R = 0.729). This relationship was described by the formula: depth (mm) = (0.63 × weight [kg]) + 9.2.@*CONCLUSION@#Skin-to-lumbar epidural distance correlated with weight in children. Our results highlighted the clinical significance of differences between Southeast Asian paediatric populations when compared to other populations.

Fibreoptic intubation in airway management: a review article

Since the first use of the flexible fibreoptic bronchoscope, a plethora of new airway equipment has become available. It is essential for clinicians to understand the role and limitations of the available equipment to make appropriate choices. The recent 4th National Audit Project conducted in the United Kingdom found that poor judgement with inappropriate choice of equipment was a contributory factor in airway morbidity and mortality. Given the many modern airway adjuncts that are available, we aimed to define the role of flexible fibreoptic intubation in decision-making and management of anticipated and unanticipated difficult airways. We also reviewed the recent literature regarding the role of flexible fibreoptic intubation in specific patient groups who may present with difficult intubation, and concluded that the flexible fibrescope maintains its important role in difficult airway management.

An Audit of 829 Paediatric Epidurals in a Tertiary Singapore Hospital: Complications and Conundrums

<p><b>INTRODUCTION</b>The incidence of complications related to epidural analgesia remains less well defined in the paediatric population as compared to adults. A retrospective review of prospectively collected data was performed to review and quantify risks of both adverse events and complications related to epidural analgesia in our Singaporean paediatric population.</p><p><b>MATERIALS AND METHODS</b>Data from the Acute Pain Service (APS) was prospectively collected over 19 years. Details included the age of the patients, level of insertion of the epidural catheter, number of attempts, staff grade of the practitioner, adverse events and complications.</p><p><b>RESULTS</b>Collectively, 829 epidurals were performed from 1 June 1997 to 31 May 2016. No deaths or major complications occurred within the 16-year period. There were 5 instances of dural puncture (0.6%). The incidence of minor postoperative complications was 3.1% with the majority of postoperative events comprising catheter-related problems (n = 161, 22.4%). Prolonged use of the catheter beyond 3 days is associated with a statistically significant increase in the frequency of skin infective/ inflammatory changes (<0.01). We highlight common complications and conundrums faced.</p><p><b>CONCLUSION</b>Epidural analgesia has been shown to be associated with a relatively low risk of complications both in the adult and paediatric populations, albeit with a fourfold increased risk in the latter cohort. Adverse events reported are largely related to catheter problems and have minimal impact upon the patient.</p>

Anaesthetic management of acute airway obstruction

The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom's 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists' difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.