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Introduction: The COVID-19 pandemic has required clinical teams to function with an unprecedented amount of uncertainty, balancing complex risks and benefits in a highly fluid environment. This is especially the case when considering the delivery of a pregnant woman critically unwell with COVID-19. This is one maternal critical care team's reflections on establishing best practice and a shared mental model when undertaking a Caesarean section in critically unwell patients with COVID-19. Objective(s): We describe our experience of balancing the risks and streamlining the process of this high-risk intervention. Method(s): We used our standard clinical governance forums across four specialties (Obstetrics, Intensive care, Anaesthetics and Neonatology) to identify key challenges and learning points. We developed a working group to combine our learning and develop a shared mental model across the involved teams. Result(s): 1. The decision to deliver must be multidisciplinary involving Obstetrics, Intensive care, Anaesthetics, Neonatology and the patient according to their capacity to participate. The existing structure of twice daily ITU ward rounds could be leveraged as a 'pause' moment to consider the need for imminent delivery and review the risk-benefit balance of continued enhanced pharmacological thromboprophylaxis. 2. We identified a range of scenarios that our teams might be exposed to: 3. Perimortem Caesarean section 4. Critically unwell - unsafe to move to theatre 5. Critically unwell - safe to move to theatre 6. Recreating an obstetric theatre in the ICU Advantages Avoids moving a critically unstable patient, although our experience is increasing moving patients for ECMO. Some forms of maximal non-invasive therapy such as High Flow Nasal Oxygen may require interruption to move to theatre with resultant risk of harm or be difficult to continue in transport mode through a bulky ICU ventilator e.g. CPAP Disadvantages Significant logistics and coordination burden: multiple items of specialist equipment needing to be brought to the ICU. Human factors burden: performing a caesarean section in an unfamiliar environment is a significant increase in cognitive load for participating teams. Environmental factors: ICU side rooms may offer limited space vs the need to control the space if performed on an open unit. Delivering a Neonate into a COVID bubble. Conclusion(s): Developing a shared mental model across the key teams involved in delivering an emergency caesarean section in this cohort of critically unwell patients has enabled our group to own a common understanding of the key decisions and risks involved. We recommend a patient centred MDT decision making model, with a structure for regular reassessment by senior members of the teams involved. In most circumstances the human factors and logistical burden of recreating an operating theatre in the ICU outweighs the risk of transport to theatre. Pre-defined checklists and action cards mitigate the cognitive and logistical burden when multiple teams do perform an operative delivery in ICU. Action cards highlight key aspects of routine obstetric care to be replicated in the ICU environment.
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Introduction & Objectives: Since COVID-19 global pandemic started, increasing importance was given to same-day discharge (SDD) protocols to minimize viral exposure, reducing healthcare costs without compromising patients' safety. While SDD protocols have been applied for robotic radical prostatectomy, literature is still lacking studies evaluating the feasibility of meeting SSD criteria for patients who underwent RASP. Our aim was to evaluate the feasibility and safety of hospital discharge 24h after surgery. Our secondary endpoint was to assess predictors of successful discharge on 1st postoperative day (POD). Material(s) and Method(s): Patients with allergy to local anesthetics, those scheduled for concomitant surgical procedures and those with severe comorbidities (ASA score 3-4) were excluded from the analysis. Outcomes of this study were: Postoperative Hb drop, 30-day post-surgical readmission, any post-discharge complication, postoperative, time to flatus and consequent regular diet restoration, PSA, flowmetry parameters and validated questionnaires. The SDD criteria included: stable postoperative hemoglobin and vital signs, tolerance of clear liquids, pain control with oral medications and no perioperative complications requiring a prolonged hospitalization (Clavien >1). Result(s): Demographics and baseline values of 63 consecutive patients were reported in Table 1. Perioperative outcomes were shown in table 2. No perioperative complications were reported, median DELTAHb was 2.2 mg/dl, vital signs were stable for every patient. Overall, 55 (87%) patients passed flatus within 24 hours from surgery, and regular diet was restored;7 patients (11%) needed opioids for pain control. Two thirds of patients (n=42, 67%) met the criteria for SDD. At logistic regression analysis, patient's age was the only independent predictor of one night stay (OR 0.89;95% CI 0.80 - 0.98 p=0.02;Table 3). Patients younger than 60 met 24 hours discharge criteria in 90%, while those older than 70 in 50% of cases. Conclusion(s): In a selected cohort of patients with negligible comorbidities profile, discharge within 24h from RASP seems a safe and feasible option in 67% of cases. Patient' age was the only predictor of successful 1 night stay after RASP in our series. [Table presented]Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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The proceedings contain 34 papers. The topics discussed include: comparison of intra-arterial blood pressures versus two noninvasive measuring systems: a cross-sectional analytic study employing Bland-Altman and error grid analyses;prevalence of vitamin D deficiency amongst anesthesia providers at the Universitas Academic Hospital;chemical and physical stability of an admixture of anesthetic drugs;postoperative pulmonary complications in adult surgical patients in low- and middle-income countries: a systematic review and meta-analysis;the prevalence of SARS-CoV-2 infection in an academic department of anesthesiology;evaluation of the use of a 3D printed video laryngoscope for tracheal intubation in a manikin;the prevalence of caregiver anxiety in theatre at universitas academic hospital;the spectrum of disease and short-term outcomes of obstetric patients with cardiac disease at a tertiary hospital in South Africa;and almost 30% reduction in carbon footprint using volatile anesthesia - a quality improvement project introducing low-flow anesthesia in a regional hospital.
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Background: Covid 19 is a global epidemic. One of the most important steps in the fight against this epidemic is vaccination. mRNA vaccines are used in vaccination in our country. Among the additives in the vaccine, the substance with the highest allergenic risk is polyethylene glucose (PEG). There are different molecular weights of PEG. Another additive that has a high risk of cross-reaction with PEG as an additive is POLISORBAT 80. Skin tests with drugs containing PEG and POLISORBAT 80 and, if available, tests with vaccines are instructive. Among the drugs containing PEG: Moxifloxacin tablet, ciprofloxacin tablet, Amoxicillin clavulanic acid tablet;Medicines containing polysorbate include: Omalizumab vaccine, Mepolizumab vaccine. The results of the skin test with PEG-containing methylprednisolone (DEPO-MEDROL) and POLYSORBAT-containing triamcinolone (KENACORT-A) in order to be evaluated in terms of vaccine in our 2 patients who had multiple drug sensitivities before were shared. Method(s): Case 1: 33 y, F *There are diagnoses of urticaria and angioedema. Urticaria 30 minutes after taking aspirin, levofloxacin, cefdinir tablet;5 minutes after taking ciprofloxacin tablets, he has anaphylaxis. *Applies before Biontec vaccine. *The patient had a history of anaphylaxis with PEG-containing ciprofloxacin. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *The patient for whom Biontec vaccine was not recommended received Synovac vaccine without any problems. Case 2: 52 years, F * He has a diagnosis of urticaria. 5 minutes after general anesthesia and local anesthesia;The patient who had cardiac arrest 3 times was evaluated. The patient, who had Synovac for 2 times without any problems, wanted to have the 3rd dose of Biontec vaccine. *Tested with general -local anesthetic agents. *Ciprofloxacin skin tests are negative;Urticaria plaques developed after 30 minutes of 1/4 tb in oral provocation. In the skin tests performed with DEPO-MEDROL and KENACORT-A, 1/100 intradermal test was positive. *Biontec vaccine is not recommended. Result(s): A safer vaccination is ensured by testing with additives in Covid 19 vaccines. Conclusion(s): Drug additives should also be kept in mind in patients with multiple drug allergies.
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The use of ECMO methods has experienced a significant boom in recent years, mainly due to the SARS-CoV-2 pandemic. Many workplaces that had little or no experience with ECMO currently possess the relevant technology and can use this method in real clinical practice. The prone position (PP) has changed from the original position of rescue intervention to the leading position among the methods that should be considered standard in patients with a severe form of acute respiratory failure. Thus, the combination of pronation and ECMO support has received considerable attention in recent years. This text, although a year in the 2022 review, briefly discusses available evidence-based medicine publications over the past few years devoted to this topic. The use of PP in clinical conditions other than mechanical ventilation (MV), e.g. in conscious patients on non-invasive ventilatory support, is described in the next section of this text. Another topic is the correct setting of MV while using PP and the effect of PP in pregnant patients with COVID-19. Inhalational anesthetics and their use for sedation of patients on UPV are currently among the frequently discussed topics within the optimization of intensive care. Conversely, ventilator-induced dysfunction of the main respiratory muscles, especially the diaphragm, has been a serious topic in critical care for a long time. Next, critically ill patients are at risk of hyperoxemia both as part of MV and ECMO support. The negative impact of this condition is the final topic of the article.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.
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Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.Copyright © 2022
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Introduction: Patients presenting with bladder lesions identified during cystoscopy require histological diagnosis, routinely obtained by biopsy under general anaesthetic (GA). GA biopsies are resource intensive as they require the use of an operating theatre and surgical staff. Local anaesthetic cystodiathermy (LAC) is an alternative method for obtaining biopsies, suitable for bladder lesions <5mm in size. LAC can be performed in the outpatient setting thus reducing the need for theatre resources. The aim of our audit was to assess the safety and feasibility LAC bladder biopsies for indeterminate bladder lesions. Method(s): LAC were carried out at our peripheral London outpatient clinic. The main inclusion criteria was the presence of sub 5mm indeterminate lesions identified during routine and surveillance flexible cystoscopy. Patients notes were reviewed for follow up 2 months after their procedure. Result(s): 10 patients underwent LAC between July and September 2021, with an age range of 36-83 years old and ASA grade between 1 and 3. 6 patients were invited following positive findings at routine surveillance cystoscopy, 3 following cystoscopy for new haematuria, and 1 was investigated for routine UTIs. Only one patient had a malignant histology, with 90% reporting a benign biopsy. No patient required admission or subsequent GA biopsy, and no complications were reported. Conclusion(s): LAC is a resource-effective procedure eliminates the exposure of patient to GA. It avoids the need for preassessment and inpatient admission, thus freeing up theatre resources for other patients. This project supports the use of LAC for small indeterminate bladder lesions.
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Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.
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Study objective: Multidisciplinary meetings (MDMs) are increasingly implemented in complex care based on the principle that they lead to evidence-based treatment recommendations, foster adherence to clinical guidelines, induce better team performance and improve medical care. In oncofertility, the uncertain outcomes of fertility preservation procedures in children contribute to the complexity of decision-making. There is limited published information on the influence of MDMs on paediatric and adolescent oncofertility care. Aim(s): To describe the implementation, characteristics & outcomes of multidisciplinary meetings (MDMs) in a paediatric oncofertility setting. Method(s): A retrospective medical records review of oncofertility MDMs held between April 2020 and March 2021 at the Royal Children's Hospital Melbourne. Inductive content analysis of the reasons for MDM was undertaken. MDM documentation was scored out of 24, according to a Victorian Paediatric Integrated Cancer Service quality assurance checklist for MDMs, (1)) which included consent for MDM, nature of attendees, quality of discussion and documentation. Result(s): Of the 169 oncology patients treated at the Royal Children's Hospital between 1st April 2020 and 31st March 2021, MDMs were required for 40 patients (23.7%). The median number of clinical attendees was 10, and included craft groups from both paediatric and adult centres (oncology, oncofertility, gynaecology, clinical ethics, endocrinology, paediatric surgery, anaesthetics, haematology, fertility specialists and reproductive scientists). Fifty-four percent (n=22) of MDMs were for male patients (median age 8.4 [0.1-16.5] years) and 46% for females (n=18, median age 8.1[0.4-16.3] years). The commonest diagnoses presented at MDM were brain tumours (27.5%), leukemia (25%), and non malignant conditions (19.5%). Approximately 77% of all MDM patients were going to receive treatment that put them at high infertility risk and 62.5% had co-morbidities. MDMs included the following themes (i) likelihood of successful parenthood: disease progression, prognosis, neurocognitive decline;(ii) certainty or otherwise of planned treatment and infertility risks;(iii) mitigation of anaesthetic and surgical risks;(iv) ethical concerns;(v) organizational capacity and logistics in the face of covid restrictions or high dependent care between centres (vi) child and family of risks, expectations and their values regarding fertility preservation. In 87.5% of cases, it was deemed permissible to offer fertility preservation. The median score for the MDMs derived from the quality assurance checklist was 16. Conclussion: MDMs acted as a valuable educational and communication tool improving situational awareness, building shared mental models, assisting with risk mitigation and oncofertility planning.Copyright © 2023
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At Whipps Cross Hospital, multi-morbid (high-risk) patients undergoing urological surgery are routinely listed on the surgical inpatient pathway. The 'Getting it right first time' [1] review of anaesthesia recommended day-case surgery as the default for suitable procedures, to help with waiting lists as well as to provide patients with a safe environment. To improve patient choice and postoperative outcomes, an ambulatory spinal pathway was piloted. Methods An earlier scoping exercise identified a pool of urology high-risk patients who could potentially benefit from an ambulatory spinal pathway. Based on this, prilocaine use for ambulatory spinal anaesthetic was provisionally approved by the drugs and therapeutic committee. A pilot ambulatory pathway was put in place, which helped identify suitable patients. The pilot pathway was limited to a select group of anaesthetists to minimise variations. Postoperatively, patients were followed up at 3 and 24 h and assessed for postoperative nausea, vomiting, pain, mobilisation, neurological symptoms and cognitive impairment. Results The total number of patients was 19. Mean ASA was 2.9. Average age was 74 years. The mean dose of hyperbaric prilocaine 2% used was 2.9 ml, 21% of cases utilised additional intrathecal additives. Regarding intra-operative analgesia, only paracetamol was used in 15% of cases. There were no conversions to general anaesthetic. The most common procedure was a cystoscopy with or without biopsy (42%). With comorbidities, diabetes mellitus was the most common (58%), followed by cardiac disease (53%) and respiratory disease (42%). At 3 h, 100% of patients were eating and all sensation had returned, 0% had cognitive impairment, 47% were sitting out and 42% mobilising. Sixteen per cent had hypotension and 5% had pain at rest. At 24 h, 0% had cognitive impairment, 50% had required analgesia and 84% were mobilising. All patients reported they would have a spinal anaesthetic again in the future. Discussion With an ageing population, who have multiple comorbidities, there is huge benefit regarding providing the choice of a spinal anaesthetic rather than general anaesthetic, which allows patients to go home the same day. This will not only provide financial savings to the service provider but also help clear the backlog of surgeries due to the COVID-19 pandemic and enhance patient recovery.
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Background: On March 2020, because of the COVID-19 pandemic, the Swiss Federal Council mobilised conscript formations of the Swiss Armed Forces. This was the largest military mobilisation since the Second World War. Purpose(s): To assess the roles of the militia pharmacy officers deployed throughout the country to assist the healthcare system. Method(s): All missions performed by militia pharmacy officers were systematically collected and evaluated. They were also compared to the official duties of pharmacists in the Swiss Armed Forces. Result(s): Ten pharmacy officers were enlisted in two out of four hospital battalions deployed, as well as in the medical logistic battalion and in the staff of the logistic brigade that embedded them. Their missions were mainly planning, conduct and control of medical logistics, as well as hygiene and drug manufacturing activities. In the hospital battalions, they especially managed: 1) supply of medical material dedicated to mission-related training, civilian health facilities assistance and medical transportation;2) establishment and application of hygiene procedures;3) provision of conscripts' own medication. In the medical logistic battalion, the support of both military and civilian pharmaceutical production facilities was the most important activity (e.g. disinfectants and anaesthetics manufacturing). Conclusion(s): Thanks to their civilian and military background, militia pharmacy officers have been quickly and effectively deployed throughout the country. The role of pharmacists within their respective battalions has emerged as especially crucial in the pandemic context and some of the performed missions were beyond their traditional duties. Their basic training has to be further developed accordingly.
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Background: On March 16, 2020, because of the COVID-19 pandemic, the Swiss Federal Council declared an 'extraordinary situation' in terms of the Epidemics Act. Purpose(s): To assess the roles of an inter-hospital pharmacy in the fight against SARS-CoV-2. Method(s): All missions performed by our pharmacy were systematically collected and evaluated. They were also compared to its official duties. Result(s): Specific missions, which have been mainly managed by the crisis unit and the four departments of the pharmacy (Pharmaceutical Logistics, Drug Manufacturing, Clinical Pharmacy and Nursing Homes Supply), were: 1) human resources continuity;2) specific drug supply (for both hospitals and nursing homes;e.g. anaesthetics, sedatives, antiviral drugs, incl. for clinical trials);3) clinical assistance (especially in the ICU of the main acute hospital);4) individual drug manufacturing (e.g. hydroxychloroquine oral solution);5) on-site pharmacies management;6) own infrastructure securing (especially in term of hygiene);7) hand disinfectant production;and 8) hygienic masks supply for healthcare professionals in the area. The two last missions were out of the traditional duties of our pharmacy and have been achieved with the support of staff from the Swiss civil protection. A particular challenge was the management of the shortage of various products and the identification of alternative therapeutic options. Conclusion(s): Our pharmacy has faced various challenges during the acute pandemic situation. Some missions performed were even beyond our traditional ones. The disaster plan of our pharmacy has to be further developed, as well as the associated training of the staff, based on the lessons learned from this pandemic.
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Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19. Copyright © 2022 Elsevier Ltd
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Peri-operative intravenous paracetamol use has not been shown to be superior to oral administration in a randomised controlled trial looking at postoperative pain [1]. The use of intravenous paracetamol carries a wellrecognised increased financial and environmental cost compared to oral paracetamol. We audited the use of paracetamol in patients attending theatre at a district general hospital and propose a method to increase premedication with oral paracetamol. Methods We retrospectively audited the notes of all patients who underwent an elective surgical procedure in theatres, across a 5-day period at a district general hospital. Data regarding the use of paracetamol were collected. Patients who were already an inpatient and those having surgery under local anaesthetic alone were excluded. Results Forty-seven patients were included, five of whom had a spinal and 42 a general anaesthetic with representation from six different surgical specialities. Five of the patients included were under 18 years. Thirty-seven patients received paracetamol peri-operatively. Thirty-four patients received only intravenous paracetamol, two patients received oral paracetamol and one patient received both due to length of time between preoperative oral dose and surgery. Ten patients did not receive any paracetamol. No patients included had a documented allergy or contraindication to paracetamol. Discussion Our department recognised the financial and environmental benefits associated with oral pre-medication. Although many of these anaesthetists would prefer to prescribe pre-operative analgesia, the data indicate that there are barriers that prevent prescription and/or administration. As a result of the COVID-19 pandemic, elective orthopaedic surgery with an enhanced recovery protocol including the use of oral paracetamol premedication, was underrepresented in our data. Previous encouragement to prescribe oral premedication has produced good, short-term results but does not appear to provide long-lasting change. We propose a Patient Group Directive for the administration of pre-operative oral paracetamol by the admitting nurse on arrival to the pre-operative ward. We anticipate that this will both standardise and embed oral paracetamol premedication into the department and will therefore provide long-term change.
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Background: Trends in healthcare have caused a shift in training towards more competency based programmes. The COVID-19 pandemic has reduced time available for direct exposure and clinical learning, necessitating incorporation of simulation in training. The objectives of this study were to develop, pilot and evaluate a four week simulation based surgical teaching programme. Method(s): Interns pursuing a career in Surgery joined a near-peer surgical training programme delivered by NCHDs. A survey established a baseline competency. Four skills workshops were delivered. Outcomes were measured using data from pre and post course surveys as well as a surgical skills competition. Result(s): Of The 12 trainees, 71% had scrubbed in theatre before. 50% were already confident to scrub independently, increased to 75% post training. 28% were confident gowning/gloving, increased to 75% post training. 28% were confident to place a Simple suture in theatre, this did not increase despite training. 42% were confident performing an instrument tie, increased to 75% post training. 14% were confident hand tying knots, this increased to 62%. 14% of participants were comfortable performing excisional biopsy in theatre, increased to 62% post training. Preparation and administration of local anaestetic could be performed confidently by 14% before training, this increased to 87%. on completion, a surgical skills competition showed that 100% were able to satisfactorily perform basic skills. Conclusion(s): Near-peer delivery of surgical training has enhanced The basic surgical skills of interns. Similar programmes in other sites would ensure that interns have The skills required to safely care for surgical patients.
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore
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Introduction: Recruitment in intensive care has long been discussed, with the pandemic bringing this into sharp focus. Most anaesthetists in training were fully redeployed into ICU rotas or provided technical expertise. As surge rotas settle and a 'new normal' is regained, the challenge of ICU consultant recruitment needs to be addressed. Historically, ICUs have been predominantly staffed by consultants trained in both anaesthetics and intensive care medicine (ICM), but the challenges of this career path have been augmented by COVID-19. Forecasts suggest a concerning supply shortage of both anaesthetic and ICM consultants.1 The latest recruitment round for ICM has been the most competitive year for applications (ratio 2.9:1 in 2021 compared to 1.49:1 in 2020).2 However, the anaesthetic/ICM dual-training contribution to this workforce has worryingly decreased from approximately twothirds to less than a half. But what factors are causing this and has COVID-19 redeployment worsened this? Objectives: As we emerge from the second wave of the pandemic, we assessed the attitudes of anaesthetists about future careers in intensive care. Methods: We performed a brief electronic survey of 100 dual-or single-specialty anaesthetists in training from four LETBs across England who were redeployed to ICU. Results: Our survey showed that 29% had a negative experience that dissuaded them from pursuing ICM careers or, in some circumstances, relinquish their ICM training number altogether. Promisingly, 64% had a positive experience, and of these 39% reaffirmed their desire to pursue a career in ICU and 13% developed a new interest in pursuing a career in ICU since their redeployment. Positive factors included, 'teamwork', 'complexity of patients' and 'adding variety to my anaesthetic practice'. Prominent negative factors were 'additional exams', 'two separate portfolios' and 'high risk of burnout'. Respondents suggested changes to attract more anaesthetists to dual-accredit with ICM. This included the removal of hurdles such as additional exams, separate portfolios, and duplicated assessments. The additional training time was also highlighted, particularly given that trainees already contribute significantly to ICM rotas. There was a need for more flexibility in training with dual trainees wanting to undertake advanced training modules like their anaesthetic counterparts. They also reported wanting more anaesthetic sessions in their future job plans possibly reflecting the desire for varied practice as a consultant. Conclusion: Although COVID-19 has had a positive effect by increasing ICM applications, this may be at the expense of dual-trained anaesthetic/ICM trainees. FFICM should consider the factors which dissuade these applicants and its future impact on skills available in ICU. Both the RCoA and the FFICM have recently announced changes to curricula and e-portfolio which may close some of these gaps. The pandemic has grabbed the attention of a few anaesthetists and presented an opportunity to work in a team that solves difficult physiological puzzles, rapidly escalates capacity, and increasingly focuses on staff wellbeing. We should capitalise on this and hope that COVID-19 will result in the conversion of some of our anaesthetic colleagues into dual-specialty ICM consultants.
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Aim: To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with nail bed injuries to the emergency department. Method:Aretrospective cohort study was carried out over a nine-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department (PED) at Chelsea and Westminster Hospital, London, with nail bed injuries requiring repair by the plastic surgery team. The primary outcome measures are complications at the time of sedation and at outpatient follow up including surgical site infection at seven days. A secondary outcome measure of parental satisfaction was collected at four months. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken. Results: During the 9-month period, 10 nail bed repairs were performed under ketamine sedation in the PED. There were no serious adverse events recorded. No cases required further procedures and there were no cases of surgical site infections at 7 days. Parents reported favourable outcomes, with an average overall satisfaction score of 9.4 (where 10 is complete satisfaction). At follow up, there was one recorded complication which was successfully treated, with all patients being discharged from follow up within 3 months. Conclusion: This small study has shown ketamine procedural sedation in the paediatric population to be a safe and cost-effective method for the treatment of nail bed injuries in children presenting to PED. We believe that this management strategy, brought to the fore during the COVID-19 pandemic, should be considered as standard across all PEDs.