Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial.

BACKGROUND: Misidentification of the cricothyroid membrane in a "cannot intubate-cannot oxygenate" situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. METHODS: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1-easy = visual landmarks; 2-moderate = requires light palpation of landmarks; 3-difficult = requires deep palpation of landmarks; and 4-impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. RESULTS: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult-impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). CONCLUSION: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Effect of a preoperative gabapentin on postoperative analgesia in patients with inflammatory bowel disease following major bowel surgery: a randomized, placebo-controlled trial.

BACKGROUND: Postoperative pain management for patients with inflammatory bowel disease (IBD) can be challenging. These patients have a high tolerance to pain medication, and relative contraindications to the use of epidural analgesia, limiting the pain management options. We evaluated the effect of a single preoperative gabapentin dose on opioid consumption for patients with IBD undergoing abdominal surgery. Secondary outcomes were postoperative pain scores, opioid-related side effects, and patient's length of hospital stay. METHODS: Following Research Ethics Board approval and informed written consent, patients were randomly allocated into 2 groups receiving either 600 mg of oral gabapentin or placebo 1 hour before the surgery. A blinded anesthesiologist recorded pain scores at rest and movement twice daily for 2 postoperative days. Also recorded were opioid consumption, time of return of bowel function, time to discharge, and opioid-related side effects on the opioid-related symptom distress scale (ORSDS). RESULTS: Seventy-two patients completed the study. The difference in opioid consumption (P = 0.4169) and pain scores measured at rest and movement on all 4 postoperative visits was not statistically significant. There was no significant difference between gabapentin and placebo on all the 11 symptoms reported on the ORSDS. There was a slight increase in length of hospital stay in the placebo group, but the return of bowel function was similar between the groups. CONCLUSIONS: This study examined the effect of a single preoperative administration of gabapentin in patients with IBD undergoing major bowel surgery. Our results suggest a single preoperative oral dose of gabapentin 600 mg does not reduce postoperative pain scores, opioid consumption, or opioid-related side effects.

Predictors of desaturation in the postoperative anesthesia care unit: an observational study.

STUDY OBJECTIVE: To evaluate predictors of desaturation and to identify practice for patient transport following general anesthesia. DESIGN: Observational quality assurance study. SETTING: Postanesthesia Care Unit (PACU) of a university-affiliated, tertiary-care hospital. PATIENTS: All adult postsurgical patients who received general anesthesia and who were admitted to the PACU. MEASUREMENTS: Patients were observed over a three-month study period during transfer to the PACU with or without oxygen supplementation. Sixteen variables related to patient, surgery, and anesthesia were recorded. RESULTS: The study recorded a total of 502 PACU admissions. The practice pattern showed that 57% of patients were transferred without oxygen and 19% of the entire sample had an initial oxygen desaturation of less than 90% on arrival to the PACU. Only 0.8% of patients experienced oxygen desaturation when they were transferred with oxygen supplementation. After logistic regression analysis, the most significant predictor of desaturation was transport without oxygen. CONCLUSIONS: The majority of anesthesiologists did not use supplemental oxygen for patient transfer. As a result, a higher incidence of postoperative desaturation was noted in their patients. Significant predictors of desaturation after general anesthesia included patients' sedation score, low respiratory rate, and transport without oxygen. The use of oxygen almost completely prevented desaturation during transport.

Deficits in information transfer between anaesthesiologist and postanaesthesia care unit staff: an analysis of patient handover.

BACKGROUND: The immediate postoperative period is important, as the patient recovers from the acute derangements resulting from the surgical insult and anaesthesia. Incomplete or incorrect communication between the anaesthesiologist and the postanaesthesia care unit nurse during the transfer process may lead to dangerous clinical mistakes. The literature examining handovers from operating room to the postanaesthesia care unit is scarce. OBJECTIVES: The primary objective of this study was to examine the current transfer practice through observation of handovers between the anaesthesiologists and the postanaesthesia care unit staff in order to identify data omissions. The secondary objective was to learn which data items the clinicians and nurses thought were a necessary part of the transfer process and whether this information was communicated at the time of handover. DESIGN: A prospective observational study. SETTING: Academic hospital in Toronto, Canada. PARTICIPANTS AND INTERVENTIONS: After Research Ethics Board approval, a prospective observational study was conducted at a university-affiliated teaching centre. During a 2-month period, multiple observations of patient handover were performed. The data provided were marked on a checklist. At the end of the study, participating nurses and physicians were surveyed regarding the necessity of communicating different items on the checklist. RESULTS: A total of 526 transfers were observed. Of 29 data items examined, only two items (type of surgery and analgesics given) were reported in more than 90% of handovers. Only three items (difficult intubation, ST-wave changes and co-morbidities/healthy) were reported in more than 80% of cases. Many items deemed as needed to be reported by the participants in the study were not communicated. CONCLUSION: This study demonstrates that the handover process is inconsistent and in some cases information defined as important by the physicians and the nurses is not transferred. Further studies need to investigate whether a handover protocol leads to a minimisation of omissions in information transfer.

A prospective observational evaluation of an anatomically guided, logically formulated airway measure to predict difficult laryngoscopy.

CONTEXT: Difficulty during tracheal intubation is the most common cause of serious adverse respiratory events for patients undergoing anaesthesia. Current traditional bedside predictors of difficult laryngoscopy have poor sensitivity. A simple method to accurately predict difficult laryngoscopy could greatly improve patient safety. OBJECTIVES: This study examined a novel bedside predictor of difficult laryngoscopy that calculates a ratio of measurements directly affecting the ability to achieve the necessary line of vision (NLV) from the larynx to the operator (NLV ratio). DESIGN: This was a prospective observational study. SETTING: A single tertiary care surgical centre. PATIENTS: We enrolled 2046 patients scheduled for elective surgery under general anaesthesia with anticipated tracheal intubation. INTERVENTION: Prior to surgery, patients had their NLV ratio and standard airway measures recorded. The anaesthesiologist who performed the intubation was blind to the airway assessment and recorded the best view of the larynx according to the Cormack and Lehane scale. Difficult laryngoscopy was defined as a grade 3 or 4 view. MAIN OUTCOME MEASURE: The main outcome measure was the sensitivity and specificity of the NLV ratio measurement for predicting difficult laryngoscopy. RESULTS: Receiver operating characteristics curve analysis of the NLV ratio revealed an optimal sensitivity of only 41% and specificity of 77%. CONCLUSION: Although our novel measurement performed similarly to traditional bedside predictors of difficult laryngoscopy, the sensitivity was too low for the test to be clinically useful. Numerous factors which may be very difficult to predict at the bedside probably contributed to the poor performance of this novel measurement.