Intraoperative cell salvage as part of a blood conservation strategy in an obstetric population with abnormal placentation at a large Irish tertiary referral centre: an observational study.

BACKGROUND: Haemorrhagic morbidity is more common in women with abnormal placentation, that is placenta praevia or morbidly adherent placenta. The incidence of abnormal placentation is increasing due to rising caesarean section rates. Concerns regarding blood safety, blood shortages and soaring costs of blood processing have generated growing enthusiasm for blood conservation strategies. The aim of our study was to look at intraoperative cell salvage (IOCS) use and allogeneic transfusion patterns in patients with abnormal placentation. METHODS: Patients with abnormal placentation were identified from the hospital database over a 2-year period between 2015 and 2016. Information collected for those that had IOCS setup included estimated blood loss, volume of blood collected and returned, pre- and postoperative haemoglobin levels and use of allogeneic blood. RESULTS: A total of 139 cases of abnormal placentation were identified. Abnormal placentation accounted for 62% of all cases of IOCS usage and was established for 53 patients with abnormal placentation. The re-transfusion rate was 18.5%. Five patients received IOCS blood only. The allogeneic transfusion rate was 7.5% in patients who had IOCS setup compared with 6.9% in those who did not (p = 1.00). Median blood loss was greater for patients who had IOCS blood returned compared with patients who had not (p = 0.004). The median volume of blood returned was 520 (114-608) mL. Preoperative haemoglobin levels were lower for patients who received a combination of cell salvage and allogeneic blood (p = 0.006). CONCLUSIONS: IOCS contributed to a reduction or elimination of allogeneic transfusion for a proportion of this high-risk cohort and should be an integral component of a hospitals' blood conservation strategy.

The College of Anaesthetists of Ireland Simulation Training programme: a descriptive report and analysis of course participants' feedback.

BACKGROUND: Simulation-based education is a modern training modality that allows healthcare professionals to develop knowledge and practice skills in a safe learning environment. The College of Anaesthetists of Ireland (CAI) was the first Irish postgraduate medical training body to introduce mandatory simulation training into its curriculum. Extensive quality assurance and improvement data has been collected on all simulation courses to date. AIMS: Describe The College of Anaesthetists of Ireland Simulation Training (CAST) programme and report the analysis of course participants' feedback. METHODS: A retrospective review of feedback forms from four simulation courses from March 2010 to August 2016 took place. Qualitative and quantitative data from 1069 participants who attended 112 courses was analysed. RESULTS: Feedback was overall very positive. Course content and delivery were deemed to be appropriate. Participants agreed that course participation would influence their future practice. A statistically significant difference (P < 0.001) between self-reported pre- and post-course confidence scores was observed in 19 out of 25 scenarios. The learning environment, learning method and debrief were highlighted as aspects of the courses that participants liked most. CONCLUSIONS: The mandatory integration of CAST has been welcomed with widespread enthusiasm among specialist anaesthesia trainees. Intuitively, course participation instils confidence in trainees and better equips them to manage anaesthesia emergencies in the clinical setting. It remains to be seen if translational outcomes result from this increase in confidence. Nevertheless, the findings of this extensive review have cemented the place of mandatory simulation training in specialist anaesthesia training in Ireland.

Thrombocalc: implementation and uptake of personalized postpartum venous thromboembolism risk assessment in a high-throughput obstetric environment.

INTRODUCTION: Venous thromboembolism risk assessment (VTERA) is recommended in all pregnant and postpartum women. Our objective was to develop, pilot and implement a user-friendly electronic VTERA tool. MATERIAL AND METHODS: We developed "Thrombocalc", an electronic VTERA tool using Microsoft EXCEL™ . Thrombocalc was designed as a score-based tool to facilitate rapid assessment of all women after childbirth. Calculation of a total score estimated risk of venous thromboembolism in line with consensus guidelines. Recommendations for thromboprophylaxis were included in the VTERA output. Implementation was phased. Uptake of the VTERA tool was assessed prospectively by monitoring the proportion of women who gave birth in our institution and had a completed risk assessment. Factors affecting completion and accuracy of risk assessments were also assessed. RESULTS: Thrombocalc was used prospectively to risk-assess 8380 women between September 2014 and December 2015. Compliance with this tool increased dramatically throughout the study period; over 92% of women were risk-assessed in the last quarter of data collection. Compliance was not adversely affected if delivery took place out of working hours [adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 0.93-1.14]. Risk assessment was less likely in the case of cesarean deliveries (aOR 0.66, 95% CI 0.60-0.73) and stillborn infants (aOR 0.48, 95% CI 0.29-0.79). Misclassification of risk factors led to approximately 207 (2.5%) inaccurate thromboprophylaxis recommendations. CONCLUSIONS: Our electronic, score-based VTERA tool provides a highly effective mechanism for rapid assessment of individual postpartum venous thromboembolism risk in a high-throughput environment.

Jehovah's Witness patients presenting with ruptured ectopic pregnancies: two case reports.

INTRODUCTION: The management of emergencies in Jehovah's Witnesses presents several challenges to obstetricians and gynaecologists. We present two cases of ectopic pregnancies in Jehovah's Witnesses recently managed in our institution. This is the first case review series of its kind that we could identify. We feel it is of clinical importance for all physicians caring for Jehovah's Witnesses. CASE PRESENTATION: The first patient was a 28-year-old Caucasian Irish woman who presented in a state of collapse and a ruptured ectopic pregnancy was suspected. She refused treatment and took her own discharge against the advice of senior hospital staff. She re-presented to our Emergency Room 6 hours later in hypovolaemic shock. She ultimately consented to blood products including plasma and platelets and underwent laparoscopic left-sided salpingectomy. This consent was queried postoperatively by her next-of-kin but the validity of her consent was clarified by the hospital legal team.The second patient was a 35-year-old Nigerian woman who presented to our Emergency Room with a 2-week history of intermittent vaginal bleeding and abdominal pain with a haemoglobin of 5.4 g/dL. An ectopic pregnancy was diagnosed following assessment. She refused all blood products and underwent right-sided salpingectomy. Intravenous tranexamic acid was administered and cell salvage employed intraoperatively. CONCLUSIONS: We feel that this case review series emphasises the importance of appropriate management of Jehovah's Witnesses in our units. In both of the above cases, these women were in potentially life-threatening situations. Advances in haematology and pharmaceutical therapy contributed to their survival. We welcome these advances in the treatment of this patient population.

Bolus remifentanil for chest drain removal in ICU: a randomized double-blind comparison of three modes of analgesia in post-cardiac surgical patients.

PURPOSE: We compared 1 versus 0.5 microg/kg bolus remifentanil versus placebo in alleviating pain due to chest drain removal. Effects on sedation, respiratory rate (RR), oxygen saturation, heart rate (HR) and blood pressure were also evaluated. METHODS: Sixty patients following cardiac surgery were enrolled in this prospective, randomized, double-blind clinical trial. Patients were randomized to 1 or 0.5 microg/kg remifentanil or placebo. All received standardized analgesia. Visual analog scale (VAS) pain scores and cardio-respiratory data were recorded pre-procedure, at drain removal and at 2 min intervals post procedure. RESULTS: Patients receiving remifentanil had statistically significantly less pain than placebo at drain removal [median (25-75%) VAS: 0.5 microg/kg remifentanil 1 (0-2) versus placebo 5 (3-6), P = 0.001; 1.0 microg/kg remifentanil 0 (0-2) versus placebo 5 (3-6), P = 0.0001]. VAS scores between remifentanil groups were equivalent. Remifentanil 1 microg/kg versus placebo at drain removal revealed significant reductions in HR [mean +/- standard deviation (SD): 76 +/- 15 versus 92 +/- 10, P = 0.01], blood pressure [mean +/- SD: 103 +/- 22 versus 131 +/- 14, P = 0.01] and RR [median (25-75%): 10 (8-12) versus 16 (14-18), P = 0.001]. Remifentanil 0.5 microg/kg versus placebo at drain removal revealed significant reductions in blood pressure [mean +/- SD: 116 +/- 19 versus 131 +/- 14, P = 0.02] and RR [median (25-75%): 12 (10-13) versus 18 (16-18), P = 0.001]. SpO(2) at drain removal was significantly reduced when comparing 1 microg/kg remifentanil versus placebo [median (25-75%): 94 (88-97) versus 97 (96-98), P = 0.049] but not 0.5 microg/kg remifentanil versus placebo. Two patients became apnoeic following 1 microg/kg remifentanil, necessitating respiratory support. Sedation scores in all groups were similar. CONCLUSIONS: Bolus remifentanil at the tested doses delivers excellent analgesia, but 1 microg/kg remifentanil results in respiratory depression. Remifentanil bolus at 0.5 microg/kg is safe and effective for chest drain removal after heart surgery in ICU.

A comparison of four techniques of emergency transcricoid oxygenation in a manikin.

Cricothyroidotomy is the final rescue maneuver in difficult airway management. We compared 4 techniques of oxygenation via the cricothyroid membrane in a manikin. The techniques were wire guided, trocar, cannula with jet ventilation, and blade technique (scalpel with endotracheal tube). In the wire-guided group, the time taken to ventilation was slower on all attempts, and there were no successful attempts in <40 seconds. There were no differences between the other groups at any time. Time to ventilation improved with repetition in all groups. Skills were retained at 1 month.

Airway injury during emergency transcutaneous airway access: a comparison at cricothyroid and tracheal sites.

BACKGROUND: Oxygenation via the cricothyroid membrane (CTM) may be required in emergencies, but inadvertent tracheal cannulation may occur. In this study, we compared airway injury between the tracheal and CTM sites using different techniques for airway access. METHODS: Anesthesiologists performed 4 airway access techniques on excised porcine tracheas. The techniques were 1) wire-guided (WGT), 2) trocar (TT), 3) needle cannula (NCT), and 4) surgical-scalpel with endotracheal tube (ST). Participants performed each technique at both the CTM and tracheal sites. Specimens were assessed for injury. RESULTS: Injury was observed in 8 of 40 and 27 of 40 specimens at the CTM and tracheal sites, respectively (P < 0.001). Injury was more frequent at the tracheal site compared with the CTM in both the TT and ST groups (P = 0.02) but not for the NCT and WGT. The rank order for any injury at the tracheal site was ST (9 of 10) = TT (9 of 10) > WGT (6 of 10) > NCT (3 of 10) (P = 0.02, highest versus lowest), whereas there was no difference in injury at the CTM. The rank order for posterior injury at the tracheal site was TT (9 of 10) = ST (9 of 10) > WGT (5 of 10) > NCT (2 of 10) (P = 0.005, highest versus lowest). The rank order for penetrating injury at the tracheal site was ST (6 of 10) = TT (6 of 10) > WGT (2 of 10) > NCT (1 of 10) (P = 0.057, highest versus lowest). There was no difference in the incidence of lateral, superficial, or perforating injuries among sites and techniques. Fractures were more common at the tracheal site (15 of 40 vs 0 of 40, P < 0.001) and differed by technique. The rank order of fracture incidence at the tracheal site was ST (6 of 10) > WGT (5 of 10) > TT (4 of 10) > NCT (0 of 10) (P = 0.011, highest to lowest). Compression of >50% was seen in 10 of 40 vs 28 of 40 (P < 0.001) specimens at the CTM and tracheal sites, respectively. The rank order of compression of >50% of airway lumen for both sites was TT > ST > WGT > NCT (P = 0.03, P < 0.001, CTM and tracheal sites, respectively, highest versus lowest). CONCLUSION: Airway injury and luminal compression were more common at the tracheal site than at the CTM. The ST and TT were associated with the highest incidence of injury. This has implications for emergency airway access in cases in which it may be difficult to accurately identify the CTM.