Evaluation of a novel emergency front of neck access device in a benchtop model of obesity.

BACKGROUND: Emergency front of neck access (eFONA) is a critical step in oxygenation in cases of unrelieved airway obstruction. Multiple techniques are used in clinical practice without agreement regarding the optimal approach. We evaluated a novel device, the Cric-Guide (CG), a channelled bougie introducer that enters the airway in a single action and compared it with a scalpel-bougie-tube (SBT) technique in laboratory benchtop model. METHODS: Seven anaesthesiologists attempted eFONA on both obese and non-obese models using both techniques in randomized order on an excised porcine trachea with an intact larynx with variable subcutaneous tissue depth. The primary outcome was successful tracheal cannulation. Secondary outcomes included false passage rate, time and tissue injury. RESULTS: Anaesthesiologists performed 4 cricothyroidotomies on each model with each device. The CG was more successful in airway cannulation (47/56 [89.4%] vs. 33/56 [58.9%], P = 0.007). This difference was observed in the obese model only. The CG was associated with fewer false passages than the standard technique in the obese model (8/56 [14.3%] vs. 23/56 [41.1%], P = 0.006). There were no significant differences in time to completion or injury patterns between the techniques in the obese model, but the SBT was faster in the non-obese model. There was no difference in the proportion of specimens injured. CONCLUSION: The Cric-Guide device was more successful than the standard SBT technique in airway cannulation in an obese neck model and with equivalent frequency and distribution of injury but performed equivalently in the non-obese model.

Too noisy to sleep safely?-An observational study of noise levels and distractions during critical phases of pediatric anesthesia.

BACKGROUND: Noise and distraction are recognized as contributing factors in critical incidents associated with surgery and anesthesia. In addition, excessive noise exposure can have negative effects on patients and staff members in these environments. AIMS: We aimed to quantify noise exposure of the anesthesiology team and patients in pediatric operating theaters, comparing them to adult studies, internationally recognized standards, and identifying factors contributing to noise and/or distraction. METHODS: We measured noise levels during three phases of anesthesia (pre-induction, induction, and postinduction/maintenance) and recorded additional environmental sources of distraction and noise. RESULTS: We included 49 theater cases. The median and interquartile range (IQR) of mean noise levels during pre-induction, induction, and maintenance were 61 (59.7-63.5), 61.9 (60.6-63.3), and 61.6 (60.4-63.7) dB, respectively, while the median (IQR) of maximal noise levels was 81.4 (77.3-86.8), 83.7 (78.5-87.4), and 86.3 (84.6-90.4), respectively. There was an average of 8.3 people present in the room during induction. In 23 cases, there were additional unnecessary conversations occurring within the room at induction. We noted the maintenance phase was the noisiest phase of anesthesia. We recorded frequent potential sources of distraction during pre-induction and induction, though no significant correlations between these distractions and recorded noise levels. CONCLUSIONS: We documented noise levels well above recommended levels during all phases of pediatric anesthesia. We highlighted factors with potential to contribute to noise and distraction but found no statistically significant correlation with noise levels.

The role of type I hypersensitivity reaction and IgE-mediated mast cell activation in acute interstitial nephritis.

BACKGROUND: Acute interstitial nephritis (AIN) presents with acute kidney injury, with evidence of interstitial inflammation and tubulitis on histology, and the presence of fever, rash, and eosinophiluria. Although the pathogenesis of this disease is not well understood, cell-mediated immunity is thought to play a major role. We hypothesized that IgE mediated mast cell activation is also involved in the pathogenesis of renal injury in AIN. METHODS: 28 patients, with biopsy proven AIN over a 5-year period, were included in this study. Clinical data, including renal outcomes and the etiologies of AIN, were evaluated in all patients. Available tissues (renal biopsy) from 26 of the patients were stained for ß-tryptase (marker for mast cell degranulation), IgE, IL-16, and CD3. A negative control for immunostaining was included. RESULTS: Samples from all 26 individuals stained positive for ß-tryptase (mean of 11.16 cells/high power field), IgE (mean average of 0.68 cells/HPF), IL-16 (28% of the interstitium), and CD3 (33% of the interstitium). Acute interstitial nephritis was due to medication in 73%, systemic disease in 15%, and unknown (idiopathic) in 12% of the cases. 86% of patients were treated with corticosteroids. 18% required acute inpatient dialysis, with 7% remaining on dialysis longterm. CONCLUSIONS: Our study suggests that IgE and mast cell activation may play a role in the pathogenesis of AIN.

Incidence of Adverse Events during Continuous Renal Replacement Therapy.

BACKGROUND/AIMS: The incidence of adverse events (AEs) in adults who receive continuous renal replacement therapy (CRRT) is unknown. We report the incidence of mechanical, metabolic, and hemodynamic CRRT AEs. METHODS: This is a retrospective study of all consecutive adult patients (≥18 years) who underwent CRRT from January 1, 2007 to December 31, 2009. RESULTS: Out of 595 patients who underwent CRRT, 366 (62%) were male and 500 (84%) were Caucasian. Regional citrate anticoagulation was used in 98.6% of all patients. The most common clinically significant electrolyte derangements were ionized hypocalcemia (22%), ionized hypercalcemia (23%), and hyperphosphatemia (44%). Almost all (97%) patients had at least one additional AE including new onset hypotension (within the first hour after CRRT initiation) (43%), hypothermia (44%), new onset arrhythmias (29%), new onset anemia (31%) and thrombocytopenia (40%). CONCLUSIONS: ICU patients who require CRRT have a high incidence of AEs. Although the extent to which these complications are attributable to CRRT is not known, clinicians need to be cautious and aware of their high prevalence in this patient population.