Guidelines for the management of tracheal intubation in critically ill adults.

These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Asian MODY: are we missing an important diagnosis?

AIMS: Maturity onset diabetes of the young (MODY) is a monogenic form of diabetes where correct diagnosis alters treatment, prognosis and genetic counselling. The first UK survey of childhood MODY identified 20 White, but no Asian children with MODY. We hypothesized that MODY causes diabetes in UK Asians, but is underdiagnosed. METHODS: Children with dominant family histories of diabetes were recruited. Direct sequencing for mutations in the two most common MODY genes; HNF1A (TCF1) and GCK was performed in autoantibody-negative probands. We also compared MODY testing data for Asian and White cases from the Exeter MODY database, to 2001 UK census data. RESULTS: We recruited 30 families and identified three Asian families with MODY gene mutations (two HNF1A, one GCK) and three White UK families (two HNF1A, one GCK). Heterozygous MODY phenotypes were similar in Asians and Whites. Only eight (0.5%) of 1369 UK referrals for MODY testing were known to be Asian, but in 2001 Asians represented 4% of the English/Welsh population and have a higher prevalence of diabetes. CONCLUSIONS: We identified three cases of childhood MODY in UK Asians and demonstrated reduced rates of MODY testing in Asians, which has negative implications for treatment. It is unclear why this is. MODY should be considered in autoantibody-negative Asian diabetes patients lacking evidence of insulin resistance.

Audit of nurse-led-training for epipen in a District General Hospital.

BACKGROUND: A community-based study in the London Borough of Hounslow, which included patients in our District General Hospital (DGH) Paediatric Department, found that most families who had been prescribed adrenaline auto-injectors could not use them properly. This prompted the establishment of a new protocol for doctors and an Allergy Clinic where one nurse was responsible for training all patients. AIM: This audit was done to reassess this service 3 years after the changes were made. METHODS: 68 of the 81 (83%) patients followed up in our District General Hospital Nurse led Allergy Clinic agreed to participate. They were compared with the District General Hospital sub-group of the previous study. RESULTS: We found that most patients now reported they were trained to use the devise, had written instructions, were able to demonstrate competence on a dummy and would appropriately call an ambulance. This was significantly better than the previous situation. CONCLUSION: The study shows that training can be improved in a DGH setting with the strategy of protocolised prescribing and a Nurse led Allergy Clinic.

Preoperative use of herbal medicines: a patient survey.

BACKGROUND: There has been recent concern in the media over the possible detrimental effects of herbal medicines on the perioperative period. Perceived by the public as 'natural' and therefore safe, herbal remedies may have led to adverse events such as myocardial infarction, bleeding, prolonged or inadequate anaesthesia and rejection of transplanted organs. In addition, herbal remedies can interact with many drugs given in the perioperative period. In this article we summarize the potential perioperative complications that can occur. METHODS: In order to determine the extent of use of herbal medicines, we conducted a survey of patients presenting for anaesthesia. During a 3-month period, patients were directly asked by anaesthetic staff if they were currently self-administering herbal medication. RESULTS: Of 2723 patients, 131 (4.8%) were taking one or more herbal remedy. In only two cases was this recorded in the patients' notes. Women and patients aged 40-60 yr were most likely to be taking a herbal product (P<0.05 and P<0.001 respectively). The most commonly used compounds were, in descending order, garlic, ginseng, ginkgo, St John's wort and echinacea. CONCLUSION: Self-administration of herbal medicines is common in patients presenting for anaesthesia. Because of the potential for side-effects and drug interactions it is important for anaesthetists to be aware of their use.

Airway control during percutaneous dilatational tracheostomy: pilot study with the intubating laryngeal mask airway.

Percutaneous dilatation tracheostomy has become a common procedure for bedside insertion of tracheostomy tubes in the intensive care unit. Management of the airway during the procedure using the laryngeal mask airway (LMA) and other methods has been described. The intubating laryngeal mask airway has several potential benefits for airway management during percutaneous dilatation tracheostomy compared with the LMA. These include the use of both the fibreoptic bronchoscope and tracheal tube if necessary. We report the results of a pilot study of 10 patients that illustrates these advantages.

Rising incidence of type 1 diabetes in Scottish children, 1984-93. The Scottish Study Group for the Care of Young Diabetics.

OBJECTIVES: To calculate the incidence of type 1 diabetes in Scottish children aged less than 15 years between 1984 and 1993; to examine changes in incidence; and to calculate the prevalence of diabetes at the end of this period. DESIGN: Three data sources were used to construct the Scottish Study Group for the Care of Young Diabetics register: active reporting of all new cases; reports from the Scottish Morbidity Register 1; and local registers. SUBJECTS: All children resident in Scotland diagnosed with primary insulin dependent diabetes mellitus when less than 15 years of age between 1984 and 1993. MAIN OUTCOME MEASURES: Annual incidence and prevalence rate for Scotland; time trend in incidence over the 10 years; differences in incidence between the three different age groups; and completeness of the register. RESULTS: The average annual incidence for Scotland was 23.9/100,000 children. The prevalence rate was 1.5/1000 in 1993. A total of 2326 cases was identified from the three sources. Capture-recapture analysis suggests a case ascertainment of 98.6%. The annual incidence rates increased at a rate of 2% each year (rate ratio = 1.02, 95% confidence interval (CI) 1.01 to 1.03). The incidence was higher in boys than girls (rate ratio = 1.08, 95% CI 1.00 to 1.18), and the incidence rates increased with age: 15.3/100,000/year for age 0-4 years, 24.4/ 100,000/year for age 5-9 years, and 31.9/ 100,000/year for age 10-14 years. CONCLUSIONS: The incidence of type 1 diabetes in Scotland is increasing and the prevalence is relatively high. These findings have important implications for health service resource allocation. The Scottish Study Group for the Care of Young Diabetics' register provides a base for monitoring and research.

Reduction of propofol pain--fentanyl vs lidocaine.

To compare the local efficacy of lidocaine and fentanyl in reducing propofol injection pain (PIP), we conducted a prospective randomized double-blind study in 75 ASA I and II adult patients. When administered 20 seconds before propofol with a venous tourniquet, lidocaine but not fentanyl or placebo, reduced the incidence of moderate to severe pain on subsequent injection of propofol (P < 0.001). Two patients (8%) in the lidocaine group (n = 25) experienced a moderate degree of pain and none experienced severe pain. Fifteen (60%) in the fentanyl group (n = 25) experienced moderate or severe degrees of pain, compared with 15 (60%) in the saline group (n = 25). We conclude that lidocaine, acting locally, reduce propofol injection pain while fentanyl does not.