Pre-oxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction.

Pre-oxygenation using high-flow nasal oxygen can decrease the risk of desaturation during rapid sequence induction in patients undergoing emergency surgery. Previous studies were single-centre and often in limited settings. This randomised, international, multicentre trial compared high-flow nasal oxygen with standard facemask pre-oxygenation for rapid sequence induction in emergency surgery at all hours of the day and night. A total of 350 adult patients from six centres in Sweden and one in Switzerland undergoing emergency surgery where rapid sequence induction was required were included and randomly allocated to pre-oxygenation with 100% oxygen using high-flow nasal oxygen or a standard tight-fitting facemask. The primary outcome was the number of patients developing oxygen saturations <93% from the start of pre-oxygenation until 1 min after tracheal intubation. Data from 349 of 350 patients who entered the study were analysed (174 in the high-flow nasal oxygen group and 175 in the facemask group). No difference was detected in the number of patients desaturating <93%, five (2.9%) vs. six (3.4%) patients in the high-flow nasal oxygen and facemask group, respectively (p = 0.77). The risk of desaturation was not increased during on-call hours. No difference was seen in end-tidal carbon dioxide levels in the first breath after tracheal intubation or in the number of patients with signs of regurgitation between groups. These results confirm that high-flow nasal oxygen maintains adequate oxygen levels during pre-oxygenation for rapid sequence induction.

Lack of significant treatment effect of plasma exchange in the treatment of drug-induced toxic epidermal necrolysis?

OBJECTIVE: Comparison of outcome in patients with toxic epidermal necrolysis (TEN) in patients who received plasma exchange (PE) compared with the results in two other centres that used almost identical treatment protocols but without PE. DESIGN: Retrospective comparative case series with two recently published case series serving as controls. SETTING: National burns intensive care unit (ICU) and Department of Transfusion Medicine at Linköping University Hospital, Sweden. PATIENTS: 8 consecutive patients admitted with TEN who received PE during 1987-1997. INTERVENTIONS: Neither prophylactic antibiotics nor cortisone were used. The patients were given a median of 5.5 PE treatments (range 1-8). RESULTS: Eight patients with a median (range) age of 45 years (5-89) and with a median skin involvement total body surface area (TBSA) of 38% (12-100) were treated. The length of stay in the burns ICU was 15 (13-25) days and the time from onset of the cutaneous signs until complete re-epithelialisation was 24 days (13-55) for the seven survivors. Five patients fulfilled the diagnostic criteria of sepsis. One patient with extensive ischaemic cardiac disease developed septic shock and died (mortality 12.5%). Two patients developed side effects from PE. CONCLUSIONS: To our knowledge, this is the largest series yet presented using PE in the treatment of TEN. Our results, in patients with less cutaneous involvement, similar causative agents, and similar demographic data as in the other two studies (controls), were no different as far as mortality, length of stay, or time to re-epithelialisation were concerned. This finding does not support the use of PE in the treatment of TEN.