CONTEXT:

Patients with multisystem trauma undergoing intubation with manual in-line stabilisation (MILS) have a higher incidence of difficult or failed intubations.

OBJECTIVE:

To compare the effectiveness of the Macintosh laryngoscope with three other intubating devices in a high fidelity simulation model.

DESIGN:

Cross-over, simulation-based study.

SETTING:

Tertiary referral and level 1 trauma centre between June and November 2011.

PARTICIPANTS:

Thirty-five experienced airway physicians.

INTERVENTION:

Each participant performed tracheal intubations on a Laerdal SimMan manikin in both a normal airway and a difficult airway scenario with MILS. The devices utilised in a randomised order were the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway (iLMA).

MAIN OUTCOME MEASURES:

The primary outcome was time to intubation. Success rates, grade of laryngoscopy and force of intubation were also measured.

RESULTS:

One hundred and forty intubations were attempted by 35 participants in both the normal and MILS scenarios. In the normal airway, there was no difference in success rates and time to intubation. In the difficult airway with MILS, there was no difference in success rates. However, the Airtraq was associated with a longer time to intubation than the Macintosh, McCoy and iLMA, 39.3, 26.7, 23.3, 39.3, 22.8 s, respectively (P < 0.0001). The Airtraq delivered the best glottic view and lowest force of intubation in both scenarios (P < 0.0001), but was associated with the only failed intubation in the study. The McCoy was associated with a significant improvement in the glottic visualisation (P < 0.05) and reduction in the force of intubation (P <0.0001) compared with the Macintosh.

CONCLUSION:

In this manikin study, the McCoy demonstrated multiple advantages over the Macintosh. The iLMA was associated with the fastest time to intubation and minimum force of insertion.

CONTEXT:

Inadequate fluid resuscitation of acute burns may result in hypovolaemic shock. Excessive fluid resuscitation may result in fluid overload. A nomogram which uses the popular Parkland formula and '4-2-1' regime has been recently described to facilitate the calculation of fluid requirements in children during the first 24 h following burn injury.

OBJECTIVE:

To compare the accuracy and speed of calculation of three different methods (pen and paper, electronic calculator and nomogram), which all use the Parkland formula and '4-2-1' regime to calculate maintenance and resuscitation fluid requirements for children in the first 24 h after burn injury.

DESIGN:

A double-blinded randomised volunteer study using computer-generated simulated patient data.

SETTING:

Welsh Centre for Burns, ABM University Local Health Board, Swansea, UK. Data were collected between February 2011 and October 2011.

PARTICIPANTS:

The group consisted of 36 volunteers including trainee and consultant surgeons and anaesthetists.

INTERVENTION:

Thirty-six participants performed 318 calculations, using each of the three methods of calculation up to three times.

MAIN OUTCOME MEASURES:

Accuracy, speed and acceptability of the different methods.

RESULTS:

For nomogram, calculator and pen and paper: magnitude of error [low (≥25%), medium (≥50%) and high (≥75%)]: [5.7, 4.7 and 3.8%], [12.1, 12.1 and 7.5%], [28.6, 21.9 and 16.2%]; [P <0.001, P = 0.001 and P = 0.006]. Calculation time: [s; mean (SD)]: 121 (48), 109 (52) and 240 (140); P <0.001. The mean (SD) of the difficulty scores were 17.3 (13), 20.6 (13.4) and 62.2 (23.4); P <0.001.

CONCLUSION:

The nomogram was the most accurate method of calculating fluid requirements using the Parkland formula, was only slightly slower than the electronic calculator and was deemed the easiest to use. The nomogram is also low cost, robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the primary method of resuscitation fluid calculation. We, therefore, suggest that the nomogram is a suitable method for the calculation of the Parkland formula to guide resuscitation and maintenance fluid requirements in the first 24 h of paediatric burns or for cross-checking the results obtained by other means of calculation.

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient's tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

CONTEXT:

There is little information on the interaction between magnesium sulphate (MgSO4) and rocuronium in elderly patients. With a growing number of older patients who need surgical procedures, it is increasingly important to study this age group.

OBJECTIVE:

To evaluate the effects of MgSO4 administration on the pharmacodynamics of rocuronium in patients aged 60 years or older.

DESIGN:

A randomised controlled trial.

SETTING:

A tertiary care hospital.

PATIENTS:

Sixty-four patients, aged 60 years or older, American Society of Anesthesiologists (ASA) physical status classes I to III, scheduled for elective oncological head and neck surgery. Exclusion criteria were severe renal insufficiency (calculated creatinine clearance <30 ml min), preoperatorive serum magnesium concentration of more than 1.25 mmol l and patients receiving drugs known to affect neuromuscular function.

INTERVENTIONS:

Patients were randomly allocated to one of two groups: in the magnesium group, patients received MgSO4 30 mg kg intravenously, for 10 min, and then a continuous intravenous infusion at a rate of 1 g h. The control group received the same volume of physiological saline. Neuromuscular function was evaluated continuously in both groups.

MAIN OUTCOME MEASURES:

Total recovery time was the primary outcome. Onset time, clinical duration, recovery index and recovery time were considered as secondary endpoints. Values are given as mean [SD].

RESULTS:

Total recovery time from neuromuscular block (NMB) was 113 [36] min in the magnesium group and 101 [39] min in the control group. Clinical duration was 69 [23] min in the magnesium group and 59 [28] min in the control group. Recovery index was 19 [36] min in the magnesium group and 17 [6] min in the control group. Recovery time was 44 [22] min in the magnesium group and 42 [18] min in the control group. There were no statistically significant differences between the groups in any of the recovery indices. In the magnesium group, the mean onset time was 144 [58] s, significantly shorter than the onset time in the group that received physiological saline, which was 187 [90] s (P = 0.03). Group variances were compared using an F test: onset time varied significantly less in the magnesium group (P = 0.02).

CONCLUSION:

In oncology patients of 60 or more years of age, preadministration of MgSO4, with the doses used in this study, significantly reduced the onset time of NMB induced by rocuronium.

CONTEXT:

In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown.

OBJECTIVE:

To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery.

DESIGN:

A randomised, double-blind, placebo-controlled clinical trial.

SETTING:

Single tertiary centre.

PATIENTS:

Inclusion criteria: day-case surgery; age at least 18 years. Exclusion criteria: insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam.

INTERVENTION:

Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery.

MAIN OUTCOME MEASURE:

Quality of Recovery-40 (QoR-40) score. Secondary outcomes: State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex.

RESULTS:

Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.2, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04).

CONCLUSION:

In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression.

TRIAL REGISTRATION:

ClinicalTrials.gov identifier: NCT01441843.

CONTEXT:

Peripheral neuropathy may affect nerve conduction in patients with diabetes mellitus.

OBJECTIVE:

This study was designed to test the hypothesis that the electrical stimulation threshold for a motor response of the sciatic nerve is increased in patients suffering from diabetic foot gangrene compared to non-diabetic patients.

DESIGN:

Prospective non-randomised trial with two parallel groups.

SETTING:

Two university-affiliated hospitals.

PARTICIPANTS:

Patients scheduled for surgical treatment of diabetic foot gangrene (n = 30) and non-diabetic patients (n = 30) displaying no risk factors for neuropathy undergoing orthopaedic foot or ankle surgery.

MAIN OUTCOME MEASURE:

The minimum current intensity required to elicit a typical motor response (dorsiflexion or eversion of the foot) at a pulse width of 0.1 ms and a stimulation frequency of 1 Hz when the needle tip was positioned under ultrasound control directly adjacent to the peroneal component of the sciatic nerve.

RESULTS:

The non-diabetic patients were younger [64 (SD 12) vs. 74 (SD 7) years] and predominantly female (23 vs. 8). The geometric mean of the motor stimulation threshold was 0.26 [95% confidence interval (95% CI) 0.24 to 0.28] mA in non-diabetic and 1.9 (95% CI 1.6 to 2.2) mA in diabetic patients. The geometric mean of the electrical stimulation threshold was significantly (P < 0.001) increased by a factor of 7.2 (95% CI 6.1 to 8.4) in diabetic compared to non-diabetic patients.

CONCLUSION:

The electrical stimulation threshold for a motor response of the sciatic nerve is increased by a factor of 7.2 in patients with diabetic foot gangrene, which might hamper nerve identification.