Airway topicalization in pediatric anesthesia: An international cross-sectional study

BACKGROUND

There is no national or international consensus or guideline on recommended dosing of lidocaine for airway topicalization in children. Doses quoted in the literature vary substantially.

AIMS

The primary aim of the study was to ascertain current international dosing practices (mg.kg-1 and concentration of solution) for lidocaine airway topicalization in children. The secondary aims included examining aftercare instructions for those receiving lidocaine airway topicalization and instances of local anesthetic systemic toxicity secondary to the use of lidocaine for airway topicalization in pediatric patients.

METHODS

This cross-sectional study consisted of 11-20 questions across three domains-population demographics, clinical practice, and local anesthetic systemic toxicity. It adhered to the consensus-based checklist for reporting of survey studies. Responses were collected over 14 weeks using a combination of probability (cluster and simple random) and nonprobability (purposive, convenience and snowball) sampling. Data were analyzed based on the response rate per question with proportions expressed as percentages and nonparametric data expressed as median (interquartile range [range]) in an effort to minimize nonresponse error. No weighting of items or propensity scoring was applied.

RESULTS

After initial exclusions, 1501 participants from 69 countries, across six continents, were included. Consultant anesthetists or those with an equivalent level of experience accounted for 1262/1501 (84.1%) of responses. Results showed heterogeneity in dosing and timing regimens and evidence that dosing may contribute to adverse outcomes. The maximum dose reported by participants who use lidocaine for airway topicalization as part of their normal practice was 5 mg.kg-1 (4-6 mg.kg-1 [0.5-50]) median (interquartile range [range]) over 2 h (1-4 h [0-30]).

CONCLUSION

The results support the need for further research and consensus in this area, in order to provide safe provision of lidocaine airway topicalization in children. It is hoped the results of this study can support future collaborative work in this area.

The effects of acute hyperglycaemia on sports and exercise performance in type 1 diabetes: A systematic review and meta-analysis

OBJECTIVES

People with type 1 diabetes (T1D) are advised by health care professionals to target mild hyperglycaemia before and during exercise, to reduce the risk of hypoglycaemia. This review aimed to summarise the available evidence on the effects of acute hyperglycaemia on sports and exercise performance in T1D.

DESIGN

Systematic review and meta-analysis.

METHODS

Medline, EMBASE, CENTRAL, and Web of Science were searched until 29th May 2023 for studies investigating the effects of acute hyperglycaemia on any sports or exercise performance outcome in T1D. Random-effects meta-analysis was performed using standardised mean differences (SMD) when more than one study reported data for similar outcomes. Certainty of evidence for each outcome was assessed using GRADE.

RESULTS

Seven studies were included in the review, comprising data from 119 people with T1D. Meta-analysis provided moderate-certainty evidence that acute hyperglycaemia does not significantly affect aerobic exercise performance (SMD -0.17; 95 % CI -0.59, 0.26; p = 0.44). There is low- or very-low certainty evidence that acute hyperglycaemia has no effect on anaerobic (two outcomes), neuromuscular (seven outcomes) or neurocognitive performance (three outcomes), except impaired isometric knee extension strength. One study provided low-certainty evidence that the performance effects of hyperglycaemia may depend on circulating insulin levels.

CONCLUSIONS

Acute hyperglycaemia before or during exercise appears unlikely to affect aerobic performance to an extent that is relevant to most people with T1D, based on limited evidence. Future research in this field should focus on anaerobic, neuromuscular and neurocognitive performance, and examine the relevance of circulating insulin levels.

Need for tracheostomy in major head and neck ablative surgery: a paradigm shift during the COVID-19 pandemic

INTRODUCTION

Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy.

METHODS

We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation.

RESULTS

Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients.

CONCLUSIONS

Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

Design and testing of the safety of the SARUS-CPR hood for novice resuscitators

BACKGROUND AND AIMS

Bystanders should be protected against aerosols, droplets, saliva, blood and vomitus during resuscitation after cardiac arrest The SARUS (safer - airway - resuscitation) CPR airway hood™ is a clear plastic cover and integrated mask that envelopes the head and torso. Our objectives were to test leakage using saline aerosol generation tests, then assess the performance of the hood during mock cardio-pulmonary resuscitation on a manikin.

METHODS

A checklist was validated by comparing the performance of 10 novices against 10 experts during mock resuscitation. Thereafter, 15 novices were tested with and without the hood, in a randomised cross-over study, one week apart.

RESULTS

Laboratory analysis showed a > 99% reduction of saline particles detected 5 cm, 75 cm and 165 cm above volunteers wearing the hood. On manikins, experts scored better compared to novices, 8.5 (0.7) vs 7.6 (1.2), difference (95%CI) 0.9 (0.4-1.3), P = 0.0004. Novice performance was equivalent using the hood and standard equipment, 7.3 (1.4) vs 7.3 (1.1) respectively, difference (90%CI) 0.0 (-0.3 - 0.3), P = 0.90.

CONCLUSION

Aerosol transmission reduced in the breathing zone. Simulated resuscitation by novices was equivalent with and without the hood.

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

BACKGROUND AND AIMS

Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival.

APPROACH AND RESULTS

A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver.

CONCLUSIONS

In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.

Airway management guidance for the endemic phase of COVID-19

It is now apparent that severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) and coronavirus disease 2019 (COVID‐19) will remain endemic for some time. Improved therapeutics and a vaccine may shorten this period, but both are far from certain. Plans must be put in place on the assumption that the virus and its disease will continue to affect the care of patients and the safety of staff. This will impact particularly on airway management due to the inherent risk to staff during such procedures. Research is needed to clarify the nature and risk of respiratory aerosol‐generating procedures. Improved knowledge of the dynamics of SARS‐CoV‐2 infection and immunity is also required. In the meantime, we describe the current status of airway management during the endemic phase of the COVID‐19 pandemic. Some controversies remain unresolved, but the safety of patients and staff remains paramount. Current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management. Theatre efficiency and training issues are a challenge that must be addressed, and new information may enable this.

Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies.

Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK)

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

Short- and long-term effects of gestational diabetes mellitus on healthcare cost: a cross-sectional comparative study in the ATLANTIC DIP cohort

AIMS

This paper examines the association between gestational diabetes mellitus and costs of care during pregnancy and 2-5 years post pregnancy.

METHODS

Healthcare utilization during pregnancy was measured for a sample of 658 women drawn from the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) network. Healthcare utilization 2-5 years post pregnancy was assessed for a subsample of 348 women via a postal questionnaire. A vector of unit costs was applied to healthcare activity to calculate the costs of care at both time points. Differences in cost for women with gestational diabetes mellitus compared with those with normal glucose tolerance during the pregnancy were examined using univariate and multivariate regression analyses.

RESULTS

Gestational diabetes mellitus was independently associated with an additional €817.60 during pregnancy (€1192.1 in the gestational diabetes mellitus group, €511.6 in the normal glucose tolerance group), in the form of additional delivery and neonatal care costs, and an additional €680.50 in annual healthcare costs 2-5 years after the index pregnancy (€6252.4 in the gestational diabetes mellitus group, €5434.8 in the normal glucose tolerance group).

CONCLUSIONS

These results suggest that gestational diabetes mellitus is associated with increased costs of care during and post pregnancy. They provide indication of the associated cost that can be avoided or reduced by the screening, prevention and management of gestational diabetes mellitus in pregnancy. These estimates are useful for further studies that examine the cost and cost-effectiveness of such programmes.

Young adult type 1 diabetes care in the West of Ireland: an audit of hospital practice

BACKGROUND

It is well recognised that management of young adults with type 1 diabetes (T1DM) poses difficult challenges for physicians and health care organisations as a whole. In Ireland and in particular the west of Ireland there has been little audit or research on young adults with T1DM and the services available to them.

DESIGN

In 2011 a retrospective review of this patient population in our territory referral centre was carried out.

RESULTS

The average glycaemic control in this population was poor at 81mmols/mol and diabetes related complications were present in 32%. Engagement by this population with services was poor with an average of 3 missed clinic appointments over a 24 month period.

CONCLUSION

These results have prompted a re think of how health care professionals can deliver a service that better suits the needs of this challenging patient group.

ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes

OBJECTIVE

Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM.

METHODS

Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (s.d. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used.

DESIGN, COHORT STUDY, AND RESULTS

The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66).

CONCLUSIONS

Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (s.d.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

Low mood and challenging behaviour in people with severe and profound intellectual disabilities

BACKGROUND

We investigated the relationship between low mood and challenging behaviour in people in the severe and profound range of intellectual disability, while controlling for the presence of potentially confounding variables such as diagnosis of autism, physical and sensory problems and ill health.

METHODS

The key workers of 52 people with severe and profound intellectual disability completed measures of depression, communication, challenging behaviour and provided information on relevant demographic and health variables.

RESULTS

Using the Mood, Interest and Pleasure Questionnaire for classification of mood, a significant difference was found between a 'low mood' and 'normothymic' group in the reported occurrence of challenging behaviour. This difference remained even when confounding variables such as the presence of autism, health and sensory difficulties were controlled. The frequency and severity of challenging behaviour was predicted by measures indicating the presence of low mood.

CONCLUSION

People with severe and profound show clear and measurable signs of low mood, and in this relatively small sample of institutionalised individuals, low mood was associated with challenging behaviour.

Statistical analysis of the El Niño-Southern Oscillation and sea-floor seismicity in the eastern tropical Pacific

We present statistical evidence for a temporal link between variations in the El Niño-Southern Oscillation (ENSO) and the occurrence of earthquakes on the East Pacific Rise (EPR). We adopt a zero-inflated Poisson regression model to represent the relationship between the number of earthquakes in the Easter microplate on the EPR and ENSO (expressed using the southern oscillation index (SOI) for east Pacific sea-level pressure anomalies) from February 1973 to February 2009. We also examine the relationship between the numbers of earthquakes and sea levels, as retrieved by Topex/Poseidon from October 1992 to July 2002. We observe a significant (95% confidence level) positive influence of SOI on seismicity: positive SOI values trigger more earthquakes over the following 2 to 6 months than negative SOI values. There is a significant negative influence of absolute sea levels on seismicity (at 6 months lag). We propose that increased seismicity is associated with ENSO-driven sea-surface gradients (rising from east to west) in the equatorial Pacific, leading to a reduction in ocean-bottom pressure over the EPR by a few kilopascal. This relationship is opposite to reservoir-triggered seismicity and suggests that EPR fault activity may be triggered by plate flexure associated with the reduced pressure.

Potential for a hazardous geospheric response to projected future climate changes

Periods of exceptional climate change in Earth history are associated with a dynamic response from the geosphere, involving enhanced levels of potentially hazardous geological and geomorphological activity. The response is expressed through the adjustment, modulation or triggering of a broad range of surface and crustal phenomena, including volcanic and seismic activity, submarine and subaerial landslides, tsunamis and landslide 'splash' waves, glacial outburst and rock-dam failure floods, debris flows and gas-hydrate destabilization. In relation to anthropogenic climate change, modelling studies and projection of current trends point towards increased risk in relation to a spectrum of geological and geomorphological hazards in a warmer world, while observations suggest that the ongoing rise in global average temperatures may already be eliciting a hazardous response from the geosphere. Here, the potential influences of anthropogenic warming are reviewed in relation to an array of geological and geomorphological hazards across a range of environmental settings. A programme of focused research is advocated in order to: (i) understand better those mechanisms by which contemporary climate change may drive hazardous geological and geomorphological activity; (ii) delineate those parts of the world that are most susceptible; and (iii) provide a more robust appreciation of potential impacts for society and infrastructure.

Climate forcing of volcano lateral collapse: evidence from Mount Etna, Sicily

In this study, we present evidence for early Holocene climatic conditions providing circumstances favourable to major lateral collapse at Mount Etna, Sicily. The volcano's most notable topographic feature is the Valle del Bove, a 5 x 8 km cliff-bounded amphitheatre excavated from the eastern flank of the volcano. Its origin due to prehistoric lateral collapse is corroborated by stürtzstrom deposits adjacent to the amphitheatre's downslope outlet, but the age, nature and cause of amphitheatre excavation remain matters for debate. Cosmogenic (3)He exposure ages determined for eroded surfaces within an abandoned watershed flanking the Valle del Bove support channel abandonment ca 7.5 ka BP, as a consequence of its excavation in a catastrophic collapse event. Watershed development was largely dictated by pluvial conditions during the early Holocene, which are also implicated in slope failure. A viable trigger is magma emplacement into rift zones in the eastern flank of a water-saturated edifice, leading to the development of excess pore pressures, consequent reduction in sliding resistance, detachment and collapse. Such a mechanism is presented as one potential driver of future lateral collapse in volcanic landscapes forecast to experience increased precipitation or melting of ice cover as a consequence of anthropogenic warming.

A rare benign renal tumour presenting as polycythaemia in a teenage girl

We present the case of a 15-year-old girl who presented with polycythemia. CT abdomen revealed an enhancing mass in the upper pole of her left kidney with features suggestive of renal cell carcinoma. She underwent a laparoscopic radical nephrectomy. Histology demonstrated a well circumscribed, focally encapsulated, round blue cell tumour showing areas of microcalcifications and numerous psammoma bodies. Imunostaining showed diffuse positive staining for CD 57. This was consistent with a diagnosis of metanephric adenoma a rare benign epithelial renal tumour.

Pleiotropic role of VEGF-A in regulating fetal pulmonary mesenchymal cell turnover

Tight regulation of VEGF-A production and signaling is important for the maintenance of lung development and homeostasis. VEGF null mice have provided little insight into the role of VEGF during the later stages of lung morphogenesis. Therefore, we examined the in vitro effects of autocrine and paracrine VEGF-A production and the inhibition of VEGF-A signaling on a Flk-1-negative subset of fetal pulmonary mesenchymal cells (pMC). We hypothesized that VEGF-A receptor signaling regulates turnover of fetal lung mesenchyme in a cell cycle-dependent manner. VEGF receptor blockade with SU-5416 caused cell spreading and decreased proliferation and bcl-2 localization. Nuclear expression of the cell cycle inhibitory protein, p21, was increased with SU-5416 treatment, and p27 was absent. Autocrine VEGF production by pMC resulted in proliferation and p21/p27-dependent contact inhibition. In contrast, exogenous VEGF-A increased cell progression through the cell cycle. Selective activation of Flt by placental growth factor demonstrated the importance of this receptor/kinase in the VEGF-A responsiveness of pMC. The expression and localization of the survival factor bcl-2 was dependent on VEGF. These results provide evidence that VEGF-A plays a critical role in the regulation of fetal pulmonary mesenchymal proliferation, survival, and the subsequent development of normal lung architecture through bcl-2 and p21/p27-dependent cell cycle control.

Hyaluronidase assisted reduction of intestinal intussusception; a novel application

Failed manual reduction of entero-enteric intussusception in adults leads to intestinal resection for benign disease. The case of a twenty-year old male with an eight inch jejuno-jejunal intussusception is presented. The authors resected a hamartomatous polyp from the apex of the intussusceptum and a subsequent attempt at manual reduction was unsuccessful. Hyaluronidase was injected into the neck of the intussusception and dissipation of tissue oedema facilitated reduction within two minutes. To our knowledge, this is the first reported case of this application of Hyaluronidase.

A possible function of the preference for hind nipples in prairie voles (Microtus ochrogaster)

Prairie vole pups (Microtus ochrogaster) in laboratory cages prefer hind nipples. In this research, the author observed 8 litters of prairie voles in a seminatural environment to confirm the preference for hind nipples and to determine if young on hind nipples were groomed more frequently or dislodged less frequently than were young on other nipples. Prairie vole pups in seminatural environments preferred hind nipples; this preference was illustrated by the progressive use of more anterior nipples only as litter size increased and by the reluctance of pups to voluntarily release their hold on hind nipples. Maternal grooming of young did not vary with suckling location. Prairie vole young on hind nipples, however, were dislodged less frequently than were young on other nipples. Less frequent dislodgment from hind nipples during maternal movements may play a role in the preference for hind nipples in prairie voles.

The envenomation syndrome caused by the Australian Red-bellied Black Snake Pseudechis porphyriacus

The Australian elapids inject venom which is characteristic of each species; and which cause characteristic and specific envenomation syndromes in human victims of snakebite. Because many of the medically significant Australian elapids look similar, when glimpsed in the field by snakebite victims, defining human envenomation syndromes with secure species identification has been a slow process. Correlations between securely identified species and the human envenomation syndromes which they produce are still evolving. The genus Pseudechis is the most widespread in Australia of the dangerous Australian elapid genera; and P. porphyriacus, the Red-bellied Black Snake, was the first terrestrial Australian elapid to be described and illustrated and the first to be the subject of experimental study. We present here five previously unreported cases of human envenomation in which the species diagnosis is secure. From these and with the perspective of a selected literature review, we describe the full envenomation syndrome of this species. Until the development of the Commonwealth Serum Laboratories' Venom Detection Kit in 1979 and the occasional case report of victims of securely identified species, envenomation syndromes for most Australian snake species have remained indeterminate, because of the lack of professional expertise in the identification of the species involved. Symptoms of the P. porphyriacus envenomation syndrome include those of bite-site pain, nausea and vomiting, generalised pruritus, chest pain, prostration and abnormalities of taste and smell. Signs include local necrosis and scarring of tissue at the bite-site, gross inflammation of surrounding tissues and, at least in one case, epilepsy. Although envenomation by the Red-bellied Black Snake is not lethal in adults, the correct therapy is Tiger Snake antivenom, administered with judgement, taking into account knowledge of the specific envenomation syndrome of this species and the clinical status of the victim.