Ian Nesbitt

A Double-Blind Randomized Controlled Clinical Trial to Assess the Effect of Doppler Optimized Intraoperative Fluid Management on Outcome Following Radical Cystectomy

PURPOSE Cardiovascular optimization via esophageal Doppler can minimize gastrointestinal hypoperfusion, reducing the risk of multiple organ dysfunction and postoperative complications during major surgery. We assessed the effect of esophageal Doppler guided cardiovascular optimization in patients undergoing radical cystectomy. MATERIALS AND METHODS We conducted a prospective, randomized, double-blind controlled trial at a United Kingdom teaching hospital between 2006 and 2009. A total of 66 patients were randomized to a control arm (34) and an intervention arm (32). The control group received standard intraoperative fluids. The intervention group received (additional) Doppler guided fluid. Primary outcomes were markers of gastrointestinal morbidity such as ileus, flatus and bowel opening. Secondary outcomes were postoperative nausea and vomiting, wound infection and operative intravenous fluid volumes (total and hourly). RESULTS There were significant reductions in the control and intervention arms in the incidence of ileus (18 vs 7, p <0.001), flatus (5.36 vs 3.55 days, p <0.01) and bowel opening (9.79 vs 6.53 days, p = 0.02), respectively. Nausea and vomiting were significantly reduced in the study group at 24 and 48 hours postoperatively (11 vs 3, p <0.01 and 13 vs 1, p <0.0001). Wound infection rates were significantly reduced (8 vs 1 superficial, p <0.01 and 10 vs 2 combined, p <0.01). Study patients received significantly higher volumes (ml/kg per minute) of intravenous fluid (0.19 vs 0.23, p <0.01) related to a significantly higher volume (ml/kg) in the first hour of surgery (14.1 vs 21.0, p = 0.0001). CONCLUSIONS Cardiovascular optimization using esophageal Doppler significantly improved postoperative markers of gastrointestinal function.

The Impact of Influenza A on Critical Care in the North of England, Winter 2010–11:

Influenza A(H1N1)pdm09 virus infection placed a significant burden on intensive care services in the north of England during winter 2010–11 compared with the influenza outbreak in 2009–10. The clinical characteristics of 160 adult patients requiring mechanical ventilation are described in this paper. Comparisons are made with other reported series. Issues related to patient transfers along with logistical and ethical issues arising from national guidance are also discussed.

Phaeochromocytoma Crisis Presenting under Anaesthesia with Profound Left Ventricular Failure — Successful Treatment with Intra-Aortic Balloon Pump

A patient presented with a phaeochromocytoma crisis during routine anaesthesia for minor ENT surgery. The ensuing cardiac arrest and profound left ventricular failure were successfully treated with an intra-aortic balloon pump until alpha blockade with phenoxybenzamine took effect. The rapid diagnosis of phaeochromocytoma and management of phaeochromocytoma crisis are reviewed.

Risks and benefits of tight glycaemic control

mucus, an insufficient jaw thrust, a narrow passage to the larynx and inadequate placement of the intubating airway [2]. From previous work [3, 4] the selection of the correct size of Berman airway was critical. We found the no. 10 airway was often too long in our study group. This size of airway often causes a down-folding of the epiglottis across the glottic opening. Could Iqbal and her co-authors clarify whether the failures in their study with the Berman airway occurred mostly with this particular size? The authors stated that ‘while it remains possible that our favourable results with the anterior jaw lift may not extend to comparisons with all other airways, we think this unlikely’. Though airways such as the Ovassapian, Berman and the Williams have some characteristics in common, I feel that one drawback of the Berman is the extension of its ventral surface, which is not present in the Williams airway. This extension would seem unnecessary and may cause the downfolding of the epiglottis mentioned above [4]. The authors did not use any scoring systems to assess the ease with which the vocal cords could be viewed. Instead, they chose to record the time to view the cords (or failure) as a more objective endpoint. Though the authors did conclude that jaw lift was better than the Berman airway in their group of patients, I would be interested at what level in the upper airway (tongue or epiglottis) the failures occurred. This would help to better understand how the Berman and jaw lift may be improved or should be avoided in certain clinical situations., Finally, I would like to support their statement that there are no clear guidelines on how to select the Berman airway for an individual patient. Further work is necessary to clarify this issue.

Use of a plastic Yankauer sucker for the reinsertion of a displaced percutaneous dilational tracheostomy tube

This may account for the transient bronchospam or at least have contributed to it. Postoperatively, there were no thrombotic or respiratory complications, but graft function was delayed for 2 days and he was temporarily dialysed. He is now home and recovering well after a successful transplant. In summary, the pre-operative assessment of Anderson-Fabry disease should concentrate on end-organ damage to the heart, brain, lungs and kidneys. The older the patient, the more likely it is that they will have a significant degree of organ impairment that will require consideration before major surgery. Investigations should include urinalysis, 12-lead ECG, echocardiography, spirometry and a comprehensive renal assessment. Respiratory function should be carefully assessed in those who continue to smoke and pre-operative treatment with hydrocortisone should perhaps be considered. The need for bronchodilators must be anticipated and avoiding drugs and clinical interventions that are commonly associated with histamine release appears sensible. In elective cases we also advocate having a low threshold for noninvasive cardiac stress tests in those > 30 years of age and relevant symptoms.