Jorge E. Zamora

A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy

&NA; Current treatments for post‐injury movement‐evoked pain are inadequate. Non‐opioids may complement opioids, which preferentially reduce spontaneous pain, but most have incomplete efficacy as single agents. This trial evaluates efficacy of a gabapentin–rofecoxib combination following hysterectomy. In addition to IV‐PCA morphine, 110 patients received either placebo, gabapentin (1800 mg/day), rofecoxib (50 mg/day) or a gabapentin–rofecoxib combination (1800/50 mg/day) starting 1 h pre‐operatively for 72 h. Outcomes included pain at rest, evoked by sitting, peak expiration and cough, morphine consumption and peak expiratory flow (PEF). For placebo, gabapentin, rofecoxib and combination, 24 h pain (100 mm VAS) was: at rest—23.6 (P<0.05 vs. all treatments), 13.8, 14.4 and 12.1; during cough—50.7 (P<0.05 vs. all treatments), 41.5, 44.8 and 30.8; 48 h morphine consumption (mg) was: 130.4 (P<0.05 vs. all treatments), 81.7, 75.6 and 57.2 (P<0.05 vs. gabapentin and rofecoxib) and 48 h PEF (% baseline) was: 63.9 (P<0.05 vs. all treatments), 77.2, 76.7 and 87.5 (P<0.05 vs. gabapentin and rofecoxib). Adverse effects were similar in all groups except sedation which was more frequent with gabapentin. Combination and rofecoxib reduced pain interference with movement, mood and sleep (P<0.05) and combination was superior to gabapentin for all these three (P<0.05). These data suggest that a gabapentin–rofecoxib combination is superior to either single agent for postoperative pain. Other benefits include opioid sparing, reduced interference with movement, mood and sleep and increased PEF suggesting accelerated pulmonary recovery. Future research should identify optimal dose‐ratios for this and other analgesic combinations.

Contamination: a comparison of 2 personal protective systems

Background: The purpose of this study was to examine the difference in self-contamination rates and levels of contact and droplet protection associated with enhanced respiratory and contact precautions (E-RCP) and a personal protective system that included a full body suit, personal protective equipment and a powered air-purifying respirator (PAPR). Methods: In this prospective, randomized, controlled crossover study, 50 participants donned and removed E-RCP and PAPR in random order. Surrogate contamination consisted of fluorescein solution and ultraviolet (UV) light– detectable paste, which was applied after each ensemble was donned. A blinded evaluator inspected participants for contamination using a UV lamp after removal of each ensemble. Areas of contamination were counted and measured in square centimetres. Donning and removal violations were recorded. The primary end point was the presence of any contamination on the skin or base clothing layer. Results: Participants wearing E-RCP were more likely to experience skin and base-clothing contamination; their contamination episodes measuring ≥ 1 cm2 were more frequent, and they had larger total areas of contamination (all p < 0.0001). The anterior neck, forearms, wrists and hands were the likeliest zones for contamination. Participants donning PAPR committed more donning procedure violations (p = 0.0034). Donning and removing the PAPR system took longer than donning and removing E-RCP garments (p < 0.0001). Interpretation: Participants wearing E-RCP were more likely to experience contamination of their skin and base clothing layer. Those wearing PAPR required significantly more time to don and remove the ensemble and violated donning procedures more frequently.

Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway

STUDY OBJECTIVE To assess the performance and cervical (C)-spine movement associated with laryngoscopy using the Bullard laryngoscope (BL), GlideScope videolaryngoscope (GVL), Viewmax, and Macintosh laryngoscopes during conditions of a) unrestricted and b) restricted C-spine and temporomandibular joint (TMJ) mobility. DESIGN Prospective, controlled, randomized, crossover study. SETTING University teaching hospital. SUBJECTS 21 cadavers with intact C-spine anatomy. INTERVENTIONS Each cadaver underwent to total of 8 intubation attempts to complete the intubation protocol using all four devices under unrestricted and restricted C-spine and TMJ mobility. MEASUREMENTS Laryngoscopic view was graded using the modified Cormack-Lehane system. Time to best laryngoscopic view and total time to intubation were recorded. C-spine movement was measured between McGregors line and each vertebra from radiographs taken at baseline and at best laryngoscopic view. MAIN RESULTS During both intubating conditions, the BL achieved the highest number of modified Cormack-Lehane grade 1 and 2A laryngoscopic views as compared to the other three devices (P < 0.05) and had fewer intubation failures than the Viewmax or Macintosh laryngoscopes (P < 0.05). The GVL had superior laryngoscopic performance as compared to the Viewmax and Macintosh laryngoscopes (P < 0.05) and had fewer intubation failures than those two devices (P < 0.05). All devices except the Macintosh laryngoscope in restricted mobility achieved median times to intubation in less than 30 seconds. For both conditions, BL showed the least total absolute movement between Occiput/C1 and C3/C4 of all the devices (all P < 0.05). Most of the difference was seen at C1/C2. CONCLUSIONS In cadavers with unrestricted and restricted C-spine mobility, the BL provided superior laryngoscopic views, comparable intubating times, and less C-spine movement than the GVL, Viewmax, or Macintosh laryngoscopes.

The best care anywhere.

![Figure][1] FIGURE. The trauma bay and medical staff at work in the multinational medical unit in Khandahar, Afghanistan. Dr. J.E. Zamora I remember how well everyone worked together and the patients that we cared for as if it were yesterday. Despite the decreasing coverage of events in

Combitube rescue for Cesarean delivery followed by ninth and twelfth cranial nerve dysfunction.

Purpose: The Combitube™ has been shown to be effective in many airway management scenarios. We describe its use as a rescue device in a “cannot intubate cannot ventilate” (CICV) situation that was encountered during a Cesarean delivery (CD) followed by transient cranial nerve dysfunction.Clinical features: A 24-yr-old gravida 4 para 1 (weight 112 kg, body mass index 44 kg·m−2) at 34 weeks gestation, with pregnancy induced hypertension and a prior history of uneventful airway management, presented for urgent CD. She refused regional anesthesia and attempts at awake laryngoscopy and intubation. Following rapid sequence induction, attempts at direct laryngoscopy and intubation failed. Ventilation via facemask and laryngeal mask also failed. A Combitube was inserted and inflated according to manufacturer’s instructions and resulted in successful ventilation of the patient. The Combitube was in place for approximately three hours and then removed uneventfully. The following day, the patient presented with signs and symptoms consistent with bilateral glossopharyngeal and unilateral hypoglossal nerve dysfunction. Three months later the patient’s nerve dysfunction had completely resolved.Conclusion: Although this patient’s transient nerve dysfunction was most likely due to the Combitube, we believe its inclusion as part of any difficult airway armamentarium should be encouraged. Training in its use should be promoted. It has an important role in emergency airway management and can be effective when other non-surgical ventilation techniques fail. Despite this, clinicians must remain vigilant for complications following its use.RésuméObjectif: Il a été démontré que le Combitube? peut être efficace dans de nombreux contextes de prise en charge des voies aériennes. Nous décrivons ici son utilisation comme appareil de sauvetage dans une situation où l’intubation et la ventilation sont impossibles (« cannot intubate cannot ventilate » — CICV) survenue pendant un accouchement par césarienne (AC) et suivie par un dysfonctionnement temporaire des nerfs crâniens.Éléments cliniques: Une femme de 24 ans (G4, P1) (poids 112 kg, indice de masse corporelle 44 kg·m−2) à 34 semaines de grossesse, souffrant d’une hypertension provoquée par la grossesse et n’ayant pas d’antécédents de prise en charge des voies aériennes difficile, s’est présentée pour un AC urgent. Elle a refusé l’anesthésie régionale et les tentatives de laryngoscopie et d’intubation vigiles. À la suite de l’induction en séquence rapide, les tentatives de laryngoscopie et d’intubation ont échoué. La ventilation par masque facial et masque laryngé ont également échoué. Un Combitube a été inséré et gonflé selon les instructions du fabricant, résultant en une ventilation réussie de la patiente. Le Combitube est resté en place durant environ trois heures, puis a été retiré sans complication. Le jour suivant, la patiente a manifesté des signes et des symptômes compatibles avec une atteinte bilatérale des nerfs glossopharyngiens et unilatérale du grand hypoglosse. Trois mois plus tard, l’atteinte nerveuse de la patiente avait complètement disparu.Conclusion: Bien que l’atteinte nerveuse temporaire de la patiente fut très probablement due au Combitube, nous pensons que l’inclusion de cet appareil dans l’arsenal thérapeutique de n’importe quelle prise en charge des voies aériennes difficile devrait être soutenu. La formation quant à son usage devrait être encouragée. Le Combitube joue un rôle important dans la prise en charge d’urgencedes voies aériennes et peut être efficace lorsque les autres techniques de ventilation non chirurgicales échouent. Malgré son utilité, les cliniciens doivent demeurer vigilants et attentifs aux complications qui peuvent survenir à la suite de son utilisation.

Dispatch from the medical front: Khandahar arrival.

I remember awakening when the passenger beside me elbowed me in the ribs. The C–130 Hercules was filled to capacity. The engine noise and our earplugs made it impossible to hear each other unless we shouted. He gestured to “Put on your helmet and fragmentation vest.” We went through the necessary contortions to don our protective equipment before we began the descent into potentially hostile airspace. The Taliban were known to take the occasional shot at aircraft as they approached the runway. The movement of beams of sunlight inside the plane hinted at the evasive manoeuvres the aircraft was taking as we started the final portion of my long journey from Kingston, Ontario to Khandahar Airfield. Following a surprisingly gentle bump, the plane decelerated. We had landed. We disembarked from the planes darkness thankful to be on solid ground, slightly disoriented, and temporarily blinded by the intense mid-day light. I quickly recognized 2 smiling members of the operating room team sent to meet me. “Hi Rick, welcome to Khandahar Airfield,” one of them said. The base was immense and had a Wild West feel about it. Almost everyone carried pistols or rifles. Military and civilian vehicles were in constant movement and propelled an incredible amount of fine dust into the air that soon turned anything exposed to it light brown. The Canadian-led Multinational Medical Unit was an orderly and functional collection of buildings and tents. Each was surrounded by concrete blast barriers. The hospital was made of plywood, metal and canvas. It housed trauma bays, operating rooms, an intensive care unit, inpatient wards, a radiology department and all the other departments critical to the provision of health care services to this and several neighbouring provinces. Although most staff wore Canadian desert camouflage clothing there were also military, and some civilian health professionals from the Netherlands, the United Kingdom, the United States, Australia, New Zealand and Denmark. This was probably the busiest hospital in the country. In addition to treating Canadian and coalition soldiers, we provided services to foreign civilian workers, local civilians with life and limb threatening injuries, and the occasional detainee. The majority of our patients were from the Afghan Security Forces. Most arrived with injuries from firearms and improvised explosive devices. During 1 month working as the Canadian surgical teams anesthesiologist, I saw more penetrating trauma and blast injuries than I have seen in 12 years of civilian practice. — Jorge Enrique Zamora MD, Khandahar, Afghanistan Figure. The dust at the Canadian-led multinational medical unit in Khandahar, Afghanistan, is relentless. Image by: Dr. Jorge Enrique Zamora Figure. Concrete bunker, sandbag emplacement and razor wire outside of the living quarters of staff at the multinational medical unit. Image by: Dr. Jorge Enrique Zamora

Pandemic preparedness and protective clothing: priorities of health care workers in a Canadian teaching hospital

Their input isrequired when protective clothing policies are drafted.Many respiratory interventions in patients with febrilerespiratory illnesses put HCWs at high risk for diseasetransmission. During the severe acute respiratory syndrome(SARS) crisis of 2003, 9% of HCWs in Toronto who wereinvolved with the intubation of SARS patients contractedthe disease.