Joseph F Cosgrove

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.

Decreasing delays in urgent and expedited surgery in a university teaching hospital through audit and communication between peri-operative and surgical directorates

National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of ‘after‐midnight’ operating to immediate life‐, limb‐ or organ‐threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre‐operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability.

Training and assessment of competency in the transfer of critically ill patients

in an air-filled space (such as the larynx or trachea). Some of the participants in the study ‘forgot crucial steps’ using the wire-guided technique and there were four incidences of posterior tracheal wall damage. I wonder whether these participants were ENT or anaesthesia trainees? If they were mainly ENT trainees, then wire-guided techniques may still be a safe choice for anaesthesia residents. I have heard more reports of ‘collateral damage’ to patients from the catheter over the needle technique than from the wireguided technique.

A practical approach to Events Medicine provision

In the past three decades, mass casualty incidents have occurred worldwide at multiple sporting events and other mass gatherings. Organisational safety and healthcare provision can consequently be scrutinised post-event. Within the UK, such incidents in the 1980s provided incentives to improve medical services and subsequent high profile UK-based international sporting events (London Olympics and Paralympics 2012, Glasgow Commonwealth Games 2014, Rugby World Cup 2015) added a further catalyst for developing services. Furthermore in the aftermath of the abandoned France versus Germany association football match at the Stade de France (Paris Terrorist Attacks, November 2015) and the 2016 UK report from HM Coroner on the Hillsborough Inquest, medical cover at sporting events is being further reviewed. Doctors providing spectator cover therefore need to have an awareness of their likely roles at sporting venues. Formal guidance exists in many countries for the provision of such cover but remains generic even though Events Medicine is increasingly recognised as a necessary service. The current evidence base is limited with best practice examples often anecdotally cited by acute care specialists (eg, emergency medicine) who provide cover. This article is therefore intended to present an overview for doctors of the knowledge and skills required to treat ill and injured spectators and enable them to adequately risk-assess venues in cooperation with other health and safety providers, including preparation for a major incident. It also gives guidance on how activity can be adequately assessed and how doctors can have management roles in Events Medicine.

Indications for and management of tracheostomies

Abstract There has been documented evidence of tracheostomies for over two millennia with the majority being descriptions of relieving acute upper airway obstructions in an emergency situation. The refinement of anaesthetic and surgical techniques resulted in an increase of the frequency and success of the procedure and the latter half of the 20th century saw tracheostomies being used increasingly as an adjunct to long-term respiratory support, not only in patients who had lost their upper airway but also in patients who had limited bulbar function and reduced ability to clear secretions via coughing and expectorating. Further technical developments have resulted in the adoption of the percutaneous dilatational tracheostomy (PDT) as the predominant technique with it being put to frequent use to facilitate ventilatory weaning in intensive care. In the UK approximately 16% of adult intensive care patients undergo PDT and if care of these patients is to be maintained at a high level clinicians must have a working knowledge of upper airway anatomy, indications for the procedure, complications and the ongoing care and management of such patients.

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.