Judith Elizabeth Hall

A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur.

extension–extension position as used in our study (head extension with the head section of the table extended down), but demonstrates the head extension position on a flat surface. This is an important point because the results of our study [1] support the concept that one of the reasons for the utility of the sniffing position is that atlanto-occiptal extension is restricted when the head is simply extended on a flat surface. We do not understand Dr Greenland’s explanation of how a straight blade is specifically useful for retrognathia. If a straight blade requires less force in retrognathia that would also be likely in non-retrognathic patients.

Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland

Complications at extubation remain an important risk factor in anaesthesia. A postal survey was conducted on extubation practice amongst consultant anaesthetists in the United Kingdom and Ireland. The use of short acting drugs encourages anaesthetists to extubate the trachea at lighter levels of anaesthesia. The results show that oxygen (100%) is not routinely administered either before extubation or enu2003route to the recovery area. A trend towards a head up or sitting position at extubation is emerging. However, further research into the use of these positions is required. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. The role of drugs such as propofol in decreasing the incidence of these complications needs further evaluation. Some of these results give concern for patient safety and for training. The importance of teaching and adherence to continued oxygenation until complete recovery is strongly emphasised. Nerve stimulators should be used continually as standard monitoring throughout the anaesthetic period when muscle‐relaxing drugs are part of the anaesthetic technique.

Nicotinic acetylcholine receptors on basophils and mast cells.

Anaphylaxis in response to drugs administered during anaesthesia is a rare but potentially catastrophic event. The anaesthetic drugs most commonly associated with anaphylaxis are neuromuscular blocking agents. As these drugs act on the nicotinic acetylcholine receptor of the neuromuscular junction, potentiation of anaphylaxis by a nicotinic receptor on basophils and mast cells is plausible. The aim of this study was to investigate whether nicotinic acetylcholine receptors are present on a human basophil and mast cell lines as their presence may suggest a mechanism of associated anaphylaxis. Nicotinic receptors were demonstrated on a basophil and a mast cell line using an α‐bungarotoxin–fluorescein conjugate by flow cytometry and by both conventional and confocal microscopic techniques. The identity of this receptor was confirmed by reverse transcriptase PCR and quantitative PCR.

A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur*: Anaesthetic management for fractured neck of femur

We conducted a national postal survey of trauma anaesthetists in the UK to ascertain current practice for the peri‐operative anaesthetic management in patients with fractured necks of femur. We received 155 replies from 218 questionnaires sent (71.1% response rate). Regional anaesthesia was preferred by 75.8% of respondents, with 95.5% of these employing a spinal technique. This was generally performed bad side down (45.7%) using ketamine (37.3%) and/or midazolam (41.2%) to aid positioning. In all, 31.4% used fentanyl in the intrathecal injectate, whereas only 5.9% used morphine. Paracetamol and morphine were the most commonly used postoperative analgesic regimens with non‐steroidal anti‐inflammatory drugs used by only 27.4%. Continuous epidural or nerve block infusions were used rarely. Of the anaesthetists, 50.6% would only request a pre‐operative echo if there were suspicious signs or symptoms in patients with a previously undiagnosed heart murmur. The peri‐operative management of these patients can be readily improved.

An assessment of the ability of impedance respirometry distinguish oesophageal from tracheal intubation

Summary Accidental oesophageal intubation is still an important cause of anaesthetic morbidity and mortality. This study investigated the use of impedance respirometry to determine the position of a tracheal tube. Seventy‐nine patients undergoing general anaesthesia requiring tracheal intubation with muscle relaxation were recruited to the study. After pre‐oxygenation, tracheal tubes were placed in both the oesophagus and trachea; a breathing system was attached to one tube chosen randomly. A blinded observer was required to correctly identify the position of the tube within six tidal ventilations. The position of every tube connected to the breathing system was correctly identified. The median time to correctly identify tracheal and oesophageal tubes was 3 and 5u2003s, respectively. The median number of breaths to identify tracheal and oesophageal tubes was two for both groups. Every tube position was identified within the required six breaths. Impedance respirometry is a reliable method for diagnosing tracheal tube position.

Bispectral Index asymmetry and COMFORT score in paediatric intensive care patients

BACKGROUNDnThe Bispectral Index (BIS) monitor has been suggested as a potential tool to measure depth of sedation in paediatric intensive care unit (PICU) patients. The primary aim of our observational study was to assess the difference in BIS values between the left and right sides of the brain. Secondary aims were to compare BIS and COMFORT score and to assess change in BIS with tracheal suctioning.nnnMETHODSnNineteen ventilated and sedated PICU patients had paediatric BIS sensors applied to either side of their forehead. Each patient underwent physiotherapy involving tracheal suctioning. Their BIS data and corresponding COMFORT score, assessment as by their respective nurses, were recorded before, during, and after physiotherapy.nnnRESULTSnSeven patients underwent more than one physiotherapy session; therefore, 28 sets of data were collected. The mean BIS difference values (and 95% CI) between left BIS and right BIS for pre-, during, and post-physiotherapy periods were 9.2 (5.9-12.5), 15.8 (11.9-19.7), and 7.5 (5.2-9.7), respectively. Correlation between mean BIS, left brain BIS, and right brain BIS to COMFORT score was highly significant (P<0.001 for all three) during the pre- and post-physiotherapy period, but less so during the stimulated physiotherapy period (P=0.044, P=0.014, and P=0.253, respectively).nnnCONCLUSIONSnA discrepancy between left and right brain BIS exists, especially when the patient is stimulated. COMFORT score and BIS correlate well between light and moderate sedation.

Anaesthesia and safe motherhood.

The challenges of obstetric care in the developing world are enormous. Many fit young mothers die or suffer disabling birth injuries from preventable complications of pregnancy that are easily treated with basic facilities. Maternal mortality rates in excess of 1% have been recorded in a number of countries. Access to Caesarean section is a particular problem, with rates lower than 1% being commonplace. The provision of appropriate anaesthesia services is of international concern.

Fentanyl supplementation of sevoflurane induction of anasthesia

Sevoflurane induction of anasthesia has been examined extensively, but little is known about the usefulness of other drugs as adjuncts to hasten and smooth the process. Sixty patients, undergoing surgery of a type suitable for a spontaneous respiration, laryngeal mask airway anasthetic technique, were randomly allocated to receive 1.0u2003μg.kg−1 intravenous fentanyl or the equivalent volume of normal saline, 30u2003s prior to triple‐breath induction with sevoflurane. The study was double‐blind. There were no differences between the groups for the times to loss of eyelash reflex, jaw relaxation, insertion of the laryngeal mask airway or regular settled breathing. However, there was a difference in the incidence of adverse airway events (breath‐holding, coughing and laryngospasm) between the two groups (16.5% in the fentanyl group and 40% in the placebo group); this did not reach statistical significance. Both groups were haemodynamically stable throughout induction, although the fentanyl group had a statistically significant decrease in systolic blood pressure at 4u2003min compared with the placebo group, which was not considered clinically relevant. We conclude that fentanyl has no significant influence over the speed and quality of sevoflurane induction.

A comparison of the use of Trachlight and Eschmann multiple-use introducer in simulated difficult intubation

Background and objective: The Eschmann multiple‐use introducer is widely used in the management of difficult intubations. Transillumination of the neck is less commonly used. We conducted a randomized crossover study comparing the Trachlight® lightwand and Eschmann multiple‐use introducer in simulated difficult intubation. Methods: Sixty‐four healthy patients were studied using a standard anaesthetic and full muscle relaxation assessed by train of four. A Macintosh laryngoscope was then inserted and then lowered to simulate a Grade 3 view. Tracheal placement was attempted with both Trachlight® lightwand and Eschmann multiple‐use introducer in a randomized order. Anaesthetists placing the devices had extensive experience with the Eschmann multiple‐use introducer, but only 15 previous uses of the Trachlight®. Success rates and time for tracheal placement were recorded. Results: The Eschmann multiple‐use introducer and Trachlight® were successfully placed in 96.8% and 93.7%, respectively (n.s.). Mean (SD) time to intubation for Eschmann multiple‐use introducer and Trachlight® were 15(6) and *21(13), respectively (*P < 0.001). Conclusion: The Trachlight® is a potentially useful alternative to the Eschmann multiple‐use introducer in difficult intubation.

A comparison of direct laryngoscopy and jaw thrust to aid fibreoptic intubation

We compared two manoeuvres, jaw thrust and laryngoscopy, to open the airway during fibreoptic intubation in 50 patients after induction of anaesthesia in a crossover study. Patients were randomly allocated to receive either jaw thrust or conventional Macintosh laryngoscopy first. Airway clearance was assessed at both the soft palate and the epiglottis. Direct laryngoscopy provided significantly better airway clearance at the level of the soft palate than jaw thrust (44 (88%) vs 31 (62%), respectively; pu2003=u20030.002). At the level of the larynx, airway clearance was equally good in both groups (45 (90%) vs 46 (92%), respectively; pu2003=u20030.56). The times to view the larynx (median (interquartile range [range]) 4 (3–5 [2–35])u2003s vs 3 (3–4 [2–8]) s, respectively) and intubation time (20 (17–23 [11–83])u2003s vs 18 (15–20 [11–28]) s, respectively) were also similar.