Kim Vidhani

SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study

Abstract Background. High-flow nasal oxygen (HFNO) has been shown to benefit oxygenation, ventilation and upper airway patency in a range of clinical scenarios, however its use in spontaneously breathing patients during general anaesthesia has not been described. Spontaneous respiration using i.v. anaesthesia is the primary technique used at our institution for tubeless airway surgery. We hypothesized that the addition of HFNO would increase our margin of safety, particularly during management of an obstructed airway. Methods. A retrospective observational study was conducted using a SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) technique to manage 30 adult patients undergoing elective laryngotracheal surgery. Results. Twenty-six patients (87%) presented with significant airway and/or respiratory compromise (16 were stridulous, 10 were dyspnoeic). No episodes of apnoea or complete airway obstruction occurred during the induction of anaesthesia using STRIVE Hi. The median [IQR (range)] lowest oxygen saturation during the induction period was 100 [99–100 (97–100)] %. The median [IQR (range)] overall duration of spontaneous ventilation was 44 [40–49.5 (18–100)] min. The median [IQR (range)] end-tidal carbon dioxide (ETCO2) level at the end of the spontaneous ventilation period was 6.8 [6.4–7.1 (4.8–8.9)] kPa. The mean rate of increase in ETCO2 was 0.03u2009kPa min−1. Conclusions. STRIVE Hi succeeded in preserving adequate oxygen saturation, end-tidal carbon dioxide and airway patency. We suggest that the upper and lower airway benefits attributed to HFNO, are ideally suited to a spontaneous respiration induction, increasing its margin of safety. STRIVE Hi is a modern alternative to the traditional inhalation induction.

SponTaneous Respiration using IntraVEnous anaesthesia (STRIVE) facilitates fibreoptic intubation through supraglottic airway device

Dear Editor, We read with interest ‘Continuous ventilation during intubation through a supraglottic airway device guided by fibreoptic bronchoscopy: a observational assessment’ by Landsdalen et al. We agree that the use of continuous ventilation during fibreoptic bronchoscopy and intubation may increase the margin of safety and benefit patients intolerant of apnoea by improving oxygenation. Although continuous ventilation was successfully performed with positive pressure ventilation after neuromuscular blockade, we suggest that this could also be achieved with the maintenance of spontaneous respiration, further increasing the margin of safety. We have previously described the use of a SponTaneous Respiration using IntraVEnous anaesthesia and High-Flow Nasal Oxygen (STRIVE Hi) technique to manage difficult and obstructed airways, however, we also use the STRIVE technique (without High-Flow Nasal Oxygen) in conjunction with a supraglottic airway device (SAD) in certain scenarios. The STRIVE + SAD technique is used routinely for diagnostic and therapeutic bronchoscopy, and has been successfully used to facilitate asleep fibreoptic intubation with an Air-Q Intubating Laryngeal Airway (ILATM, Cookgas LLC, Mercury Medical, Clearwater, FL, USA) during management of the difficult airway. This approach may have several advantages: (1) Using an upwards staircase method to titrate the propofol infusion, we have found that general anaesthesia can be induced while preserving spontaneous respiration, even at deep levels of anaesthesia. (2) Propofol facilitates SAD placement and, supplemented with local anaesthesia delivered via the bronchoscope, provides good intubating conditions. (3) The complexities of delivering positive pressure ventilation and potential for air trapping, as described by the authors, are reduced. (4) In some circumstances, oxygenation may be preserved while passing the bronchoscope directly through the SAD without initial placement of the tracheal tube and connection to the circuit, further simplifying the equipment setup. (5) General anaesthesia is induced without ‘burning the bridge’ associated with neuromuscular blockade prior to securing a definitive airway. Preservation of spontaneous ventilation is one of four basic management choices in the American Society of Anethesiologists Practice Guidelines for Management of the Difficult Airway, however, descriptions about how to implement this in practice are limited. Use of a STRIVE + SAD technique has been reported in paediatrics but we are not aware of its description in management of the adult difficult airway. We thank the authors for their contribution to airway management and suggest that spontaneous respiration is a potential variation rather than a replacement of their technique, which may be useful in certain circumstances.

Spontaneous Respiration Using Intravenous Anesthesia and High-Flow Nasal Oxygen (STRIVE Hi) Management of Acute Adult Epiglottitis: A Case Report

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The Australian Consultant Intensivist Transition (CIT) Course: Timely and Relevant for Intensivists Everywhere

This article aims to outline a new educational initiative on offer to newly qualified intensivists in Australasia, the Consultant Intensivist Transition (CIT) course. It is timely to consider the relevance of such a course in the UK as the recently formed UK Faculty of Intensive Care addresses the training needs of the intensive care specialist of the future.

The S.T.A.B. trial-standardized testing of artificial blood: a comparative study of various products that may be used as artificial blood for high fidelity simulation training in the critical care setting.

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4–3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.