Laurence Weinberg

Children presenting to hospital with acute alcohol intoxication

Aims: To investigate the problem of children presenting to hospital with alcohol intoxication. Methods: An observational study was conducted over 18 months profiling children who presented to hospital with acute alcohol intoxication, proved by laboratory tests on blood alcohol levels (BALs). The study was part of a multicentre-funded injury prevention project based on the widely accepted Canadian Hospital Injury Reporting and Prevention Programme. Results: 62 children (31 boys), mean age 14.5 years, presented with alcohol intoxication proved by BALs. The mean BAL was 203 mg/dl (standard deviation (SD) 80.7). As a point of reference, 56 (90%) children had BAL above the UK legal driving limit of 80 mg/dl. The most common type of alcohol consumed was spirits, in the form of whisky, gin, vodka and tequila. No significant association was seen between age and BAL. Children with high alcohol levels were much more likely to have lower Glasgow Coma Scores (p<0.001), but in contrast with conventional teaching, there was no association between blood glucose levels and BALs. The median Glasgow Coma Score on admission to the emergency department was 12. 15 (24%) children had a score ⩽8/15. Injuries were present in 21 (34%) children, most of which were minor injuries. Minor head injury was most common, accounting for 42% of the injuries. The most common cause of injury was a fall. Discussion: The results of this study confirm the heavy use of alcohol by some young children. This highlights a definite problem, which needs to be dealt with by a variety of measures, giving particular consideration to the ease of access to alcohol by children.

Crystalloid fluid therapy

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

A Fast Track Recovery Program Significantly Reduces Hospital Length of Stay Following Uncomplicated Pancreaticoduodenectomy

CONTEXT Factors affecting length of hospital stay after uncomplicated pancreaticoduodenectomy have not been reported. We hypothesized that patients undergoing uncomplicated pancreaticoduodenectomy treated by fast track recovery program would have a shorter length of hospital stay compared to those managed by a standard program. METHODS Patients without surgical or medical complications following pancreaticoduodenectomy managed by fast track or standard protocols, between 2005 and 2011, were identified and prognostic predictors for length of hospital stay determined. RESULTS Forty-one patients treated by pancreaticoduodenectomy had no medical or surgical complications during this period. Of these patients, 20 underwent fast track recovery program compared to 21 who underwent standard care. Patients in the standard group were more likely to have a feeding jejunostomy tube (P<0.001), pylorus preserving procedure (P=0.001) and a nasogastric tube in place longer than 24 hours postoperatively (P<0.001). The median postoperative length of stay was shorter in the fast track recovery program group (8 days, range: 7-16 days) versus 14 days, range: 8-29 days; P<0.001). There were three readmissions in the fast track recovery program related to abdominal pain and none in the standard group. The overall length of stay, accounting for readmissions, still remained significantly shorter in the fast track recovery program group (median 9 days, range: 7-17 days versus median14 days, range: 8-29 days ; P<0.001). There were no significant differences in discharge destination between groups. On multivariate analysis, the only factor independently associated with postoperative discharge by day 8 was fast track recovery program (OR: 37.1, 95% CI: 4.08-338; P<0.001). CONCLUSION Fast track recovery program achieved significantly shorter length of stay following uncomplicated pancreaticoduodenectomy.

Nitrous Oxide Diffusion and the Second Gas Effect on Emergence from Anesthesia

Background:Rapid elimination of nitrous oxide from the lungs at the end of inhalational anesthesia dilutes alveolar oxygen, producing “diffusion hypoxia.” A similar dilutional effect on accompanying volatile anesthetic agent has not been evaluated and may impact the speed of emergence. Methods:Twenty patients undergoing surgery were randomly assigned to receive an anesthetic maintenance gas mixture of sevoflurane adjusted to bispectral index, in air-oxygen (control group) versus a 2:1 mixture of nitrous oxide-oxygen (nitrous oxide group). After surgery, baseline arterial and tidal gas samples were taken. Patients were ventilated with oxygen, and arterial and tidal gas sampling was repeated at 2 and 5 min. Arterial sampling was repeated 30 min after surgery. Sevoflurane partial pressure was measured in blood by the double headspace equilibration technique and in tidal gas using a calibrated infrared gas analyzer. Time to eye opening and time extubation were recorded. The primary endpoint was the reduction in sevoflurane partial pressures in blood at 2 and 5 min. Results:Relative to baseline, arterial sevoflurane partial pressure was 39% higher at 5 min in the control group (P < 0.04) versus the nitrous oxide group. At 30 min the difference was not statistically significant. Time to eye opening (8.7 vs. 10.1 min) and time to extubation (11.0 vs.13.2 min) were shorter in the nitrous oxide group versus the control group (P < 0.04). Conclusions:Elimination of nitrous oxide at the end of anesthesia produces a clinically significant acceleration in the reduction of concentrations of the accompanying volatile agents, contributing to the speed of emergence observed after inhalational nitrous oxide anesthetic.

Reduction in Delayed Gastric Emptying Following Non-Pylorus Preserving Pancreaticoduodenectomy by Addition of a Braun Enteroenterostomy

CONTEXT Delayed gastric emptying is a major cause of morbidity following pancreaticoduodenectomy. OBJECTIVE The impact of a Braun enteroenterostomy on delayed gastric emptying, used in reconstruction following classic pancreaticoduodenectomy, was assessed. PATIENTS Forty-four consecutive patients undergoing non-pylorus preserving pancreaticoduodenectomy from 2009 to 2011 by a single surgeon were included in this study. INTERVENTIONS The first 20 patients had a standard antecolic gastroenterostomy and the subsequent 24 had the addition of a Braun enteroenterostomy. RESULTS Patient characteristics, the extent of surgery, surgical findings and tumor characteristics were similar between the two groups. The delayed gastric emptying rate in the Braun enteroenterostomy (1/24, 4.2%) was significantly lower (P=0.008) than the standard reconstruction group (7/20, 35.0%). In the standard group, 6 of 7 cases (85.7%) of delayed gastric emptying were class C in nature. After exclusion of 8 total pancreatectomy patients, the pancreatic fistula rate in the Braun enteroenterostomy group (4/19, 21.1%) was similar (0.706) to the standard reconstruction group (5/17, 29.4%) as was the median length of hospital stay (10 days vs. 15 days; P=0.291). Braun enteroenterostomy technique was the only significant independent factor associated with reduced delayed gastric emptying with an odds ratio of 0.08 (95% confidence interval: 0.01-0.73; P=0.025). CONCLUSION The use of Braun enteroenterostomy following non-pylorus preserving pancreaticoduodenectomy appears to result in a significant reduction in delayed gastric emptying.

A review of video laryngoscopes relevant to the intensive care unit

The incidence of difficult direct intubation in the intensive care unit (ICU) is estimated to be as high as 20%. Recent advances in video-technology have led to the development of video laryngoscopes as new intubation devices to assist in difficult airway management. Clinical studies indicate superiority of video laryngoscopes relative to conventional direct laryngoscopy in selected patients. They are therefore an important addition to the armamentarium of any clinician performing endotracheal intubation. We present a practical review of commonly available video laryngoscopes with respect to design, clinical efficacy, and safety aspects relevant to their use in the ICU.

Outcomes following fractured neck of femurin an Australian metropolitan teaching hospital.

Objectives To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care. Methods We performed a retrospective observational study of 185 consecutive adult patients admitted to an Australian metropolitan teaching hospital with fractured neck of femur between 2009 and 2010. The main outcome measures were 30-day and one-year mortality rates, major complications and factors influencing mortality. Results The majority of patients were elderly, female and had multiple comorbidities. Multiple peri-operative medical complications were observed, including pre-operative hypoxia (17%), post-operative delirium (25%), anaemia requiring blood transfusion (28%), representation within 30 days of discharge (18%), congestive cardiac failure (14%), acute renal impairment (12%) and myocardial infarction (4%). Mortality rates were 8.1% at 30 days and 21.6% at one year. Factors predictive of one-year mortality were American Society of Anesthesiologists (ASA) score (odds ratio (OR) 4.2 (95% confidence interval (CI) 1.5 to 12.2)), general anaesthesia (OR 3.1 (95% CI 1.1 to 8.5)), age > 90 years (OR 4.5 (95% CI 1.5 to 13.1)) and post-operative oliguria (OR 3.6 (95% CI 1.1 to 11.7)). Conclusions Results from an Australian metropolitan teaching hospital confirm the persistently high morbidity and mortality in patients presenting with a fractured neck of femur. Efforts should be aimed at medically optimising patients pre-operatively and correction of pre-operative hypoxia. This study provides planning data for future interventional studies. Cite this article: Bone Joint Res 2013;2:162–8.

The application of three‐dimensional printing technology in anaesthesia: a systematic review

Three‐dimensional printing has rapidly become an easily accessible, innovative and versatile technology, with a vast range of applications across a wide range of industries. There has been a recent emergence in the scientific literature relating to its potential application across a multitude of fields within medicine and surgery; however, its use within anaesthesia has yet to be formally explored. We undertook a systematic review using MEDLINE and EMBASE databases of three‐dimensional printing in anaesthesia. We identified eight relevant articles. Due to the paucity of studies, we also completed a narrative review of the applications of three‐dimensional printing pertinent to anaesthetic practice that our department are currently exploring, and suggest potential future uses for this technology relevant to our speciality.

Cognitive changes after saline or plasmalyte infusion in healthy volunteers: a multiple blinded, randomized, cross-over trial.

Background:In an incidental finding, during a study of plasma chemistry after crystalloid infusion, participants reported subjective cognitive changes, particularly slower thinking, after saline but not Hartmann’s (Ringer’s lactate) solution. The authors tested the hypothesis that saline infusion would produce greater adverse cognitive changes than Plasmalyte infusion. Methods:The authors conducted a randomized, cross-over, multiple blinded study of healthy adult volunteers. On separate days, participants received 30 ml/kg over 1 h of either 0.9% saline or Plasmalyte with the order randomly allocated. Plasma chemistry was tested on venous samples. As part of a battery of cognitive tests our primary endpoint was the reaction time index after infusion. Results:The authors studied 25 participants. Plasma chloride was greater after saline than after Plasmalyte: mean difference 5.4 mM (95% CI, 4.1–6.6 mM; P < 0.001). Saline was also associated with greater metabolic acidosis: base-excess 2.5 mM more negative (95% CI, 1.9–3.0 mM more negative; P < 0.001). There was no evidence of a difference in the reaction time index between the two interventions: mean reaction time index 394 ms (SD, 72) after saline versus 385 ms (SD, 55) after Plasmalyte. Difference: saline 9 ms slower (95% CI, 30 ms slower to 12 ms faster; P = 0.39). There were minimal differences in the other cognitive and mood tests. Conclusions:Despite expected differences in plasma chemistry, the authors found that measures of cognition did not differ after infusions of Plasmalyte or saline.

Total pancreatectomy for the treatment of pancreatic neoplasms

Total pancreatectomy (TP) is an operation that has long been associated with high morbidity and mortality, and rarely advocated for treatment of pancreatic tumours. Because of the improvements in diabetes management, there has been renewed interest in TP for treatment of pancreatic neoplasm, with a need to reassess outcomes.