WORLD HOSPITAL DIRECTORY
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Hon. H.E. Sir. Dr. Raphael Louis-PM Candidate (2015 - 2020)


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WORLD HOSPITAL DIRECTORY is the one and only largest database of hospitals around the world. There are over 35,000 plus records of hospitals across globe

WORLD HOSPITAL DIRECTORY has the World's largest online database of general, multispeciality, eye, dental, children, maternity, cardiac care, orthopedic, nephrology, neurology, diabetic, psychiatric, cancer, ENT, hospice, Rehabilitation, alternate medicine, veterinary hospitals across globe. Discover the complete list of hospitals available in North America, South America, Europe, Asia, Australia, New Zealand, rest of the world and online.

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1CEMIC
CEMIC
Category: General Hospitals
Argentina
South America, America
2Croydon Hospital (Tablelands HSD)
Croydon Hospital (Tablelands HSD)
Category: Mulispeciality Hospitals
Australia
Australia and New Zealand, Oceanic
3Regionaal Hospital Sint-Maria
Regionaal Hospital Sint-Maria
Category: Mulispeciality Hospitals
Belgium
Western Europe, Europe
4Bairro Passo D'areia Farmaconte Dist. Produtos Hospitalares Ltda.
Bairro Passo D'areia Farmaconte Dist. Produtos Hospitalares Ltda.
Category: Mulispeciality Hospitals
Brazil
South America, America
5BCIT - Technology Centre, Health Technology Research Group
BCIT - Technology Centre, Health Technology Research Group
Category: General Hospitals
Canada
North America, America

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Associate Editorial Board


Cover Page


Editorial Board


General Information


Contents Page


In the September BJA .....


Preoperative fast heart rate: a harbinger of perioperative adverse cardiac events


Valid consent - A pathway to improved care


Continuing to excel in anaesthesia through the 'big five: teaching, training, testing, quality, and research


I spy with my little eye something beginning with S: spotting sepsis


A forcing strategy to improve the evaluation of clinical superiority in anaesthesia trials


Fluid resuscitation management in patients with burns: update
<p>Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the &lsquo;goal-directed therapy&rsquo; concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.</p>


Thoracic paravertebral blocks in abdominal surgery - a systematic review of randomized controlled trials
<p>Thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multimodal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery. We performed a systematic review of randomized controlled trials, to clarify the impact of TPVB on perioperative analgesic outcomes in adult abdominal surgery. We identified 20 published trials involving a total of 1044 patients that met inclusion criteria; however there was significant heterogeneity in terms of type of surgery, TPVB technique, comparator groups and study quality. Pain scores and opioid requirements in the early postoperative period were generally improved when compared with systemic analgesia, but there was insufficient evidence for any definitive conclusions regarding comparison with epidural analgesia or other peripheral block techniques, or the benefit of continuous TPVB techniques. The reported primary block failure rate was 2.8% and the incidence of complications was 1.2% (6/504); there were no instances of pneumothorax. TPVB therefore appears to be a promising analgesic technique for abdominal surgery in terms of efficacy and safety. But further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anaesthesia techniques.</p>


Preoperative platelet function predicts perioperative bleeding complications in ticagrelor-treated cardiac surgery patients: a prospective observational study
<sec><st>Background</st> <p>Treatment with P2Y<SUB>12</SUB> receptor antagonists increases the risk for perioperative bleeding, but there is individual variation in the antiplatelet effect and time to offset of this effect. We investigated whether preoperative platelet function predicts the risk of bleeding complications in ticagrelor-treated cardiac surgery patients.</p> </sec> <sec><st>Methods</st> <p>Ninety patients with ticagrelor treatment within &lt;5 days of surgery were included in a prospective observational study. Preoperative platelet aggregation was assessed with impedance aggregometry using adenosine diphosphate (ADP), arachidonic acid (AA), and thrombin receptor-activating peptide (TRAP) as initiators. Severe bleeding complications were registered using a new universal definition of perioperative bleeding. The accuracy of aggregability tests for predicting severe bleeding was assessed using receiver operating characteristic (ROC) curves, which also identified optimal cut-off values with respect to sensitivity and specificity, based on Youden's index.</p> </sec> <sec><st>Results</st> <p>The median time from the last ticagrelor dose to surgery was 35 (range 4&ndash;108) h. The accuracy of platelet function tests to predict severe bleeding was highest for ADP [area under the ROC curve 0.73 (95% confidence interval 0.63&ndash;0.84, <I>P</I>&lt;0.001); TRAP 0.61 (0.49&ndash;0.74); AA 0.53 (0.40&ndash;0.66)]. The optimal cut-off for ADP-induced aggregation was 22 U. In subjects with ADP-induced aggregation below the cut-off value, 24/38 (61%) developed severe bleeding compared with 8/52 (14%) when aggregation was at or above the cut-off value (<I>P</I>&lt;0.001). The positive and negative predictive values for this cut-off value were 63 and 85%, respectively.</p> </sec> <sec><st>Conclusions</st> <p>Preoperative ADP-induced platelet aggregability predicts the risk for severe bleeding complications in ticagrelor-treated cardiac surgery patients.</p> </sec>


Validation of non-invasive arterial pressure monitoring during carotid endarterectomy
<sec><st>Background</st> <p>Patients undergoing carotid endarterectomy require strict arterial blood pressure (BP) control to maintain adequate cerebral perfusion. In this study we tested whether non-invasive beat-to-beat Nexfin finger BP (BP<SUB>fin</SUB>) can replace invasive beat-to-beat radial artery BP (BP<SUB>rad</SUB>) in this setting.</p> </sec> <sec><st>Methods</st> <p>In 25 consecutive patients (median age 71 yr) scheduled for carotid endarterectomy and receiving general anaesthesia, BP<SUB>fin</SUB> and BP<SUB>rad</SUB> were monitored simultaneously and ipsilaterally during the 30-min period surrounding carotid artery cross-clamping. Validation was guided by the standard set by the Association for the Advancement of Medical Instrumentation (AAMI), which considers a BP monitor adequate when bias (precision) is &lt;5 (8) mm Hg, respectively.</p> </sec> <sec><st>Results</st> <p>BP<SUB>fin</SUB> <I>vs</I> BP<SUB>rad</SUB> bias (precision) was &ndash;3.3 (10.8), 6.1 (5.7) and 3.5 (5.2) mm Hg for systolic, diastolic, and mean BP, respectively. One subject was excluded due to a poor quality BP curve. In another subject, mean BP<SUB>fin</SUB> overestimated mean BP<SUB>rad</SUB> by 13.5 mm Hg.</p> </sec> <sec><st>Conclusion</st> <p>Mean BP<SUB>fin</SUB> could be considered as an alternative for mean BP<SUB>rad</SUB> during a carotid endarterectomy, based on the AAMI criteria. In 23 of 24 patients, the use of mean BP<SUB>fin</SUB> would not lead to decisions to adjust mean BP<SUB>rad</SUB> values outside the predefined BP threshold.</p> </sec> <sec><st>ClinicalTrials.gov</st> <p>NCT01451294.</p> </sec>


Baroreflex impairment and morbidity after major surgery
<sec><st>Background</st> <p>Baroreflex dysfunction is a common feature of established cardiometabolic diseases that are most frequently associated with the development of critical illness. Laboratory models show that baroreflex dysfunction impairs cardiac contractility and cardiovascular performance, thereby increasing the risk of morbidity after trauma and sepsis. We hypothesized that baroreflex dysfunction contributes to excess postoperative morbidity after major surgery as a consequence of the inability to achieve adequate perioperative tissue oxygen delivery.</p> </sec> <sec><st>Methods</st> <p>In a randomized controlled trial of goal-directed haemodynamic therapy (GDT) in higher-risk surgical patients, baroreflex function was assessed using the spontaneous baroreflex sensitivity (BRS) method via an arterial line placed before surgery, using a validated sequence method technique (one beat lag). The BRS was calculated during the 6 h postoperative GDT intervention. Analyses of BRS were done by investigators blinded to clinical outcomes. The primary outcome was the association between postoperative baroreflex dysfunction (BRS &lt;6 mm Hg s<sup>&ndash;1</sup>, a negative prognostic threshold in cardiovascular pathology) and early postoperative morbidity. The relationship between baroreflex dysfunction and postoperative attainment of preoperative indexed oxygen delivery was also assessed.</p> </sec> <sec><st>Results</st> <p>Patients with postoperative baroreflex dysfunction were more likely to sustain infectious {relative risk (RR) 1.75 [95% confidence interval (CI): 1.07&ndash;2.85], <I>P</I>=0.02} and cardiovascular morbidity [RR 2.39 (95% CI: 1.22&ndash;4.71), <I>P</I>=0.008]. Prolonged hospital stay was more likely in patients with baroreflex dysfunction [unadjusted hazard ratio 1.62 (95% CI: 1.14&ndash;2.32), log-rank <I>P</I>=0.004]. Postoperative O<SUB>2</SUB> delivery was 36% (95% CI: 7&ndash;65) lower in patients with baroreflex dysfunction in those not randomly assigned to GDT (<I>P</I>=0.02).</p> </sec> <sec><st>Conclusions</st> <p>Baroreflex dysfunction is associated with excess morbidity, impaired cardiovascular performance, and delayed hospital discharge, suggesting a mechanistic role for autonomic dysfunction in determining perioperative outcome.</p> </sec> <sec><st>Clinical trial registration</st> <p>ISCRTN76894700.</p> </sec>


Pilot study of closed-loop anaesthesia for liver transplantation
<sec><st>Background</st> <p>Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia&ndash;reperfusion syndrome. We assessed the behaviour of this automated controller during OLT.</p> </sec> <sec><st>Methods</st> <p>Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval).</p> </sec> <sec><st>Results</st> <p>Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg<sup>&ndash;1</sup> h<sup>&ndash;1</sup> and 4.6 [3.5-8.1] mg kg<sup>&ndash;1</sup> h<sup>&ndash;1</sup>; <I>P</I>&lt;0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] &micro;g kg- <sup>1</sup> min<sup>&ndash;1</sup>). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 &micro;g ml<sup>&ndash;1</sup> and limits of agreement of &ndash;2.2 to +3.7 &micro;g ml<sup>&ndash;1</sup>) and remifentanil (bias of 1.3 ng ml<sup>&ndash;1</sup> and limits of agreement &ndash;4.3 to +6.8 ng ml<sup>&ndash;1</sup>). No adverse events were reported during anaesthesia.</p> </sec> <sec><st>Conclusions</st> <p>This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.</p> </sec>


Predicting arterial blood gas and lactate from central venous blood analysis in critically ill patients: a multicentre, prospective, diagnostic accuracy study
<sec><st>Background</st> <p>The estimation of arterial blood gas and lactate from central venous blood analysis and pulse oximetry <f>(SpO2)</f> readings has not yet been extensively validated.</p> </sec> <sec><st>Methods</st> <p>In this multicentre, prospective study performed in 590 patients with acute circulatory failure, we measured blood gases and lactate in simultaneous central venous and arterial blood samples at 6 h intervals during the first 24 h after insertion of central venous and arterial catheters. The study population was randomly divided in a 2:1 ratio into model derivation and validation sets. We derived predictive models of arterial pH, carbon dioxide partial pressure, oxygen saturation, and lactate, using clinical characteristics, <f>SpO2</f>, and central venous blood gas values as predictors, and then tested their performance in the validation set.</p> </sec> <sec><st>Results</st> <p>In the validation set, the agreement intervals between predicted and actual values were &ndash;0.078/+0.084 units for arterial pH, &ndash;1.32/+1.36 kPa for arterial carbon dioxide partial pressure, &ndash;5.15/+4.47% for arterial oxygen saturation, and &ndash;1.07/+1.05 mmol litre<sup>&ndash;1</sup> for arterial lactate (i.e. around two times our predefined clinically tolerable intervals for all variables). This led to ~5% (or less) of extreme-to-extreme misclassifications, thus giving our predictive models only marginal agreement. Thresholds of predicted variables (as determined from the derivation set) showed high predictive values (consistently &gt;94%), to exclude abnormal arterial values in the validation set.</p> </sec> <sec><st>Conclusions</st> <p>Using clinical characteristics, <f>SpO2</f>, and central venous blood analysis, we predicted arterial blood gas and lactate values with marginal accuracy in patients with circulatory failure. Further studies are required to establish whether the developed models can be used with acceptable safety.</p> </sec>


Use of deep laryngeal oxygen insufflation during laryngoscopy in children: a randomized clinical trial
<sec><st>Background</st> <p>Brief periods of haemoglobin oxygen desaturation are common in children during induction of general anaesthesia. We tested the hypothesis that oxygen insufflation during intubation slows desaturation.</p> </sec> <sec><st>Methods</st> <p>Patients 1&ndash;17 yr old undergoing nasotracheal intubation were enrolled and randomly assigned to one of three groups: standard direct laryngoscopy (DL); laryngoscopy with Truview PCD videolaryngoscope (VLO<SUB>2</SUB>); or laryngoscopy with an oxygen cannula attached to the side of a standard laryngoscope (DLO<SUB>2</SUB>). The co-primary outcomes were time to 1% reduction in <f>SpO2</f> from baseline, and the slope of overall desaturation <I>vs</I> time. All three groups were compared against each other.</p> </sec> <sec><st>Results</st> <p>Data from 457 patients were available for the final analysis: 159 (35%) DL; 145 (32%) DLO<SUB>2</SUB>; and 153 (33%) VLO<SUB>2</SUB>. Both VLO<SUB>2</SUB> and DLO<SUB>2</SUB> were superior to DL in both time to a 1% reduction in <f>SpO2</f> from baseline and the overall rate of desaturation (all <I>P</I>&lt;0.001). The 25th percentile (95% confidence interval) of time to a 1% saturation decrease was 30 (24, 39) s for DL, 67 (35, 149) s for DLO<SUB>2</SUB> and 75 (37, 122) s for VLO<SUB>2</SUB>. Mean desaturation slope was 0.13 (0.11, 0.15)% s<sup>&ndash;1</sup> for DL, 0.04 (0.02, 0.06)% s<sup>&ndash;1</sup> for DLO<SUB>2</SUB> and 0.03 (0.004, 0.05)% s<sup>&ndash;1</sup> for VLO<SUB>2</SUB>. We did not find a correlation between decrease in <f>SpO2</f> percentage and BMI or age.</p> </sec> <sec><st>Conclusions</st> <p>Laryngeal oxygen insufflation increases the time to 1% desaturation and reduces the overall rate of desaturation during laryngoscopy in children.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT01886807.</p> </sec>


Surgical pleth index in children younger than 24 months of age: a randomized double-blinded trial
<sec><st>Background</st> <p>The surgical pleth index (SPI) is a measurement of intraoperative nociception. Evidence of its usability in children is limited. Given that the autonomic nervous system is still developing during the first years of life, the performance of the SPI on small children cannot be concluded from studies carried out in older age groups.</p> </sec> <sec><st>Methods</st> <p>Thirty children aged &lt;2 yr, planned for elective open inguinal hernia repair or open correction of undescended testicle, were recruited. The children were randomized into two groups; the saline group received ultrasound-guided saline injection in the ilioinguinal and iliohypogastric nerve region before surgery and ropivacaine after surgery, whereas the block group received the injections in the opposite order. The SPI was recorded blinded and was analysed at the time points of intubation, incision, and when signs of inadequate anti-nociception were observed.</p> </sec> <sec><st>Results</st> <p>There was a significant increase in the SPI after intubation (<I>P</I>=0.019) and after incision in the saline group (<I>P</I>=0.048), but not at the time of surgical incision in the block group (<I>P</I>=0.177). An increase in the SPI was also seen at times of clinically apparent inadequate anti-nociception (<I>P</I>=0.008). The between-patient variability of the SPI was large.</p> </sec> <sec><st>Conclusions</st> <p>The SPI is reactive in small children after intubation and after surgical stimuli, but the reactivity of the SPI is rather small, and there is marked inter-individual variability in reactions. The reactivity is blunted by the use of ilioinguinal and iliohypogastric nerve block.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT02045810.</p> </sec>


Patient coping and expectations about recovery predict the development of chronic post-surgical pain after traumatic tibial fracture repair
<sec><st>Background</st> <p>The association of patient expectations about recovery with the development of chronic post-surgical pain (CPSP) is uncertain.</p> </sec> <sec><st>Methods</st> <p>Three hundred and fifty-nine patients enrolled in the SPRINT trial completed the Somatic Preoccupation and Coping (SPOC) questionnaire six weeks after a traumatic tibial fracture repair. The SPOC questionnaire measures patients' somatic complaints, coping, and optimism for recovery. Using adjusted models, we explored the association of SPOC scores with &ge; mild CPSP and &ge; moderate pain interference with activity at one yr after surgery.</p> </sec> <sec><st>Results</st> <p>Of 267 tibial fracture patients with data available for analysis, 147 (55.1%) reported CPSP at one yr. The incidence of CPSP was 37.6% among those with low (&le;40) SPOC scores, 54.1% among those with intermediate (41&ndash;80) scores, and 81.7% among those with high (&gt;80) scores. Addition of SPOC scores to an adjusted regression model to predict CPSP improved the <I>c</I>-statistic from 0.61 (95% CI 0.55&ndash;0.68) to 0.70 (95% CI 0.64&ndash;0.76, <I>P</I>=0.005 for the difference) and found the greatest risk was associated with high SPOC scores (OR 6.56, 95% CI 2.90&ndash;14.81). Similarly, an adjusted regression model to predict pain interference with function at one yr (<I>c</I>-statistic 0.77, 95% CI 0.71&ndash;0.83) found the greatest risk for those with high SPOC scores (OR 10.10, 95% CI 4.26&ndash;23.96).</p> </sec> <sec><st>Conclusions</st> <p>Patient's coping and expectations of recovery, as measured by the SPOC questionnaire, is an independent predictor of CPSP and pain interference one yr after traumatic tibial fracture. Future studies should explore whether these beliefs can be modified, and if doing so improves prognosis.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT 00038129</p> </sec>


Surgical pleth index: prediction of postoperative pain and influence of arousal
<sec><st>Background</st> <p>There are conflicting reports concerning the outcome after anaesthesia guided by the surgical pleth index (SPI; GE Healthcare, Helsinki, Finland). One potential explanation may be the lack of evidence for the selection of SPI cut-off values. The aim of this trial was to investigate the correlation between SPI, arousal, and postoperative pain and to define a cut-off value for SPI to predict moderate-to-severe pain.</p> </sec> <sec><st>Methods</st> <p>After obtaining ethical approval and written informed consent, 70 patients undergoing non-emergency surgery were enrolled. Data relating to SPI, heart rate, mean arterial pressure, and state entropy were recorded every 10 s for the last 10 min of surgery (state entropy &lt;60 at all times). Subsequently, recordings continued during the phase of arousal. After recovery room admission, pain scores (numerical rating scale 0&ndash;10) were obtained every 3 min for 15 min.</p> </sec> <sec><st>Results</st> <p>Data from 65 patients were analysed. Receiver-operating characteristic curve analysis revealed an optimal intraoperative cut-off SPI value of 30 to discriminate between numerical rating scale scores 0&ndash;3 and 4&ndash;10. For this value, the negative and positive predictive values to discriminate between numerical rating scale scores 0&ndash;3 and 4&ndash;10 were 50 and 89.7%, respectively. The SPI was significantly affected by arousal, and SPI scores obtained during this phase were not predictive of postoperative pain.</p> </sec> <sec><st>Conclusions</st> <p>Surgical pleth index values are predictive of postoperative pain only if obtained before patient arousal. In contrast to previous studies, a relatively low SPI,&nbsp;&gt;30, appears to predict pain with a high positive predictive value and may therefore be suggested for future studies of SPI-guided anaesthesia.</p> </sec> <sec><st>Clinical trial registration</st> <p>Australian New Zealand Clinical Trials Registry: ACTRN12615000804583.</p> </sec>


The impact of the acute respiratory distress syndrome on outcome after oesophagectomy
<sec><st>Background</st> <p>The Acute Respiratory Distress Syndrome (ARDS) is a serious complication of major surgery and consumes substantial healthcare resources. Oesophagectomy is associated with high rates of ARDS. The aim of this study was to characterize patients and identify risk factors for developing ARDS after oesophagectomy.</p> </sec> <sec><st>Methods</st> <p>A secondary analysis of data from 331 patients gathered during the Beta Agonists Lung Injury Prevention Trial was undertaken. Characteristics and outcomes of patients with early (first 72 h postoperatively) and late (after 72 h) ARDS were determined. Linear and multivariate regression analysis was used to study the differences between early and late ARDS and identify risk factors.</p> </sec> <sec><st>Results</st> <p>ARDS was associated with more non-respiratory organ failure (early 44.1%, late 75.0%, no ARDS 27.6% <I>P</I>&lt;0.001), longer ICU stay (mean early 12.1, late 20.2, no ARDS 7.3 days <I>P</I>&lt;0.001) and longer hospital stay (mean early 18.1, late 24.5, no ARDS 14.2 days <I>P</I>&lt;0.001) but no difference in mortality or quality of life. Older patients (OR 1.06 (1.00 to 1.13), <I>P</I>=0.045) and those with mid-oesophageal tumours (OR 7.48 (1.62&ndash;34.5), <I>P</I>=0.010) had a higher risk for ARDS.</p> </sec> <sec><st>Conclusions</st> <p>Early and late ARDS after oesophagectomy increases intensive care and hospital length of stay. Given the high incidence of ARDS, cohorts of patients undergoing oesophagectomy may be useful as models for studies investigating ARDS prevention and treatment. Further investigations aimed at reducing perioperative ARDS are warranted.</p> </sec>


Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial
<sec><st>Background</st> <p>Pectoral nerve (PecS) block is a recently introduced technique for providing surgical anaesthesia and postoperative analgesia during breast surgery. The present study was planned to compare the efficacy and safety of ultrasound-guided PecS II block with thoracic paravertebral block (TPVB) for postoperative analgesia after modified radical mastectomy.</p> </sec> <sec><st>Methods</st> <p>Forty adult female patients undergoing radical mastectomy were randomly allocated into two groups. Group 1 patients received a TPVB with ropivacaine 0.5%, 25 ml, whereas Group 2 patents received a PecS II block using same volume of ropivacaine 0.5% before induction of anaesthesia. Patient-controlled morphine analgesia was used for postoperative pain relief.</p> </sec> <sec><st>Results</st> <p>The duration of analgesia was significantly prolonged in patients receiving the PecS II block compared with TPVB [mean (<scp>sd</scp>), 294.5 (52.76) <I>vs</I> 197.5 (31.35) min in the PecS II and TPVB group, respectively; <I>P</I>&lt;0.0001]. The 24 h morphine consumption was also less in the PecS II block group [mean (<scp>sd</scp>), 3.90 (0.79) <I>vs</I> 5.30 (0.98) mg in PecS II and TPVB group, respectively; <I>P</I>&lt;0.0001]. Postoperative pain scores were lower in the PecS II group compared with the TVPB group in the initial 2 h after surgery [median (IQR), 2 (2&ndash;2.5) <I>vs</I> 4 (3&ndash;4) in the Pecs II and TPVB group, respectively; <I>P</I>&lt;0.0001]. Seventeen patients in the PecS II block group had T2 dermatomal spread compared with four patients in the TPVB group (<I>P</I>&lt;0.001). No block-related complication was recorded.</p> </sec> <sec><st>Conclusions</st> <p>We found that the PecS II block provided superior postoperative analgesia than the TPVB in patients undergoing modified radical mastectomy without causing any adverse effect.</p> </sec> <sec><st>Clinical trial registration</st> <p>CTRI/2014/06/004692.</p> </sec>


A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks
<sec><st>Background</st> <p>Posterior variants of abdominal wall block include the quadratus lumborum type I, quadratus lumborum type II and quadratus lumborum transmuscular blocks. Our objectives were to compare the spread of injectate and nerve involvement, after conducting blocks using ultrasound guidance in soft embalmed cadavers.</p> </sec> <sec><st>Methods</st> <p>After randomization, an experienced anaesthetist conducted three quadratus lumborum 1, three quadratus lumborum 2 and four transmuscular blocks on the left or right sides of five cadavers. All cadavers were placed in the lateral position and the quadratus lumborum muscle seen using a 3&ndash;9 MHz ultrasound probe placed in the flank. For each block, a 20 ml mixture of 17.75 ml water, 2 mls latex and 0.25 ml India ink was injected. The lumbar region and abdominal flank were dissected 72 h later.</p> </sec> <sec><st>Results</st> <p>We conducted 10 blocks. Two quadratus lumborum 1 and two quadratus lumborum 2 blocks were associated with spread of dye within the TAP plane. One quadratus lumborum 1 block spread to the deep muscles of the back and one quadratus lumborum 2 block dispersed within the subcutaneous tissue surrounding the abdominal flank. All transmuscular quadratus lumborum blocks spread consistently to L1 and L3 nerve roots and within psoas major and quadratus lumborum muscles.</p> </sec> <sec><st>Conclusions</st> <p>Consistent spread to lumbar nerve roots was achieved using the transmuscular approach through the quadratus lumborum.</p> </sec>


Stellate ganglion block increases blood flow in the anastomotic artery after superficial temporal artery-middle cerebral artery bypass


Giant pseudoaneurysm of the left ventricle


Positive end-expiratory pressure-induced increase in central venous pressure to predict fluid responsiveness: don't forget the peripheral venous circulation!


Predictive performance of passive leg raising in patients with atrial fibrillation


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Liberal transfusion strategy improves survival in perioperative but not in critically ill patients


Liberal transfusion strategy improves survival in perioperative but not in critically ill patients


Perioperative populations are not homogeneous


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Patient factors that influence cerebral desaturation during transcatheter aortic valve implantation


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Cricoid pressure force retention analysis using a simulator


Reversal by the specific antidote, idarucizumab, of elevated dabigatran exposure in a patient with rectal perforation and paralytic ileus


Does the plethysmographic variability index predict fluid responsiveness in mechanically ventilated children? A meta-analysis


Improved postoperative oxygenation after antagonism of moderate neuromuscular block with sugammadex versus neostigmine after extubation in 'blinded conditions


Physical Diagnosis of Pain: an Atlas of Signs and Symptoms


Preoperative coronary calcium score is predictive of early postoperative cardiovascular complications in liver transplant recipients


Associate Editorial Board


Cover Page


Editorial Board


General Information


Contents Page


In the August BJA ...


End-of-life in the ICU: moving from 'withdrawal of care to a palliative care, patient-centred approach


Measurement for improvement in anaesthesia and intensive care


Limitations of videolaryngoscopy


Effects of anaesthesia on paediatric lung function
<p>Respiratory adverse events are one of the major causes of morbidity and mortality in paediatric anaesthesia. Aside from predisposing conditions associated with an increased risk of respiratory incidents in children such as concurrent infections and chronic airway irritation, there are adverse respiratory events directly attributable to the impact of anaesthesia on the respiratory system. Anaesthesia can negatively affect respiratory drive, ventilation/perfusion (V/Q) matching and tidal breathing, all resulting in potentially devastating hypoxaemia. Understanding paediatric respiratory physiology and its changes during anaesthesia will enable anaesthetists to anticipate, recognize and prevent deterioration that can lead to respiratory failure. This review aims to give a comprehensive overview of the effects of anaesthesia on respiration in children. It focuses on the impact of the different components of anaesthesia, patient positioning and procedure-related changes on respiratory physiology.</p>


Acute risk change (ARC) identifies outlier institutions in perioperative cardiac surgical care when the standardized mortality ratio cannot
<sec><st>Background</st> <p>With improvements in short-term mortality after cardiac surgery, the sensitivity of the standardized mortality ratio (SMR) as a performance-monitoring tool has declined. We assessed acute risk change (ARC) as a new and potentially more sensitive metric to differentiate overall cardiac surgical unit performance.</p> </sec> <sec><st>Methods</st> <p>Retrospective analysis of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database and Australian and New Zealand Intensive Care Society Adult Patient Database was performed. The 16 656 patients who underwent coronary artery bypass grafting or cardiac valve procedures during a 4 yr period were included. The ARC was generated using the change between preoperative and postoperative probability of death. Outlier institutions were those with higher (outside 99.8% confidence intervals) ARC or SMR on annual and 4&nbsp;yr funnel plots. Outliers were grouped and compared with non-outliers for baseline characteristics, intraoperative events, and postoperative morbidity.</p> </sec> <sec><st>Results</st> <p>No outliers were identified using SMR. Two outliers were identified using ARC. Outliers had higher rates of new renal failure (5.7 <I>vs</I> 4.5%, <I>P</I>=0.017), stroke (1.6 <I>vs</I> 0.9%, <I>P</I>=0.001), reoperation (9 <I>vs</I> 6.0%, <I>P</I>&lt;0.001), and prolonged ventilation (15.3 <I>vs</I> 9.5%, <I>P</I>&lt;0.001). Outliers transfused more blood products (<I>P</I>&lt;0.001) and had longer cardiopulmonary bypass times (<I>P</I>&lt;0.001) and less senior surgeons operating (<I>P</I>&lt;0.001).</p> </sec> <sec><st>Conclusions</st> <p>Acute risk change was able to discriminate between units where SMR could not. Outliers had more adverse events. Acute risk change can be calculated before mortality outcome and identifies outliers with lower patient numbers. This may allow early recognition and investigation of outlier units.</p> </sec>


Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study
<sec><st>Background</st> <p>Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS).</p> </sec> <sec><st>Methods</st> <p>We performed a secondary analysis of a prospective international cohort study of patients aged &ge;45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds.</p> </sec> <sec><st>Results</st> <p>Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (&gt;96 beats&nbsp;min<sup>&ndash;1</sup>) was independently associated with MINS {odds ratio (OR) 1.48 [1.23&ndash;1.77]; <I>P</I>&lt;0.01}, MI (OR 1.71 [1.34&ndash;2.18]; <I>P</I>&lt;0.01), and mortality (OR 3.16 [2.45&ndash;4.07]; <I>P</I>&lt;0.01). The lowest decile (&lt;60 beats&nbsp;min<sup>&ndash;1</sup>) was independently associated with reduced mortality (OR 0.50 [0.29&ndash;0.88]; <I>P</I>=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile.</p> </sec> <sec><st>Conclusions</st> <p>Preoperative heart rate &gt;96 beats&nbsp;min<sup>&ndash;1</sup> is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT00512109.</p> </sec>


A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department
<sec><st>Background</st> <p>The 4th National Audit Project of the Royal College of Anaesthetists' and Difficult Airway Society (NAP4) made recommendations to improve reliability and safety of airway management in hospitals. This survey examines its impact.</p> </sec> <sec><st>Methods</st> <p>A survey was sent to all UK National Health Service hospitals to examine changes in practice in response to NAP4. We performed a &lsquo;gap analysis&rsquo; to determine whether NAP4 had reduced the &lsquo;safety gap&rsquo; between actual and ideal practice.</p> </sec> <sec><st>Results</st> <p>The response rate was 62% (192 of 307 hospitals), and 78% answered all questions. Most (97%) respondents reported changes in practice in response to NAP4 but these differed by specialty: 95% in anaesthesia; 80% in intensive care (ICU) and 59% in the emergency department (ED). Approximately 25% reported changes in organizational aspects of airway and human factors teaching. Practice changes led to a median closure of the &lsquo;safety gap&rsquo; in anaesthesia of 39% (IQR 14&ndash;66%, range 11&ndash;83%), 59% in ICU (IQR 54&ndash;73%, range 31&ndash;81%) and 48% in ED (IQR 39&ndash;53%, range 35&ndash;53%).</p> </sec> <sec><st>Conclusions</st> <p>Publication of NAP4 was followed by changes in practice in the majority of responding departments within two yr. Improvements included improved provision of difficult airway equipment and more widespread routine use of capnography. The biggest change occurred in ICU; the impact on training nursing and junior staff was modest and here, significant safety gaps remain.</p> </sec>


Covert stroke after non-cardiac surgery: a prospective cohort study
<sec><st>Background</st> <p>Overt stroke after non-cardiac surgery has a substantial impact on the duration and quality of life. Covert stroke in the non-surgical setting is much more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac, non-carotid artery surgery.</p> </sec> <sec><st>Methods</st> <p>We undertook a prospective, international cohort study to determine the incidence of covert stroke after non-cardiac, non-carotid artery surgery. Eligible patients were &ge;65 yr of age and were admitted to hospital for at least three nights after non-cardiac, non-carotid artery surgery. Patients underwent a brain magnetic resonance study between postoperative days 3 and 10. The main outcome was the incidence of perioperative covert stroke.</p> </sec> <sec><st>Results</st> <p>We enrolled a total of 100 patients from six centres in four countries. The incidence of perioperative covert stroke was 10.0% (10/100 patients, 95% confidence interval 5.5&ndash;17.4%). Five of the six centres that enrolled patients reported an incident covert stroke, and covert stroke was found in patients undergoing major general (3/27), major orthopaedic (3/41), major urological or gynaecological (3/22), and low-risk surgery (1/12).</p> </sec> <sec><st>Conclusions</st> <p>This international multicentre study suggests that 1 in 10 patients &ge;65 yr of age experiences a perioperative covert stroke. A larger study is required to determine the impact of perioperative covert stroke on patient-important outcomes.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT01369537.</p> </sec>


Ultrasonographic measurement of antral area for estimating gastric fluid volume in parturients
<sec><st>Background</st> <p>The aim of this prospective observational study was to assess the performance of ultrasonographic gastric antral area (GAA) to predict gastric fluid volumes of &gt;0.4, &gt;0.8 and &gt;1.5 ml kg<sup>&ndash;1</sup>, in fasted women in established labour.</p> </sec> <sec><st>Methods</st> <p>A first ultrasound examination of the antrum was performed, in order to confirm gastric vacuity by using a qualitative score. Baselines GAA measurements were obtained in both supine and right lateral decubitus positions. Thereafter, parturients were allowed to drink clear fluids only. Measurement of GAA was repeated 15 min after last fluid intake, in both supine and right lateral positions. Receiver operating characteristics (ROC) curves were constructed to determine the accuracy of GAA to diagnose ingested volumes of &gt;0.4, &gt;0.8 and &gt;1.5 ml kg<sup>&ndash;1</sup>.</p> </sec> <sec><st>Results</st> <p>Data from forty parturients were analysed. The areas under the ROC curves ranged from 80% to 86%. The cut-off value for antral area measured in supine position, to detect a volume &gt;0.4 ml kg<sup>&ndash;1</sup>, was 387 mm<sup>2</sup>, with a sensitivity of 87%, a specificity of 70% and a negative predictive value of 85%. A cut-off value of 608 mm<sup>2</sup> predicted a fluid volume &gt;1.5 ml kg<sup>&ndash;1</sup>, with a specificity of 94%, a sensitivity of 75% and a negative predictive value of 92%.</p> </sec> <sec><st>Conclusions</st> <p>This study provides cut-off values for GAA that could be used in addition to the qualitative assessment of the antrum to define a full stomach in labouring patients.</p> </sec>


Microcirculatory changes in children undergoing cardiac surgery: a prospective observational study
<sec><st>Background</st> <p>The effects of cardiac surgery on the microcirculation of children are unknown. The aim of this study was to assess the microcirculatory changes in children undergoing surgery for correction of congenital heart disease.</p> </sec> <sec><st>Methods</st> <p>We used a videomicroscope (Sidestream Dark Field, SDF) in a convenience sample of 24 children &lt;five yr old. Total vascular density (TVD, vessels mm<sup>&ndash;2</sup>), microvascular flow index (MFI, arbitrary units), proportion of perfused small vessels (PPV, percentage), and perfused vessel density (PVD) were obtained after induction of anaesthesia (T1), at the end of the surgical procedure (T2), after intensive care unit (ICU) admission (T3), and at six h (T4) and 12h (T5) after ICU admission.</p> </sec> <sec><st>Results</st> <p>Microcirculatory variables did not significantly change over time. Haemodynamic parameters and microcirculatory variables were not correlated. In a subanalysis conducted for cyanotic (<I>n</I>=7) and acyanotic (<I>n</I>=17) children, repeated measures ANOVA showed a significant interaction between time and the presence of cyanosis for PPV (<I>P</I>=0.03), TVD (<I>P</I>=0.03), and PVD (<I>P</I>=0.03). Weak inverse correlations were found between storage time of transfused red blood cell (RBCs) and MFI at T3 (<I>r</I>=&ndash;0.63, <I>P</I>=0.01) and T4 (<I>r</I>=&ndash;0.53, <I>P</I>=0.03).</p> </sec> <sec><st>Conclusions</st> <p>Microcirculatory variables have a different time-related trend in cyanotic and acyanotic children undergoing cardiac surgery. The storage time of transfused RBCs seems to negatively impact the microcirculation. Further and larger studies are warranted to prove the potential implications of this study.</p> </sec>


Cerebrospinal fluid volume in neonates undergoing spinal anaesthesia: a descriptive magnetic resonance imaging study
<sec><st>Background</st> <p>Spinal anaesthesia (SA) reduces the risk of postoperative apnoea after general anaesthesia in neonates. In 30% of patients, however, the duration of anaesthesia provided does not allow completion of surgery. When compared with term infants, formerly preterm neonates experience a shorter duration of anaesthesia after SA. A difference in the cerebrospinal fluid (CSF) volume between those two populations could explain this difference, but this has never been investigated. The study was designed to evaluate the relationship between the spinal CSF volume and patient characteristics in neonates.</p> </sec> <sec><st>Methods</st> <p>Sixty-seven neonates, aged 30&ndash;60 weeks postconception, were included in this study. Their spinal CSF volumes were calculated using magnetic resonance imaging, and these volumes were plotted individually against sex, term at birth, birth weight, current gestational age, civil age, and weight. Correlations between CSF volume and these variables were investigated.</p> </sec> <sec><st>Results</st> <p>Fifty-four neonates completed the study. The CSF volume was found to be closely and linearly correlated with weight and postconceptional age. The relationship between spinal CSF volume and weight can be described as follows: CSF volume (ml)=1.94 weight (kg)+0.13. The CSF volume was not correlated with sex, weight, or term at birth, nor with civil age.</p> </sec> <sec><st>Conclusions</st> <p>The amount of spinal CSF in neonates can be estimated as 2 ml kg<sup>&ndash;1</sup> in both term and formerly preterm neonates. A difference in the CSF volume between them does not provide an explanation for a shorter duration of SA in the latter. Our findings reinforce weight-adjusted dosage of SA in neonates.</p> </sec>


Displacement of popliteal sciatic nerve catheters after major foot and ankle surgery: a randomized controlled double-blinded magnetic resonance imaging study
<sec><st>Background</st> <p>Popliteal sciatic nerve catheters (PSNCs) are associated with a high frequency of displacement. We aimed to estimate the frequency of catheter displacement after 48 h with magnetic resonance imaging (MRI) in patients with PSNCs after major foot and ankle surgery randomized to catheter insertion either with a short-axis in-plane (SAX-IP) approach perpendicular to the nerve or with a short-axis out-of-plane (SAX-OOP) approach parallel to the nerve.</p> </sec> <sec><st>Methods</st> <p>Forty patients were randomly allocated to SAX-IP or SAX-OOP PSNC. Ropivacaine 0.75% 20 ml was injected via the catheter followed by ropivacaine 0.2% 10 ml h<sup>&ndash;</sup>1 infusion. Correct primary catheter placement was ensured after initial injection of local anaesthetic via the catheter. Forty-eight hours after insertion, MRI was performed after injection of saline with added contrast (Dotarem) via the catheter. The primary outcome was catheter displacement estimated as the frequency of spread of contrast exclusively outside the paraneurium.</p> </sec> <sec><st>Results</st> <p>All patients had correct primary catheter placement. The frequency of displacement 48 h after insertion of the PSNC was 40% when inserted perpendicular to the nerve <I>vs</I> 10% parallel to the nerve (difference was 30 percentage points, 95% CI: 3&ndash;53 percentage points). The relative risk of displacement was four times larger (95% CI: 0.8&ndash;10, <I>P</I>&lt;0.028) in the SAX-IP <I>vs</I> the SAX-OOP group. The morphine consumption was 150% greater in the SAX-IP compared with the SAX-OOP group.</p> </sec> <sec><st>Conclusion</st> <p>Popliteal sciatic nerve catheters for major foot and ankle surgery inserted with ultrasound guidance parallel to the sciatic nerve have a significantly lower frequency of displacement compared with those inserted perpendicular to the nerve.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT02200016.</p> </sec>


Perioperative assessment of regional ventilation during changing body positions and ventilation conditions by electrical impedance tomography
<sec><st>Background</st> <p>Lung-protective ventilation is claimed to be beneficial not only in critically ill patients, but also in pulmonary healthy patients undergoing general anaesthesia. We report the use of electrical impedance tomography for assessing regional changes in ventilation, during both spontaneous breathing and mechanical ventilation, in patients undergoing robot-assisted radical prostatectomy.</p> </sec> <sec><st>Methods</st> <p>We performed electrical impedance tomography measurements in 39 patients before induction of anaesthesia in the sitting (M1) and supine position (M2), after the start of mechanical ventilation (M3), during capnoperitoneum and Trendelenburg positioning (M4), and finally, in the supine position after release of capnoperitoneum (M5). To quantify regional changes in lung ventilation, we calculated the centre of ventilation and &lsquo;silent spaces&rsquo; in the ventral and dorsal lung regions that did not show major impedance changes.</p> </sec> <sec><st>Results</st> <p>Compared with the awake supine position [2.3% (2.3)], anaesthesia and mechanical ventilation induced a significant increase in silent spaces in the dorsal dependent lung [9.2% (6.3); <I>P</I>&lt;0.05]. Capnoperitoneum and the Trendelenburg position led to a significant increase in such spaces [11.5% (8.9)]. Silent space in the ventral lung remained constant throughout anaesthesia.</p> </sec> <sec><st>Conclusion</st> <p>Electrical impedance tomography was able to identify and quantify on a breath-by-breath basis circumscribed areas, so-called silent spaces, within healthy lungs that received little or no ventilation during general anaesthesia, capnoperitoneum, and different body positions. As these silent spaces are suggestive of atelectasis on the one hand and overdistension on the other, they might become useful to guide individualized protective ventilation strategies to mitigate the side-effects of anaesthesia and surgery on the lungs.</p> </sec>


Surgicric 2: A comparative bench study with two established emergency cricothyroidotomy techniques in a porcine model
<sec><st>Background</st> <p>&lsquo;Can't Intubate, Can't Oxygenate&rsquo; is a rare but life threatening event. Anaesthetists must be trained and have appropriate equipment available for this. The ideal equipment is a topic of ongoing debate. To date cricothyroidotomy training for anaesthetists has concentrated on cannula techniques. However cases reported to the NAP4 audit illustrated that they were associated with a high failure rate. A recent editorial by Kristensen and colleagues suggested all anaesthetists must master a surgical technique. The surgical technique for cricothyroidotomy has been endorsed as the primary technique by the recent Difficult Airway Society 2015 guidelines.</p> </sec> <sec><st>Methods</st> <p>We conducted a bench study comparing the updated Surgicric 2 device with a scalpel-bougie-tube surgical technique, and the Melker seldinger technique, using a porcine model. Twenty six senior anaesthetists (ST5+) participated. The primary outcome was insertion time. Secondary outcomes included success rate, ease of use, device preference and tracheal trauma.</p> </sec> <sec><st>Results</st> <p>There was a significant difference (<I>P</I>&lt;0.001) in the overall comparisons of the insertion times. The surgical technique had the fastest median time of 62 s. The surgical and Surgicric techniques were significantly faster to perform than the Melker (both <I>P</I>&lt;0.001). The surgical technique had a success rate of 85% at first attempt, and 100% within two attempts, whereas the others had failed attempts. The surgical technique was ranked first by 50% participants and had the lowest grade of posterior tracheal wall trauma, significantly less than the Surgicric 2 (<I>P</I>=0.002).</p> </sec> <sec><st>Conclusions</st> <p>This study supports training in and the use of surgical cricothyroidotomy by anaesthetists.</p> </sec>


An appropriate inspiratory flow pattern can enhance CO2 exchange, facilitating protective ventilation of healthy lungs
<sec><st>Background</st> <p>In acute lung injury, CO<SUB>2</SUB> exchange is enhanced by prolonging the volume-weighted mean time for fresh gas to mix with resident alveolar gas, denoted mean distribution time (MDT), and by increasing the flow rate immediately before inspiratory flow interruption, end-inspiratory flow (EIF). The objective was to study these effects in human subjects without lung disease and to analyse the results with respect to lung-protective ventilation of healthy lungs.</p> </sec> <sec><st>Methods</st> <p>During preparation for intracranial surgery, the lungs of eight subjects were ventilated with a computer-controlled ventilator, allowing breath-by-breath modification of the inspiratory flow pattern. The durations of inspiration (<I>T</I><SUB>I</SUB>) and postinspiratory pause (<I>T</I><SUB>P</SUB>) were modified, as was the profile of the inspiratory flow wave (i.e. constant, increasing, or decreasing). The single-breath test for CO<SUB>2</SUB> was used to quantify airway dead space (<I>V</I><SUB>Daw</SUB>) and CO<SUB>2</SUB> exchange.</p> </sec> <sec><st>Results</st> <p>A long MDT and a high EIF augment CO<SUB>2</SUB> elimination by reducing <I>V</I><SUB>Daw</SUB> and promoting mixing of tidal gas with resident alveolar gas. A heat and moisture exchanger had no other effect than enlarging <I>V</I><SUB>Daw</SUB>. A change of <I>T</I><SUB>I</SUB> from 33 to 15% and of <I>T</I><SUB>P</SUB> from 10 to 28%, leaving the time for expiration unchanged, would augment tidal elimination of CO<SUB>2</SUB> by 14%, allowing a 10% lower tidal volume.</p> </sec> <sec><st>Conclusions</st> <p>In anaesthetized human subjects without lung disease, CO<SUB>2</SUB> exchange is enhanced by a long MDT and a high EIF. A short <I>T</I><SUB>I</SUB> and a long <I>T</I><SUB>P</SUB> allow significant reduction of tidal volume when lung-protective ventilation is required.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT01686984.</p> </sec>


Phorbol-12-myristate-13-acetate induces nociceptin in human Mono Mac 6 cells via multiple transduction signalling pathways
<sec><st>Background</st> <p>Nociceptin in the peripheral circulation has been proposed to have an immunoregulatory role with regards to inflammation and pain. However, the mechanisms involved in its regulation are still not clear. The aim of this study was to investigate signalling pathways contributing to the regulation of the expression of nociceptin under inflammatory conditions.</p> </sec> <sec><st>Methods</st> <p>Mono Mac 6 cells (MM6) were cultured with or without phorbol-12-myristate-13-acetate (PMA). Prepronociceptin (ppNOC) mRNA was detected by RT-qPCR and extracellular nociceptin by fluorescent-enzyme immunoassay. Intracellular nociceptin and phosphorylated kinases were measured using flow cytometry. To evaluate the contribution of various signalling pathways to the regulation of ppNOC mRNA and nociceptin protein, cells were pre-treated with specific kinase inhibitors before co-culturing with PMA.</p> </sec> <sec><st>Results</st> <p>ppNOC mRNA was expressed in untreated MM6 at low concentrations. Exposure of cells to PMA upregulated ppNOC after nine h compared with controls without PMA (median normalized ratio with IQR: 0.18 (0.15&ndash;0.26) vs. 0 (0&ndash;0.02), <I>P</I>&lt;0.01). Inhibition of mitogen-activated protein kinases specific for signal transduction reversed the PMA effects (all <I>P</I>&lt;0.001). Induction of nociceptin protein concentrations in PMA stimulated MM6 was prevented predominantly by identity of ERK inhibitor (<I>P</I>&lt;0.05).</p> </sec> <sec><st>Conclusions</st> <p>Upregulation of nociceptin expression by PMA in MM6 cells involves several pathways. Underlying mechanisms involved in nociceptin expression may lead to new insights in the treatment of pain and inflammatory diseases.</p> </sec>


Association of intraoperative arterial blood pressure lability with postoperative adverse outcome: no one size fits all


Response


Impairment of innate immune function by hydroxyethyl starch


Programmes, guidelines, and protocols: the antithesis of precision medicine?


Heterogeneous population


Reply: heterogeneous population


Dexmedetomidine: a valuable sedative currently not widely available in the UK


Restoration to normal physiology without the use of excessive fluids


Ketamine: a 'One Health issue for us all


Ketamine: a positive-negative anaesthetic agent


Simultaneous measurement of mean arterial pressure with reference to both the phlebostatic axis and middle cranial fossa in the calculation of cerebral perfusion pressure


Fentanyl-induced cough is a risk factor for postoperative nausea and vomiting


Effect of positive end-expiratory pressure on pulmonary shunt and dynamic compliance during abdominal surgery


Editorial Advisory Board


Cover Page


Editorial Board


Subscription Page


Contents Page


In the June BJA ...


Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?


Skeletal muscle and plasma concentrations of cefazolin


Need to consider human factors when determining first-line technique for emergency front-of-neck access


In support of 'usual perioperative care


Value of knowing physical characteristics of the airway device before using it


Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review
<sec> <p>The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials.</p> </sec> <sec><st>Clinical trial registration</st> <p>This systematic review was registered in the international prospective register of systematic reviews. PROSPERO: CRD42015019817.</p> </sec>


Randomized evaluation of fibrinogen vs placebo in complex cardiovascular surgery (REPLACE): a double-blind phase III study of haemostatic therapy
<sec><st>Background</st> <p>Single-dose human fibrinogen concentrate (FCH) might have haemostatic benefits in complex cardiovascular surgery.</p> </sec> <sec><st>Methods</st> <p>Patients undergoing elective aortic surgery requiring cardiopulmonary bypass were randomly assigned to receive FCH or placebo. Study medication was administered to patients with a 5 min bleeding mass of 60&ndash;250 g after separation from bypass and surgical haemostasis. A standardized algorithm for allogeneic blood product transfusion was followed if bleeding continued after study medication.</p> </sec> <sec><st>Results</st> <p>519 patients from 34 centres were randomized, of whom 152 (29%) met inclusion criteria for study medication. Median (IQR) pretreatment 5 min bleeding mass was 107 (76&ndash;138) and 91 (71&ndash;112) g in the FCH and placebo groups, respectively (<I>P</I>=0.13). More allogeneic blood product units were administered during the first 24 h after FCH, 5.0 (2.0&ndash;11.0), when compared with placebo, 3.0 (0.0&ndash;7.0), <I>P</I>=0.026. Fewer patients avoided transfusion in the FCH group (15.4%) compared with placebo (28.4%), <I>P</I>=0.047. The FCH immediately increased plasma fibrinogen concentration and fibrin-based clot strength. Adverse event rates were comparable in each group.</p> </sec> <sec><st>Conclusions</st> <p>Human fibrinogen concentrate was associated with increased allogeneic blood product transfusion, an unexpected finding contrary to previous studies. Human fibrinogen concentrate may not be effective in this setting when administered according to 5-minute bleeding mass. Low bleeding rates and normal-range plasma fibrinogen concentrations before study medication, and variability in adherence to the complex transfusion algorithm, may have contributed to these results.</p> </sec> <sec><st>Clinical trial registration</st> <p>ClinicalTrials.gov identifier no. NCT01475669; EudraCT trial no. 2011-002685-20.</p> </sec>


Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery
<sec><st>Background</st> <p>The impact of levosimendan treatment on clinical outcome in patients undergoing extracorporeal membrane oxygenation (ECMO) support after cardiovascular surgery is unknown. We hypothesized that the beneficial effects of levosimendan might improve survival when adequate end-organ perfusion is ensured by concomitant ECMO therapy. We therefore studied the impact of levosimendan treatment on survival and failure of ECMO weaning in patients after cardiovascular surgery.</p> </sec> <sec><st>Methods</st> <p>We enrolled a total of 240 patients undergoing veno-arterial ECMO therapy after cardiovascular surgery at a university-affiliated tertiary care centre into our observational single-centre registry.</p> </sec> <sec><st>Results</st> <p>During a median follow-up period of 37 months (interquartile range 19&ndash;67 months), 65% of patients died. Seventy-five per cent of patients received levosimendan treatment within the first 24 h after initiation of ECMO therapy. Cox regression analysis showed an association between levosimendan treatment and successful ECMO weaning [adjusted hazard ratio (HR) 0.41; 95% confience interval (CI) 0.22&ndash;0.80; <I>P</I>=0.008], 30 day mortality (adjusted HR 0.52; 95% CI 0.30&ndash;0.89; <I>P</I>=0.016), and long-term mortality (adjusted HR 0.64; 95% CI 0.42&ndash;0.98; <I>P</I>=0.04).</p> </sec> <sec><st>Conclusions</st> <p>These data suggest an association between levosimendan treatment and improved short- and long-term survival in patients undergoing ECMO support after cardiovascular surgery.</p> </sec>


Influence of variations in arterial PCO2 on surgical conditions during laparoscopic retroperitoneal surgery
<sec><st>Background</st> <p>Although deep neuromuscular block (post-tetanic-count 1-2 twitches) improves surgical conditions during laparoscopic retroperitoneal surgery compared with standard block (train-of-four 1-2 twitches), the quality of surgical conditions varies widely, often related to diaphragmatic contractions. Hypocapnia may improve surgical conditions. Therefore we studied the effect of changes in arterial carbon dioxide concentrations on surgical conditions in patients undergoing laparoscopic surgery under general anaesthesia and deep neuromuscular block.</p> </sec> <sec><st>Methods</st> <p>Forty patients undergoing elective laparoscopic surgery for prostatectomy or nephrectomy received propofol/remifentanil anaesthesia and deep neuromuscular block with rocuronium. Patients were randomized to surgery under hypocapnic or hypercapnic conditions. During surgery, the surgical conditions were evaluated using the 5-point Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor conditions) to 5 (optimal conditions) by the surgeon, who was blinded to group.</p> </sec> <sec><st>Results</st> <p>Mean (<scp>sd</scp>) arterial carbon dioxide concentrations were 4.5 (0.6) [range: 3.8&ndash;5.6] kPa under hypocapnic and 6.9 (0.6) [6.1&ndash;8.1] kPa under hypercapnic conditions. The L-SRS did not differ between groups: 4.84 (0.4) [4-5] in hypocapnia and 4.77 (0.4) [3.9&ndash;5] in hypercapnia. Ninety-nine percent of ratings were good or excellent irrespective of treatment.</p> </sec> <sec><st>Conclusions</st> <p>Deep neuromuscular block provides good to optimal surgical conditions in laparoscopic retroperitoneal urological surgery, independent of the level of arterial <f>PCO2</f>.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT01968447.</p> </sec>


Compliance with an empirical antimicrobial protocol improves the outcome of complicated intra-abdominal infections: a prospective observational study
<sec><st>Background</st> <p>Despite improvements in medical and surgical care, mortality attributed to complicated intra-abdominal infections (cIAI) remains high. Appropriate initial antimicrobial therapy (ABT) is key to successful management. The main causes of non-compliance with empirical protocols have not been clearly described.</p> </sec> <sec><st>Methods</st> <p>An empirical ABT protocol was designed according to guidelines, validated in the institution and widely disseminated. All patients with cIAI (2009&ndash;2011) were then prospectively studied to evaluate compliance with this protocol and its impact on outcome. Patients were classified into two groups according to whether or not they received ABT in compliance with the protocol.</p> </sec> <sec><st>Results</st> <p>310 patients were included: 223 (71.9%) with community-acquired and 87 (28.1%) with healthcare-associated cIAI [mean age 60(17&ndash;97) yr, mean SAPS II score 24(16)]. Empirical ABT complied with the protocol in 52.3% of patients. The appropriateness of empirical ABT to target the bacteria isolated was 80%. Independent factors associated with non-compliance with the protocol were the anaesthetist's age &ge;36 yr [OR 2.1; 95%CI (1.3&ndash;3.4)] and the presence of risk factors for multidrug-resistant bacteria (MDRB) [OR 5.4; 95%CI (3.0&ndash;9.5)]. Non-compliance with the protocol was associated with higher mortality (14.9 <I>vs</I> 5.6%, <I>P</I>=0.011) and morbidity: relaparotomy (<I>P</I>=0.047), haemodynamic failure (<I>P</I>=0.001), postoperative pneumonia (<I>P</I>=0.025), longer duration of mechanical ventilation (<I>P</I>&lt;0.001), longer ICU stay (<I>P</I>&lt;0.001) and longer hospital stay (<I>P</I>=0.002). On multivariate logistic regression analysis, non-compliance with the ABT protocol was independently associated with mortality [OR 2.4; 95% CI (1.1&ndash;5.7), <I>P</I>=0.04].</p> </sec> <sec><st>Conclusions</st> <p>Non-compliance with empirical ABT guidelines in cIAI is associated with increased morbidity and mortality. Information campaigns should target older anaesthetists and risk factors for MDRB.</p> </sec>


Sumatriptan improves postoperative quality of recovery and reduces postcraniotomy headache after cranial nerve decompression
<sec><st>Background</st> <p>Microvascular decompression (MVD) is a surgical treatment for cranial nerve disorders via a small craniotomy. The postoperative pain of this procedure can be classified as surgical site somatic pain and postcraniotomy headache similar in nature to a migraine, including its association with photophobia, nausea, and vomiting. This headache can be difficult to treat and can impact on postoperative recovery. Sumatriptan is used to treat migraine-like headaches in various settings. This single-centre randomized controlled trial investigated whether postoperative administration of sumatriptan after MVD surgery impacts the quality of postoperative recovery.</p> </sec> <sec><st>Methods</st> <p>Fifty patients who complained of postoperative headache after MVD were randomized to receive an s.c. injection of sumatriptan (6 mg) or saline. The primary outcome was quality of recovery as measured by the Quality of Recovery-40 (QoR-40) score at 24 h.</p> </sec> <sec><st>Results</st> <p>The QoR-40 scores were significantly higher in the sumatriptan group (median 184; interquartile range 169&ndash;196) than in the placebo group (133; 119&ndash;155; <I>P</I>&lt;0.01), suggesting higher quality of recovery. The sumatriptan group also had significantly lower headache scores at 4, 12, and 24 h. There were no significant differences in other secondary outcomes.</p> </sec> <sec><st>Conclusions</st> <p>Use of sumatriptan improved the quality of recovery as measured by the QoR-40 and reduction of headache at 24 h after surgery. Sumatriptan is a useful alternative treatment for postcraniotomy headache. The mechanism remains unknown but could be related to reduction in headache, mood modulation, or both, mediated by a serotonin effect.</p> </sec> <sec><st>Clinical trial registration</st> <p>NCT01632657.</p> </sec>


Inhibiting NADPH oxidase protects against long-term memory impairment induced by neonatal sevoflurane exposure in mice
<sec><st>Background</st> <p>Neonatal exposure to anaesthetics such as sevoflurane has been reported to result in behavioural deficits in rodents. However, while oxidative injury is thought to play an underlying pathological role, the mechanisms of neurotoxicity remain unclear. In the present study, we investigated whether the NADPH oxidase inhibitor apocynin protects against long-term memory impairment produced by neonatal sevoflurane exposure in mice.</p> </sec> <sec><st>Methods</st> <p>Postnatal day six mice were divided into four groups; (1) non-anaesthesia, (2) intraperitoneal apocynin (50 mg kg<sup>&ndash;1</sup>) treatment, (3) 3% sevoflurane exposure for 6 h, and (4) apocynin treatment combined with sevoflurane exposure. Superoxide concentrations and NADPH oxidase expression in the brain were determined using dihydroethidium fluorescence and immunoblotting, respectively. Cleaved caspase-3 immunoblotting was used for the detection of apoptosis, and cytochrome c immunoblotting was performed to evaluate mitochondrial function. Long-term cognitive impairment was evaluated using the fear conditioning test in adulthood.</p> </sec> <sec><st>Results</st> <p>Sevoflurane exposure increased concentrations of superoxide (109%) and the NADPH oxidase subunit p22phox (39%) in the brain, and apocynin abolished these increases. Neonatal sevoflurane exposure caused learning deficits in adulthood. Apocynin also maintained long-term memory function in mice given neonatal sevoflurane exposure, and it reduced apoptosis and decreased cytochrome c concentrations in the brains of these mice.</p> </sec> <sec><st>Conclusions</st> <p>Apocynin reduces neuronal apoptosis and protects against long-term memory impairment in mice, neonatally exposed to sevoflurane by reducing superoxide concentrations. These findings suggest that NADPH oxidase inhibitors may protect against cognitive dysfunction resulting from neonatal anaesthesia.</p> </sec>


Skeletal muscle and plasma concentrations of cefazolin during complex paediatric spinal surgery
<sec><st>Background</st> <p>Surgical site infections (SSIs) can have devastating consequences for children who undergo spinal instrumentation. Prospective evaluations of prophylactic cefazolin in this population are limited. The purpose of this study was to describe the pharmacokinetics and skeletal muscle disposition of prophylactic cefazolin in a paediatric population undergoing complex spinal surgery.</p> </sec> <sec><st>Methods</st> <p>This prospective pharmacokinetic study included 17 children with adolescent idiopathic scoliosis undergoing posterior spinal fusion, with a median age of 13.8 [interquartile range (IQR) 13.4&ndash;15.4] yr and a median weight of 60.6 (IQR 50.8&ndash;66.0) kg. A dosing strategy consistent with published guidelines was used. Serial plasma and skeletal muscle microdialysis samples were obtained during the operative procedure and unbound cefazolin concentrations measured. Non-compartmental pharmacokinetic analyses were performed. The amount of time that the concentration of unbound cefazolin exceeded the minimal inhibitory concentration for bacterial growth for selected SSI pathogens was calculated.</p> </sec> <sec><st>Results</st> <p>Skeletal muscle concentrations peaked at a median of 37.6 (IQR 26.8&ndash;40.0) &micro;g ml<sup>&ndash;1</sup> within 30&ndash;60 min after the first cefazolin 30 mg kg<sup>&ndash;1</sup> dose. For patients who received a second 30 mg kg<sup>&ndash;1</sup> dose, the peak concentrations reached a median of 40.5 (IQR 30.8&ndash;45.7) &micro;g ml<sup>&ndash;1</sup> within 30&ndash;60 min. The target cefazolin concentrations for SSI prophylaxis for meticillin-sensitive <I>Staphylococcus aureus</I> (MSSA) and Gram-negative pathogens were exceeded in skeletal muscle 98.9 and 58.3% of the intraoperative time, respectively.</p> </sec> <sec><st>Conclusions</st> <p>For children with adolescent idiopathic scoliosis undergoing posterior spinal fusion, the cefazolin dosing strategy used in this study resulted in skeletal muscle concentrations that were likely not to be effective for intraoperative SSI prophylaxis against Gram-negative pathogens.</p> </sec>


Introduction of a paediatric anaesthesia comic information leaflet reduced preoperative anxiety in children
<sec><st>Background</st> <p>The aim of the study was to determine whether the introduction of a paediatric anaesthesia comic information leaflet reduced preoperative anxiety levels of children undergoing major surgery. Secondary objectives were to determine whether the level of understanding of participants and other risk factors influence STAIC-S (State&ndash;Trait Anxiety Inventory for Children&mdash;State subscale) score in children.</p> </sec> <sec><st>Methods</st> <p>We performed a randomized controlled parallel-group trial comparing preoperative anxiety between two groups of children aged &gt;6 and &lt;17 yr. Before surgery, the intervention group received a comic information leaflet at home in addition to routine information given by the anaesthetist at least 1 day before surgery. The control group received the routine information only. The outcome measure was the difference between STAIC-S scores measured before any intervention and after the anaesthetist's visit. A multiple regression analysis was performed to explore the influence of the level of education, the anxiety of parents, and the childrens' intelligence quotient on STAIC-S scores.</p> </sec> <sec><st>Results</st> <p>One hundred and fifteen children were randomized between April 2009 and April 2013. An intention-to-treat analysis on data from 111 patients showed a significant reduction (<I>P</I>=0.002) in STAIC-S in the intervention group (<I>n</I>=54, mean=&ndash;2.2) compared with the control group (<I>n</I>=57, mean=0.90). The multiple regression analysis did not show any influence on STAIC-S scores of the level of education, parental anxiety, or the intelligence quotient of the children.</p> </sec> <sec><st>Conclusions</st> <p>A paediatric anaesthesia comic information leaflet was a cheap and effective means of reducing preoperative anxiety, measured by STAIC-S, in children.</p> </sec> <sec><st>Clinical trials registration</st> <p>NCT 00841022.</p> </sec>


Team-based model for non-operating room airway management: validation using a simulation-based study
<sec><st>Background</st> <p>Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone <I>vs</I> with a resident partner when encountering simulated non-OR airway management scenarios.</p> </sec> <sec><st>Methods</st> <p>Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group).</p> </sec> <sec><st>Results</st> <p>Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 <I>vs</I> 5.5 out of 10; <I>P</I>&lt;0.001) and PEA (8.5 <I>vs</I> 5.8 out of 10; <I>P</I>&lt;0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 <I>vs</I> 23.5 s (<I>P</I>&lt;0.001) and 13.3 <I>vs</I> 36.0 s (<I>P</I>&lt;0.001), respectively].</p> </sec> <sec><st>Conclusions</st> <p>Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.</p> </sec>


Capnogram slope and ventilation dead space parameters: comparison of mainstream and sidestream techniques
<sec><st>Background</st> <p>Capnography may provide useful non-invasive bedside information concerning heterogeneity in lung ventilation, ventilation&ndash;perfusion mismatching and metabolic status. Although the capnogram may be recorded by mainstream and sidestream techniques, the capnogram indices furnished by these approaches have not previously been compared systematically.</p> </sec> <sec><st>Methods</st> <p>Simultaneous mainstream and sidestream time and volumetric capnography was performed in anaesthetized, mechanically ventilated patients undergoing elective heart surgery. Time capnography was used to assess the phase II (<I>S</I><SUB>II,T</SUB>) and III slopes (<I>S</I><SUB>III,T</SUB>). The volumetric method was applied to estimate phase II (<I>S</I><SUB>II,V</SUB>) and III slopes (<I>S</I><SUB>III,V</SUB>), together with the dead space values according to the Fowler (<I>V</I><SUB>DF</SUB>), Bohr (<I>V</I><SUB>DB</SUB>), and Enghoff (<I>V</I><SUB>DE</SUB>) methods and the volume of CO<SUB>2</SUB> eliminated per breath (<f>VCO2</f>). The partial pressure of end-tidal CO<SUB>2</SUB> (<f>PETCO2</f>) was registered.</p> </sec> <sec><st>Results</st> <p>Excellent correlation and good agreement were observed in <I>S</I><SUB>III,T</SUB> measured by the mainstream and sidestream techniques [ratio=1.05 (<scp>sem</scp> 0.16), <I>R</I><sup>2</sup>=0.92, <I>P</I>&lt;0.0001]. Although the sidestream technique significantly underestimated <f>VCO2</f> and overestimated <I>S</I><SUB>III,V</SUB> [1.32 (0.28), <I>R</I><sup>2</sup>=0.93, <I>P</I>&lt;0.0001], <I>V</I><SUB>DF</SUB>, <I>V</I><SUB>DB</SUB>, and <I>V</I><SUB>DE</SUB>, the agreement between the mainstream and sidestream techniques in the difference between <I>V</I><SUB>DE</SUB> and <I>V</I><SUB>DB</SUB>, reflecting the intrapulmonary shunt, was excellent [0.97 (0.004), <I>R</I><sup>2</sup>=0.92, <I>P</I>&lt;0.0001]. The <f>PETCO2</f> exhibited good correlation and mild differences between the mainstream and sidestream approaches [0.025 (0.005) kPa].</p> </sec> <sec><st>Conclusions</st> <p>Sidestream capnography provides adequate quantitative bedside information about uneven alveolar emptying and ventilation&ndash;perfusion mismatching, because it allows reliable assessments of the phase III slope, <f>PETCO2</f> and intrapulmonary shunt. Reliable measurement of volumetric parameters (phase II slope, dead spaces, and eliminated CO<SUB>2</SUB> volumes) requires the application of a mainstream device.</p> </sec>


Predictors of difficult videolaryngoscopy with GlideScope(R) or C-MAC(R) with D-blade: secondary analysis from a large comparative videolaryngoscopy trial
<sec><st>Background</st> <p>Tracheal intubation using acute-angle videolaryngoscopy achieves high success rates, but is not without difficulty. We aimed to determine predictors of &lsquo;difficult videolaryngoscopy&rsquo;.</p> </sec> <sec><st>Methods</st> <p>We performed a secondary analysis of a data set (<I>n</I>=1100) gathered from a multicentre prospective randomized controlled trial of patients for whom difficult direct laryngoscopy was anticipated and who were intubated with one of two videolaryngoscopy devices (GlideScope<sup>&reg;</sup> or C-MAC<sup>&reg;</sup> with D-blade). &lsquo;Difficult videolaryngoscopy&rsquo; was defined as &lsquo;first intubation time &gt;60 s&rsquo; or &lsquo;first attempt intubation failure&rsquo;. A multivariate logistic regression model along with stepwise model selection techniques was performed to determine independent predictors of difficult videolaryngoscopy.</p> </sec> <sec><st>Results</st> <p>Of 1100 patients, 301 were identified as difficult videolaryngoscopies. By univariate analysis, head and neck position, provider, type of surgery, and mouth opening were associated with difficult videolaryngoscopy (<I>P</I>&lt;0.05). According to the multivariate logistic regression model, characteristics associated with greater risk for difficult videolaryngoscopy were as follows: (i) head and neck position of &lsquo;supine sniffing&rsquo; <I>vs</I> &lsquo;supine neutral&rsquo; {odds ratio (OR) 1.63, 95% confidence interval (CI) [1.14, 2.31]}; (ii) undergoing otolaryngologic or cardiac surgery <I>vs</I> general surgery (OR 1.89, 95% CI [1.19, 3.01] and OR 6.13, 95% CI [1.85, 20.37], respectively); (iii) intubation performed by an attending anaesthestist <I>vs</I> a supervised resident (OR 1.83, 95% CI [1.14, 2.92]); and (iv) small mouth opening (OR 1.18, 95% CI [1.02, 1.36]).</p> </sec> <sec><st>Conclusion</st> <p>This secondary analysis of an existing data set indicates four covariates associated with difficult acute-angle videolaryngoscopy, of which patient position and provider level are modifiable.</p> </sec>


Comparison of pathogenicity prediction tools on missense variants in RYR1 and CACNA1S associated with malignant hyperthermia
<sec><st>Background</st> <p>Malignant hyperthermia (MH) is a pharmacogenetic disorder that has been linked to the skeletal muscle calcium release channel (<I>RYR1</I>) and the &alpha;1S subunit of the voltage-dependent L-type calcium channel (<I>CACNA1S</I>). Genomic DNA capture and next generation sequencing are becoming the preferred method to identify mutations in these genes. Bioinformatic pathogenicity prediction of identified variants may help to determine if these variants are in fact disease causing.</p> </sec> <sec><st>Methods</st> <p>Eight pathogenicity prediction programmes freely available on the web were used to determine their ability to correctly predict the impact of a missense variant on RyR1 or dihydropyridine receptor (DHPR) protein function. We tested MH-causative variants, variants that had been shown to alter calcium release in cells, and common sequence variants in <I>RYR1</I> and <I>CACNA1S</I>.</p> </sec> <sec><st>Results</st> <p>None of the prediction programmes was able to identify all of the variants tested correctly as either &lsquo;damaging&rsquo; (MH-causative variants, variants that had been shown to alter calcium release in cells) or as &lsquo;benign&rsquo; (common sequence variants). The overall sensitivity of predictions ranged from 84% to 100% depending on the programme used, with specificity from 25% to 83%.</p> </sec> <sec><st>Conclusions</st> <p>In this study we determined the sensitivity and specificity of bioinformatic pathogenicity prediction tools for <I>RYR1</I> and <I>CACNA1S</I>. We suggest that the prediction results should be treated with caution, as none of the programmes tested predicted all the variants correctly and should only be used in combination with other available data (functional assays, segregation analysis).</p> </sec>


Continuous non-invasive cardiac output monitoring during exercise: validation of electrical cardiometry with Fick and thermodilution methods


Effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid haemorrhage


Comparison of high and low pillow heights for tracheal tube intubation with the Pentax-AWS Airwayscope(R): a prospective randomized clinical trial


Anticipating guidelines for ultrasound-guided arterial catheterization


Relationship between bioreactance and magnetic resonance imaging stroke volumes


A further plea for a unified classification of supraglottic (extraglottic) airway devices


A new view of safety: Safety 2


Increasing opportunities for intubation training for foundation doctors


Achieving both patient safety and developing trainees' airway skills


CUMSUM cannot define competency


Reply


Feasibility study questions


A randomized feasibility study to assess a novel strategy to rationalize fluid in patients after cardiac surgery


Ultrasound-Guided Regional Anesthesia in Children (A Practical Guide)