An evaluation of the relative efficacy of an open airway, an oxygen reservoir and continuous positive airway pressure 5 cmH2O on the non-ventilated lung

Publisher's copy made available with the permission of the publisher © Australian Society of AnaesthetistsThe aim of this study, during one-lung ventilation, was to evaluate if oxygenation could be improved by use of a simple oxygen reservoir or application of 5 cmH2O continuous positive airway pressure (CPAP) to the non-ventilated lung compared with an open airway. Twenty-three patients with lung malignancy, undergoing thoracotomy requiring at least 60 minutes of one-lung ventilation before lung lobe excision, were studied. After routine induction and establishment of one-lung ventilation, the three treatments were applied in turn to the same patient in a sequence selected randomly. The first treatment was repeated as a fourth treatment and these results of the repeated treatment averaged to minimize the effect of slow changes. Arterial oxygenation was measured by an arterial blood gas 15 minutes after the application of each treatment. Twenty patients completed the study. Mean PaO2 (in mmHg) was 210.3 (SD 105.5) in the 'OPEN' treatment, 186.0 (SD 109.2) in the 'RESERVOIR' treatment, and 240.5 (SD 116.0) in the 'CPAP' treatment. This overall difference was not quite significant (P=0.058, paired ANOVA), but comparison of the pairs showed that there was a significant better oxygenation only with the CPAP compared to the reservoir treatments (t=2.52, P=0.021). While the effect on the surgical field was not apparent in most patients, in one patient surgery was impeded during CPAP. Our results show that the use of a reservoir does not give oxygenation better than an open tube, and is less effective than the use of CPAP 5 cmH2O on the non-ventilated lung during one-lung ventilation.J. Slimani, W. J. Russell, C. Jurisevichttp://www.aaic.net.au/Article.asp?D=200404

Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature.

Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management

Recurrent chest infections in two young non-smoker men

Pulmonary mucinous cystic carcinomas are rare salivary gland type carcinomas of the lung. They form part of a wide spectrum of mucin secreting glandular mixed type tumours. They comprise 0.1 – 0.2% of all lung tumours. They occur more frequently in young patients and present with cough or recurrent chest infections and therefore may be easily misdiagnosed. Since treatment depends fully on complete surgical resection early diagnosis is essential. Even with treatment the 10-year survival is quoted at 53%. We describe two cases of such rare tumours both of who underwent curative surgical resection. Both patients were younger than 35 years old and presented with recurrent chest infections. The patients were followed for up to eight years and the outcome recorded. A literature search confirms the occurrence in younger patients, who often present with pneumonias and that surgery is the only hope for cure.peer-reviewe

Recommendations for the management of MPS IVA: systematic evidence- and consensus-based guidance.

IntroductionMucopolysaccharidosis (MPS) IVA or Morquio A syndrome is an autosomal recessive lysosomal storage disorder (LSD) caused by deficiency of the N-acetylgalactosamine-6-sulfatase (GALNS) enzyme, which impairs lysosomal degradation of keratan sulphate and chondroitin-6-sulphate. The multiple clinical manifestations of MPS IVA present numerous challenges for management and necessitate the need for individualised treatment. Although treatment guidelines are available, the methodology used to develop this guidance has come under increased scrutiny. This programme was conducted to provide evidence-based, expert-agreed recommendations to optimise management of MPS IVA.MethodsTwenty six international healthcare professionals across multiple disciplines, with expertise in managing MPS IVA, and three patient advocates formed the Steering Committee (SC) and contributed to the development of this guidance. Representatives from six Patient Advocacy Groups (PAGs) were interviewed to gain insights on patient perspectives. A modified-Delphi methodology was used to demonstrate consensus among a wider group of healthcare professionals with experience managing patients with MPS IVA and the manuscript was evaluated against the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument by three independent reviewers.ResultsA total of 87 guidance statements were developed covering five domains: (1) general management principles; (2) recommended routine monitoring and assessments; (3) disease-modifying interventions (enzyme replacement therapy [ERT] and haematopoietic stem cell transplantation [HSCT]); (4) interventions to support respiratory and sleep disorders; (5) anaesthetics and surgical interventions (including spinal, limb, ophthalmic, cardio-thoracic and ear-nose-throat [ENT] surgeries). Consensus was reached on all statements after two rounds of voting. The overall guideline AGREE II assessment score obtained for the development of the guidance was 5.3/7 (where 1 represents the lowest quality and 7 represents the highest quality of guidance).ConclusionThis manuscript provides evidence- and consensus-based recommendations for the management of patients with MPS IVA and is for use by healthcare professionals that manage the holistic care of patients with the intention to improve clinical- and patient-reported outcomes and enhance patient quality of life. It is recognised that the guidance provided represents a point in time and further research is required to address current knowledge and evidence gaps

Increasing Effectiveness of the Surgical Airway Response System: Introduction of the Otolaryngology Airway Pager, Quality Improvement Project of the PGY-2 Class

Introduction: The need for an Otolaryngology airway pager is based on several external and internal factors. The current communication pathway for emergent airways at our institution is well established but often misinterpreted. The protocol is outlined in Figure 1. The priority to reach out to other departments is based on their availability of an attending in house overnight. Furthermore, there is often a delay in contacting the Otolaryngology department. Our service has multiple pagers to accommodate for each of our inpatient teams, which can be confusing for other services. One of the driving events for this project was an incident at JHN where a tracheostomy tube became dislodged. There were several attempts to contact our team through the wrong pager and by the time we were notified the patient had expired. In addition our personal cell phones are commonly used as the primary means of contact for urgent situations. On several occasions the wrong person has been called in the middle of the night or the on-call resident is contacted while they are in the operating room during the day, resulting in a slower response time. From the perspective of the Otolaryngology Department at times we receive multiple pages and answer in the order that the pages were received, not in order of acuity as this is unknown. A dedicated airway pager will help us prioritize our decisions most safely.https://jdc.jefferson.edu/patientsafetyposters/1067/thumbnail.jp

Perioperative and anesthetic deaths: toxicological and medico legal aspects

Background: Anesthesia has become safer during decades, though there is still a preventable mortality; the complexity of medical and surgical interventions, increasingly older and sicker patients, has created a host of new hazards in anesthesiology. In this paper, some of these perioperative (PO) fatal adverse events are investigated in terms of health responsibility. Selective literature research in several data bases, concerning perioperative and anesthetic deaths and medical responsibility, was performed. Main text: A generally accepted definition of the anesthesia and perioperatory-related death still remains one of the major concerns in forensic pathology, and the terms “operative deaths” and “anesthetic deaths” are usually applied inaccurately within the medico-legal literature. Such events involve comprehensively PO fatalities and allow for subtle separation of natural and unnatural death, at least from the prospective of forensic pathology. Iatrogenic deaths in this field can be separated into some major categories, as attributable to previous patient’s unfavorable conditions or depending from surgical procedure per se (such as PO cardiac and cerebrovascular events). In this review, the authors carried out syntheses of specific research areas regarding epidemiology, complications of general and spinal anesthetic, failure in airway management and patient’s circulatory homeostasis, and adverse drugs reactions; analysis considering the challenge of anesthetic-related mortality, epidemiology and classifications, by indicating causal chain of death, in respect of both contributing and associated anesthetic and surgery facts. Conclusions: Perioperative quality control programs and its relevance for medico-legal evaluation are emphasized as, although mortality rates have decreased worldwide over the last decades, however, preventable drug-related deaths still happen. Such fatal events have to be considered within the field of forensic pathology experts, with regard of malpractice claims, to implement a strategy for preventing potentially fatal complications