Techniques, advantages and pitfalls of ultrasound-guided internal jugular cannulation:a qualitative study

Background: National guidelines advocating ultrasound-guidance of internal jugular venous cannulation were introduced in the United Kingdom in 2002, followed by international guidelines a decade later. However the benefits of ultrasound-guidance do not appear to have universally translated into clinical practice. This study therefore aimed to investigate the effect of ultrasound on the practice of internal jugular vein cannulation. Methods: We conducted an ethnographic study incorporating observations, interviews and focus groups in two hospitals in the North of England over a four-month period. Results: Twenty-seven clinical observations, ten interviews and three focus groups were conducted. In 25 clinical episodes ultrasound-guidance was used. Four distinct needling techniques were observed which we have classified in terms of needle angulation as the traditional landmark technique, the ultrasound-guided traditional approach, ultrasound-guided medial angulation, and the ultrasound-guided steep approach. The latter two techniques represent a departure from conventional practice and appear to have developed alongside ultrasound-guidance. Though no serious complications were observed, there appears to be enhanced potential for them to occur with medial angulation and the steep approach. Participants described a loss of anatomical knowledge and a ‘false sense of security’ associated with the adoption of ultrasound-guidance, which may account for the emergence of new, potentially riskier needling techniques. Conclusion: The introduction of safe technologies may lead to unintended consequences, and clinicians should attempt to recognise and mitigate them when they occur. Education to increase awareness of the pitfalls of ultrasound-guidance is recommended

Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly surgical patients

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare maintenance of general anaesthesia for elderly surgical patients using total intravenous anaesthesia (TIVA) or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthetic care unit (PACU), and hospital stay

Strongyloides hyperinfection syndrome following resection of meningioma

In this report, we present the case of a patient who developed the strongyloides hyperinfection syndrome 3 weeks after an uneventful resection of a sphenoid wing meningioma. She originally presented with symptoms of raised intracranial pressure and was given dexamethasone before surgery. The pathology, diagnosis and management of Strongyloides stercoralis are reviewed

Diabetes insipidus in pregnancy

Key content There are various types of diabetes insipidus that occur due to different pathology that occurs outside of, during, and as a result of pregnancy. All pregnant women presenting with polyuria and polydipsia should be investigated with blood tests including urea and electrolytes, calcium levels and thyroid function tests. Plasma and urine osmolality can also be helpful in making the diagnosis. Additional symptoms that are suggestive of diabetes insipidus secondary to other underlying pathology (e.g. a pituitary tumour) are likely to require radiological imaging. Women diagnosed with diabetes insipidus should have regular consultant review in clinic with monitoring of serum electrolytes. They should also receive an antenatal anaesthetic review. A multidisciplinary approach should be adopted during labour and they should be managed on delivery suite with senior obstetric and anaesthetic input. Pre‐eclamptic toxaemia (PET) and haemolysis, elevated liver enzymes and low platelets (HELLP) can exacerbate diabetes insipidus as hepatic dysfunction leads to a reduction in vasopressinase metabolism. Furthermore, it has been suggested that pituitary hypoperfusion due to this syndrome could also be a cause of gestational diabetes insipidus. These women present a therapeutic challenge as they are in a volume‐depleted state as a consequence of DI, however they require judicious fluid management because of their PET. Early detection and effective management will reduce morbidity and mortality in both the mother and fetus. Untreated or undiagnosed, it has the potential to have serious consequences for the expectant mother and fetus. Learning objectives To understand the different subtypes of diabetes insipidus, their pathophysiologies and their effects during the ante‐, peri‐ and postnatal periods. To appreciate that diabetes insipidus can herald the onset of underlying hepatic dysfunction with associated serious maternal and fetal consequences arising from both the biochemical abnormalities associated with diabetes insipidus and the secondary problems of impaired liver function. To appraise the current theories of the link between PET and diabetes insipidus