Effect of removal of AuraOnce™ laryngeal mask in awake or deep anaesthesia: a randomized controlled trial

Background: The manufacturer Ambu® recommends that the AuraOnce™ laryngeal mask be removed once the patient is fully awake. Studies have shown benefit in removal of the laryngeal mask airway while a patient is deeply anaesthetized. Current evidence is inconclusive, as to which approach is preferable and safer in adults. Methods: one hundred and sixteen adult patients were randomly assigned to two groups of 58. For the deep arm; The AuraOnceTM laryngeal mask was removed after attaining an end tidal minimum alveolar concentration of Isoflurane of 1.15%. Occurrence of airway complication(s) (One or more of the following; Airway obstruction requiring airway manipulation; Laryngospasm; Desaturation to 90% or less on pulse oximetry) was noted until the subject was fully awake (appropriate response to command) in the post-anaesthesia care unit. For the awake arm; The AuraOnceTM laryngeal mask was removed on attaining an end tidal minimum alveolar concentration of Isoflurane of \u3c0.5% and an appropriate response to command or obtaining appropriate response to command irrespective of end tidal concentration. Occurrence of airway complication(s) in theatre and post anaesthesia care unit was recorded. Time to theatre exit was recorded for both groups. Results: Baseline demographic characteristics were similar between the groups. More airway complications were encountered in the Deep arm - 13 (22.4%) relative to the Awake arm -5 (8.6%), this was found to be statistically and clinically significant, P value P=0.040, odds ratio 3.0622; 95% CI, 1.0139 to 9.2483. Conclusion: The removal of the AuraOnceTM laryngeal mask while the patient is still deeply anaesthetised is not as safe as or safer than awake removal

Effect of removal of AuraOnceTM laryngeal mask in awake or deep anaesthesia: a randomized controlled trial

Background: The manufacturer Ambu\uae recommends that the AuraOnce\u2122 laryngeal mask be removed once the patient is fully awake. Studies have shown benefit in removal of the laryngeal mask airway while a patient is deeply anaesthetized. Current evidence is inconclusive, as to which approach is preferable and safer in adults. Methods: one hundred and sixteen adult patients were randomly assigned to two groups of 58. For the deep arm; The AuraOnceTM laryngeal mask was removed after attaining an end tidal minimum alveolar concentration of Isoflurane of 1.15%. Occurrence of airway complication(s) (One or more of the following; Airway obstruction requiring airway manipulation; Laryngospasm; Desaturation to 90% or less on pulse oximetry) was noted until the subject was fully awake (appropriate response to command) in the post-anaesthesia care unit. For the awake arm; The AuraOnceTM laryngeal mask was removed on attaining an end tidal minimum alveolar concentration of Isoflurane of <0.5% and an appropriate response to command or obtaining appropriate response to command irrespective of end tidal concentration. Occurrence of airway complication(s) in theatre and post anaesthesia care unit was recorded. Time to theatre exit was recorded for both groups. Results: Baseline demographic characteristics were similar between the groups. More airway complications were encountered in the Deep arm - 13 (22.4%) relative to the Awake arm -5 (8.6%), this was found to be statistically and clinically significant, P value P=0.040, odds ratio 3.0622; 95% CI, 1.0139 to 9.2483. Conclusion: The removal of the AuraOnceTM laryngeal mask while the patient is still deeply anaesthetised is not as safe as or safer than awake removal

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally. Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen\u27s kappa \u3e0.6 indicative of good inter-rater agreement. Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives

Capacity of anesthesiology residency programs in four East African countries: Can supply meet the demand?

Background: By 2015, 4 East African countries (Kenya, Uganda, Rwanda, and Burundi) had identified a deficit in the number of anesthesiologists, with a mean density of 0.30 physician anesthesia providers (PAP) per 100,000 population, which was significantly lower than the World Federation of Societies of Anaesthesiologists (WFSA) recommended minimum of 5.0/100,000 population. This workforce shortfall has been recognized as 1 factor that may negatively affect surgical outcomes. This survey sought to assess the capacity of anesthesia residency programs to meet recommended human resource standards in these countries. Methods: This retrospective cross-sectional study surveyed heads of anesthesia departments, principals of medical colleges that host residency programs and registrars of national medical councils in 4 East African countries. A descriptive analysis of the infrastructural characteristics, human resources, cost of training, enrollment, and output from the programs over 5 years (2015–2020) was conducted. The growth in the number of registered PAP and trends in workforce density were determined. The 2020 needs deficit was calculated based on the WFSA benchmark, and the projected workforce needs in 2030 were estimated based on the population growth trajectory. Results: There were 7 accredited university-based anesthesia residency programs in 2020, with median (range) enrollment and graduation rates of 10.5 (2–18) and 5.5 (0–13) residents/ country/year, respectively. Enrollment was unstable with some countries having years with no enrollment at all. Only 1 country had new programs planned. There was a median resident to supervisor ratio of 1.44 (0.89–7):1 and 50.3 (21.4–100)% of residency training supervisors had no academic faculty appointment. The median university tuition was $1677 (600–6165)/ year. The number of PAP increased in all 4 countries median 5-year growth of 79.3 (22.7–150)%, with minimal impact on the low workforce density, median of 0.23 (0.04–0.35)/100,000 in 2020. The median deficit in PAP in 2020 was an estimated 1410 (589–2499) PAP, with a median need for 1763 (763–2911) new specialists per country by 2030. Conclusions: The PAP workforce deficits significantly outstripped the annual output of all residency programs. Anesthesia societies need to raise awareness about this deficit and engage policymakers to increase investment in anesthesia training, including providing scholarships and employment of PAP in training institutions. Integrating nonuniversity-based residency programs may support an increased output. The attainability of the 2030 workforce goals will need review. National strategies are needed to increase the total anesthesia workforce, which includes nonphysician anesthesia providers (NPAPs) as part of the task-sharing framework. (Anesth Analg 2024;XXX:00–00