Rapid Induction Of Anaesthesia Research Articles

Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction

This study investigates the effect of suxamethonium vs rocuronium on the onset of haemoglobin desaturation during apnoea, following rapid sequence induction of anaesthesia. Sixty patients were randomly allocated to one of three groups. Anaesthesia was induced with lidocaine 1.5 mg.kg(-1), fentanyl 2 microg.kg(-1) and propofol 2 mg.kg(-1), followed by either rocuronium 1 mg.kg(-1) (Group R) or suxamethonium 1.5 mg.kg(-1) (Group S). The third group received propofol 2 mg.kg(-1) and suxamethonium 1.5 mg.kg(-1) only (Group SO). The median (IQR [range]) time to reach S(p)O(2) of 95% was significantly shorter in Group S (358 (311-373 [245-430]) s) [corrected] than in Group R (378 (370-393 [366-420]) s; p = 0.003), and shorter in Group SO (242 (225-258 [189-270]) s) [corrected] than in both Group R (p < 0.001) and Group S (p < 0.001). When suxamethonium is administered for rapid sequence induction of anaesthesia, a faster onset of oxygen desaturation is observed during the subsequent apnoea compared with rocuronium. However, time to desaturation is prolonged whenever lidocaine and fentanyl precede suxamethonium.

Comparison of Single-use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial. One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score. Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P < 0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P < 0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result. The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

THIS MONTH IN Anesthesiology

Postoperative noninvasive ventilation can help prevent postoperative hypoxemia and acute respiratory failure.Chinese anesthesiologists are poised to play a significant role in tobacco control in China.Hypercapnia may be beneficial in early sepsis, but potentially deleterious in prolonged sepsis. See the accompanying Editorial View on page 269 Dose of local anesthetic but not concentration and volume influence nerve block characteristics.Techniques on ultrasound-guided peripheral nerve blocks of the extremities and trunk are discussed.Unrecognized patient deterioration in the postoperative period may lead to increased intensive care unit (ICU) admission rates or even death. A patient surveillance system based on pulse oximetry and wireless pagers was used for nursing notification of violation of alarm limits. Data were collected on a postoperative orthopedic ward for 11 months before and 10 months after implementation of the system and compared with matched outcome data on two other postoperative units. Rescue events decreased by 2.2 per 1,000 patient discharges and ICU transfers by 1.7 per 1,000 patient days while the comparison units had no change. Rescue events and ICU transfers were decreased after implementation of this patient surveillance system on a postoperative orthopedic ward. See the accompanying Editorial View on page 272 Factor VII is affected during the early phase of warfarin therapy and high international normalized ratios (INR &gt; 1.4) are considered unsafe for epidural catheter placement or removal by the American Society of Regional Anesthesia. Data from 121 patients who took warfarin after undergoing total joint surgery and had INRs and factor VII levels determined were reviewed. Patients had INR &gt; 1.4 on postoperative days (POD) 1 (n = 11), POD 2 (n = 78), and POD 3 (n = 84) and mean factor VII activities were 60 ± 28%, 32 ± 15%, and 44 ± 19%, respectively. Predictors of INR &gt; 1.4 on POD 2 were warfarin dose on POD 1 and factor VII activity on POD 2. The range of factor VII activities in the patients with INR &gt; 1.4 within 12 h of warfarin therapy was compatible with adequate hemostasis. Based on factor VII activity levels, the authors found no evidence that epidural catheters should not be removed even with INR up to 1.9, the highest INR on POD 1 noted in their study. See the accompanying Editorial View on page 277 Intubation efficiency varies depending on the type of laryngoscope blade used. In a multicenter cluster randomized trial, 1,072 adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades. The rate of failed intubation was significantly decreased with metal single-use blade at the first attempt compared with the reusable blade (2.8% vs. 5.4%). The proportion of grades 3 and 4 in Cormack and Lehane score were also significantly decreased with single-use metal blade (6% vs. 10%). The global complication rate tended to be lower in the single-use group (6.8% vs. 11.5%). The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia for emergency surgery.

Testing adherence to the DAS algorithm for difficult tracheal intubation during rapid sequence induction of anaesthesia

Testing adherence to the DAS algorithm for difficult tracheal intubation during rapid sequence induction of anaesthesia

Regulation of sevoflurane on immune factors

Sevoflurane is a potent non-explosive inhalational anesthetic agent which provides rapid anesthetic induction and recovery consistent with its low distribution coefficient and high efficacy. Recently, the immune responses to sevoflurane and immune regulation have attracted sufficient attention, mainly focusing on its anti-inflammatory effects, attenuation of the stress response and relief of the ischemia-reperfusion injury. This review briefly demonstrates the immune responses and the immuno-mechanism of red blood cell, lymphocyte and cytokines when exposed to sevoflurane. Since the regulation of sevoflurane is precise and complex, the diversification deserves further experimental and clinical evidences. Key words: Sevoflurane; Regulation; Immune factors

On Cricoid Pressure: “May the Force Be with You”

Jerrold Lerman, MD, FRCPC, FANZCA*† Cricoid pressure has become the quintessential cornerstone of the rapid sequence induction of anesthesia in patients at risk for passive regurgitation of gastric fluids. Despite an almost 5-decade history, the level of evidence to support its effectiveness in preventing passive regurgitation is a paltry 4 or 5, resulting in a Grade D recommendation for its use. However, guidelines in anesthesia and other medical specialties endorse its use, and the legal community exploits its omission from the anesthetic record as evidence of a practice below the “accepted” standards. In this month’s issue of Anesthesia & Analgesia, Rice et al. explore the cricoidhypopharyngeal unit to determine whether cricoid pressure occludes the esophageal lumen when the latter is displaced lateral to the cervical spine. The time has come to critically review what we know and what we do not know about cricoid pressure and to set the record straight once and for all. Cricoid pressure was first reported by Sellick in 1961 for use at induction of anesthesia. His seminal report in which he established the effectiveness of cricoid pressure in 26 patients who required emergency surgery transformed the practice of anesthesia. However, several details in his report are not well known and merit our consideration. First, each patient in his report was positioned “head down slightly with the head turned” for induction of anesthesia. Upon release of the cricoid pressure, he noted that 3 of the patients (12%) regurgitated. Some readers may be surprised that such a large proportion of patients regurgitated when cricoid pressure was released (it contrasts sharply with our clinical experience), whereas others might attribute the high incidence of regurgitation simply to the patients’ head-down position. The pervasive fear of regurgitation and aspiration during induction of anesthesia with the early ether anesthetics led to this positioning to direct regurgitant fluids away from the larynx. Currently, the head-down position is never used at induction of general anesthesia; moreover, Sellick’s study has never been repeated with patients in the supine position. Second, Sellick suggested that “firm” pressure be applied to the cricoid ring after positioning the neck in the “tonsil” position (in which the neck is fully extended). Sellick never determined how much force was required to occlude the lumen of the esophagus. Currently, a minority of anesthesiologists and assistants are aware of the magnitude of the force required to occlude the esophageal lumen. Many more apply an insufficient force (although some apply excessive force) to occlude the lumen of the esophagus and prevent passive fluid regurgitation (a force of 30–44 N is required with loss of consciousness, where 10 N is the force of gravity on an object with a mass of approximately 1 kg). Although Sellick recommended that the tonsil position be used when performing this maneuver, the majority of patients are positioned with the head in the “sniffing” or “neutral,” but not tonsil, position. Third, Sellick claimed that a nurse or assistant could be instructed in this maneuver in “a few seconds.” Currently, anesthesiologists infrequently instruct others in the correct technique for applying cricoid pressure. If the principles espoused by Sellick were followed, then anesthesiologists need to revisit the details of how we perform this maneuver: we must agree on a uniform position for the patient’s head and neck and ensure that all From the *Department of Anesthesiology, Women and Children’s Hospital of Buffalo, State University of New York at Buffalo, Buffalo; and †Strong Memorial Hospital, University of Rochester, Rochester, New York. Accepted for publication August 1, 2009. Supported by Department of Anesthesiology, Women and Children’s Hospital of Buffalo, State University of New York at Buffalo and Strong Memorial Hospital, University of Rochester, Rochester, NY. Address correspondence and reprint requests to Jerrold Lerman, MD, FRCPC, FANZCA, Women and Children’s Hospital of Buffalo, 219 Bryant St., Buffalo, NY 14222. Address e-mail to jerrold.lerman@ gmail.com. Copyright © 2009 International Anesthesia Research Society

BIS Monitoring During Sevoflurane Anesthesia Induction in Children

Objective: to estimate the time course of changes in the BIS index during rapid, over-pressure, induction of anesthesia with sevoflurane in children. Subjects and methods. Twenty-three children aged 6 months to 12 years were examined during rapid inhalation induction of sevoflurane anesthesia at short-term facial plastic surgery. The BIS index as a criterion for depressed consciousness during anesthesia and systemic hemodynamic parameters, were studied. Results. The anesthesia induction protocol that envisaged the initial inhalation of high (8%) sevoflurane concentrations in a 100% oxygen stream with a gradual decrease in the concentration of the anesthetic to 4 and 2% by minutes 4 and 8, respectively, after the initiation of its inhalation was found to achieve an adequate steady depth of depressed consciousness, as confirmed by the values of the BIS index. The latter reduced to 51.56±4.89 and 45±3.12 within the first minute after the initiation of sevoflurane inhalation and by the end of the second minute, respectively, which suggested deep sedation. The minimum value of the index was 39.00±1.72 at minute 5. The found hemodynamic changes were induced by the inhaled anesthetic and did not exceed the admissible values. Conclusion. The estimation of the changes in brain electric activity during the described technology of anesthesia induction has suggested that the procedure for BIS index recording is of high prognostic value in preventing possible impairments in anesthetic maintenance, i. e. inadequate or excess depressed consciousness. Key words: anesthesia induction, children, sevoflurane, inhalation anesthesia, BIS index, sedation.

A Study of Priming Technique of Rocuronium in Facilitating Intubation

Tracheal intubation is usually performed after induction of anaesthesia followed by relaxation of skeletal muscle with depolarizing or nondepolarizing Neuro Muscuc c lar Block Agent (NMBA). The ability to intubate the trachea rapidly and safely is still paramount in all clinical situations. Suxamethonium is still the drug of choice for this purpose. This short-acting depolarizing NMBA is probably the most popular drug used for making intubation quick, easy and atraumatic. But this drug has many side effects like post operative muscle pain, hyperkalemia, malignant hyperthermia, masseter rigidity etc. For these reasons, researchers have concentrated to develop an alternative drug to suxamethonium or an alternative method of using non-depolarizing NMBA (Neuromuscular Blocking Agent) for rapid sequence induction to intubation technique. Rocuronium bromide, an aminosteroid nondepolarizing NMBA, the onset time of which is significantly shorter than equivalent doses of other non-depolarizing NMBA .Priming technique with rocuronium has been investigated by several authors in an attempt to reduce the onset time and also to optimize it's efficacy and reduce the incidence of side-effects. This study was performed to investigate the influence of priming technique on the intubating time and intubation conditions with standard intubating dose of rocuronium (0.6 mg/kg), which may be comparable with standard intubation dose of suxamethonium (1.5 mg/kg). Thus using priming technique Rocuronium with standard intubating dose (0.6 mg/kg) may be suitable alternative to suxamethonium for rapid sequence induction of anaesthesia. So, we can avoid many life-threatening side-effects associated with suxamethonium like, hyperkalemia, massater spasm, malignant hyperthermia and we can also avoid mega-dose of rocuronium (0.9-1.2 mg/kg) used for same purpose. A total number of 90 adult subjects, aged 18-45 yr, ASA I-II, undergoing elective surgery were studied. The selected patients were equally divided into three groups, 30 patients in each group.Following induction with thiopentone (5mg/kg) and Fentanyl (2?gm/kg), patients in group-I (n=30) received suxamethonium 1.5 mg/kg, group-II (n=30) received a priming dose of rocuronium 0.06 mg/ kg followed 3 minutes later by an intubating dose of 0.54 mg/kg and group-III (n=30) received rocuronium 0.6 mg/kg in single bolus injection. Neuromuscular function was assessed at the wrist using acceleration transducer (TOF-watch). In priming group any unpleasant symptoms during priming like visual disturbance, feeling of dyspnoea, difficulty in controlling tongue were closely observed. Intubating conditions were assessed using the intubation criteria of Cooper et al. as excellent, good, fair or poor, based on jaw relaxation, position of the vocal cords and response of the diaphragm to intubation. The main outcome variables were intubating time and intubating conditions.Timing at intubation showed that all of the patients of suxamethonium group (group-I), 86.7% of the priming group (group-II) and nearly three quarter (73.3%) of the single dose rocuronium group (group-III) were feasible to be intubated within 60 second. The difference between the priming and the single dose rocuronium group was not statistically significant in terms of timing of intubation (p = 0.329). While evaluating intubating conditions, no significant difference was also observed between priming group (group-II) and single dose rocuronium group (group-III) in jaw relaxation (p=0.698), vocal cords movement (p=0.646) and response to intubation (p=0.514).The suxamethonium group allowed much earlier intubation compared to other two groups (p = 0.039) and in terms of intubating conditions, smooth intubation was significantly higher in suxamethonium group (Group-I) compared to other two groups (p = 0.043). In terms of unpleasant effects of priming it was observed that 1.1% of the patients of priming group had visual disturbances, 3.3% dyspnoea, 1.1% difficulty in controlling tongue and 2.2% difficulty in swallowing during the priming interval and remaining 92.7% was free of any unwanted sideeffects. Haemodynamic state at intubation and just after intubation demonstrateds that the haemodynamic variables like pulse rate, systolic blood pressure, diastolic blood pressure, oxygen saturation (SpO2) all were within physiological range and almost homogeneously distributed among the three groups and no adverse outcome was noticed. Using priming technique with standard intubating dose of rocuronium 0.6 mg/kg has no beneficial effects on reducing intubation time and providing better intubating conditions over single bolus injection of rocuronium 0.6 mg/kg .So Rocuronium 0.6 mg/kg in single bolus injection can replace suxamethonium for quick endotracheal intubation in surgical procedures of short and medium duration. Journal of BSA, Vol. 21, No. 1, January 2008 3-11

Perception of emergency medicine by consultants and specialist registrars from other hospital specialties

Background: This is the first study to consider feedback on the specialty of emergency medicine (EM) given by other hospital specialties. Method: A questionnaire was sent to 100 randomly selected...

Venom extraction from anesthetized Florida cottonmouths, Agkistrodon piscivorus conanti, using a portable nerve stimulator

Florida cottonmouth snakes ( Agkistrodon piscivorus conanti) were anesthetized with the injectable anesthetic propofol, and venom expulsion was induced with a commercially available human nerve stimulator. We observed rapid anesthetic induction with strong correlation between animal mass and both propofol dose and induction time. We also found a positive correlation between venom yield and animal mass. The method we describe produced consistent venom extraction, maximized yield by completely emptying the glands, potentially reduced animal stress by reducing time of conscious physical restraint, and decreased the likelihood of human envenomation. This technique could also be used in remote field locations.

Rapid sequence induction in the emergency department: induction drug and outcome of patients admitted to the intensive care unit

Objectives:Etomidate is used widely for rapid sequence induction (RSI) of anaesthesia in the emergency department (ED) as a result of its relative cardiovascular stability. There is concern over possible adrenal...

Should patients be manually ventilated during rapid sequence induction of anaesthesia?

Pulmonary aspiration of gastric contents has been recognized as a cause of significant morbidity and mortality during anaesthesia since the classic publication by Mendelson in 1946. The introduction of suxamethonium 5 years later allowed tracheal intubation to be achieved under complete muscle relaxation within 1 minute of induction of anaesthesia. In 1961 Sellick described the use of cricoid pressure to prevent gastric regurgitation.

A multi‐regional survey of drugs used for rapid sequence induction of anaesthesia

Rapid sequence induction (RSI) of anaesthesia involves the use of rapidly acting drugs to cause loss of consciousness and facilitate the placement of a tracheal tube. RSI is widely practiced in the UK. A 2001 survey [1] showed there was variation in the drugs used for RSI. We planned to see if practice had changed since this survey, and also to assess how anaesthetists felt the imminent arrival of the cyclodextran sugammadex would affect their practice. A questionnaire was distributed to every anaesthetist working in eight hospitals over three UK regions. We asked questions about the drugs used routinely and occasionally for RSI, and the doses used. The final two questions concerned sugammadex. Our local ethics committee felt this was service review and therefore formal ethical approval was not required. Data were analysed in Microsoft®Excel. Where appropriate, differences between groups were analysed using the chi-squared test. We issued 373 questionnaires and received 309 responses (83%). Ten anaesthetists did not perform RSI so this left 299 questionnaires for analysis. Fifty-three per cent of replies were from consultants, 33% from specialist registrars (SpRs), 11% from senior house officers and 3% from non-consultant career grades. Results are in Table 1, which compares the present survey with the 2001 survey. There were differences between grades, with consultants significantly more likely to have propofol as their first choice drug (p < 0.0001). The dose of rocuronium chosen varied widely, from 0.3 mg.kg−1 to 2 mg.kg−1. As regards sugammadex, 76% of anaesthetists were aware of research into the drug, with SpRs significantly more likely to be aware of it (p = 0.0027). Eighty-two per cent of anaesthetists currently predominantly using suxamethonium feel their practice of RSI will be changed by sugammadex: 48% are likely to use rocuronium instead of suxamethonium in selected patients; 27% in most patients; and 7% in all patients. Practice of RSI has changed compared with 2001. Propofol is now the most widely used induction agent both overall and first choice. Etomidate is used much less than before. Suxamethonium is still the most favoured muscle relaxant, but the number of anaesthetists using suxamethonium exclusively has fallen by half. Correspondingly, rocuronium is used more frequently, as are opioids. Most anaesthetists are aware of the research into sugammadex, and more than 80% expect this drug to change their practice of RSI.

Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?

In rapid sequence induction of anaesthesia in the emergency setting in shocked or hypotensive patients (e.g. ruptured abdominal aortic aneurysm, polytrauma or septic shock), prior resuscitation is often suboptimal and comorbidities (particularly cardiovascular) may be extensive. The induction agents with the most favourable pharmacological properties conferring haemodynamic stability appear to be ketamine and etomidate. However, etomidate has been withdrawn from use in some countries and impairs steroidogenesis. Ketamine has been traditionally contra-indicated in the presence of brain injury, but we argue in this review that any adverse effects of the drug on intracranial pressure or cerebral blood flow are in fact attenuated or reversed by controlled ventilation, subsequent anaesthesia and the greater general haemodynamic stability conferred by the drug. Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised patients.

Teaching anaesthetic nurses optimal force for effective cricoid pressure: a literature review

This literature review explores the role of force and education in cricoid pressure, an essential aspect of practice for any nurse within a critical care environment. Cricoid pressure is utilized in everyday practice during rapid sequence induction (RSI) of anaesthesia. The purpose of cricoid pressure is to occlude the oesophagus in order to reduce the risk of acid aspiration during emergency induction of anaesthesia. The importance of best practice cannot be overstated because of high rates of mortality following acid aspiration. Literature searches were conducted using the key words cricoid pressure, Sellick manoeuvre, rapid sequence induction and acid aspiration syndrome. Articles were obtained from online searches, with literature published in the last 10 years being used; some seminal literature and textbooks were incorporated for definition purposes. The literature displayed a disparity in practice and differing opinions on the optimal force to occlude the oesophagus. The role of education in correct application of cricoid pressure was explored, with unanimous conclusions that education plays a role in ensuring best practice. Forces of 20-30 N are adequate to occlude the oesophagus and minimize the risk of acid aspiration. However, it is difficult for practitioners to accurately estimate this force in everyday practice. Various methods of assessing force were discussed, with the use of a 50-mL syringe suggested as a cost-effective and simple method to utilize in practice. The literature review demonstrated that the subject of cricoid pressure is relevant in critical care practice in order to ensure patient safety during RSI. Thus, all critical care nurses have a duty to gain a working knowledge on the subject if patient safety is to be maintained. This paper provides a source of information on cricoid pressure and realistic methods of maintaining best practice.

Clinical evaluation of Alfaxan‐CD® as an intravenous anaesthetic in young cats

To describe and evaluate the use of Alfaxan-CD as an intravenous anaesthetic in young cats. Thirty-five Domestic Short-hair cats aged from 3 to 12 months were admitted into the University Veterinary Teaching Hospital-Sydney for elective surgery. Anaesthesia was induced with Alfaxan-CD and maintained with isoflurane: 22 cats received no premedication and 13 cats received acepromazine (0.03 mg/kg) and butorphanol (0.3 mg/kg) subcutaneously 30 min prior to induction. Qualitative and quantitative data for induction and recovery were recorded. Physiological parameters were recorded at 0, 2 and 5 min post induction, and every 5 min thereafter until the end of the procedure. Intravenous injection of Alfaxan-CD resulted in rapid induction of anaesthesia with a mean time to intubation of 122 s. The mean dose of Alfaxan-CD used was 4.2 mg/kg in unpremedicated cats and 2.7 mg/kg in premedicated cats. All cats maintained a heart rate above 95 beats/min. No cat developed hypoxaemia. Hypercapnoea was detected in 4 cats and hypotension was observed in 18 cats. Time to extubation ranged from 1 to 9 min. The mean time to sternal recumbency for premedicated cats was 11 min; 77% of premedicated cats and 23% of unpremedicated cats had a recovery score of 1 or 2. Alfaxan-CD is an effective anaesthetic agent in young healthy cats, providing a smooth induction and rapid recovery. Cats that were premedicated with acepromazine and butorphanol prior to induction with Alfaxan-CD had better recovery scores than those that were not premedicated.

Management of neuromuscular block: time for a change?

Management of neuromuscular block: time for a change?

Trauma: we care. More for discussion

I read with interest the recent letter by Zafar et al. [1] and felt that some of the issues raised required clarification. Firstly, there seems to be some confusion in the letter between transfer/retrieval medicine and pre-hospital medicine. Transfer and retrieval in civilian practice in the United Kingdom is concerned with delivery of patients between hospitals, i.e. patients who have already been admitted to a medical care facility. Pre-hospital medicine may include this role, but more commonly refers to ‘the provision of skilled healthcare at the site of a trauma incident or medical emergency’ [2]. Secondly, the authors also make reference to pre-hospital tracheal intubation, implying that paramedics intubate trauma patients. Paramedics in the United Kingdom currently do intubate patients, but only those who do not require pharmacological agents to assist intubation. This group of patients, in the context of trauma, have a near 100% mortality rate [3]. Rapid sequence induction of anaesthesia is only performed currently by pre-hospital doctors. This seems unlikely to change in light of a Joint Royal Colleges Ambulance Liaison Committee report of June 2008, which states ‘paramedic tracheal intubation cannot be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format’ [4]. The authors seem to suggest a retrieval system based on the military model, presumably referring to Medical Emergency Response Teams, currently operating in Afghanistan. A typical Medical Emergency Response Team setup will include a consultant or senior trainee anaesthetist. As the authors rightly state, medical treatment is started en route to base, in the back of the helicopter. Cramped as it may be, a CH-47 helicopter is still a great deal larger than the majority of civilian air ambulances. There are also restrictions on when civilian air ambulances may fly without an instrument rating; some may not carry passengers after dusk. Most are not based at the site of tertiary referral or trauma centres, necessitating a crew waiting at the airfield and removed from other clinical work. In particular, I find the suggestion regarding a Physician’s Assistant being utilised in retrieval particularly worrying. The Royal College of Anaesthetists explicitly states that Physician’s Assistants must not undertake initial airway assessment and management of acutely ill or injured patients and cannot work without a named consultant being both within the theatre suite and being immediately available [5]. The authors summarise by calling for raised standards for transfer training, which appears to be a perfectly reasonable aim. There are already many in the pre-hospital community who are working tirelessly towards raising standards in the field of pre-hospital care. It is important however that we don’t lose sight of the issues surrounding each speciality by confusing transfer/retrieval medicine with pre-hospital care.

Emergency Management of Pediatric Convulsive Status Epilepticus

To perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) to sites within the Paediatric Research in Emergency Departments International Collaborative. Retrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. Data were obtained from 542 eligible episodes of CSE. Demographics and seizure history were similar across all sites. One third of children with CSE presented with their first seizure. A preexisting diagnosis that predisposed to seizures was present in 59%. Median duration of seizures before hospitalization was 45 minutes, and median duration of treatment in ED before termination was 30 minutes. Prehospital duration did not seem to influence the timing of key ED interventions such as the administration of second-line anticonvulsants or progression to rapid sequence induction (RSI) of anesthesia and intubation. Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and RSI in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. Marked variation in the use of RSI for refractory seizures was observed between sites. Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the prehospital and hospital phases. Persistent seizure activity beyond 40 minutes contrasts with current published guidelines. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy.

Intubação traqueal e o paciente com o estômago cheio

Pulmonary aspiration of gastric contents, despite its infrequent occurrence, demands special preventive care. Decreased oesophageal sphincter function and protective airway reflexes caused by depression of consciousness, predispose patients to this severe complication. Recently developed preoperative fasting guidelines suggest shorter fasting periods, especially for liquids, providing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing incidence of perioperative pulmonary aspiration. Routine use of drugs decreasing gastric acidity and volume seems to be indicated only for high risk patients. Tracheal intubation after rapid sequence induction of anesthesia is indicated for patients at risk of gastric content aspiration without suspicion of difficult intubation. Adequate indication of the technique, its judicious application and rational use of available drugs may promote excellent intubation conditions, with fast onset, early return to consciousness and spontaneous breathing should tracheal intubation fail. This review intends to discuss methods recently used to control volume and pH of the gastric content, protect the airways during the intubation maneuver and to decrease the gastroesophageal reflux.