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Table of Contents for Anaesthesia. List of articles from both the latest and EarlyView issues.
Updated: 6 days 12 hours ago

Propofol use in children with allergies to egg, peanut, soybean or other legumes

11. May 2019 - 14:42
Summary

Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic administered and any adverse events or signs of an allergic reaction in the peri‐operative period. A convenience sample of patients without any known food allergies was identified from our prospective anaesthesia research database and acted as a control group. We identified 304 food‐allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy‐free patients who were exposed to propofol. In 10 (3%) allergy patients and 124 (14%) allergy‐free patients, criteria for a possible allergic reaction were met. In nine of the food‐allergic children and in all the controls valid non‐allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

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Double‐lumen tracheal tubes and bougies: a bench study to investigate factors that influence the risk of shearing

9. May 2019 - 9:42
Summary

Tracheal intubation with a double‐lumen tube can be more challenging than with a single‐lumen tube. A bougie can be used to facilitate intubation. Case reports have described fragment shearing from bougies when they are removed from the tube after intubation. These fragments have the potential to cause harm. It has even been suggested that bougies and double‐lumen tubes should not be used together. We conducted a benchtop trial to investigate factors that influence the risk of shearing. We investigated three brands of double‐lumen tube (each in three sizes and both lateralities) and four brands of bougie. We simulated one intubation and 29 further insertions/removals of bougie with every bougie–double‐lumen tube combination. We inspected the inside of the tube for evidence of shearing after first, tenth and thirtieth removals. We found that brand of bougie, brand of double‐lumen tube and size of double‐lumen tube (but not its laterality) all influenced the degree of shearing. Certain bougie–double‐lumen tube combinations produced a particularly high degree of shearing, so these should be avoided.

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Requirement for urgent tracheal intubation after traumatic injury: a retrospective analysis of 11,010 patients in the Trauma Audit Research Network database

8. May 2019 - 19:14
Summary

Advanced airway management is a treatment priority in trauma care. It is likely that a proportion of patients who receive urgent airway management on arrival in the emergency department represent an unmet demand for airway intervention in the pre‐hospital phase. This study aimed to investigate emergency airway practice in major trauma patients and establish any unmet demand in this patient group. A retrospective review of the Trauma Audit and Research Network database was performed to identify airway intervention(s) performed for patients admitted to major trauma centres in England from 01 April 2012 to 27 June 2016. In total, 11,010 patients had airway interventions: 4375 patients (43%) had their tracheas intubated in the pre‐hospital setting compared with 5889 patients (57%) in the emergency department. Of the patients whose tracheas were intubated in the emergency department, this was done within 30 min of hospital arrival in 3264 patients (75%). Excluding tracheal intubation, 1593 patients had a pre‐hospital airway intervention of which 881 (55%) subsequently had their trachea intubated in the emergency department; tracheal intubation was done within 30 min of arrival in the majority of these cases (805 patients (91%)). Over 70% of emergency department tracheal intubations in patients with traumatic injuries were performed within 30 min of hospital arrival; this suggests there may be an unmet demand in pre‐hospital advanced airway management for trauma patients in England.

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Dexamethasone in regional anaesthesia: travelling up a blind alley?

8. May 2019 - 19:08
Anaesthesia, EarlyView.
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Comparison of portable blood‐warming devices under simulated pre‐hospital conditions: a randomised in‐vitro blood circuit study

7. May 2019 - 20:00
Summary

Pre‐hospital transfusion of blood products is a vital component of many advanced pre‐hospital systems. Portable fluid warmers may be utilised to help prevent hypothermia, but the limits defined by manufacturers often do not reflect their clinical use. The primary aim of this randomised in‐vitro study was to assess the warming performance of four portable blood warming devices (Thermal Angel, Hypotherm X LG, °M Warmer, Buddy Lite) against control at different clinically‐relevant flow rates. The secondary aim was to assess haemolysis rates between devices at different flow rates. We assessed each of the four devices and the control, at flow rates of 50 ml.min−1, 100 ml.min−1 and 200 ml.min−1, using a controlled perfusion circuit with multisite temperature monitoring. Free haemoglobin concentration, a marker of haemolysis, was measured at multiple points during each initial study run with spectrophotometry. At all flow rates, the four devices provided superior warming performance compared with the control (p < 0.001). Only the °M Warmer provided a substantial change in temperature at all flow rates (mean (95%CI) temperature change of 21.1 (19.8–22.4) °C, 20.4 (19.1–21.8) °C and 19.4 (17.7–21.1) °C at 50 ml.min−1, 100 ml.min−1 and 200 ml.min−1, respectively). There was no association between warming and haemolysis with any device (p = 0.949) or flow rate (p = 0.169). Practical issues, which may be relevant to clinical use, also emerged during testing. Our results suggest that there were significant differences in the performance of portable blood warming devices used at flow rates encountered in clinical practice.

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Mapping sources of noise in an intensive care unit

7. May 2019 - 17:35
Summary

Excessive noise in hospitals adversely affects patients’ sleep and recovery, causes stress and fatigue in staff and hampers communication. The World Health Organization suggests sound levels should be limited to 35 decibels. This is probably unachievable in intensive care units, but some reduction from current levels should be possible. A preliminary step would be to identify principal sources of noise. As part of a larger project investigating techniques to reduce environmental noise, we installed a microphone array system in one with four beds in an adult general intensive care unit. This continuously measured locations and sound pressure levels of noise sources. This report summarises results recorded over one year. Data were collected between 7 April 2017 and 16 April 2018 inclusive. Data for a whole day were available for 248 days. The sound location system revealed that the majority of loud sounds originated from extremely limited areas, very close to patients’ ears. This proximity maximises the adverse effects of high environmental noise levels for patients. Some of this was likely to be appropriate communication between the patient, their caring staff and visitors. However, a significant proportion of loud sounds may originate from equipment alarms which are sited at the bedside. A redesign of the intensive care unit environment to move alarm sounds away from the bed‐side might significantly reduce the environmental noise burden to patients.

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Characterisation of aluminium release by the enFlow® fluid‐warming system in crystalloids and blood products

7. May 2019 - 17:19
Summary

The use of uncoated aluminium‐heated plates in an intravenous fluid‐warming system has been shown to produce high levels of aluminium in Sterofundin 1/1E, a balanced crystalloid solution. However, the effect of this fluid‐warming device on other balanced crystalloid solutions and blood products has not been studied. Using mass spectrometry we measured aluminium levels in Plasma‐Lyte 148, compound sodium lactate solution, 4% human albumin solution, expired resuspended packed red cells and fresh frozen plasma that were pumped through an enFlow® fluid‐warming system at 2 ml.min−1. Samples were taken at baseline before heating and then at 10‐min intervals up to 60 min with the system set to warm the fluids to 40 °C. High concentrations of aluminium were found for Plasma‐Lyte 148 and compound sodium lactate solutions (mean (SD) 223 (0.6) μmol.l−1 and 163 (0.2) μmol.l−1 at 60 min, respectively); both concentrations were significantly greater than the United States Food and Drug Administration recommended maximum limit for aluminium in intravenous nutrition of 25 μg.l−1 (0.9 μmol.l−1 ). Lower aluminium levels were found in 4% human albumin solutions, expired resuspended red cells and fresh frozen plasma at 60 min (mean (SD) 5.7 (0.1) μmol.l−1, 2.7 (0.0) μmol.l−1 and 2.3 (0.4) μmol.l−1, respectively). The process allowing addition of aluminium to be added to Sterofundin 1/1E by the enFlow fluid warmer also occurs in Plasma‐Lyte 148 and compound sodium lactate solutions and to a lesser degree in blood products. The exact mechanism facilitating this process and its clinical significance remain unclear.

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Electroshock from a nerve stimulator charging cable

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 811-811, June 2019.
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Aluminium release during fluid warming

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 819-819, June 2019.
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Offsetting the genotoxic effects of sleep disruption

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 815-815, June 2019.
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Electroshock from a nerve stimulator charging cable – manufacturer's reply

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 811-811, June 2019.
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Pre‐oxygenation vs. apnoeic oxygenation in obstetrics

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 822-823, June 2019.
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Global capnography and airway teaching. A reply

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 813-813, June 2019.
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Carbon dioxide clearance during apnoea

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 816-817, June 2019.
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Introducing new emergency front‐of‐neck access equipment into clinical practice

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 814-814, June 2019.
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Carbon dioxide clearance during apnoea. A reply

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 818-819, June 2019.
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Global capnography and airway teaching

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 812-812, June 2019.
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Airway management research: what problem are we trying to solve?

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 704-707, June 2019.
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Issue Information – Editorial Board

7. May 2019 - 13:39
Anaesthesia, Volume 74, Issue 6, Page 689-689, June 2019.
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