We report a case where unexpected difficulty was encountered during a modified rapid sequence induction of anaesthesia (RSI) and was successfully managed with a Proseal laryngeal mask airway (PLMA: Intravent Orthofix, Maidenhead, UK). A 50-year-old man with severe oral steroid dependent asthma and gastro-oespohageal reflux presented with appendicitis. Pre-operative assessment revealed obvious Cushingoid features (body mass index of 30 kg.m−2), a Mallampati class I view with normal neck extension and mandibular protrusion. Respiratory examination revealed a mild polyphonic wheeze in the upper zones. The patient was premedicated with nebulised salbutamol and ipratropium bromide. Prior to induction, the patient's airway position was optimised. The patient was adequately preoxygenated with an end tidal oxygen concentration of 80%. Anaesthesia was induced with propofol, fentanyl and succinylcholine with cricoid pressure. Direct laryngoscopy revealed a Cormack and Lehane grade 3 view with a deep and posterior larynx. Cricoid manipulation and a McCoy blade did not improve laryngoscopic view. A gum elastic bougie was passed with difficulty. A tracheal tube could not be railroaded over the bougie despite numerous manoeuvres, changes of tube size and a brief removal of cricoid pressure. The patient's oxygen saturation had fallen to 84%. Ventilation was possible but difficult with an oropharyngeal airway and jaw thrust with cricoid pressure. The patient's oxygen saturation had improved to 88%. A size 5 classic laryngeal mask airway was inserted with brief release of cricoid pressure during placement then reapplication. Ventilation was inadequate with peak airway pressures of 32 cm of water, tidal volumes of 150 ml and a large leak. Oxygen saturation had not improved. A size 5 PLMA was then inserted which provided an excellent seal and enabled ventilation with tidal volumes of 600 ml with peak airway pressures of 26 cm H2O. A gastric tube was then inserted down the oesophageal port, which drained gastric contents. In view of the need for urgent surgery, reluctance to further instrument the airway of a brittle asthmatic and satisfactory ventilatory parameters, it was decided to proceed with surgery at this point. Surgery and emergence from anaesthesia both proceeded uneventfully. The significance of the difficulties experienced was explained to the patient and he was provided with a letter summarizing the events. The PLMA does not appear in any currently published airway algorithms but it is likely to be included in the UK Difficult Airway Society guidelines when they are published (J. Henderson. Difficult Airway Society Meeting, London 2002.) The PLMA has been recommended for use in obstetrics to salvage failed intubation [1,2] and such a case recently occurred in this hospital [3]. Our case is noteworthy as the initial management of failure to intubate during RSI was insertion of a classic laryngeal mask airway as recommended in several algorithms [4,5] and routinely practised by most anaesthetists in this country [6]. While the classic laryngeal mask provided a clear airway, ventilation was inadequate because of airway leak. Substitution with the PLMA provided a clear airway, reliable ventilation and access to drain the stomach. In addition, this is only the second case reported where the PLMA has been used to secure the airway after failure to intubate during RSI and the first in non-obstetric surgery. The PLMA was introduced in the UK in 2001. It has several important potential advantages over the classic laryngeal mask in these circumstances. It allows functional separation of the gastrointestinal and respiratory tracts [7] and provides a 50% better airway seal, which facilitates controlled ventilation [8]. The drain tube assists in confirmation of correct mask placement [7], reduces the likelihood of gastric inflation, allows drainage of the stomach and provides an 'escape route' if regurgitation does occur [9]. These potential advantages must be balanced against slightly greater difficulty in PLMA insertion and the likelihood that the PLMA has a longer learning curve than the classic laryngeal mask [8]. On the basis of the available evidence, we believe the PLMA does offer advantages in the circumstance of failed urgent intubation in a patient with a potentially full stomach. Finally, it is of further interest that two cases of failed intubation during RSI both managed with a PLMA should be reported from the same hospital. This department has considerable experience with the PLMA; trainees are taught in its use during elective cases and the PLMA has been part of our difficult airway trolley for over a year. It is likely that theoretical knowledge and practical familiarity with the PLMA has meant that trainees are confident to use the PLMA during these difficult cases.
A 15-year-old boy with trisomy 21, moderate left atrioventricular (AV) valve regurgitation and a previously repaired AV septal defect developed Aerococcus urinae infective endocarditis. The infected left AV valve and surrounding tissue were surgically removed and replaced with a prosthetic mitral valve; this was followed by 6 weeks of intravenous antibiotics. Towards the end of his antibiotic course, his C reactive protein level began to rise, and he subsequently developed worsening hip pain and severe anaemia …
Abstract Aim Aortic graft infections (AGI) are rare with no global consensus for diagnosis and management, we report our experience of management and complex in situ reconstruction. Methods Retrospective cohort study of 49 patients who developed AGI following EVAR and open aortic intervention from January 2010 to December 2020. Results Primary intervention was open aortic repair in 40 (81.6%) patients (7 ruptured aneurysm (rAAA), 22 aneurysmal disease and 11 aortoiliac-occlusive disease). Nine (18.4%) patients had an EVAR (3 for rAAA). AGI was identified at a median of 18 months post primary intervention. All patients were commenced on long term antibiotics. 22 (45%) patients were unfit for explantation, 8 (16.3%) were on surveillance for low grade infection, while 15 (30.6%) had an explant and aortic graft in situ reconstruction, with 2 (13.3%) requiring interval aortic stent prior to explant. Femoral vein (53%) and bovine pericardium (20%) were most commonly used conduit. Post-operative 30 day mortality was 13.3% (2 patients). Survival post-explant was 69% and 65% at 2 years and 5 years respectively versus 43% and 29% in the non-operative group. Conclusion Infrarenal aortic graft in situ reconstruction is safe following AGI with a reasonable 5 year survival rate. Patient fitness assessment is pertinent due to high perioperative risk.
Abstract Background Vascular surgical care has changed dramatically in recent years with little knowledge of the impact of system failures on patient safety. The primary aim of this multicentre observational study was to define the landscape of surgical system failures, errors and inefficiency (collectively termed failures) in aortic surgery. Secondary aims were to investigate determinants of these failures and their relationship with patient outcomes. Methods Twenty vascular teams at ten English hospitals trained in structured self-reporting of intraoperative failures (phase I). Failures occurring in open and endovascular aortic procedures were reported in phase II. Failure details (category, delay, consequence), demographic information (patient, procedure, team experience) and outcomes were reported. Results There were strong correlations between the trainer and teams for the number and type of failures recorded during 88 procedures in phase I. In 185 aortic procedures, teams reported a median of 3 (i.q.r. 2–6) failures per procedure. Most frequent failures related to equipment (unavailability, failure, configuration, desterilization). Most major failures related to communication. Fourteen failures directly harmed 12 patients. Significant predictors of an increased failure rate were: endovascular compared with open repair (incidence rate ratio (IRR) for open repair 0·71, 95 per cent c.i. 0·57 to 0·88; P =0·002), thoracic aneurysms compared with other aortic pathologies (IRR 2·07, 1·39 to 3·08; P < 0·001) and unfamiliarity with equipment (IRR 1·52, 1·20 to 1·91; P < 0·001). The major failure total was associated with reoperation (P =0·011), major complications (P = 0·029) and death (P = 0·027). Conclusion Failure in aortic procedures is frequently caused by issues with team-working and equipment, and is associated with patient harm. Multidisciplinary team training, effective use of technology and new-device accreditation may improve patient outcomes.
In this issue of Angiology, Gray et al assessed the prevalence of carotid artery stenosis (CAS) and peripheral arterial disease (PAD) in patients with abdominal aortic aneurysms (AAAs); 30.4% of patients with AAA had concomitant CAS and 45.3% had PAD (resting ankle–brachial pressure index [ABPI] 50%) used to define ‘‘significant’’ carotid atherosclerosis. It was argued that severe carotid atherosclerosis is indeed a predictor of concomitant arterial disease in other vascular beds, whereas this does not apply to moderate forms of the disease. Specific factors may lead to the development of vascular disease in 1 vascular territory rather than in another. Crosssectional data from the National Health and Nutrition Examinations Surveys 1999 to 2004 were pooled (total 7550 patients). Active smoking was more common among patients with PAD (30.0% vs 23.9%, respectively; P 1⁄4 .02), whereas hyperlipidemia was more prevalent among patients with coronary heart disease (CHD; 68.4% vs 54.0%, respectively; P < .001). The CHD was more prevalent than PAD in whites (84.6% vs 76.6%, respectively; P 1⁄4 .001), whereas the opposite was true for blacks (6.7% vs 15.9%, respectively; P < .001). An increased risk of CHD was observed only with very low (<15 ng/mL) serum vitamin D concentrations (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.02-2.14; P < 0.01). In contrast, there was a strong dose–response relationship between serum vitamin D concentration and PAD. Even a mild reduction in serum vitamin D levels (25-30 mg/dL) was associated with an increased risk of PAD (OR: 1.48; 95% CI: 1.06-2.07; P < .01). This association became considerably stronger at lower (<15 ng/mL) serum vitamin D concentrations (OR: 3.16; 95% CI: 2.05-4.87; P < .001). Increased age and smoking are strong risk factors for both vascular and malignant disease. Indeed, several multicenter randomized controlled trials publishing the long-term followup results of patients with AAA and PAD reported a high incidence of malignant neoplasms. Thus, a diagnosis of PAD, CAS, or AAAs should alert physicians to the possible concomitant presence, or future development, of several forms of cancer. Besides smoking cessation, another measure that should be implemented in vascular patients is statin treatment whether they are managed conservatively or undergo open surgical or endovascular procedures. Preoperative statin use is associated with lower perioperative/periprocedural death, myocardial infarction, and stroke rates. Additionally, statins may reduce postoperative complications, hospitalization rates, and associated costs. Furthermore, statins reduce the incidence of postoperative/postprocedural renal insufficiency and aid the earlier recovery of kidney function. Finally, statins reduce stroke risk in patients with CAS. Screening for AAAs and PAD is a controversial issue. The ABPI provides information not only for the peripheral circulation but also for the generalized atherosclerotic burden and the risk of cardiovascular events. Another emerging marker of
Purpose of the study To investigate the feasibility of undertaking a definitive Randomised Controlled Trial (RCT) to determine the effectiveness of early physiotherapy for sciatica. Methods Patient...
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