Local anaesthesia for carotid endarterectomy: Pro: protect the brain

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The effects of intraoperative lung protective ventilation with positive end-expiratory pressure on blood loss during hepatic resection surgery: A secondary analysis of data from a published randomised control trial (IMPROVE)

BACKGROUND: During high-risk abdominal surgery the use of a multi-faceted lung protective ventilation strategy composed of low tidal volumes, positive end-expiratory pressure (PEEP) and recruitment manoeuvres, has been shown to improve clinical outcomes. It has been speculated, however, that mechanical ventilation using PEEP might increase intraoperative bleeding during liver resection. OBJECTIVE: To study the impact of mechanical ventilation with PEEP on bleeding during hepatectomy. DESIGN: Post-hoc analysis of a randomised controlled trial. SETTING: Seven French university teaching hospitals from January 2011 to August 2012. PARTICIPANTS: Patients scheduled for liver resection surgery. INTERVENTION: In the Intraoperative Protective Ventilation trial, patients scheduled for major abdominal surgery were randomly assigned to mechanical ventilation using low tidal volume, PEEP between 6 and 8 cmH2O and recruitment manoeuvres (lung protective ventilation strategy) or higher tidal volume, zero PEEP and no recruitment manoeuvres (non-protective ventilation strategy). MAIN OUTCOME AND MEASURE: The primary endpoint was intraoperative blood loss volume. RESULTS: A total of 79 (19.8%) patients underwent liver resections (41 in the lung protective and 38 in the non-protective group). The median (interquartile range) amount of intraoperative blood loss was 500 (200 to 800) ml and 275 (125 to 800) ml in the non-protective and lung protective ventilation groups, respectively (P = 0.47). Fourteen (35.0%) and eight (21.5%) patients were transfused in the non-protective and lung protective groups, respectively (P = 0.17), without a statistically significant difference in the median (interquartile range) number of red blood cells units transfused [2.5 (2 to 4) units and 3 (2 to 6) units in the two groups, respectively; P = 0.54]. CONCLUSION: During hepatic surgery, mechanical ventilation using PEEP within a multi-faceted lung protective strategy was not associated with increased bleeding compared with non-protective ventilation using zero PEEP. TRIAL REGISTRATION: The current study was not registered. The original Intraoperative Protective Ventilation study was registered on clinicaltrials.gov; number NCT01282996.

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Local anaesthesia for carotid endarterectomy: Con: decrease the stress for all

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Regional or general anaesthesia for carotid endarterectomy: Does it matter?

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Reply to: how to minimise ventilator-induced lung injury in transplanted lungs

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Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: A prospective observational study

BACKGROUND: There is conflicting evidence as to whether obesity and neck circumference are predictors of difficult intubation in the surgical population. In addition, the cut-off neck circumference related to difficult intubation has not been clearly identified. OBJECTIVES: The primary study objective was to determine whether neck circumference and obesity were predictors of difficult intubation in morbidly obese surgical patients. Secondary outcomes included difficult mask ventilation. DESIGN: A prospective, noninterventional study. SETTING: Canadian tertiary care surgical centre between October 2012 and August 2013. PATIENTS: A total of 104 morbidly obese surgical patients (BMI ≥40 kg m−2) were included in the study. Eighty-eight patients were women and 16 were men. Exclusions were known difficult airway and emergency surgery. MAIN OUTCOME MEASURES: The primary outcome of the study was difficult tracheal intubation. An Intubation Difficulty Scale (IDS) was derived using seven parameters and difficult intubation was defined as IDS of at least 5. The secondary outcome was difficult mask ventilation; mask ventilation was graded as easy or difficult (inadequate, desaturation, two-handed or impossible). RESULTS: Univariate analyses showed that difficult intubation was associated with neck circumference, males, BMI more than 50 kg m−2, American Society of Anesthesiologists (ASA) status and waist circumference, and difficult mask ventilation with neck circumference, males, BMI more than 50 kg m−2 and thyromental distance. Multiple logistic regression analysis showed that neck circumference more than 42 cm (P = 0.044) and BMI more than 50 kg m−2 (P = 0.017) were independent predictors of difficult intubation. Male sex (P = 0.004) and BMI more than 50 kg m−2 (P = 0.031) were independent predictors of difficult mask ventilation.

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Reply to: preventing hypoxia

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