SummaryWe studied the LMA Supreme TM in 100 elective, anaesthetised, healthy patients assessing: ease of use, airway quality, anatomical and functional positioning, airway leak and complications. Insertion was successful on first, second or third attempt in 90, nine and one patient respectively. Thirty manipulations were required in 22 patients to achieve a clear airway. Median [interquartile (range)] insertion time was 18 [10-25 (5-120)] s. During ventilation, an expired tidal volume of 7 ml.kgwas achieved in all patients. Median [interquartile (range)] airway leak pressure was 24 [20-28 (13-40)] cmH 2 O. On fibreoptic examination via the device, vocal cords were visible in 83 patients (85%). During maintenance, five patients (5%) required 13 airway manipulations. There was one episode of minor regurgitation, without aspiration. Other complications and patient side-effects were mild and few. The LMA Supreme is easily and rapidly inserted, providing a reliable airway and good airway seal. Further studies are indicated to assess safety and performance compared to other supraglottic airway devices.

Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization.

Evidence for ERAS within thoracic surgery (ERATS) is building. The key to enabling early recovery and ambulation is ensuring that postoperative pain is well controlled. Surgery on the chest is considered to be one of the most painful of surgical procedures for both open and minimally invasive surgery (MIS) approaches. Increasing use of MIS and improved perioperative care pathways has resulted in shorter length of stay (LOS), requiring patients to achieve optimal pain control earlier and meet discharge criteria sooner, sometimes on the same day as surgery. This requires optimizing pain control earlier in the postoperative recovery phase in order to enable ambulation and a better recovery profile, as well as to minimize the risk for development of chronic persistent postoperative pain (CPPP). This review will focus on the options for pain management protocols within an ERAS program for thoracic surgery patients (ERATS).

Objective: Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs. Methods: Sixteen emergency medicine residents volunteered for a pre-and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence. Results: Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p < 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p < 0.01) and all felt satisfied with the training program. Conclusion: This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.

Background: Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches.Methods: Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery. Conclusions: Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required.Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Background: Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial.Methods: Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL).Results: A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3⋅1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was −111 ml (P = 0⋅456). Among patients at high risk of transfusion, the median EBL difference was −448 ml (P = 0⋅069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7⋅6(1⋅9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0⋅326).Conclusion: Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 (http://www.clinicaltrials.gov).

Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace.

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