Traditional conscious sedation for endobronchial ultrasound procedures places patients at risk of desaturation, and high-flow nasal oxygen may reduce the risk. We designed a parallel-group randomised controlled trial of high-flow nasal oxygen at a flow rate of 30-70 l.min via nasal cannulae, compared with standard oxygen therapy at 10 l.min via a bite block in adults planned for conscious sedation for endobronchial ultrasound. The primary outcome was the proportion of patients experiencing desaturation (defined as SpO < 90%). Secondary outcomes included oxygen saturation after pre-oxygenation, lowest oxygen saturation during procedure, number of hypoxic episodes, duration of hypoxia, end-procedure end-tidal CO , satisfaction scores and complications. Thirty participants were allocated to each group. Baseline patient characteristics, procedure time and anaesthetic agents used were similar between the groups. Desaturation occurred in 4 out of 30 patients allocated to the high-flow nasal oxygen group, compared with 10 out of 30 allocated to the standard oxygenation group, a non-significant difference (p = 0.07) with intention to treat analysis. The difference was significant (p = 0.047) when using a per-protocol analysis. Oxygen saturation after pre-oxygenation and the lowest oxygen saturation during procedure were significantly higher in the high-flow nasal oxygen group compared with the standard oxygenation group; median (IQR [range] 100 (99-100 [93-100]) vs. 98 (97-99 [94-100]), p = 0.0001 and 97.5 (94-99 [77-100]) vs. 92 (88-95 [79-98]), p < 0.001, respectively. There were no differences in other secondary outcomes. Although high-flow nasal oxygen may prevent desaturation due to some causes, it does not protect against hypoxaemia in all circumstances.

The C-MAC videolaryngoscope allowed a quicker intubation time, fewer intubation attempts, and greater ease of intubation compared with the McGrath videolaryngoscope when used in patients with the Mallampati grade of ≥3.

This study explored the use of high-flow nasal oxygen (HFNO) in both pre-oxygenation and apnoeic oxygenation in adults who were intubated following a non-rapid sequence induction. Fifty patients were randomised to receive pre-oxygenation via a standard facemask or the Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) device. After five minutes of pre-oxygenation, induction and muscle relaxant agents were given. While waiting for complete paralysis, patients in the standard facemask group received bag-mask ventilation (BMV), whereas patients in the HFNO group received apnoeic oxygenation via the THRIVE device. Serial blood samples for arterial blood gas analysis were taken. Baseline patient and airway characteristics were similar. The median PaO 2 after pre-oxygenation was 357 (interquartile range [IQR] 324-450 [range 183-550]) mmHg in the facemask group, compared to 471 (IQR 429-516 [range 185-550]) mmHg in the HFNO group (P=0.01). The median arterial partial pressure of oxygen (PaO 2) in the HFNO group decreased after a period of apnoeic oxygenation, and was significantly lower when compared to patients who received BMV in facemask group. The arterial carbon dioxide partial pressure (PaCO 2) level after complete paralysis was significantly higher in the HFNO group when compared to the facemask group (median 52 [IQR 48-55 {range 40-65}] versus median 43 [IQR 40-48 {range 35-63}] mmHg, P=0.0005 and P=0.004 respectively). There were no differences in the time to muscle paralysis and time to intubation. Seven patients required use of airway adjuncts during BMV in the facemask group, compared to none in the HFNO group (P=0.004). No complications were observed in either group. HFNO produces a higher PaO 2 after pre-oxygenation and safe PaO 2 during intubation. However, the subsequent fall in PaO 2 and rise in PaCO 2 indicates that it is not as effective as BMV in maintaining oxygenation and ventilation following neuromuscular blockade.

Identification of the LFCN by ultrasound is technically feasible and more accurate than anatomical landmarks.

We investigated whether potassium (K(+)) disturbances during and following intense exercise may be pronounced when utilizing a large contracting muscle mass, examining maximal 2,000-m rowing exercise effects on radial arterial plasma K(+) concentration ([K(+)]a) in 11 healthy adults. Blood was sampled at baseline, preexercise, each 30 s during rowing, and for 30 min postexercise. Time to complete 2,000 m was 7.26 ± 0.59 min; power output at 30 s was 326 ± 81 W (mean ± SD). With exercise time expressed in deciles, power output fell 16.5% from the first to fourth decile (P < 0.05) and 19.9% at the ninth decile (P < 0.05); EMG median frequency declined 4.6% by the third decile and 5.5% by the eighth decile (P < 0.05). Plasma [K(+)]a increased from 3.89 ± 0.13 mM at rest to 6.13 ± 0.46 mM by 90 s rowing (P < 0.001) and was then sustained until end exercise (P < 0.001). In recovery, [K(+)]a decreased abruptly, reaching 3.33 ± 0.22 mM at 5 min postexercise (P < 0.001) and remaining below preexercise after 30 min (P < 0.005). At end exercise, blood [lactate]a (preexercise 0.64 ± 0.18 mM) reached 10.87 ± 1.33 mM, plasma volume decreased 9.7 ± 2.3% from preexercise, and pHa decreased to 7.10 ± 0.07 units (P < 0.001). In conclusion, arterial hyperkalemia was sustained during exhaustive rowing reflecting a balance between K(+) release and reuptake in contracting muscles and K(+) uptake by inactive muscles. While high, the [K(+)]a was lower than anticipated compared with maximal cycling or sprinting, possibly reflecting greater adrenergic response and Na(+),K(+)-ATPase activity in contracting muscles; fatigue was evidenced by reduced power output and EMG median frequency. A prolonged hypokalemia after rowing likely reflected continuing muscular Na(+),K(+)-ATPase activity.

HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass.

HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass.

SummaryWe compared nerve blockade with and without the Infiniti TM needle guide in an ultrasound in-plane porcine simula- Ultrasound is routinely used to assist vascular access and regional anaesthesia [1,2]. One of the most difficult ultrasonographic skills is continuous demonstration of the needle tip, a skill that promotes efficacy and safety [3]. Needle guides, mounted on the ultrasound probe, help practitioners keep the needle in sight. These devices reduce the number of cannulation attempts and the time taken to complete ultrasound-guided central venous access [4][5][6]. Guides also improve needle visibility and speed performance by novices in a porcine phantom [7]. Unfortunately, most guides limit adjustment of the needle path as they fix the angle of insertion at the skin, preventing their widespread use [3]. However, some guide prototypes allow a range of insertion angles and subsequent adjustment [6,7]. Recently, a commercial needle guide allowing a continuously variable needle angle has been released. We recruited both trainee and consultant anaesthetists to test the hypothesis that the use of a variable-angle needle guide increases the percentage of time the needle tip is kept in view, compared with a free-hand technique. MethodsThe Melbourne Health Human Research Ethics Committee approved this crossover simulation study. We recruited anaesthetic registrars and consultants after written informed consent. We recorded how many ultrasound-guided in-plane clinical procedures each participant had performed. We instructed participants how to contact a metal rod embedded 4 cm below the skin of a porcine specimen with a regional block needle Stimuplex â needle (BBraun, Melsungen AG, Germany); completion of a circuit, powered by a standard battery, illuminated a lamp (Fig. 1). We allowed the participants 5 min to practise their needling technique on a gel model, with and without the needle guide, assisted by instructors to achieve the best view. Participants were then randomly 826 Anaesthesia