Anaesthetic training in accident and emergencyEDITOR,-I read with interest the comments of Boyle et al 1 regarding anaesthetic training for accident and emergency (A&E) specialist registrars. They suggest that there is a definite advantage of spending six months as a "true" anaesthetic SHO as part of the A&E specialist registrar scheme, rather than as a supernumerary extra in theatre. As someone who initially undertook a training in anaesthesia with a view to entering higher training in A&E via this route, I would agree that it oVers much more than the opportunity to become confident and competent at advanced airway management in the relatively controlled theatre setting. Training in anaesthesia oVers the chance to gain many other skills that are extremely useful to the A&E trainee, particularly in the resuscitation setting, including the assessment and management of critically ill patients, providing ventilatory and circulatory support where necessary, the use of anaesthetic equipment, invasive haemodynamic monitoring techniques and transportation of critically ill patients. The opportunity to become proficient at the various regional anaesthetic techniques and to gain an understanding of pain management is also very relevant to A&E practice.The possession of the FRCA, which requires at least 2.5 years of training in anaesthesia, is one of the established ways to enter the A&E specialist registrar grade. Surprisingly, in the current membership list of the British Association of A&E Medicine, only 60 (0.05%) members possess the DA (or old primary FRCA), with only 12 (0.01%) possessing the FRCA or equivalent.2 As our specialty continues to develop and accepts more responsibility for early advanced airway management, ventilatory and circulatory support and rapid sequence inductions, both within the A&E department and in the pre-hospital setting, I feel that we should encourage more of our junior trainees interested in a career in A&E to enter the specialist registrar grade via this route.
INTRODUCTION:Antibiotics administered when membranes rupture (ROM) after viability increase latency to delivery. This may also be true in previable prelabor preterm rupture of membranes (pPPROM). This study assesses the effect of prophylactic antibiotics on latency in individuals with pPPROM.METHODS:Retrospective cohort of pregnancies with pPPROM less than 23 weeks 0 days in a single health system (2013–2022). Patients opting for termination or with contraindication to expectant management were excluded. Prophylactic antibiotic administration (48 hours IV azithromycin/ampicillin followed by 5 days oral amoxicillin) was at clinician discretion. The primary outcome was latency (weeks) from diagnosed pPPROM to delivery. Secondary outcomes included maternal and neonatal morbidity and mortality. Bivariate statistics compared patients who did and did not receive antibiotics. Kaplan-Meier/Cox proportional hazards ratio using significant covariates (P<.1) in bivariate analysis models antibiotic effect on latency.RESULTS:Ninety-three patients had pPPROM; 46 (49%) met inclusion criteria. Thirty-four (74%) received prophylactic antibiotics. Median gestational age (GA) at ROM trended later among those who received antibiotics (22.0 weeks [20.6, 22.4] versus 20.9 weeks [19.6, 21.7], P=.09). Median latency (interquartile range) did not differ with antibiotic receipt (1 week [0.4, 2.6] versus 0.6 weeks [0.3, 0.9], P=.27). When adjusted for GA at ROM, antibiotics were not associated with longer latency (hazard ratio 1.33 [0.91, 1.93]). Antibiotic receipt was associated with lower rates of previable delivery (23.0 weeks [22.7, 24.0] versus 21.3 weeks [20.5, 23.1], P=.006). After controlling for GA at ROM, adjusted odds of previable delivery remained lower with receipt of antibiotics (adjusted odds ratio 0.20 [0.04, 0.90]).CONCLUSION:Antibiotics at the time of pPPROM were not associated with longer latency but, after controlling for confounders, did increase the odds of delivering after viability. Further study should address optimal antibiotics strategies for this unique population.
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