ARISE trial participants with isolated hyperlactatemia had worse adjusted 90-day mortality than those with isolated refractory hypotension. In septic patients, isolated hyperlactatemia may define greater illness severity and worse outcomes than isolated refractory hypotension.

Emergency front-of-neck access to achieve a percutaneous airway can be a life-saving intervention, but there is debate about the preferred technique. This prospective, observational study was designed to compare the two most common emergency surgical airway techniques in a wet lab simulation using an ovine model. Forty-three doctors participated. After providing standardised reading, a lecture and dry lab benchtop training, participants progressed to a high-fidelity wet lab simulation. Participants entered an operating theatre where a 'cannot intubate, cannot oxygenate' situation had been declared and were directed to perform emergency front-of-neck access: first with a cannula technique (14-gauge cannula insertion with ventilation using a Rapid-O2 â cricothyroidotomy insufflation device); and subsequently, a scalpel-bougie technique (surgical incision, bougie insertion into trachea and then tracheal tube passed over bougie, with ventilation using a self-inflating bag). The primary end-point was time from declaration of 'cannot intubate, cannot oxygenate' to delivery of oxygen via a correctly placed percutaneous device. If a cannula or tracheal tube was not placed within 240 s, the attempt was marked as a failure. There was one failure for the cannula approach and 15 for the scalpel-bougie technique (OR 0.07 (95%CI 0.00-0.43); p <0.001). Median (IQR [range]) time to oxygenation, if successful, was 65 (57-78 [28-160]) s for the cannula approach and 90 (74-115 [40-265]) s for the scalpel-bougie technique (p=0.005). In this ovine model, emergency front-of-neck access using a cannula had a lower chance of failure and (when successful) shorter time to first oxygen delivery compared with a scalpel-bougie technique.Additional supporting information may be found online in the Supporting Information section at the end of the article.Appendix S1. Specifics of emergency front of neck access (eFONA) techniques.

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Background: It is important to restore horizontal and vertical stability to the acromioclavicular (AC) joint when treating dislocations of this joint. Most surgical stabilization techniques of the AC joint have primarily addressed the coracoclavicular ligament complex; however, these techniques may not satisfactorily restore horizontal stability to the AC joint. Purpose: To evaluate the strength and bidirectional stability of 3 AC joint stabilizing techniques in a cadaveric model. Study Design: Controlled laboratory study. Methods: A total of 24 cadaveric shoulders were randomly allocated to 3 treatment groups. For each group, a standardized AC joint stabilizing procedure was performed, and the specimens were potted for mechanical testing. The following reconstruction techniques were used: a single clavicular tunnel for group A, a double clavicular tunnel for group B, and a double clavicular tunnel plus suture fixation across the AC joint for group C. The specimens underwent cyclic loading in the horizontal and vertical planes and then load to failure. Eight control specimens also underwent cyclic loading in both planes. Construct stiffness during cyclic loading, change in displacement after cyclic loading in both planes, load to failure in the vertical plane, and mode of failure were evaluated, and stiffness was compared among the treatment groups as well as with a control group. Results: There was a decrease in joint stiffness for all groups, including controls, during the cyclic loading. Compared with controls, all 3 treatment groups demonstrated equivalent stiffness and displacement in the vertical plane. In the horizontal plane, all 3 treatment groups demonstrated decreased stiffness, increased displacement, or both when compared with controls. When groups were compared, no treatment arm proved superior regarding stiffness or displacement in either plane. Load-to-failure testing of the 3 treatment groups in the vertical plane demonstrated construct strength and stiffness comparable with reports for the native AC joint. The mode of failure was predominantly fracture at the point of fixation to the testing apparatus. Conclusion: There was no difference in bidirectional strength and stability between the single– and double–clavicular tunnel techniques of coracoclavicular reconstruction. The addition of a stabilizing suture across the AC joint does not improve horizontal stability in the absence of repair of the AC joint capsule and deltotrapezial fascia. Clinical Relevance: This laboratory study provides further evidence of the importance of the AC joint capsule and associated soft tissues in affording horizontal stability to that joint. Information from this and subsequent studies utilizing a bidirectional model can influence the choice of surgical procedure in the clinical treatment of AC joint dislocations.

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Platelet transfusion was not associated with increased mortality or infective complications following first cardiac surgery. Further prospective studies are required to identify patients most likely to benefit from platelet transfusion.

BACKGROUND: Pectoral nerves (PECS II) block is a popular regional analgesia technique for breast surgery. PECS II block or local infiltration by surgeon may improve outcomes including quality of recovery (QoR). METHODS: In this multicenter randomized clinical trial, 104 female patients undergoing breast surgery received: (1) PECS II block with local anesthetic and surgical infiltration with 0.9% saline (PECS group) or (2) PECS II block with 0.9% saline and surgical infiltration with local anesthetic (infiltration group). Patients, anesthetists, surgeons, nursing staff, and research assistants were blinded to group allocation. Patients received standardized general anesthesia and multimodal analgesia. The primary outcome was the global score (maximum score, 150; good recovery, 118) of the multidimensional (pain, comfort, independence, psychological, emotional) QoR-15 questionnaire measured 24 hours postoperatively. Secondary outcomes were pain, and its functional interference measured 24 hours and 3 months postoperatively using the Brief Pain Inventory (BPI) short form (0, optimal; 120, worst possible). Randomly assigned groups were compared on outcomes using the Wilcoxon rank-sum test, and the results were reported as median difference with 95% confidence interval. RESULTS: One hundred eight patients were recruited from August 17, 2016 to June 8, 2018, and 4 patients were withdrawn. Twelve patients from 104 had mastectomy, with the remainder having less invasive surgery. Baseline QoR-15 global scores reported as median [quartiles] were 135 [129, 143] in the PECS group and 139 [127, 143] in the infiltration group. The 24-hour QoR-15 global score reported as median [quartiles] was 131 [116, 140] in the PECS group and 123 [117, 143] in the infiltration group (P = .60), with median difference (95% confidence interval) of −2 (−9 to 5). The median difference reported as infiltration minus PECS for QoR-15 domains was pain 0 (−2 to 1), physical comfort −1 (−3 to 2), physical independence 0 (−2 to 1), psychological support 0 (0–0), and emotions 0 (−1 to 2) (P > .28). The BPI pain subscale at 24 hours (0–40, lower score indicates less pain), reported as median [quartiles], was 7 [2, 13] in the PECS group and 10 [5, 17] in the infiltration group (P = .15). The BPI global score at 24 hours, reported as median [quartiles], was 20 [7, 36] in the PECS group and 23 [10, 43] in the infiltration group (P = .34) and at 3 months was 0 [0, 14] and 0 [0, 11] (P = .85). CONCLUSIONS: After mostly minor surgery for breast cancer, PECS II block was not superior to local infiltration by the surgeon.

Purpose This pilot study evaluated the feasibility of investigating the effect of the erector spinae plane (ESP) block on the patient-centred outcomes of quality of recovery-15 (QoR-15), and brief pain inventory (BPI) in thoracic and breast surgery patients. Methods In this randomized-controlled pilot trial, 82 patients undergoing video-assisted thoracoscopic surgery (n = 77) and mastectomy (n = 5) received either continuous ESP block with ropivacaine (ropivacaine group) or the same procedure with 0.9% saline (saline group). All patients received surgical intercostal block (thoracic surgery) or local anesthetic infiltration (breast surgery). Feasibility as the primary outcome was evaluated on recruitment (three patients per week), catheter retention (above 90% at 24 hr), and patient attrition (less than 10%). Secondary outcomes comprised of QoR-15, BPI, and opioid consumption.Results Recruitment rate was 1.8 patients per week. Catheters were retained in 77 patients (94%) at 24 hr. At three months, five patients were lost to follow-up (6%). At 24 hr compared with baseline, the ropivacaine group had a smaller decline in QoR-15 score (median difference, 14; 95% confidence interval [CI], 2 to 26; P = 0.02) and a smaller increase in BPI global score (median difference, 14; 95% CI, 0 to 24; P = 0.048). There was no difference in opioid consumption (P = 0.08). Conclusions In this pilot study, the target recruitment rate was not met, but catheter retention and patient attrition rates were both satisfactory. A definitive trial with QoR-15 as the primary outcome would require 300 study participants. Trial registration Australian New Zealand Clinical Trials Registry (ID12618000701224); registered 30 April 2018.