Background. Nasotracheal intubation typically comprises three distinct stages: (i) nasopharyngeal intubation; (ii) direct laryngoscopy to identify the vocal cords; and (iii) the passage of the tracheal tube into the trachea. The aim of this study was to identify and compare the cardiovascular responses associated with each of these stages. Methods. Seventy-®ve ASA I or II patients, aged 16±65 yr, requiring nasotracheal intubation as part of their anaesthetic management, received a standardized general anaesthetic and were allocated randomly to receive either nasopharyngeal intubation or nasopharyngeal intubation plus direct laryngoscopy or full nasotracheal intubation. Results. There was a signi®cant hypertensive response, compared with pre-induction levels, in all three groups. The maximum mean (SD) mean arterial pressure in the nasotracheal intubation group was 113 (17.1) mm Hg, which was signi®cantly greater than that in the nasopharyngeal intubation (97 (13) mm Hg) (P<0.001) and in the nasopharyngeal intubation plus laryngoscopy (103 (10.3) mm Hg) (P=0.007) groups. There was no signi®cant difference between the nasopharyngeal intubation and nasopharyngeal intubation plus laryngoscopy groups (P=0.206). A similar pattern was seen for both systolic and diastolic arterial pressure. Nasotracheal intubation caused a signi®cant increase in maximum mean (SD) heart rate, compared with pre-induction values, whereas the other two groups caused signi®cant falls. The heart rate in the nasotracheal intubation group (92 (16.5) beats min ±1) was signi®cantly greater than in the other two groups (74 (8.6) (P<0.001) and 76 (12) (P<0.001) beats min ±1 respectively). There was no signi®cant difference in heart rates between the nasopharyngeal intubation and nasopharyngeal intubation plus laryngoscopy groups (P=0.420). Conclusions. Nasopharyngeal intubation causes a signi®cant pressor response. Stimulation of the larynx and trachea by the passage of the tracheal tube, but not direct laryngoscopy, causes a signi®cant increase in this response.
Background and objectivesEducational initiatives are a sustainable means to address provider shortages in resource-limited settings (RLS), yet few regional anesthesia curricula for RLS have been described. We sought to design a reproducible training model for RLS called Global Regional Anesthesia Curricular Engagement (GRACE), implement GRACE at an RLS hospital in Ghana, and measure training and practice-based outcomes associated with GRACE implementation.MethodsFourteen of 15 physician anesthesiologists from the study location and three from an outside orthopedic specialty hospital consented to be trainees and trainers, respectively, for this prospective single-center observational study with pre–post evaluations. We conducted an initial needs assessment to determine current clinical practices, participants’ learning preferences, and available resources. Needs assessment findings, expert panel recommendations, and investigator consensus were then used to generate a site-specific curriculum that was implemented during two 3-week periods. We evaluated trainee satisfaction and changes in knowledge, clinical skill, and peripheral nerve block (PNB) utilization using the Kirkpatrick method.ResultsThe curriculum consisted of didactic lectures, simulations, and clinical instruction to teach ultrasound-guided PNB for limb injuries. Pre–post evaluations showed trainees were satisfied with GRACE, median knowledge examination score improved from 62.5% (15/24) to 91.7% (22/24) (p<0.001), clinical examination pass rate increased from 28.6% (4/14) to 85.7% (12/14) (p<0.01), and total PNB performed in 3 months grew from 48 to 118.ConclusionsGRACE applied in an RLS hospital led to the design, implementation, and measurement of a regional anesthesia curriculum tailored to institutional specifications that was associated with positive Kirkpatrick outcomes.
Pre-operative optimisation of high-risk patients undergoing major elective surgery has been shown to decrease peri-operative morbidity and mortality. It is also cost effective because of the resulting decrease in postoperative complications. A questionnaire was sent to 170 intensive care and high dependency units in Britain in order to quantify the number of units practising pre-operative optimisation. There was a 91% response rate. Of the respondents familiar with the evidence advocating pre-operative optimisation, 91% believe pre-operative optimisation improves outcome but only 62% admit patients for such preparation. Moreover, only eight units (6%) admit more than 25% of eligible patients. The reasons given for not admitting such patients pre-operatively are a lack of manpower, beds or both. This survey demonstrates the need for greater investment of resources into intensive care and high dependency units, so that clinicians can deliver high-quality evidence-based healthcare in accordance with the principles of clinical governance.
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