BackgroundThe difference in patient comfort with conscious sedation (CS) versus general anaesthesia (GA) for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with CS is non-inferior to GA.Methods96 subjects were randomized to receive CS or GA for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included: Willingness to undergo a repeat procedure if necessary andlevel of sedation assessed clinically and by Bispectral Index (BIS) monitoring.ResultsThere was no significant difference between subject comfort scores (difference −0.01 (95% CI −0.63, 0.61 on a 10 point scale,, p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, (95% CI −4.8%, 15.5%); p=0.37). Deeper levels of sedation in the GA cohort was confirmed with both clinical and BIS. There was no significant difference in diagnostic accuracy (CS: 93.9% (95% CI 80.4%, 98.3%) versus GA: 86.5% (95% CI 72.0%, 94.1%); p=0.43). There were more complications (29.6% (95% CI 18.2%, 44.2%) versus 6.1% (95% CI 2.1%, 16.5%); p<0.01) in the GA group. There was no relationship between high BIS scores and subject discomfort. BIS levels of less than 40 during a procedure was associated with increased complications.ConclusionCS is not inferior to GA in providing patient comfort during bronchoscopy despite lighter sedation and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.
Acute noninvasive ventilation (NIV) is a well-established therapy for acute respiratory failure but the dose–response characteristics of this therapy have not been defined. The aim of this study was to define this dose–response relationship.This study was a retrospective review of patients receiving NIV for acute respiratory failure in a tertiary hospital respiratory high-dependency unit between July 2012 and June 2017. Mask-on time (rather than the period that NIV was in use) as the “dose” was compared with hospital survival as the “response”.654 patients were included, 594 (91%) with hypercapnic respiratory failure (HCRF). NIV was used for a median (interquartile range (IQR)) duration of 2.74 (1.51–4.73) days and median (IQR) mask-on time was 34 (18–60) h (56.1% (41.2–69.5%) of treatment time). There was evidence of a dose–response relationship in the HCRF group up to a ceiling of 24 h mask-on time, but not in the hypoxaemic respiratory failure (HRF) group. There was a difference in survival with as little as 2 h mask-on time (92% compared with 73%; p<0.001). Patients requiring NIV for 80–100% of therapy time had lower survival.We conclude that there is evidence of a dose–response relationship between cumulative NIV usage (mask-on time) and survival from as little as 2 h to a ceiling of ∼24 h in HCRF, but not in HRF.
In this observational study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest and in the post-ROSC transfer phase. Further research is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.
Introduction: Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS)
are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness
of chemical sedation and any associated complications.Methods: A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used
as the primary outcome measure.Results: A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT
scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical
restraint.Conclusion: Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need
for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.
The instigation of a clinical pathway focused on the use of bedside pleural ultrasound, and teaching of drainage techniques with procedure supervision vastly improved patient outcomes. This not only allowed better quality of care for patients, it also provided the acquisition of new skills to medical staff, not limiting these skills to specialised staff.
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