We thank Shah et al. for their comments [1] on the updated Association of Anaesthetists' safe vascular access guideline [2]. The lack of robust clinical evidence to support platelet transfusion thresholds has been acknowledged within the guidelines and supports the equipoise upon which the Thresholds for Platelets (T4P) trial is based. We await the future findings of this work, which will no doubt be invaluable in informing platelet thresholds in future guidelines. However, in the interim, the anaesthetic and critical care community requires guidance to support clinical decision-making, and our guidelines sought to advise the community based on knowledge and expertise that is currently available.
The use of viscoelastic testing has been well documented in cardiac surgery, liver transplant surgery and trauma [3]. Although there is no robust evidence for its use in central venous catheter insertion, it remains theoretically valid that it can provide valuable information regarding clot formation and strength. For example, the critical care population is highly heterogeneous, and coagulation abnormalities are common and varied [4]. The functional assessment of coagulation provided by viscoelastic testing is likely to be informative as well as a step towards the personalised care that these patients require. We recognise the use of viscoelastic testing in central venous catheter insertion as an area for further research and strongly encourage studies in this area. There is also a need to develop standardised protocols to guide use and interpretation due to a lack of familiarity with the technology and its output together with cost and resource constraints [5].
We reiterate that the updated safe vascular access guidelines are based on current available evidence, and we welcome initiatives such as the T4P trial which aims to provide the community with a strong evidence base to inform future guidelines.
Peri-operative respiratory adverse events remain a major cause of morbidity and mortality in children undergoing general anaesthesia; those with asthma are at higher risk. The aim of this feasibility study was to determine whether pre-operative measurements of fractional exhaled nitric oxide and the forced oscillation technique are feasible in children, and to explore whether these measurements can predict peri-operative respiratory adverse events.
We assigned children into respiratory or control groups, according to the presence or absence of respiratory symptoms. We recorded pre-operative measurements of fractional exhaled nitric oxide as well as respiratory mechanics, as determined by the forced oscillation technique. We then recorded the incidence of peri-operative respiratory adverse events.
We enrolled 120 children of which 116 were included. Fractional exhaled nitric oxide and respiratory mechanics (forced oscillation technique) were recorded in 106/116 (91%) and 71/116 (61%), respectively. Peri-operative respiratory adverse events occurred in 17/116 (15%) patients but there was no difference between groups (OR 2.11, 95%CI 0.74–6.55). Pre-operative fractional exhaled nitric oxide levels did not predict the occurrence of peri-operative respiratory adverse events. The measurement of respiratory mechanics using the forced oscillation technique did not predict peri-operative respiratory adverse events.
We have shown the feasibility of study enrolment and pre-operative fractional exhaled nitric oxide measurement but had difficulty obtaining measurements of respiratory mechanics (forced oscillation technique). Neither test improved the prediction of peri-operative respiratory adverse events reliably in this group of patients. A thorough pre-operative clinical history combined with care by an experienced paediatric anaesthetist remains the most reliable means of reducing peri-operative respiratory adverse events.
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