Anaesthesia and Intensive Care最新文献

Central venous catheter (CVC) line insertion packs contain single-use plastic and metal items that are disposed of after the pack is opened, regardless of whether the item was used. This study aimed to collect data on the experiences and views of Australian clinicians who use CVC line insertion packs in paediatric critical care, elicit possible solutions to reduce waste associated with these packs, and to estimate the potential for financial and carbon footprint savings from a refined pack. This study was performed in two large paediatric tertiary referral hospitals in Sydney, Australia. Clinicians were invited to a survey and an interview to determine if and what items from a CVC line insertion pack could be excluded. Outcome measures included financial costs and embodied carbon emissions (CO_2e). Of approximately 200 eligible clinicians who were invited, 25 (12.5%) completed the survey and 18 (9%) were interviewed (five did both). All survey respondents were willing to use a new pack that had less waste. They identified five items within the existing CVC pack as commonly non-essential. Interview data identified additional strategies for waste minimisation, including use of a trolley that allowed choice of items to use. Many clinicians expressed moral distress concerning healthcare's impact on the environment. We calculated that a refined CVC pack without these five items would save the two participating hospitals approximately A$1400 and 230 kg CO_2e per year. Financial and carbon savings may be achieved through removing items that are infrequently used and/or through use of a trolley.

Extracorporeal membrane oxygenation (ECMO) is a method of life support provided in a limited number of (typically centralised) intensive care units (ICUs) which may lead to inequity in the delivery of ECMO. We conducted a retrospective cohort study of all ICU admissions in Australia and New Zealand reported to the Australian and New Zealand Intensive Care Society Adult Patient Database between 2018 and 2022. We performed descriptive and propensity-matched analyses to determine how healthcare jurisdiction, remoteness, and initial admitting hospital type (based on ECMO capability) affected the chance of receiving ECMO. There were 703,529 patients at 199 hospitals who met inclusion criteria, of whom 1654 (0.2%) received ECMO. After propensity matching, patients had a reduced odds of receiving ECMO if admitted in the Australian Capital Territory (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.86), New Zealand (OR 0.42, 95% CI 0.26 to 0.67), Northern Territory (OR 0.29, 95% CI 0.1 to 0.86), Queensland (OR 0.53, 95% CI 0.45 to 0.63) or Western Australia (OR 0.46, 95% CI 0.35 to 0.62) compared with New South Wales. Patients from Outer Regional areas were less likely to receive ECMO than those residing in a Major City (OR 0.77, 95% CI 0.63 to 0.94). Initial admission in a non-ECMO centre was associated with reduced odds of receiving ECMO (OR 0.60, 95% CI 0.52 to 0.69), whilst initial admission in a Major ECMO centre was associated with increased odds of receiving ECMO (OR 2.03, 95% CI 1.78 to 2.31), compared with Minor ECMO centres. Our study suggests there is inequity in the delivery of ECMO in Australia and New Zealand, which should inform policy and planning for ECMO provision throughout the region.

Fibreoptic intubation (FOI) is an essential skill expected of specialist anaesthetists. With advances in alternative techniques for managing difficult airways, training opportunities for FOI have diminished. We sought to investigate the cumulative number of FOIs performed by anaesthesia trainees and assess their confidence in both independently performing and teaching FOI. An online survey was emailed to all registrars and provisional fellows working in Western Australian (WA) anaesthesia departments. There were 224 surveys sent and 100 (44.6%) respondents. The median cumulative number of FOIs was 5 (interquartile range (IQR) 0-30), with trainee registrars performing a median of 4 (IQR 0-20) and provisional fellows performing 18 (IQR 9.0-27.5) FOIs. The trainees rarely performed FOIs unsupervised, as 98.7% of trainee registrar and 88.6% of provisional fellow FOIs had level 1-2 supervision. Confidence to teach or independently perform FOI was low, even among provisional fellows. The Pearson correlation coefficient between the number of awake FOIs and confidence was 0.751. Extrapolating from these responses, the number of awake FOIs required for trainees to feel very confident in independent awake FOI was 19 (R² = 0.564, P < 0.001). Fibreoptic bronchoscopy simulator use was common (72%); however, completion of an awake fibreoptic course was low (32%). This survey found FOI among trainee and provisional fellow respondents in WA to be infrequent, and confidence to independently perform or teach an awake FOI to be low. We recommend increasing opportunities for awake FOI and implementing an advanced airway management course to help address this gap in anaesthesia training.

This case report describes the management of a patient with a lumbar arachnoid cyst requesting epidural labour analgesia. The patient was otherwise healthy but had suffered from multiple dural punctures during attempted epidural placement in a previous pregnancy. Magnetic resonance imaging following the dural punctures revealed the cyst, which was at the level of the L3-4 interspace, effacing the posterior epidural space at that level. Multidisciplinary management in this subsequent pregnancy, involving radiology and anaesthesia specialists, allowed ultrasound-guided identification of a higher epidural space, and successful and uneventful epidural placement during labour. Multiple dural punctures with attempted epidural placement should prompt anaesthetists to consider spinal magnetic resonance imaging to identify anatomical abnormalities that may be present, which may have implications for future management.