If you were to ask a person in the street what they knew about surveys, they would almost certainly mention opinion polls, possibly the census, and they might also mention market research surveys. If you pressed them a little further, they might comment about the fact that opinion polls were fun to follow if there wasn't any other news in the papers or on TV, but that they seemed to get the wrong answers much of the time. Mention of the census might be accompanied by comments about its infrequency these days, while market research surveys might prompt re ̄ections about interviewers stopping you in the street, or phoning you at home. If you think about your own experiences with surveys, you may be able to identify a wider range of approaches and purposes for surveys. You will certainly have read the headlines in the newspapers about controversial or unexpected ®ndings that have emerged from some survey or other. There may well have been in-depth articles or TV programmes discussing the ®ndings, or following up the implications of the ®ndings from some survey. However, it is usually only in professional journals that detailed articles give the sort of technical details which allow you to make some judgement about the quality of the survey and hence the reliability of its ®ndings. So what conclusions can you draw from all this? From the experience you already have of surveys, you can conclude that they vary in their purposes, in the methods they use for collecting data, in the timeframes in which they operate (from the 24 hours for a political `eve of poll' survey, to the 10 years or so that it can take to publish some of the more complex census data. They also vary in quality. What they all have in common are key methodological and practical issues that have to be resolved prior to ®eldwork, and data collection, transformation and analysis concerns to resolve prior to the presentation and dissemination of the ®ndings. THE NEED FOR SURVEYS IN MEDICINE

Survey research methods

Background:Mask ventilation is an essential element of airway management that has rarely been studied as the primary outcome. The authors sought to determine the incidence and predictors of difficult and impossible mask ventilation.Methods:A four-point scale to grade difficulty in performing mask ve

/pdf/incidence-and-predictors-of-difficult-and-impossible-mask-4yzczclitn.pdf

Incidence and Predictors of Difficult and Impossible Mask Ventilation

Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complications occur in easy airways: these complications can and do lead to harm and death. Because these events are rare, most of our learning comes from large litigation and critical incident databases that help identify patterns and areas where care can be improved: but both have limitations. The recent 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society provides important detailed information and our best estimates of the incidence of major airway complications. A significant proportion of airway complications occur in Intensive Care Units and Emergency Departments, and these more frequently cause patient harm/death and are associated with suboptimal care. Hypoxia is the commonest cause of airway-related deaths. Obesity markedly increases risk of airway complications. Pulmonary aspiration remains the leading cause of airway-related anaesthetic deaths, most cases having identifiable risk factors. Unrecognized oesophageal intubation is not of only historical interest and is entirely avoidable. All airway management techniques fail and prediction scores are rather poor, so many failures are unanticipated. Avoidance of airway complications requires institutional and individual preparedness, careful assessment, good planning and judgement, good communication and teamwork, knowledge and use of a range of techniques and devices, and a willingness to stop performing techniques when they are failing. Analysis of major airway complications identifies areas where practice is suboptimal; research to improve understanding, prevention, and management of such complications remains an anaesthetic priority.

Complications and failure of airway management

Several clinical multifactorial indexes have been described for predicting difficult laryngoscopy or intubation, or both, mostly in general surgery, and less frequently in ENT surgery. The objective of this study was to develop and validate a single clinical index for prediction of difficulty in tracheal intubation in both ENT and general surgery. We studied a population of 1200 consecutive ENT and general surgical patients. Clinical criteria were tested using univariate and multivariate analysis. Difficult intubation was defined as requiring unusual techniques. Logistic regression identified seven criteria as independent predictors of difficult tracheal intubation; previous history of difficult intubation; pathologies associated with difficult intubation; clinical symptoms of pathological airway; inter-incisor gap and mandible luxation; thyromental distance; head and neck movement; and Mallampati's modified test. Point values were assigned to each of these factors in proportion to regression coefficients representing the relative weight of each predictive intubation difficulty factor, the sum comprising the score. The best predictive threshold was chosen using a receiver operating characteristic curve. We then prospectively studied and validated the score in a population of 1090 consecutive ENT and general surgery patients. The sensitivity and specificity of the predictions were 94% and 96% in general surgery, 90% and 93% in non-cancer ENT surgery, and 92% and 66% in ENT cancer surgery, respectively.

/pdf/preoperative-assessment-for-difficult-intubation-in-general-2sxumaimc2.pdf

Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index.

Cervical spinal injury occurs in 2% of victims of blunt trauma; the incidence is increased if the Glasgow Coma Scale score is less than 8 or if there is a focal neurologic deficit. Immobilization of the spine after trauma is advocated as a standard of care. A three-view x-ray series supplemented with computed tomography imaging is an effective imaging strategy to rule out cervical spinal injury. Secondary neurologic injury occurs in 2‐10% of patients after cervical spinal injury; it seems to be an inevitable consequence of the primary injury in a subpopulation of patients. All airway interventions cause spinal movement; immobilization may have a modest effect in limiting spinal movement during airway maneuvers. Many anesthesiologists state a preference for the fiberoptic bronchoscope to facilitate airway management, although there is considerable, favorable experience with the direct laryngoscope in cervical spinal injury patients. There are no outcome data that would support a recommendation for a particular practice option for airway management; a number of options seem appropriate and acceptable. THE provision of acute medical care to patients with cervical spinal injuries (CSIs) is a complex, challenging, and rewarding task. It is also an anxiety-provoking endeavor because care is provided in a milieu where there is constant concern about medical interventions resulting in the conversion of a spinal injury without neurologic sequelae to one in which the two are now concurrent. It is also a topic of continuous debate because care providers struggle in an environment of limited data and incomplete answers to try to craft clinical care paradigms designed to optimize preservation and return of neurologic function, while minimizing the risk of creating additional injury and neurologic compromise. Many questions regarding the initial care of these patients, particularly as they relate to airway management, remain unresolved, but there has been great effort, energy, and enthusiasm expended during the past two decades searching for these answers. This article reviews the literature that has been generated on the topic of airway management after CSI, particularly that published in the past 10 yr, identifying new areas of knowledge and evolving practice patterns. It also attempts to address and resolve controversy surrounding areas of care that have proven more contentious, most particularly the use of the direct laryngoscope to facilitate direct tracheal intubation in these patients.

/pdf/airway-management-in-adults-after-cervical-spine-trauma-1f8t56qcqw.pdf

Airway management in adults after cervical spine trauma.

Two hundred and fifty three patients were examined before surgery for cervical spine disease. The grade of glottic visibility was determined at direct laryngoscopy, using the classification proposed by Cormack and Lehane. The overall prevalence of difficulty (grades 3 and 4) was 20%. Patients with disease that includes the occipito-atlanto-axial complex have a higher prevalence of difficulty than those with disease below the axis vertebra. Occipito-atlanto-axial disease is associated with poor mandibular protrusion. The best single predictor of difficulty was reduced separation of the posterior elements of the first and second cervical vertebrae on lateral radiographs. The Mallampati examination was the best single predictor on physical examination. The Mallampati may be an indicator of poor cranio-cervical extension. Difficulty was rare in patients with class A mandibular protrusion, and invariable in patients with class C protrusion.

Difficult direct laryngoscopy in patients with cervical spine disease

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Difficult direct laryngoscopy in patients with cervical spine disease