Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy–hypoxaemia–re-oxygenation cycles can escalate to airway loss and the ‘can't intubate, can't ventilate’ scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81]) years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]) and direct laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9–19 [5–65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9–15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min−1. We conclude that THRIVE combines the benefits of ‘classical’ apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop–start process to a smooth and unhurried undertaking.

https://emcrit.org/wp-content/uploads/2011/10/Thrive.pdf

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

Postoperative pain has been poorly managed for decades. Recent surveys from USA and Europe do not show any major improvement. Persistent postoperative pain is common after most surgical procedures, and after thoracotomy and mastectomy, about 50% of patients may experience it. Opioids remain the mainstay of postoperative pain treatment in spite of strong evidence of their drawbacks. Multimodal analgesic techniques are widely used but new evidence is disappointing. Regional anaesthetic techniques are the most effective methods to treat postoperative pain. Current evidence suggests that epidural analgesia can no longer be considered the 'gold standard'. Perineural techniques are good alternatives for major orthopaedic surgery but remain underused. Infiltrative techniques with or without catheters are useful for almost all types of surgery. Simple surgeon-delivered local anaesthetic techniques such as wound infiltration, preperitoneal/intraperitoneal administration, transversus abdominis plane block and local infiltration analgesia can play a significant role in improvement of postoperative care, and the last of these has changed orthopaedic practice in many institutions. Current postoperative pain management guidelines are generally 'one size fits all'. It is well known that pain characteristics such as type, location, intensity and duration vary considerably after different surgical procedures. Procedure-specific postoperative pain management recommendations are evidence based, and also take into consideration the role of anaesthetic and surgical techniques, clinical routines and risk-benefit aspects. The role of acute pain services to improve pain management and outcome is well accepted but implementation seems challenging. The need for upgrading the role of surgical ward nurses and collaboration with surgeons to implement enhanced recovery after surgery protocols with regular audits to improve postoperative outcome cannot be overstated.

Current issues in postoperative pain management.

High-flow nasal cannula (HFNC) oxygen therapy is carried out using an air/oxygen blender, active humidifier, single heated tube, and nasal cannula. Able to deliver adequately heated and humidified medical gas at flows up to 60 L/min, it is considered to have a number of physiological advantages compared with other standard oxygen therapies, including reduced anatomical dead space, PEEP, constant F(IO2), and good humidification. Although few large randomized clinical trials have been performed, HFNC has been gaining attention as an alternative respiratory support for critically ill patients. Published data are mostly available for neonates. For critically ill adults, however, evidence is uneven because the reports cover various subjects with diverse underlying conditions, such as hypoxemic respiratory failure, exacerbation of COPD, postextubation, preintubation oxygenation, sleep apnea, acute heart failure, and conditions entailing do-not-intubate orders. Even so, across the diversity, many published reports suggest that HFNC decreases breathing frequency and work of breathing and reduces the need for respiratory support escalation. Some important issues remain to be resolved, such as definitive indications for HFNC and criteria for timing the starting and stopping of HFNC and for escalating treatment. Despite these issues, HFNC has emerged as an innovative and effective modality for early treatment of adults with respiratory failure with diverse underlying diseases.

http://rc.rcjournal.com/content/respcare/61/4/529.full.pdf

High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects

Background
Gabapentinoid (pregabalin and gabapentin) abuse is increasingly being reported.

Abuse and Misuse of Pregabalin and Gabapentin.

Recent studies showed that nasal high flow (NHF) with or without supplemental oxygen can assist ventilation of patients with chronic respiratory and sleep disorders. The hypothesis of this study was to test whether NHF can clear dead space in two different models of the upper nasal airways. The first was a simple tube model consisting of a nozzle to simulate the nasal valve area, connected to a cylindrical tube to simulate the nasal cavity. The second was a more complex anatomically representative upper airway model, constructed from segmented CT-scan images of a healthy volunteer. After filling the models with tracer gases, NHF was delivered at rates of 15, 30, and 45 l/min. The tracer gas clearance was determined using dynamic infrared CO2 spectroscopy and 81mKr-gas radioactive gamma camera imaging. There was a similar tracer-gas clearance characteristic in the tube model and the upper airway model: clearance half-times were below 1.0 s and decreased with increasing NHF rates. For both models, the anterior compartments demonstrated faster clearance levels (half-times < 0.5 s) and the posterior sections showed slower clearance (half-times < 1.0 s). Both imaging methods showed similar flow-dependent tracer-gas clearance in the models. For the anatomically based model, there was complete tracer-gas removal from the nasal cavities within 1.0 s. The level of clearance in the nasal cavities increased by 1.8 ml/s for every 1.0 l/min increase in the rate of NHF. The study has demonstrated the fast-occurring clearance of nasal cavities by NHF therapy, which is capable of reducing of dead space rebreathing.

Nasal high flow clears anatomical dead space in upper airway models

Hypercarbic respiratory failure, occurring secondary to chronic lung disease, is a frequently encountered problem. These patients present a significant challenge to respiratory and critical care services, as many are unsuitable for mechanical ventilation and most have multiple comorbidities. Recently, noninvasive ventilation (NIV) has become established as the primary modality for respiratory support in this group of patients. Several factors limit patient compliance with NIV, not least comfort and tolerability. A recent innovation in adult critical care is the use of high-flow nasal oxygen (HFNO) devices. These systems are capable of delivering high gas flows via nasal cannulae, with the ability to blend air and oxygen to give a controlled FiO2. Few clinical studies have been conducted in adults, although several are planned. To date the majority of available evidence addresses the use of HFNO in hypoxemic respiratory failure. Here we present a case in which a HFNO system was used to successfully manage hypercarbic respiratory failure in a patient unable to tolerate conventional NIV.

https://journals.sagepub.com/doi/pdf/10.1177/1753465814521890

The use of high-flow nasal oxygen therapy in the management of hypercarbic respiratory failure:

Objectives & Background Since ‘legal highs9 emerged as drugs of abuse in the UK, Emergency Physicians have battled to keep up with the latest drug craze. Whilst many of these drugs present with recognisable toxidromes, the effect of new compounds or medications cannot be readily predicted. In Belfast, we have witnessed a recent increase in the number of patients presenting after recreational abuse of Pregabalin (Lyrica). Patients, state that the medication induces a state similar to drunkenness, hence the street name ‘Budweiser9s’. To our knowledge this is the first case series detailing the recreational abuse of Pregabalin, a drug which has become popular in primary care. Methods We conducted a one year review of all patients presenting to our department after recreational drug abuse. Those who admitted to Pregabalin usage were identified and case notes were reviewed. Results Between 02/12–02/13, 10 patients presented to our ED following recreational Pregabalin abuse. All were aged between 20 and 35 years of age. Dosages ranged from 500–1400 mg. Six patients presented with seizures (5 of which were ‘first9 seizures). Two patients required intubation and ventilation and were admitted to the ICU. In total, nine patients were admitted for a minimum of 24 hours, whilst one patient discharged against advice. Conclusion Emergency Physicians should be aware of the current use of Pregabalin as a recreational drug. Patients are either taking tablets whole or cutting and snorting them. 60% of patients in this case series presented to the ED with seizures and 20% required ICU admission. We recommend that patients who present with potential Lyrica toxicity should be admitted for observation with the treating physician being mindful of the potential for seizure activity.

https://emj.bmj.com/content/emermed/30/10/874.2.full.pdf

Lyrica nights–recreational pregabalin abuse in an urban emergency department

The 2016 budget gave the NHS in Northern Ireland a small amount of new funding.1 We like many others were delighted to hear the announcement, by the chancellor and the minister of health at the Northern Ireland Assembly, of funding for a helicopter emergency medical service (HEMS). …

/pdf/need-for-systematic-audit-of-trauma-care-in-northern-ireland-21je9l7rte.pdf

Need for systematic audit of trauma care in Northern Ireland

The use of carbohydrate counting is a common means by which patients with type 1 diabetes mellitus may improve their glycemic control and has been shown to be efficacious in adults. Despite this, judging the carbohydrate content of meals and snacks is often difficult, with underestimation being associated with higher glycemic variability and a shorter time spent within the glycemic target range. A challenge to carbohydrate counting may be posed by the unknowing consumption of sugarsweetened soft drinks. The increasing consumption of soft drinks is a global phenomenon, with annual average worldwide consumption estimated at 45.1L (11.4 gallons) per person in 2010. In response to an increasing public awareness of the potential harms associated with soft drink consumption, many manufacturers have started to produce low-sugar or sugar-free alternatives. Although the sugar content of drinks is usually made clear by producers, and in fact often used to promote a product, in social circumstances drinks packaging may not be readily available. In addition, previous investigation has shown that distinguishing sugar-sweetened from sugar-free products by taste is inaccurate. Reagent test strips (or dipsticks) are routinely used to identify the presence of glucose in urine. The presence of glucose in solution is indicated by a color change on the test strip, which requires no advanced knowledge or training to recognize. These strips are of low cost and are easily stored with a long shelf life. We investigated the ability of urine test strips to distinguish between sugar-free and sugar-sweetened soft drinks. Commercially available urine test strips (Combur; Roche Diagnostics, Rotkreuz, Switzerland) were used to test four common soft drinks for the presence of glucose: Coca-Cola, Diet Coca-Cola, Sprite and Sprite Zero (The Coca-Cola Company, Atlanta, GA, USA). The sugar content for each beverage was retrieved from the manufacturer’s website (http://www.coca-cola.co.uk/drinks/cocacola/, accessed 11 May 2016). Diet Coca-Cola and Sprite Zero were reported as being sugar free, whereas Coca-Cola contains 10.6g/dL sugar and Sprite contains 6.6g/dL sugar. Two investigators, blinded to the identity of the beverages, conducted the experiments. Beverages were obtained from 2-L containers of cola, diet cola, clear diet soda or clear soda and, from each, 20 50-mL samples were decanted into polystyrene cups. Each sample was tested using the test strips as per the manufacturer’s instructions, as if urine was being analyzed. The presence or absence of glucose was noted. Urine test strips showed strongly positive for glucose in all 40 sugar-containing samples. Equally, test strips remained unequivocally negative for glucose in all 40 sugar-free samples. Results were clear within 60 s in all tests. This investigation demonstrates that urine test strips are a convenient, cheap, and accurate means of differentiating sugar-sweetened from sugar-free soft drinks. However, there are several limitations to the present study. First, urine dipsticks only test for the presence of glucose. Many soft drinks also contain sugar as fructose or sucrose, which would not be detected by these strips. Second, we did not formally assess whether the use of the test strips adversely altered the flavor or safety of the beverage, and therefore recommend that drinks should only be tested by obtaining small aliquots that are subsequently discarded. Given the global soft drink variety and consumption, patients with type 1 diabetes who rely on carbohydrate counting to enhance glycemic control require an easy means of avoiding inadvertent sugar consumption. The use of urine test strips, easily available, may provide a practical means of identification.

The soda dipstick: A convenient and cost-effective means of identifying the sugar content of soft drinks.

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The use of high-flow nasal oxygen therapy in the management of hypercarbic respiratory failure:

Lyrica nights–recreational pregabalin abuse in an urban emergency department

Need for systematic audit of trauma care in Northern Ireland

The soda dipstick: A convenient and cost-effective means of identifying the sugar content of soft drinks.