A randomised controlled trial comparing incentive spirometry with the Acapella® device for physiotherapy after thoracoscopic lung resection surgery

Lung resection surgery has been associated with numerous postoperative complications. Seventy‐eight patients scheduled for elective video‐assisted thoracoscopic lung resection were randomly assigned to receive standard postoperative care with incentive spirometry or standard care plus positive vibratory expiratory pressure treatment using the Acapella^® device. There was no significant difference between incentive spirometry and the Acapella device in the primary outcome, forced expiratory volume in 1 s, on the third postoperative day, mean (SD) 53% (16%) vs 59% (18%) respectively, p = 0.113. Patients treated with both devices simultaneously found incentive spirometry to be less comfortable compared with the Acapella device, using a numeric rating scale from 1 to 5 with lower scores indicating higher comfort, median (IQR [range]) 3 (2–3 [2–4]) vs 1 (1–2 [1–3]) respectively, p < 0.001. In addition, 37/39 patients (95%) stated a clear preference for the Acapella device. Postoperative treatment with the Acapella device did not improve pulmonary function after thoracoscopic lung resection surgery compared with incentive spirometry, but it may be more comfortable to use.     

Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective,double-blind randomised clinical trial*

Rebound pain after brachial plexus block resolution and development of long-lasting pain are problems associated with volar plate fixation for distal radius fractures. The aim of this double-blind study was to evaluate the effect of a single prophylactic intravenous dose of dexamethasone in this setting. The primary endpoint was highest pain score during the first 24 hours after surgery. We included 51 adults of ASA physical status 1–2 due to undergo planned acute fixation of the radius. All received premedication with oral paracetamol and etoricoxib, and a pre-operative brachial plexus block with ropivacaine. Patients were randomly allocated into two groups: a dexamethasone group receiving 16 mg dexamethasone intravenously at start of surgery and a control group receiving 4 ml saline. After surgery, all patients received fixed doses of paracetamol, etoricoxib and oxycodone, with further oxycodone added as needed in the first 48 hours. Pain, analgesic consumption and daily function were registered at predefined times up to 1 year after surgery. Median (IQR [range]) worst pain score in the first 24 hours, as assessed by verbal numeric rating scale (0–10), was 4 (2-6 [0–7]) in the dexamethasone group compared with 8 (5–8 [2–10]) in the placebo group (p < 0.001). Average pain score, 2 (1–4 [0–5]) vs. 5 (3–6 [0–8]), p = 0.001 and rescue oxycodone consumption, 5 (0-10 [0-35]) mg vs. 10 (5-15 [0-50]) mg, p = 0.037), respectively, were both significantly lower in the dexamethasone group compared with control from 8 to 24 hours. Brachial plexus block duration was 69% longer in the dexamethasone group, 21.5 (19.1-23.4 [12.9-24.1]) hours vs. 12.7 (11.9-15.3 [7.4-26.6]) hours, p < 0.001. Two patients (9%) in the dexamethasone group compared with 12 (50%) in the placebo group experienced worst pain scores of 8-10 during the first 36 hours (p = 0.002). At 3 and 7 days postoperatively, there were no significant differences between groups for pain scores or opioid consumption. At 6 months, 27 patients (57%) reported pain at the site of surgery, with significantly higher average pain score (p = 0.024) in the placebo group. At 1 year, two patients in the dexamethasone group reported pain compared with 10 in the placebo group (p = 0.015), and worst pain score was significantly higher in the placebo group (p = 0.018). We conclude that intravenous dexamethasone improves early postoperative analgesia and may also improve clinical outcomes after 6 and 12 months.     

The numerical translation of verbal probability expressions by patients and clinicians in the context of peri-operative risk communication

Shared decision-making is central to the pre-operative consent process and accurate communication of risk is dependent on a clear understanding of numerical information by both the patient and clinician. The risk of an adverse event or complication is often described using verbal probability expressions but how these are interpreted by clinicians and patients in the pre-operative setting has not been studied. We asked patients and clinicians to assign a numerical translation (as a percentage) for seven verbal probability expressions in relation to the probability of a major peri-operative complication occurring. In total, data from 290 patients and 57 clinicians were analysed. There was a wide range in percentages assigned by patients to all verbal probability expressions. Patients assigned a wider range of percentage values to each of the verbal probability expressions and these were all significantly higher than those assigned by clinicians: median (IQR [range]) negligible risk 5% (1–15 [0–100]) vs. 0% (0–0 [0–5]); minimal risk 5% (2–10) [0–100]) vs. 1% (0–1 [0–10]); low risk 10% (3–10 [0–100]) vs. 1% (0–2) [0–10]); standard risk 20% (10–40) [0–100]) vs. 1% (1–5) [0–30]); moderate risk 33% (20–50) [0–100]) vs. 5% (3–10) [0–80]); high risk 70% (30–90 [0–100]) vs. 15% (10–40) [1–75]); and very high risk 90% (50–95 [0–100]) vs. 40% (20–50 [5–100]), respectively (p < 0.005 for all comparisons). There is considerable variation in the numerical translation of verbal probability expressions by both patients and clinicians. This suggests that verbal probability expressions should not be used in isolation as part of doctor–patient discussions regarding peri-operative risk.     

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised,observer-masked,controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0–10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0–3.7 [0–7]) vs. 5.5 (5.0–7.0 [2–8]) at 12 h; 3 (2.0–4.0 [0–7]) vs. 6 (5.0–6.0 [2–8]) at 24 h; and 2.0 (2.0–4.0 [0–5]) vs. 3.0 (2.0–4.7 [0–6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.     

The effect of the jaw‐thrust manoeuvre on the ability to advance a tracheal tube over a bronchoscope during oral fibreoptic intubation

During fibreoptic intubation, it is often difficult to advance a tracheal tube over the fibreoptic bronchoscope. We performed a prospective randomised study to investigate the effect of the jaw‐thrust manoeuvre on the ability to advance a tracheal tube during oral fibreoptic intubation. After placing the bronchoscope in the trachea, an assistant randomly applied a jaw‐thrust manoeuvre (jaw‐thrust group) or sham manoeuvre (control group) in 82 patients during tube advancement. The jaw‐thrust group had a higher success rate on the first attempt (70.7% vs 34.1%, p = 0.002), required fewer attempts (median (IQR [range]) 1 (1–2 [1–3]) vs 2 (1–3 [1–4]), p < 0.001), and took less time [6 (4–8 [2–16]) s vs 10 (7–15 [3–40]) s, p < 0.001] for tube advancement compared with the control group. The jaw‐thrust manoeuvre facilitates the advancement of a tracheal tube over the bronchoscope during oral fibreoptic intubation.     

Transnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) vs. facemask breathing pre‐oxygenation for rapid sequence induction in adults: a prospective randomised non‐blinded clinical trial

Transnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) can prolong apnoea time in adults. Therefore, THRIVE used for pre‐oxygenation in rapid sequence induction of anaesthesia could extend safe apnoea time during prolonged laryngoscopy and intubation. In this randomised controlled trial, we compared the lowest peripheral oxygen saturation (SpO₂) during intubation when pre‐oxygenating with either traditional facemask or THRIVE. Eighty adult patients, undergoing rapid sequence induction of anaesthesia for emergency surgery, were randomly allocated to pre‐oxygenation with 100% oxygen with facemask or with THRIVE. Median (IQR [range]) lowest SpO₂ until 1 min after intubation was 99% (97–100 [70–100]%) for the facemask group vs. 99% (99–100 [96–100]%) for the THRIVE group (p = 0.097). Five patients (12.5%) desaturated below 93% when pre‐oxygenated with the facemask vs. none in the THRIVE group (p = 0.019). There were no differences in intubation time or apnoea time between the groups. Median intubation time was 51 (34–66 [22–261]) s in the facemask group vs. 48 (38–63 [10–146]) s in the THRIVE group (p = 0.99). Median apnoea time was 109 (86–142 [37–291]) s and 116 (92–146 [63–249]) s when using facemask and THRIVE, respectively (p = 0.49). No signs of regurgitation of gastric content were detected. The data on desaturation indicate potential benefits of oxygenation with THRIVE for rapid sequence induction compared with facemask pre‐oxygenation.     

The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg⁻¹ morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy.     

Analgesic efficacy of pre‐operative stellate ganglion block on postoperative pain relief: a randomised controlled trial

We undertook a randomised, double‐blind, placebo‐controlled study to compare the analgesic efficacy of pre‐operative stellate ganglion block on postoperative pain relief after upper limb orthopaedic surgery. Patients were administered a 3‐ml injection during ultrasound‐guided stellate ganglion block; 15 patients received lidocaine 2% and 15 patients received 0.9% saline. Following the block, all patients received standardised general anaesthesia. Postoperative analgesia included regular intravenous diclofenac, paracetamol and patient‐controlled analgesia with tramadol for 24 h. Patients were observed at 0, 2, 4, 6, 8, 12 and 24 h after surgery for tramadol consumption, cardiovascular variables and visual analogue scale pain scores at rest and on movement. The mean (SD) hourly tramadol consumption was significantly reduced in the lidocaine group compared with the saline group at 4 h (8.0 (10.1) mg vs 28.0 (12.6) mg, respectively; p = 0.001), 6 h (5.3 (10.8) mg vs 17.3 (12.7) mg, respectively; p = 0.013) and 8 h (5.3 (11.8) mg vs 21.3 (9.1) mg, respectively; p = 0.001). The cumulative 24‐h tramadol consumption was 97.3 (16.6) mg in the lidocaine group and 150.6 (26.0) mg in the saline group (p = 0.001). There were significant differences in the pain visual analogue scale at rest at two time points; at 4 h the median (IQR [range]) visual analogue scale scores were 4 (4–6 [2–8]) in the lidocaine group and 5 (4–6 [2–7]) in the saline group (p = 0.03), and at 6 h visual analogue scale scores were 3 (3–4 [3–6]) and 4 (4–6 [2–7]), respectively (p = 0.04). Pain visual analogue scale on movement was lower in the lidocaine group at all time intervals compared with the saline group, but this did not reach statistical significance. The present study has demonstrated a postoperative tramadol‐sparing and analgesic effect of pre‐operative stellate ganglion block in patients undergoing upper limb orthopaedic surgery under general anaesthesia.     

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4–22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0–3 [0–5]) in the control group vs. 1 (0–1 [0–4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.     

A randomised controlled trial comparing the GlideScope® and the Macintosh laryngoscope for double‐lumen endobronchial intubation

Double‐lumen endobronchial tubes are the most common method of achieving lung isolation and one‐lung ventilation during thoracic anaesthesia and surgery. We compared the clinical performance of the Macintosh laryngoscope and the GlideScope^® during endobronchial intubation with a double‐lumen tube. Seventy patients with no predictors for difficult laryngoscopy were allocated randomly to the Macintosh laryngoscope or GlideScope. The time taken for endobronchial intubation with the Macintosh laryngoscope was significantly shorter compared with that taken for the GlideScope, median (IQR [range]) 33 (22–52 [11–438]) s vs 70 (39–129 [21–242]) s, respectively, p = 0.0013. There was no statistical difference in the rate of success at the first attempt (91% vs 83%, respectively). On a numerical rating scale (scored from 0 to 10), the 30 anaesthetists who took part in the study rated endobronchial intubation overall as easier using the Macintosh compared with the GlideScope, 2 (1–3 [0–8]) vs 3 (2–6 [0–10]), respectively, p = 0.003. Postoperative voice changes were also less common in the Macintosh group (8 (22%) vs 17 (58%), p = 0.045). Anaesthetists found the GlideScope more difficult to use than the Macintosh laryngoscope and endobronchial intubation took longer; therefore, we cannot recommend its routine use with double‐lumen tubes in patients who are predicted to have a normal airway.     

Using psychometric ability to improve education in ultrasound-guided regional anaesthesia: a multicentre randomised controlled trial

The learning curve for novices developing regional anaesthesia skills, such as real-time ultrasound-guided needle manipulation, may be affected by innate visuospatial ability, as this influences spatial cognition and motor co-ordination. We conducted a multinational randomised controlled trial to test if novices with low visuospatial ability would perform better at an ultrasound-guided needling task with deliberate practice training than with discovery learning. Visuospatial ability was evaluated using the mental rotations test-A. We recruited 140 medical students and randomly allocated them into low-ability control (discovery learning), low-ability intervention (received deliberate practice), high-ability control, and high-ability intervention groups. Primary outcome was the time taken to complete the needling task, and there was no significant difference between groups: median (IQR [range]) low-ability control 125 s (69–237 [43–600 s]); low-ability intervention 163 s (116–276 [44–600 s]); high-ability control 130 s (80–210 [41–384 s]); and high-ability intervention 177 s (113–285 [43–547 s]), p = 0.06. No difference was found using the global rating scale: mean (95%CI) low-ability control 53% (95%CI 46–60%); low-ability intervention 61% (95%CI 53–68%); high-ability control 63% (95%CI 56–70%); and high-ability intervention 66% (95%CI 60–72%), p = 0.05. For overall procedure pass/fail, the low-ability control group pass rate of 42% (14/33) was significantly less than the other three groups: low-ability intervention 69% (25/36); high-ability control 68% (25/37); and high-ability intervention 85% (29/34) p = 0.003. Further research is required to determine the role of visuospatial ability screening in training for ultrasound-guided needle skills.     

Fibrinogen concentrate vs. fresh frozen plasma for the management of coagulopathy during thoraco-abdominal aortic aneurysm surgery: a pilot randomised controlled trial

Major vascular surgery is frequently associated with significant blood loss and coagulopathy. Existing evidence suggests hypofibrinogenaemia develops earlier than other haemostatic deficiencies during major blood loss. The purpose of this study was to assess whether the use of an infusion of fibrinogen concentrate to prevent and treat hypofibrinogenaemia during surgery resulted in satisfactory haemostasis, removing or reducing the need for blood component transfusion. Twenty patients undergoing elective extent-4 thoraco-abdominal aortic aneurysm repair were randomly allocated to receive either fresh frozen plasma or fibrinogen concentrate to treat hypofibrinogenaemia during surgery. Coagulation was assessed during and after surgery by point-of-care and laboratory testing, respectively, and treatment was guided by pre-defined transfusion triggers. Despite blood losses of up to 11,800 ml in the patients who received the fibrinogen concentrate, none required fresh frozen plasma during surgery, and only two required platelet transfusions. The median (IQR [range]) allogeneic blood component administration during surgery and in the first 24 h postoperatively was 22.5 (14–28 [2–41]) units in patients allocated to fresh frozen plasma vs. 4.5 (3–11[0–17]) in patients allocated to fibrinogen concentrate (p = 0.011). All patients in both groups were assessed by the surgeon to have satisfactory haemostasis at the end of surgery. Mean (SD) postoperative fibrinogen concentrations were similar in patients allocated to fresh frozen plasma and fibrinogen concentrate (1.6 (0.3) g.l⁻¹ vs. 1.6 (0.2) g.l⁻¹; p = 0.36) but the mean (SD) international normalised ratio and activated partial thromboplastin time ratio were lower in patients allocated to fresh frozen plasma (1.1 (0.1) vs. 1.8 (0.3); p < 0.0001 and 1.1 (0.2) vs. 1.7 (0.5); p = 0.032, respectively). Fibrinogen concentrate may be used as an alternative to fresh frozen plasma in the treatment of coagulopathy during thoraco-abdominal aortic aneurysm repair.     

A randomised comparison of free‐handed vs air‐Q™ assisted fibreoptic‐guided tracheal intubation in children < 2 years of age

We prospectively compared free‐handed and air‐Q? assisted fibreoptic‐guided tracheal intubation in children < 2 years of age. Eighty healthy children were enrolled and randomly assigned to a technique (free‐handed or air‐Q assisted) and operator (trainee or attending). Time, number of attempts and manoeuvres required were assessed. There was no difference in median (IQR [range]) time to successful tracheal intubation between the free‐handed (52.2 (34.8–67.7 [19.7–108.0]) s), and the air‐Q assisted (60.3 (45.5–75.1 [28.1–129.0]) s; p = 0.13) groups, or the number of attempts needed. The air‐Q assisted group required fewer manoeuvres to optimise the laryngeal view (median (IQR [range]) 0 (0–1 [0–2])) than the free‐handed group (1 (1–1 [0–3]); p < 0.001). In conclusion, fibreoptic‐guided tracheal intubation times were similar with and without the use of the air‐Q, but supraglottic airway devices may be a consideration for their other practical advantages.     

A comparison of the ease of tracheal intubation using a McGrath MAC® laryngoscope and a standard Macintosh laryngoscope

We compared the McGrath MAC^® videolaryngoscope when used as both a direct and an indirect laryngoscope with a standard Macintosh laryngoscope in patients without predictors of a difficult tracheal intubation. We found higher median Intubation Difficulty Scores with the McGrath MAC as a direct laryngoscope, 1 (0–3 [0–5]) than when using it as an indirect videolaryngoscope, 0 (0–1 [0–5]) or when using the Macintosh laryngoscope, 0 (0–1 [0–5]), p = 0.04. This was mirrored in the subjective user reporting, scored out of 10, of difficulty for each method 3.0 (2.0–3.4 [0.5–80]); 2.0 (1.0–3.9 [0–70]) and 2.0 (1.0–3.3 [0–70]), respectively (p = 0.01). This difficulty is in part explained by the poorer laryngeal views recorded using the Cormack and Lehane classification system (p < 0.001) and reflected in the higher than normal operator force required (25%, 4%, 8% for each method, respectively, p < 0.001) and the increased use of rigid intubation aids (21%, 6%, 2%, respectively, p < 0.001). There was no difference between the groups in time taken to intubate or incidence of complications. There was no statistical difference in the performances as measured between the McGrath MAC used as an indirect videolaryngoscope and the Macintosh laryngoscope. We cannot recommend that the McGrath videolaryngoscope be used as a direct laryngscopic device in place of the Macintosh.     

The effect of intra‐operative passive movement therapy on non‐surgical site pain after breast reconstructive surgery: a preliminary study

Pain distant to an operative site is under‐reported but sometimes more severe than pain from the surgical site. Intra‐operative passive movement could possibly reduce this pain. This preliminary study was designed to assess the practicalities of conducting a randomised controlled trial of this therapy in anaesthetised patients. The study design was pragmatic. Forty‐two patients undergoing breast reconstruction were randomly assigned to receive either intra‐operative passive movement or standard care. Twenty‐four hours after surgery, median (IQR [range]) morphine consumption was 33 (11–42 [0–176]) mg in the passive movement group compared with 74 (15–118 [0–238]) mg with standard care (p = 0.126), while participants reported median (IQR [range]) visual analogue scores in areas distant from the surgical site of 0 (0–4 [0–34]) mm in the passive movement group compared with 10 (2–30 [0–57]) mm in those receiving standard care (p = 0.002). A full trial of intra‐operative passive movement therapy to reduce postoperative is feasible and warranted.     

Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial

Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. This was a prospective, double-blind, placebo-controlled trial. Participants were randomly allocated to receive bilateral quadratus lumborum block (40 ml levobupivacaine 0.25%) or sham block (control) after undergoing elective caesarean section under spinal anaesthesia. The primary outcome was 24-h morphine consumption measured by patient-controlled analgesia. Secondary outcomes included pain scores and quality of recovery. Data from 86 women were analysed. Median (IQR [range]) 24-h morphine consumption was similar in patients receiving quadratus lumborum block and sham block (12 (8–29 [0–68]) mg vs. 14 (5–25 [0–90]) mg, respectively; p = 0.986). There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0–14 [0–98]) mm vs. 14 (3–23 [0–64]) mm (p = 0.019); and on movement: 23 (10–51 [0–99]) mm vs. 44 (27–61 [2–94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.     

A randomised prospective trial of intra‐operative oesophageal Doppler‐guided fluid administration in major gynaecological surgery

Intra‐operative oesophageal Doppler monitor‐guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra‐operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra‐operative fluid management using an oesophageal Doppler‐guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra‐operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5–8 [4–25]) days in the oesophageal Doppler monitor group compared with 7 (5–9 [4–42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra‐operative oesophageal Doppler‐guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.     

A randomised controlled trial comparing two popliteal nerve catheter tip positions for postoperative analgesia after day‐case hallux valgus repair

We compared the effect of two different positions of a sciatic nerve catheter within the popliteal fossa on local anaesthetic consumption and postoperative analgesia in patients undergoing day‐case hallux valgus repair. Eighty‐four patients were randomly allocated to receive a sciatic nerve catheter either between the tibial and peroneal components (sciatic group) or medial to the tibial nerve (tibial group). The primary endpoint was postoperative local anaesthetic consumption, while secondary endpoints were pain scores, number of occasions where sleep was disturbed by pain and incidence of insensate limb and foot drop at 24 h and 48 h postoperatively. Postoperative median (IQR [range]) local anaesthetic consumption was 126 (106–146 [98–180]) ml in the sciatic group versus 125 (114–158 [98–200]) ml in the tibial group (p = 0.103). Insensate limb occurred in 14 patients in the sciatic group versus one patient in the tibial group (p < 0.001), while foot drop was reported by six patients in the sciatic group and none in the tibial group (p = 0.012). Sciatic nerve catheter placement medial to the tibial nerve may be a superior analgesic technique for day‐case foot surgery.     

Forces generated by Macintosh and GlideScope® laryngoscopes in four airway‐training manikins

We measured forces generated by Macintosh and GlideScope^® laryngoscope blades during airway intubation by 16 participants in four manikins: Laerdal^® SimMan; TruCorp AirSim? Advance; Laerdal^® Airway Management Trainer; and Ambu^® Airway Man. Both laryngoscopes generated the least force in the Laerdal Airway Management Trainer and the most in the Ambu Airway Man. The respective median (IQR [range]) forces generated by the Macintosh blade were 2 (1–4 [1–7]) N vs 9 (7–13 [5–16]) N, p = 0.00004, with peak forces 9 (5–11 [3–16]) N vs 18 (12–22 [3–31]) N, p = 0.0004. The respective average and peak forces generated by the GlideScope blade were 1 (1–2 [0–3]) N vs 4 (3–5 [2–6]) N, p = 0.00001, and 4 (2–7 [0–12]) N vs 7 (4–9 [3–18]) N, p = 0.054.     

Postoperative morbidity survey,mortality and length of stay following emergency laparotomy

Thirty‐day mortality following emergency laparotomy is high, and greater amongst elderly patients. Studies systematically describing peri‐operative complications are sparse, and heterogeneous. We used the postoperative morbidity survey to describe the type and frequency of complications, and their relationship with outcomes for 144 patients: 114 < 80 years old, and 30 ≥ 80 years old. Cumulative postoperative morbidity survey scores and patterns of morbidity were similar (p = 0.454); however, 28‐day mortality was higher in the elderly (10/30 (33.3%) vs 11/114 (9.6%), p = 0.008), and hospital stay was longer (median (IQR [range]) 17 (13–35 [6–62]) days vs 11 (7–21 [2–159]) days, p = 0.006). Regression analysis indicated that cardiovascular, haematological, renal and wound complications were associated with longer hospital stay, and that cardiovascular complications predicted mortality. The postoperative morbidity survey system enabled structured mapping of the number and type of complications, and their relationship with outcome, following emergency laparotomy. These results indicate that rather than a greater propensity to complications following surgery, it was the failure to tolerate these that increased mortality in the elderly.