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Background and Objective: Transtracheal or transcricothyroid placement of a cannula is a practice used in a number of aspects of airway management in anaesthesia and intensive care. In this study, we aimed to investigate whether the use of ultrasound will facilitate cannula placement in a time-critical situation in patients with difficult anterior neck airway anatomy. Method: Fifty anaesthetists were randomised to either ultrasound-guided or conventional unguided attempts, at cannula insertion into a model simulating a patient with unidentifiable anterior neck anatomy. Endpoints were the success, and time to success, of cannula placement. Results: There was a significant increase in success rate (83 vs. 43%, P = 0.011) and a significant decrease in time to successful placement (median time to successful cannulation 57 vs. 110 s, P = 0.008) using ultrasound guided compared to unguided cannula placement. Conclusion: If a 'can't intubate, can't oxygenate' scenario occurs in a patient with unidentifiable anterior neck airway anatomy in a location where an ultrasound machine is immediately available, we recommend that consideration is given to the use of ultrasound-guided cannula tracheotomy as the first-line rescue technique. [ABSTRACT FROM AUTHOR]

Serious deep neck infections may result in life-threatening airway complications. The aim of this study was to review the management of patients requiring surgical drainage with deep neck infections and to identify possible factors that may predict a greater risk of airway complications. In this study the authors reviewed the notes of patients requiring surgical drainage of deep neck infections who were admitted to Royal Perth Hospital over a seven-year period (2000 to 2007). One hundred and twenty-nine suitable patients were identified, of whom 15.5% encountered airway complications including one death due to airway obstruction. Airway complications were more common if there was no consultant anaesthetist present (odds ratio 4.01 [confidence interval 1.20 to 13.46], P = 0.02). Deep neck infections are still relatively common and are associated with significant morbidity and mortality. Patients with deep neck infections represent an anaesthetic challenge which should be managed by those with an appropriate level of experience. [ABSTRACT FROM AUTHOR]

At the Royal Perth Hospital, we have been developing and teaching a can't intubate, can't oxygenate (CICO) rescue algorithm for over 19 years, based on live animal simulation. The algorithm involves a 'cannula-first' approach, with jet oxygenation and progression to scalpel techniques if required in a stepwise fashion. There is little reported experience of this approach to the CICO scenario in humans. We present eight cases in which a cannula-first Royal Perth Hospital approach was successfully implemented during an airway crisis. We recommend that institutions teach and practice this approach; we believe it is effective, safe and minimally invasive when undertaken by clinicians who have been trained in it and have immediate access to the requisite equipment. The equipment is low cost, comprising a 14G Insyte cannula, saline, 5 ml syringe and a Rapid-O2. Training can be provided using low-fidelity manikins or part-task trainers., Competing Interests: Declaration of conflicting interestsAll authors have organised CICO training sessions based on the RPH approach, which charge delegates a fee to attend. None of the authors benefits financially from these fees. All authors have been funded by the Taiwan Society of Anesthesiologists to deliver CICO training sessions in Taiwan. SGD has received funding from the Sydney Skills and Simulation Centre for teaching on the ATTAAC course.

Background: Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy., Aims: To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates., Methods: Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt., Results: 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique., Conclusion: Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials., (© 2021 John Wiley & Sons Ltd.)

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.

Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17-0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Parents often underestimate their child's weight status, particularly when the child is overweight or obese. This study examined acculturation, stress, coping, and involuntary responses to stress and their relation to estimation of child's weight status among Mexican-origin immigrant families. Eighty-six families provided data on child's height and weight, caregiver's perception of their child's weight status, and caregiver's responses to acculturation, stress, and coping scales. Parents underestimated their child's weight status, particularly when the child was overweight or obese. Although acculturation and stress were not associated with accuracy, parents' responses to stress were linked to parent perceptions. Parents who reported more frequent use of involuntary engagement (e.g., rumination, physiological arousal) were more accurate. Future research, as well as healthcare providers, should consider how parents manage and respond to stress in order to fully understand the factors that explain weight perceptions among Mexican-origin immigrant parents.

Summertime has emerged as a high-risk period for weight gain among low-income minority youth who often experience a lack of resources when not attending school. Structured programming may be an effective means of reducing risk for obesity by improving obesogenic behaviors among these youth. The current multi-method study examined sedentary time, physical activity, and dietary intake among low-income urban minority girls in two contexts: an unstructured summertime setting and in the context of a structured 4-week community-based summer day camp program promoting physical activity. Data were analyzed using paired-sample t tests and repeated-measure analyses of variance with significance at the p < .05 level. Results evidenced no significant differences in total calories and fat consumed between the unstructured and structured settings. Participants exhibited significant increases in fruit consumption and physical activity and significant decreases in sedentary time of over 2 h/day and dairy consumption when engaged in structured summer programming. All improvements were independent of weight status and age, and African-American participants evidenced greater changes in physical activity during programming. The study concludes that structured, community-based summertime programming may be associated with fewer obesogenic behaviors in low-income urban youth and may be a powerful tool to address disparities in weight gain and obesity among high-risk samples.

Public health interventions must address poor diet among U.S. children, but research is needed to better understand factors influencing children's food choices. Using an online grocery store simulation, this research piloted a novel method to assess children's snack selection in a controlled but naturalistic laboratory setting, evaluate predictors of choice, and experimentally test whether promotions on food packages altered choices. Children (7-12 years, N = 61) were randomly assigned to one of three conditions: promotions on healthy products; promotions on unhealthy products; and no promotions (control). They selected from a variety of healthy and unhealthy foods and beverages and rated all products on healthfulness and taste. Promotions on food packaging did not affect snack selection in this study, but findings supported our other hypothesis that perceived taste would be the strongest predictor of food choice. Children accurately rated product healthfulness, but these ratings did not predict healthy snack choices or taste ratings for healthy or unhealthy snacks. These results suggest that interventions to improve children's food choices should focus on increasing availability of healthy options and identifying opportunities to enhance children's liking of healthy options. However, nutrition education alone is unlikely to improve children's diets. Further testing is required, but the simulated online grocery store method shows potential for measuring children's food choices., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: While the majority of pediatric intubations are uncomplicated, the 'Can't intubate, Can't Oxygenate' scenario (CICO) does occur. With limited management guidelines available, CICO is still a challenge even to experienced pediatric anesthetists., Objectives: To compare the COOK Melker cricothyroidotomy kit (CM) with a scalpel bougie (SB) technique for success rate and complication rate in a tracheotomy on a cadaveric 'infant airway' animal model., Methods: Two experienced proceduralists repeatedly attempted tracheotomy in eight rabbits, alternately using CM and SB (4 fr) technique. The first attempt was performed at the level of the first tracheal cartilage with subsequent experimental trials of insertion progressively more caudad. Success was defined as intratracheal placement of cannula as seen on bronchoscope. Complications were assessed both by bronchoscopic and macropathological appearance., Results: 32 attempts were made at tracheotomy. CM had an overall success rate of 100% compared to a 75% success rate for SB. Success rate for the first attempt was dependent on the level of the tracheotomy (Level 1 100%, level 2 62.5% and level 3 & 4 25%). While CM was associated with lateral and/or posterior wall damage on bronchoscopy/macropathology in 6% of 19% and 25% of 50% respectively, the damage observed was greater and more frequent with SB (19%/44% and 31%/50%, respectively)., Conclusions: At level 1, the first attempt success rate was 100% for both devices. Overall CM showed a better success rate than SB; however, both techniques were associated with significant complication rates, which were more pronounced following the scalpel bougie technique., (© 2014 John Wiley & Sons Ltd.)

We investigated multiple lines of evidence to determine if observed and paleo-reconstructed changes in acid neutralizing capacity (ANC) in Sierra Nevada lakes were the result of changes in 20th century atmospheric deposition. Spheroidal carbonaceous particles (SCPs) (indicator of anthropogenic atmospheric deposition) and biogenic silica and δ(13)C (productivity proxies) in lake sediments, nitrogen and sulfur emission inventories, climate variables, and long-term hydrochemistry records were compared to reconstructed ANC trends in Moat Lake. The initial decline in ANC at Moat Lake occurred between 1920 and 1930, when hydrogen ion deposition was approximately 74 eq ha(-1) yr(-1), and ANC recovered between 1970 and 2005. Reconstructed ANC in Moat Lake was negatively correlated with SCPs and sulfur dioxide emissions (p = 0.031 and p = 0.009). Reconstructed ANC patterns were not correlated with climate, productivity, or nitrogen oxide emissions. Late 20th century recovery of ANC at Moat Lake is supported by increasing ANC and decreasing sulfate in Emerald Lake between 1983 and 2011 (p < 0.0001). We conclude that ANC depletion at Moat and Emerald lakes was principally caused by acid deposition, and recovery in ANC after 1970 can be attributed to the United States Clean Air Act.

Background: Little evidence exists to guide the management of the 'Can't Intubate, Can't Oxygenate' (CICO) scenario in pediatric anesthesia., Objectives: To compare two intravenous cannulae for ease of use, success rate and complication rate in needle tracheotomy in a postmortem animal model of the infant airway, and trial a commercially available device using the same model., Methods: Two experienced proceduralists repeatedly attempted cannula tracheotomy in five postmortem rabbits, alternately using 18-gauge (18G) and 14-gauge (14G) BD Insyte(™) cannulae (BD, Franklin Lakes, NJ, USA). Attempts began at the first tracheal cartilage, with subsequent attempts progressively more caudad. Success was defined as intratracheal cannula placement. In each rabbit, an attempt was then made by each proceduralist to perform a cannula tracheotomy using the Quicktrach Child(™) device (VBM Medizintechnik GmbH, Sulz am Neckar, Germany)., Results: The rabbit tracheas were of similar dimensions to a human infant. 60 attempts were made at cannula tracheotomy, yielding a 60% success rate. There was no significant difference in success rate, ease of use, or complication rate between cannulae of different gauge. Successful aspiration was highly predictive (positive predictive value 97%) and both sensitive (89%) and specific (96%) for tracheal cannulation. The posterior tracheal wall was perforated in 42% of tracheal punctures. None of 13 attempts using the Quicktrach Child(™) were successful., Conclusion: Cannula tracheotomy in a model comparable to the infant airway is difficult and not without complication. Cannulae of 14- and 18-gauge appear to offer similar performance. Successful aspiration is the key predictor of appropriate cannula placement. The Quicktrach Child was not used successfully in this model. Further work is required to compare possible management strategies for the CICO scenario., (© 2012 Blackwell Publishing Ltd.)

Acute trismus can be caused by pain, muscle spasm, swelling or mechanical obstruction. Unfortunately, the cause is not always obvious during pre-operative airway assessment. In this pilot study, we prospectively evaluated mandibular nerve block as a pre-operative tool to identify patients with reversible causes of trismus, namely pain or spasm, in order to allow safe anaesthetic induction. Six patients with unilateral fractured mandibles and trismus received a mandibular nerve block before induction of general anaesthesia. There was an increase in maximal inter-incisor gap after the blocks (median (range) distance: pre-block 16.5 (14-30) and post-block 34 (32-35) mm; p = 0.027), and no further improvement after induction of general anaesthesia (post-induction 37 (30-40) mm; p = 0.276 compared with post-block). There was an improvement in pain scores (p = 0.027), and no side-effects were detected. Pre-operative mandibular nerve blockade appears to reverse trismus caused by pain and muscle spasm, allowing the anaesthetist to decide whether awake intubation is genuinely indicated.

Both the American Society of Anesthesiologists and the Difficult Airway Society of the United Kingdom have published guidelines for the management of unanticipated difficult intubation. Both algorithms end with the 'can't intubate, can't ventilate' scenario. This eventuality is rare within elective anaesthetic practice with an estimated incidence of 0.01-2 in 10,000 cases, making the maintenance of skills and knowledge difficult. Over the last four years, the Department of Anaesthetics at the Royal Perth Hospital have developed a didactic airway training programme to ensure staff are appropriately trained to manage difficult and emergency airways. This article discusses our training programme, the evaluation of emergency airway techniques and subsequent development of a 'can't intubate, can't ventilate' algorithm.

Background: Opioids are frequently used for sedation in the Paediatric Intensive Care Unit (PICU). With time the dosing often increases because of tolerance. On cessation of the sedation there is a risk of the opioid withdrawal syndrome. The aim of our study was to evaluate methadone dosing as a risk factor for opioid withdrawal and to determine optimal dose and efficacy of methadone to prevent withdrawal., Method: We undertook a clinical, retrospective, chart review study. Data were analysed from the quality improvement initiative database of a tertiary-care 18 bed PICU., Results: Data from 30 children who received an opioid infusion for >/=7 days and subsequently received methadone for opioid withdrawal (between January 2000 and July 2001) were analysed. Nurses documented the presence or absence of withdrawal signs daily. Our unit protocol has recommended converting the patient's opioid dose into fentanyl equivalents and a dose of methadone equal to the total daily dose of fentanyl to be given three times a day. Twenty patients had no or minimal withdrawal symptoms and 10 experienced significant withdrawal. Age, weight, PRISM score, lorazepam dose, muscle relaxant use and fentanyl dose were not statistically significantly between these groups. Receiver Operator Characteristics analysis showed that 80% of the suggested methadone dose was effective in minimizing withdrawal symptoms. The odds ratio for withdrawal with <80% of the predicted methadone dose was 21., Conclusions: Inadequate methadone is a risk factor for opioid withdrawal. A daily starting methadone dose equivalent to 2.5 times the daily fentanyl dose is effective in minimizing withdrawal symptoms.

Objective: To determine the incidence of physiologic deterioration in critically ill and injured pediatric patients during interhospital transport with air and ground ambulance, Design: Prospective, descriptive study, Setting: All children were treated in regional hospitals and then transported to a pediatric tertiary care center., Patients: Children (n = 100) with a median age of 1.4 years (range 1 week to 18 years), Main Results: Three sets of physiologic scores were calculated: at the time of referral, on departure from the referring hospital, and arrival at the tertiary care center. The incidence of significant physiologic deterioration based on the calculated physiologic scores was 5.6% (n = 4) during ground and 3.4% (n = 1) during air ambulance transports. Critical events occurred in 15% of ground and 31% of air ambulance transports., Conclusion: No difference existed in the incidence of adverse events or physiologic deterioration when air ambulance transports were compared with ground ambulance transports for critically ill children by our team. The physiologic scoring system we chose is simple and easy to use for quality assurance.

Objective: To document the safety and efficacy of an anaesthetic technique in paediatric patients undergoing transoesophageal echocardiography (TOE)., Methods: Prospective descriptive study performed in a children's hospital with all patients undergoing TOE. Topical analgesia of the pharynx was achieved with lidocaine. Anaesthesia was induced with midazolam (25 microg.kg-1), fentanyl (1 microg.kg-1), and propofol (0.5-1 mg.kg-1), followed by a continuous infusion of propofol (5-10 mg.kg-1.h-1)., Results: Thirty patients are reported. The mean age was 11.4 +/- 5.1 years (range 1-22) and weight 40.5 +/- 22.1 kg (range 10-110). All the patients tolerated the procedure well. Two patients experienced brief oxygen desaturations during induction, 10 patients coughed during the procedure, and six patients had significant muscle activity requiring supplemental doses of propofol. None of the patients experienced nausea or vomiting., Conclusion: We conclude that our anaesthetic technique in spontaneously breathing paediatric patients during TOE is effective and appears to be safe in children with heart disease.