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Despite pervasive need for peripheral intravenous catheters, insertion is often difficult, and approximately two thirds fail prematurely. Midline catheters are an alternative long peripheral catheter, inserted in the upper arm, ideal for patients with difficult access.The aim of this study is to test feasibility of the protocol and compare the efficacy and safety of midline catheters to peripheral intravenous catheters.A parallel-group, pilot randomized controlled trial of adult medical/surgical hospitalized patients, from a single Australian referral hospital.Participants with difficult vascular access (≤2 palpable veins) and/or anticipated ≥5 days of peripherally compatible intravenous therapy were recruited between May 2019 and March 2020. Participants were randomized to (1) peripheral intravenous catheter or (2) midline catheter. Primary feasibility outcome measured eligibility, recruitment, protocol adherence, retention and attrition. Primary clinical outcomes measured device insertion failure and post-insertion failure.In total, n = 143 participants (71 peripheral intravenous catheters and 72 midline catheters) were recruited; n = 139 were analysed. Most feasibility criteria were met. Peripheral intravenous catheters had shorter functional dwell time, with higher incidence of post-insertion failure compared to midline catheters.Midline catheters appear to be superior for patients with difficult vascular access or receiving prolonged intravenous therapy; a large, multi-centre trial to confirm findings is feasible.

Highlights Abstract Background: Peripherally inserted central catheters (PICCs) are commonly placed with the assistance of fluoroscopy or medical imaging, ultrasound, electrocardiogram guidance, or all the above. Innovative ultrasound technologies continue to emerge; however, the impact upon clinical outcomes is not well understood. In this study, we aimed to compare outcomes of an existing ultrasound system with SHERLOCK 3CG™ Tip Confirmation (preintervention) to an updated SHERLOCK 3CG Diamond Tip Confirmation system, incorporating catheter-to-vein ratio measurement capabilities and an advanced magnetic-based tip navigation system (postintervention). Methods: In this prospective pre-post cohort study, we recruited adult patients requiring a new PICC. The study was conducted at a quaternary hospital in Queensland, Australia. Data were collected between May 2017 (4 months before equipment introduction) and January 2018 (4 months after equipment introduction), with a 1-month exclusion (education or learning) period in between. Patient, PICC, and device removal details were collected. The primary outcome was first-time insertion success, defined as successful PICC insertion after a single attempt (skin puncture), with the tip confirmed in an optimal location by the navigation system and a subsequent chest x-ray (as per hospital policy). Results: There were 503 participants with patient demographics and PICC characteristics balanced between the preintervention (n = 266) and postintervention (n = 237) groups. First-time insertion success was higher in the preintervention group (203/255, 80%) than the postintervention group (166/226, 73%), but this was not statistically significant (risk ratio = 0.92, 95% confidence interval = 0.83–1.02). Conclusions: There was no change in clinical outcomes with the use of next-generation ultrasound technology. These results justify future large studies and subsequent review into the efficacy of tip-confirmation systems and processes to maintain patient safety.

Background The ‘cannot intubate cannot oxygenate' (CICO) emergency requires urgent front of neck airway (FONA) access to prevent death. In cases reported to the 4th National Audit Project, the most successful FONA was a surgical technique, almost all of which were performed by surgeons. Subsequently, UK guidelines adopted surgical cricothyroidotomy as the preferred emergency surgical FONA technique. Despite regular skills-based training, anaesthetists may still be unwilling to perform an emergency surgical FONA. Consultant anaesthetists, head and neck surgeons, and general surgeons were compared in a high-fidelity simulated emergency. We hypothesised that head and neck surgeons would successfully execute emergency surgical FONA faster than anaesthetists and general surgeons. Methods We recruited 15 consultants from each specialty (total of 45) at a single tertiary care hospital in the UK. All agreed to participate in an in situ high-fidelity simulation of an ‘anaesthetic emergency'. Participants were not told in advance that this would be a CICO scenario. Results There were no significant differences in total time to successful ventilation between anaesthetists, head and neck surgeons and general surgeons (median 86 vs 98 vs 126 s, respectively, P=0.078). Anaesthetists completed the emergency surgical FONA procedure significantly faster than general surgeons (median 50 vs 86 s, P=0.018). Despite this strong performance, qualitative data suggested some anaesthetists still believed ‘surgeons' best placed to perform emergency surgical FONA in a genuine CICO situation. Conclusion Anaesthetists regularly trained in emergency surgical FONA function at levels comparable with head and neck surgeons and should feel empowered to lead this procedure in the event of a CICO emergency.

In a ‘can’t intubate, can’t oxygenate’ scenario, success of emergency front-of-neck access is dependent upon a clinician’s skill, competence and confidence to initiate the procedure. Surgical cricothyroidotomy is an important airway skill, as it can be employed as both the primary method of emergency front-of-neck access or as a rescue approach if a needle technique should fail. We designed a collaborative surgical and anaesthetic training package to address perceived anaesthetic reluctance to perform surgical cricothyroidotomy and undertook a pilot study of the package using a mixed-methods approach. The package consisted of three elements: theory teaching, surgical experience and repeated high-fidelity simulation. Ten anaesthetic trainees were trained using the package. Training comprised face-to-face tuition on the 2015 Difficult Airway Society guidelines, the Vortex cognitive aid, manikin-based surgical cricothyroidotomy instruction and surgical experience gained from an elective surgical tracheostomy. A standardised, high-fidelity in situ ‘can’t intubate, can’t oxygenate’ simulation was used to assess performance at baseline and at two weeks and six months after training. Participants scored their self-efficacy, underwent qualitative semi-structured interviews and had their performance quantitatively assessed to evaluate this training. Six months following training, participants’ performance had improved. They reported significantly increased self-efficacy and demonstrated significantly reduced deliberation time to initiate surgical cricothyroidotomy in the simulated ‘can’t intubate, can’t oxygenate’ emergency. Thematic framework analysis of interview transcripts revealed that reluctance to perform surgical cricothyroidotomy was related to fear and anxiety in regard to performing the procedure. These results support wider adoption of collaborative educational training packages, including hands-on surgical teaching, to improve trainees’ efficacy and confidence with surgical cricothyroidotomy and front-of-neck access in an emergency ‘can’t intubate, can’t oxygenate’ scenario.

Coastal shell middens, a prominent feature of the Mesolithic archaeological record of western Scotland, suggest a maritime economy based on fishing and shellfishing. Despite evidence for the importance of fish to diet, virtually nothing is known of the fishing methods practiced, although several ‘models’ have been proposed. We tested these models by means of a series of field experiments. A range of experimental fishing gear including lines and portable traps and pots were made utilizing resources and technologies available during the Mesolithic. Fishing experiments were conducted at,or near to, the Scottish west coast Mesolithic sites of Ulva Cave and Sand (Loch Torridon), and also on the island of Colonsay, South Uist, and the Urr Estuary on the Solway Firth. Results suggested thatMesolithic fishers must have had extensive knowledge of tides as well as species behavior to successfully exploit coastal environments adjacent to the west coast midden sites. Additionally, capture of the main fish species (i.e., Pollachius virens, Labridae, and Pollachius pollachius)and brachyurans (Carcinus maenas, Liocarcinus depurator,and Cancer pagurus) identified in the middens did not require sophisticated fishing gear; simple hand-lines sufficed

The time-critical ‘can’t intubate, can’t oxygenate’ [CICO] emergency post-induction of anaesthesia is rare, but one which, should it occur, requires Anaesthetists to perform rapid emergency front of neck access [FONA] to the trachea, restoring oxygenation, and preventing death or brain hypoxia. The UK Difficult Airway Society [DAS] has directed all Anaesthetists to be trained with surgical cricothyroidotomy [SCT] as the primary emergency FONA method, sometimes referred to as ‘Cric’ as a shorthand. We present a longitudinal analysis using a classical approach to Grounded Theory methodology of ten Specialist Trainee Anaesthetists’ data during a 6-month training programme delivered jointly by Anaesthetists and Surgeons. We identified with a critical realist ontology and an objectivist epistemology meaning data interpretation was driven by participants’ narratives and accepted as true accounts of their experience. Our theory comprises three themes: ‘Identity as an Anaesthetist’; ‘The Role of a Temporary Surgeon’; and ‘Training to Reconcile Identities’, whereby training facilitated the psychological transition from a ‘bloodless Doctor’ (Anaesthetist) to becoming a ‘temporary Surgeon’. The training programme enabled Specialist Trainees to move between the role of control and responsibility (Identity as an Anaesthetist), through self-described ‘failure’ and into a role of uncertainty about one’s own confidence and competence (The Role of a Temporary Surgeon), and then return to the Anaesthetist’s role once the airway had been established. Understanding the complexity of an intervention and providing a better insight into the training needs of Anaesthetic trainees, via a Grounded Theory approach, allows us to evaluate training programmes against the recognised technical and non-technical needs of those being trained.

Recent Difficult Airway Society (DAS) awake tracheal intubation (ATI) guidelines 1 recommend that ‘effective (lidocaine) topicalisation must be established and tested ’ and that ‘sedation must not be used as a substitute for inadequate airway topicalisation ’. We are concerned this is a flawed approach that may, of itself, precipitate airway obstruction.

Temporary tracheostomies (TT) are performed to secure the airway perioperatively and postoperatively in head and neck cancer patients undergoing tumour resection and free tissue reconstructive surgery. Patients report that having a TT is unpleasant and they appreciate its removal at the earliest opportunity. Early removal not only improves patient satisfaction but should allow for a more rapid recovery. The aim of this prospective study was to assess factors that contribute to delays in decannulation following TT and hence to provide an insight into the factors that will support earlier decannulation when it is safe to do so. Consecutive patients who had TT over a six-month period were included. Delayed decannulation was defined as that after day seven postoperatively. There were 42 patients with a median (IQR) age of 70 (60-74) years, 26 of whom were men. The tracheostomy was surgical in 29 and percutaneous in 13. The median (IQR) time to decannulation was 4 (3-5) days (range 1-11 days). Seven patients had delayed removal (7-11 days), the reasons being hospital-acquired pneumonia (HAP) (n=4), prolonged stay in the high dependency unit (HDU) following postoperative myocardial infarction and cardiac arrest (n=1), failure to tolerate TT occlusion (n=1), and not stated (n=1). There were early postoperative complications in 14 patients but despite this seven decannulations were still performed within two and six days. Additional multiprofessional assessment over weekends is likely to facilitate earlier decannulation. As some TTs are removed after a few days there is a need for better selection to avoid their use in certain patients.

EditordRiddell and colleagues1 reported on a systematic review and meta-analysis of low-dose ketamine in orthopaedic surgery, concluding that low-dose ketamine was an effective adjuvant that decreased pain and opioid requirements in painful orthopaedic procedures. I do not believe their data support such a conclusion. There were three nominated primary outcomes in their study:(i) total postoperative opioid consumption, (ii) time to the first dose of opioid after surgery (minutes), and (iii) pain scores at rest using the 10 cm visual analogue scale (VAS) at 12, 24, and 48 h. They included 20 studies in their meta-analysis and found that ketamine decreased total opioid use and pain VAS scores, and delayed the time to first opioid dose. These findings seem impressive and each were statistically significant. However, standardised mean difference and P-values tell us very little about clinical significance, the degree of statistical uncertainty, or both. In their meta-analysis, the standardised mean differences and 95% confidence intervals of the morphine (?) dose reduc-tion were only 0.82 (0.40e1.24) mg at 24 h and 0.65 (0.27e1.03) at 48 h after surgery. These statistics reflect effect sizes but not actual clinical data about analgesic effectiveness or opioid-related side effects. The actual weighted mean reduction in pain VAS scores at 24 and 48 hours were not reported. Were they more than 1.0, previously defined by many investigators to be the minimal clinically important difference?2 Some au-thors have suggested that a 33% decrease,3 or a change in VAS score of 1.5 to 2.0,4�6 would indicate a clinically important change in pain intensity. As it stands, and considering the marked heterogeneity of the patient populations and keta-mine regimens, none of the findings presented by Riddell and colleagues suggests any clinically important analgesic benefits of low dose ketamine in orthopaedic surgery. The Standardised Endpoints in Perioperative Medicine (StEP) initiative undertook an extensive Delphi process to identify important, valid and reliable measures of patient comfort after surgery.7 Postoperative pain intensity at rest andon movement at 24 h, using a numerical rating scale (0e10), and (ideally) at least one other time point, were recommended. Opioid dose reduction, of itself (i.e. without a reduction in opioid-related side-effects), was not considered important, nor was time to the first dose of opioid after surgery.

Introduction Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the ‘anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. Methods A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763). Results A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns. Conclusions The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.

Key points Human factors have been defined as ‘the environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety’1 and have been described with particular relevance to anaesthesia in the Anaesthetists Non-Technical Skills Framework.2 When dealing with a patient with a complex airway, exceptional attention to human factors is vital to success. This has been noted extensively in the literature after two high profile cases.3,4 Recently, there has been adoption of human factors in healthcare at the highest level with the signing of a Concordat from the National Quality Board by organizations such as the General Medical Council, The Care Quality Commission, and Health Education England.5 The Fourth National Audit Project of the Royal College of Anaesthetists (NAP4) examined major complications in airway management and concluded that poor human factors could have contributed to 40% of the cases reported. In 25% of these cases, inadequate human factors were felt to be a major contributor to a poor outcome.6 Further analysis specifically looking at human factors in cases reported to NAP4 reported that there …

Following on from our previous research into the prehistoric aceramic distillation and production of birch bark tar, this series of exploratory experiments investigated the use of raised structures within a fire. These field-based experiments were conducted using sand, gravel, wood fuel, and bark from Betula pubescens (downy birch). The structures that were created were simple raised sand mounds, which reflected known Neanderthal combustion surfaces from the Middle Palaeolithic. The bulk of the experiments were recorded throughout using a thermocouple to provide temperature readings from the base of the bark pyrolysis chamber. The experiments proved successful at producing birch bark tar and several containers were used to catch the tar for later analysis. Based on the results, the authors contend that not only could Neanderthals control fire but that regular birch bark tar production by Neanderthals was most likely a result of specific chaines operatoires in order to provide the necessary control and outcomes.

In our tertiary head and neck center we increasingly use the Optiflow device to deliver high flow nasal oxygen (HFNO) in spontaneously ventilating patients1 or to provide trans-nasal rapid insufflation ventilatory exchange (THRIVE)2 in apnoeic, anaesthetised patients. Despite instituting regular departmental workshops, there were anecdotal reports of variable practice and incorrect usage of Optiflow. We aimed to assess anaesthetists’ knowledge and competence before and after bespoke training.

Our main aims were to assess haemoglobin (Hb) concentrations from preoperative assessment to discharge from hospital, and to review which patients had blood transfusions and compliance with national transfusion guidelines. We studied a consecutive series of 131 patients between October 2016 and September 2017 who had either neck dissection or resection and free microvascular tissue transfer. Half the patients had soft tissue free flaps (n = 65), 26% had composite free flaps (n = 34), and 24% neck dissection only (n = 32). Using the WHO definition of anaemia, 4% (1/28) of patients who had neck dissections and 19% (16/85) of those who had free flaps were anaemic preoperatively. The median (IQR) Hb at discharge was 131 (119–144) g/L for patients who had neck dissections, 103 (95–114) g/L for those who had soft free flaps, and 95 (90–104) g/L for those who had composite free flaps. No patients who had neck dissection were given a red blood cell (RBC) transfusion, whereas they were given to 26/99 (26%) of those who had free flaps. Hb concentrations were checked after each unit in 31/39 transfusions (79%). Concentrations for those who had free flaps fell by about 30 g/L from admission to operation, and only four patients were given tranexamic acid peroperatively. Postoperatively Hb remained at similar concentrations until discharge, with 23/98 (24%) given iron orally on discharge. In terms of compliance with blood transfusion guidelines there was a notable absence of the use of tranexamic acid and of iron intravenously. An increase in their use could potentially reduce the number of blood transfusions required and the postoperative incidence of anaemia, and have a favourable effect on outcomes such as complications, fatigue, and overall quality of life.

Human factors in anaesthesia were first highlighted by the publication of the Anaesthetists Non-Technical Skills Framework, and since then an awareness of their importance has gradually resulted in changes in routine clinical practice. This review examines recent literature around human factors in anaesthesia, and highlights recent national reports and guidelines with a focus on team working, communication, situation awareness and human error. We highlight the importance of human factors in modern anaesthetic practice, using the example of complex trauma.

A range of experiments were conducted in an attempt to create tar from the bark of Betula pubescens (downy birch) using an aceramic dry distillation process. Fire structures based on small pits and small kiln-like mounds were explored with a focus on fire intensities and differing burn times under field-based conditions. Heat penetration presented itself as an all-important factor, and the depth of the construction of the structures and features was considered to directly correlate to the impact of the heat. Single variable experiments confirmed that the necessary reducing atmosphere was achievable despite friable soil, but that heat would not penetrate a 50- to 80-mm-deep layer of grass turf. The evolution of structures from pits towards a raised type resulted in kiln-like structures which proved more successful. Though the experiments did not successfully produce tar as a finished product, they did lead to a better understanding of the dry distillation process of the established technology of birch bark tar extraction in aceramic societies.

The paper by Hakon Glorstad offers an interesting and thought-provoking perspective in which boats are seen as the limiting factor in the post-glacial colonization of the Norwegian coast and trees ...

In 2015, the British Difficult Airway Society (DAS) revised its guidelines for managing an unanticipated difficult airway, recommending surgical cricothyroidotomy as the new standard emergency front of neck access (FONA).1 In the UK, the 4th National Audit Project of the Royal College of Anaesthetists recommended anaesthetists to undergo frequent FONA training using simulation.2 Fidelity in simulation has physical, functional and psychological components,3 and we feel that the Crico-Trainer (Frova; VMB Medical, Newcastle, UK), currently used in our department, could be improved. A prestudy survey (n=15) of attending (consultant) anaesthetists identified ‘ideal manikin qualities’. This confirmed that important features were high-fidelity feel of: tissue (80.0%), scalpel incision (86.7%) and surface (80.0%). The ability to intubate (60.0%), haemorrhage (46.7%) and mimic an impalpable cricothyroid membrane (46.7%) were also considered important. The Frova was deemed to lack realistic tissue planes (80.0%), component feel (66.7%) and haemorrhage (46.7%). The aim of this study was to develop and evaluate our own trainer, focusing on improved fidelity. We designed and constructed our part-task trainer (figure 1) using a wooden base, proprietary reusable plastic ‘larynx/trachea’ and a novel disposable ‘neck tissue’ prosthesis, which feels realistic and bleeds when cut. The neck was fabricated from a viscoelastic polymer (Akton; Action Products, Leek, UK) coated in acrylic paint (Daler-Rowney, Bracknell, UK) and …

Background The 4th national audit project (NAP 4) by the Royal College of Anaesthetists, analysed human factors involved during the adverse management of difficult airways (1). Common themes included fixation errors, poor planning and a lack of understanding of team working and communication (1). NAP 4 recommended that human factors training using simulation scenarios should be undertaken in order to rehearse technical and non technical skills (1). The Aintree Difficult Airway Management (ADAM) course is a one day course aimed at teaching techinical advanced airway skills and planning skills for difficult airway management. Description In collaboration with ADAM faculty, The Centre For Simulation and Patient Safety has developed a high fidelity airway simulation training course. To facilitate the teaching of advanced airway management techniques, the ADAM faculty developed a method of deforming the TRUCORP AIRSIM airway. This involves taping urinary catheters to various structures within the mannequin’s airway. When the catheter balloon is inflated, it causes airway distortion. Examples of malformations that can be simulated include airway tumours, abscesses and strictures. Together, we have incorporated this technique into the airway of Laerdal’s Sim Man 3G, and applied moulage to increase fidelity. Improvements/outcomes This technique has allowed us to develop 6 high fidelity simulation scenarios designed to teach team resource management and human factors in emergency airway situations. The course will be piloted in June and will be evaluated using pre and post course questionnaires. We hope to show that participants feel more confident in managing difficult airways. We also hope to demonstrate that the airway deformities we create are of sufficient fidelity and they provide good haptic feedback. Take home messages The airway fidelity of simmulation mannequins can be increased using this simple technique. This can then be used in simulation scenarios to potentially improvve technical and non technical skills. Reference Cook T, Woodall N, Frerk C. (2011) The fourth national audit project of the Royal College of Anaesthetists and Difficult Airway Society. Major complications of difficult airway management in the United Kingdom. http://www.rcoa.ac.uk/system/files/CSQ-NAP4-Full.pdf

Background In situ simulation based training in healthcare is becoming increasingly popular 1 . The advantages of utilising this mode of education include the opportunity to identify latent errors within the system, environment and team. This is of particular use in high risk and infrequent situations and allows improvement in patient safety and also team knowledge and skill. A previous exercise at Aintree Hospital identified particular logistical and environmental latent errors in an unexpected massive haemorrhage 2 . The National Audit Project 4 run by the Royal College of Anaesthetists highlighted the need for regular multidisciplinary drills for the unanticipated difficult airway 3 . Following this, in situ scenario based training utilising high fidelity simulation has been organised to incorporate the surgical, anaesthetic and critical care directorates at Aintree Hospital. Focus will be placed upon practising existing standard operating procedures, national guidelines and recent changes within our local practices. We would like to present the findings of this event. Methodology Using a mix of actors and high fidelity mannequins the following scenarios will be undertaken: - Malignant hyperpyrexia. - Unanticipated difficult airway. - WHO checklist training incorporating recent local changes Each scenario will be video recorded. Feedback will focus on human factors and identifying latent errors. Results By performing these high risk and uncommon scenarios within the clinical environment, and by utilising the required facilities and teams, we hope to identify any latent errors which may be present. Potential Impact Detection of latent errors within healthcare is vital to improve patient safety and training for the clinical team. In situ simulation based training is well placed to support this. 4 Our aim is to highlight any latent errors within our system and environment whilst improving the knowledge of existing hospital standard operating procedures and confidence in dealing with these anaesthetic emergencies. References Mercer SJ, Wimlett S. In-Situ Simulation. Bulletin of the Royal College of Anaesthetists 2012;76:28–30 Beament T, Mercer SJ, Lacasia C. In-situ simulation for teamwork teaching and testing of a standard operating procedure for unexpected major haemorrhage in a large University Teaching Hospital. Belfast;2014:1–50. Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia . 2011;106(5):617–31 Henriksen K, et al . In SituIn Situ Simulation: Challenges and Results. Rockville (MD): Agency for Healthcare Research and Quality (US);2008

Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult airway experienced in the deployed field hospital. In order to establish an overview of current practice, three methods of investigation were undertaken; a literature review, a survey of DMS Anaesthetists and a search of the UK Joint Theatre Trauma Database. Results are discussed in terms of anatomical site, bleeding in the airway, facial distortion, patient positioning and an anaesthetic approach. There are certain key principles that should be considered in all cases and these are considered. Potential pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented.