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Ultrasonography is an established modality in medical imaging and is evermore entering clinical practice. This chapter provides an introduction to the principles of clinical ultrasonography. It describes the use of airway ultrasonography for identification of the cricothyroid membrane, the trachea and for confirming correct tracheal intubation. Bedside ultrasonography by the anaesthetist has a much higher success rate than palpation for identifying the cricothyroid membrane, especially in patients with neck pathology. It should be applied before initiation of airway management and not be delayed until airway problems are apparent. The role of lung ultrasonography for identification of normal ventilation and pathology is described. Gastric ultrasonography for assessing the starvation status of a patient is described.
Transoral robotic surgery (TORS) allows resection of otherwise inaccessible pathology. It generates unique challenges to the airway management of the patient due to the shared location of the anaesthetist and the surgeon’s equipment. A close cooperation between the anaesthetic and surgical team is required, for the safe handling of the airway. The anaesthetist needs to be able to employ a variety of airway manoeuvres in order to ensure the airway patency throughout the perioperative and post-operative period. The airway of the TORS patient is characterised by its dynamic nature, as it changes due to the surgery, swelling and bleeding.
Bleeding in the upper airway is an important cause of airway-related death, even in young and otherwise healthy individuals. The estimated lifetime incidence of epistaxis is approximately 60%; post-tonsillectomy haemorrhage occurs in 6–15% of tonsillectomy cases; and bleeding following surgery for malignancy in the upper airway is one of the leading causes of requirement of an emergency front of neck airway. Pre-oxygenation may be difficult or impossible. Cornerstone techniques commonly employed to secure the airway, such as direct/videolaryngoscopy and flexible optical laryngoscopy, may be ineffective due to soiling of the hypopharynx – and the equipment – with blood. Supraglottic airway devices may be employed but are typically of limited efficacy due to the increased risk of aspiration and their potential interference with surgical access to the bleeding site in the hypopharynx, glottis and trachea. The clinician may thus be forced to use other, less familiar techniques and modify their approach to airway management, particularly if bleeding is profuse and/or conventional intubation and airway rescue techniques are predicted to be difficult. Cardiovascular compromise from blood loss may further complicate airway management and anaesthesia. We identify techniques and strategies that may be employed in this situation.
A major challenge of airway management is safe care of the patient with a narrowed airway. Small tracheal tubes offer one solution but pose a problem with ventilation. While inspiration may be achieved by use of a high-pressure source to overcome airway resistance, two problems exist: first, the high-pressure source demands technical excellence and exposes the patient to a high risk of barotrauma; second, conventional (passive) exhalation through a narrow tube is slow and cannot achieve a normal minute ventilation with a tracheal tube of less than 4.5 mm diameter. Recently technical developments have led to the ability to assist expiration and make it, like inspiration, an active process. This technology is used in the Ventrain manual ventilator, the 2.4 mm wide Tritube tracheal tube and the Evone automatic ventilator. These new devices and the applied technology enable solutions for safe management of the narrowed upper airway.
Management of the airway is an important and challenging aspect of many clinicians' work and is a source of complications and litigation. The new edition of this popular book remains a clear, practical and highly-illustrated guide to all necessary aspects of airway management. The book has been updated throughout, to cover all changes to best practice and clinical management and provides extensive coverage of the key skills and knowledge required to manage airways in a wide variety of patients and clinical settings. The best of the previous editions has been preserved, whilst new chapters on videolaryngoscopy, awake tracheal intubation, lung separation, airway ultrasonography, airway management in an epidemic and many more have been added. This is an essential text for anyone who manages the airway including trainees and specialists in anaesthesia, emergency medicine, intensive care medicine, prehospital medicine as well as nurses and other healthcare professionals.
To test whether healthcare workers' knowledge of and compliance with the basic principle of the Universal Precautions policy (i.e., that all patients should be treated equally regarding contact with body fluids) influenced the rate of contact with patient blood.
Survey based on anonymous questionnaires.
A 380-bed secondary and tertiary care hospital receiving emergency and elective patients.
All employees having any contact with patients. Nine hundred one of 1,308 (69%) of the questionnaires were returned.
Twelve percent of the respondents (95% confidence interval [CI95] = 10.0%-14.4%) had experienced any contact with patient blood in the week preceding their answer. Physicians had the highest rate of contact with blood followed by nurses. In the five groups-physicians, nurses, laboratory technicians and phlebotomists, nursing aides, and student nurses-contact with blood was less frequent in the subgroup that did know and comply with the basic principle of the Universal Precautions policy, compared with the subgroup that did not. When adding the results for the 5 groups, contact with blood was experienced by 91 of 571 (15.9%, CI95=13%-19%) of the personnel who did not know and comply with Universal Precautions. The personnel who did know and comply with Universal Precautions had a significantly lower (9 of 111 [8.1%], p<.05, CI95 = 3.8%- 15%) rate of contact with blood.
The healthcare workers who knew and complied with Universal Precautions had a significant lower rate of contact with patient blood than those who did not.
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