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Papers by Tim strang

Research paper thumbnail of Guideline for resuscitation in cardiac arrest after cardiac surgery

European Journal of Cardio-Thoracic Surgery, Jul 1, 2009

The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provide... more The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given. This guideline is subject to continuous informal review, and when new evidence becomes available.

Research paper thumbnail of Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

Interactive CardioVascular and Thoracic Surgery, Mar 26, 2008

Research paper thumbnail of The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery

The Annals of Thoracic Surgery

Research paper thumbnail of Best evidence topic - Cardiac general Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VFypulseless VT. However, they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as 'indeterminate'. Thus, in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery.

Research paper thumbnail of Airway stents: anaesthetic implications

Continuing Education in Anaesthesia Critical Care Pain, Feb 21, 2010

Interventional management of airway lesions occluding the tracheobronchial tree include argon pla... more Interventional management of airway lesions occluding the tracheobronchial tree include argon plasma coagulation, forceps debulking, brachytherapy, cryotherapy, photodynamic therapy, and the use of tracheobronchial stents. This review considers airway stenting and the implications for the anaesthetist. Stents are placed into the airway for both

Research paper thumbnail of Abstract P159: The Cardiac Surgery Advanced Life Support Course: Delivering Significant Improvements in Emergency Cardiothoracic Care

Research paper thumbnail of If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

Interactive CardioVascular and Thoracic Surgery, 2008

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4-5 min. In addition, four large studies including the AHA National Registry of Cardiopulmonary Resuscitation, who reported the findings of 6789 in-hospital arrests, emphasise the importance of early defibrillation within 1-2 min. More concerning in patients post-cardiac surgery are four case reports after cardiothoracic surgery and five in the nonsurgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no inhospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.

Research paper thumbnail of Additional specialist training for cardiac intensive care staff on cardiac arrests is urgently needed

Anaesthesia

order to obtain median values and percentiles for each postoperative day. Results Data (median an... more order to obtain median values and percentiles for each postoperative day. Results Data (median and percentile) are shown in Fig. 1. Median CRP reached peak values in the second and third postoperative days (179 and 194 mg.dl)1 respectively). Discussion Values of CRP increase following uncomplicated valve surgery with peak values on days 2-3 postoperatively. Further analysis is required to ascertain whether this early CRP profile differs from that in patients who develop postoperative complications. References 1 Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation.

Research paper thumbnail of Cardiac Advanced Life Support Manual

Research paper thumbnail of Resuscitation in the cardiac intensive care setting

Cardiothoracic Critical Care, 2014

Research paper thumbnail of Training in anaesthesia: the US perspective

Postgraduate Medical Journal, 1996

In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Spe... more In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Specialist training in anaesthesia, supervision and assessment', there is currently much debate concerning the future of anaesthesia training in the UK. We present a description of anaesthesia training in the US for discussion and comparison. US residency training is short and seamless. It is highly

Research paper thumbnail of Best evidence topic - Cardiac general If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. ... more Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the

Research paper thumbnail of Does the laryngeal mask airway compromise cricoid pressure?

Anaesthesia, 1992

The laryngeal mask airway was inserted in 10 cadavers. At postmortem the chest was opened and an ... more The laryngeal mask airway was inserted in 10 cadavers. At postmortem the chest was opened and an infusion set primed with a dilute barium solution was inserted into the oesophagus and ligated in place. A cricoid force of 43 N was then applied and the infusion set was positioned so that when the clamp was opened it generated a pressure of 7.8 kPa within the oesophagus. The cricoid pressure was able to stop the p o w of @id into the oesophagus. This demonstrates that cricoid pressure is effective in preventing reJrux at intragastric pressures which are encountered clinically and the presence of the laryngeal mask airway does not compromise this.

Research paper thumbnail of Resuscitation after cardiac surgery: results of an international survey

European Journal of Cardio-thoracic Surgery, 2009

Objective: A survey was conducted on CTSNet, the cardiothoracic network website in order to ascer... more Objective: A survey was conducted on CTSNet, the cardiothoracic network website in order to ascertain an international viewpoint on a range of issues in resuscitation after cardiac surgery. Methods: From 40 questions, 19 were selected by the EACTS clinical guidelines committee. Respondents were anonymous but their location was determined by their Internet protocol (IP) address. The responses were checked for

Research paper thumbnail of A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fiberoptic intubation

Anesthesiology, 2001

Background: The design of an endotracheal tube has been shown to influence the passage of the tub... more Background: The design of an endotracheal tube has been shown to influence the passage of the tube through the glottis during fiberoptic intubation. Difficulty in passing the endotracheal tube can occur if the aryepiglottic folds obstruct the passage of the bevel. The relevant aspects of endotracheal tube design include the shape of the bevel, the material used by the manufacturer, and the ability of the tube to conform to the shape of the fiberscope. The aim of the current study was to compare the ease of passage through the glottis of two different tubes. One tube was a wire reinforced polyvinyl chloride tube with a standard bevel and the other was a newly designed tube with a bevel of different shape and made of silicone rubber. The new design is for use with the a commerical intubating laryngeal mask. Methods: The authors studied a population of 30 patients who received a standard anesthetic. In all cases, oral fiberoptic intubation was attempted. Anesthetic was administered to each patient using both tubes, and before the study the order of the tubes was randomized. The difficulty in passing the tube was assessed by a blinded observer and graded using a three-point scale (grade 1: no difficulty passing the tube; grade 2: obstruction to passing the tube relieved by withdrawal and a 90°anticlockwise rotation; grade 3: obstruction necessitating more than one manipulation or external laryngeal manipulation). Results: In 27 patients, no difficulty was shown by use of the silicone-tipped tube. In only three patients was there difficulty that necessitated a 90°anticlockwise twist. With the wire-reinforced tube, no difficulty was experienced on 14 occasions. Grade 1 difficulty was experienced eight times and difficulty necessitating more than one maneuver, head movement, or external laryngeal manipulation was seen on eight occasions. Statistical significance was achieved at P ‫؍‬ 0.0002 (Wilcoxon signed rank test). Conclusions: The authors conclude that the use of the silicone-tipped tube with the new bevel design may provide an advantage in the clinical situation of fiberoptic intubation.

Research paper thumbnail of Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

… and Thoracic Surgery, 2008

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is beneficial to give additional antibiotics or an iodine washout after an emergency re-sternotomy on the intensive care unit. Using the reported search, 527 papers were identified. Nine papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. For patients who require an emergency re-sternotomy on the intensive care unit, the incidence of sternal wound infection or sepsis after this emergency treatment is around 5%. We found only seven papers that documented the incidence of infection after emergency re-sternotomy. Of these seven papers, five documented that they routinely gave additional intravenous antibiotics and a povodine-iodine washout. The other two papers did not report whether this was done. We conclude that even though the incidence of subsequent infection is low in the cardiac arrest situation, full aseptic technique including gown and gloves might be regarded as best practice. It is common practice also to give additional antibiotics and a povodine-iodine washout although we could identify no studies other than uncontrolled cohort studies in support of this.

Research paper thumbnail of Anaesthetic log books

Anaesthesia, 2007

Since 1989, the Royal College of Anaesthetists has encouraged trainees to keep log books, althoug... more Since 1989, the Royal College of Anaesthetists has encouraged trainees to keep log books, although there is little information about the benefits of this practice as a part of anaesthetic training. A postal survey of all grades of trainee anaesthetist in the North West Region of England was conducted to obtain information about the present use of log books. The survey showed that log books are only used diligently by the more junior grades of anaesthetic staff. Although the practice of keeping a log resulted in an increased ability of the trainee to describe his clinical experience, the subsequent exploitation of this information to monitor or correct deficiences in training was disappointingly low.

Research paper thumbnail of The effects of protamine overdose on coagulation parameters as measured by the thrombelastograph

European Journal of Anaesthesiology, 2010

Protamine is routinely administered following cardiopulmonary bypass in order to neutralize the e... more Protamine is routinely administered following cardiopulmonary bypass in order to neutralize the effects of heparin. An excess of protamine can contribute to coagulopathy, hence predisposing to bleeding with associated morbidity and mortality. Thromboelastography (TEG) is recognized as an invaluable bedside tool to detect coagulation parameters; however, the effects of protamine overdose on TEG parameters have not been fully established. Forty-six patients undergoing cardiac surgery using cardiopulmonary bypass were recruited in the study. Following heparinization, the patient's blood heparin level was measured using Hepcon HMS. Incremental doses of protamine [at a protamine-to-Hepcon-derived heparin ratio (PHR) of 1:1, 2:1 and 3:1] were added to patients' blood samples in vitro and four TEG coagulation parameters, including R (time to clot initiation), K (clot kinetics), alpha (clot kinetics) and maximum amplitude (ultimate clot strength), were monitored. Statistical analysis was performed using NCSS software. Protamine caused dose-dependent worsening of coagulation parameters on TEG; K was significantly elevated, whereas alpha and maximum amplitude showed significant reduction (P < 0.001) compared with baseline at a PHR of 2:1 and 3:1, respectively. R was significantly prolonged compared with baseline (P < 0.001) at a PHR of 3:1. Protamine adversely affects clot initiation time, clot kinetics and platelet function in a dose-dependent manner, which can predispose to bleeding.

Research paper thumbnail of Guideline for resuscitation in cardiac arrest after cardiac surgery

European Journal of Cardio-Thoracic Surgery, Jul 1, 2009

The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provide... more The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given. This guideline is subject to continuous informal review, and when new evidence becomes available.

Research paper thumbnail of Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

Interactive CardioVascular and Thoracic Surgery, Mar 26, 2008

Research paper thumbnail of The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery

The Annals of Thoracic Surgery

Research paper thumbnail of Best evidence topic - Cardiac general Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VFypulseless VT. However, they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as 'indeterminate'. Thus, in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery.

Research paper thumbnail of Airway stents: anaesthetic implications

Continuing Education in Anaesthesia Critical Care Pain, Feb 21, 2010

Interventional management of airway lesions occluding the tracheobronchial tree include argon pla... more Interventional management of airway lesions occluding the tracheobronchial tree include argon plasma coagulation, forceps debulking, brachytherapy, cryotherapy, photodynamic therapy, and the use of tracheobronchial stents. This review considers airway stenting and the implications for the anaesthetist. Stents are placed into the airway for both

Research paper thumbnail of Abstract P159: The Cardiac Surgery Advanced Life Support Course: Delivering Significant Improvements in Emergency Cardiothoracic Care

Research paper thumbnail of If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

Interactive CardioVascular and Thoracic Surgery, 2008

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4-5 min. In addition, four large studies including the AHA National Registry of Cardiopulmonary Resuscitation, who reported the findings of 6789 in-hospital arrests, emphasise the importance of early defibrillation within 1-2 min. More concerning in patients post-cardiac surgery are four case reports after cardiothoracic surgery and five in the nonsurgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no inhospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.

Research paper thumbnail of Additional specialist training for cardiac intensive care staff on cardiac arrests is urgently needed

Anaesthesia

order to obtain median values and percentiles for each postoperative day. Results Data (median an... more order to obtain median values and percentiles for each postoperative day. Results Data (median and percentile) are shown in Fig. 1. Median CRP reached peak values in the second and third postoperative days (179 and 194 mg.dl)1 respectively). Discussion Values of CRP increase following uncomplicated valve surgery with peak values on days 2-3 postoperatively. Further analysis is required to ascertain whether this early CRP profile differs from that in patients who develop postoperative complications. References 1 Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation.

Research paper thumbnail of Cardiac Advanced Life Support Manual

Research paper thumbnail of Resuscitation in the cardiac intensive care setting

Cardiothoracic Critical Care, 2014

Research paper thumbnail of Training in anaesthesia: the US perspective

Postgraduate Medical Journal, 1996

In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Spe... more In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Specialist training in anaesthesia, supervision and assessment', there is currently much debate concerning the future of anaesthesia training in the UK. We present a description of anaesthesia training in the US for discussion and comparison. US residency training is short and seamless. It is highly

Research paper thumbnail of Best evidence topic - Cardiac general If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. ... more Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the

Research paper thumbnail of Does the laryngeal mask airway compromise cricoid pressure?

Anaesthesia, 1992

The laryngeal mask airway was inserted in 10 cadavers. At postmortem the chest was opened and an ... more The laryngeal mask airway was inserted in 10 cadavers. At postmortem the chest was opened and an infusion set primed with a dilute barium solution was inserted into the oesophagus and ligated in place. A cricoid force of 43 N was then applied and the infusion set was positioned so that when the clamp was opened it generated a pressure of 7.8 kPa within the oesophagus. The cricoid pressure was able to stop the p o w of @id into the oesophagus. This demonstrates that cricoid pressure is effective in preventing reJrux at intragastric pressures which are encountered clinically and the presence of the laryngeal mask airway does not compromise this.

Research paper thumbnail of Resuscitation after cardiac surgery: results of an international survey

European Journal of Cardio-thoracic Surgery, 2009

Objective: A survey was conducted on CTSNet, the cardiothoracic network website in order to ascer... more Objective: A survey was conducted on CTSNet, the cardiothoracic network website in order to ascertain an international viewpoint on a range of issues in resuscitation after cardiac surgery. Methods: From 40 questions, 19 were selected by the EACTS clinical guidelines committee. Respondents were anonymous but their location was determined by their Internet protocol (IP) address. The responses were checked for

Research paper thumbnail of A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fiberoptic intubation

Anesthesiology, 2001

Background: The design of an endotracheal tube has been shown to influence the passage of the tub... more Background: The design of an endotracheal tube has been shown to influence the passage of the tube through the glottis during fiberoptic intubation. Difficulty in passing the endotracheal tube can occur if the aryepiglottic folds obstruct the passage of the bevel. The relevant aspects of endotracheal tube design include the shape of the bevel, the material used by the manufacturer, and the ability of the tube to conform to the shape of the fiberscope. The aim of the current study was to compare the ease of passage through the glottis of two different tubes. One tube was a wire reinforced polyvinyl chloride tube with a standard bevel and the other was a newly designed tube with a bevel of different shape and made of silicone rubber. The new design is for use with the a commerical intubating laryngeal mask. Methods: The authors studied a population of 30 patients who received a standard anesthetic. In all cases, oral fiberoptic intubation was attempted. Anesthetic was administered to each patient using both tubes, and before the study the order of the tubes was randomized. The difficulty in passing the tube was assessed by a blinded observer and graded using a three-point scale (grade 1: no difficulty passing the tube; grade 2: obstruction to passing the tube relieved by withdrawal and a 90°anticlockwise rotation; grade 3: obstruction necessitating more than one manipulation or external laryngeal manipulation). Results: In 27 patients, no difficulty was shown by use of the silicone-tipped tube. In only three patients was there difficulty that necessitated a 90°anticlockwise twist. With the wire-reinforced tube, no difficulty was experienced on 14 occasions. Grade 1 difficulty was experienced eight times and difficulty necessitating more than one maneuver, head movement, or external laryngeal manipulation was seen on eight occasions. Statistical significance was achieved at P ‫؍‬ 0.0002 (Wilcoxon signed rank test). Conclusions: The authors conclude that the use of the silicone-tipped tube with the new bevel design may provide an advantage in the clinical situation of fiberoptic intubation.

Research paper thumbnail of Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

… and Thoracic Surgery, 2008

A best evidence topic in cardiac surgery was written according to a structured protocol. The ques... more A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is beneficial to give additional antibiotics or an iodine washout after an emergency re-sternotomy on the intensive care unit. Using the reported search, 527 papers were identified. Nine papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. For patients who require an emergency re-sternotomy on the intensive care unit, the incidence of sternal wound infection or sepsis after this emergency treatment is around 5%. We found only seven papers that documented the incidence of infection after emergency re-sternotomy. Of these seven papers, five documented that they routinely gave additional intravenous antibiotics and a povodine-iodine washout. The other two papers did not report whether this was done. We conclude that even though the incidence of subsequent infection is low in the cardiac arrest situation, full aseptic technique including gown and gloves might be regarded as best practice. It is common practice also to give additional antibiotics and a povodine-iodine washout although we could identify no studies other than uncontrolled cohort studies in support of this.

Research paper thumbnail of Anaesthetic log books

Anaesthesia, 2007

Since 1989, the Royal College of Anaesthetists has encouraged trainees to keep log books, althoug... more Since 1989, the Royal College of Anaesthetists has encouraged trainees to keep log books, although there is little information about the benefits of this practice as a part of anaesthetic training. A postal survey of all grades of trainee anaesthetist in the North West Region of England was conducted to obtain information about the present use of log books. The survey showed that log books are only used diligently by the more junior grades of anaesthetic staff. Although the practice of keeping a log resulted in an increased ability of the trainee to describe his clinical experience, the subsequent exploitation of this information to monitor or correct deficiences in training was disappointingly low.

Research paper thumbnail of The effects of protamine overdose on coagulation parameters as measured by the thrombelastograph

European Journal of Anaesthesiology, 2010

Protamine is routinely administered following cardiopulmonary bypass in order to neutralize the e... more Protamine is routinely administered following cardiopulmonary bypass in order to neutralize the effects of heparin. An excess of protamine can contribute to coagulopathy, hence predisposing to bleeding with associated morbidity and mortality. Thromboelastography (TEG) is recognized as an invaluable bedside tool to detect coagulation parameters; however, the effects of protamine overdose on TEG parameters have not been fully established. Forty-six patients undergoing cardiac surgery using cardiopulmonary bypass were recruited in the study. Following heparinization, the patient's blood heparin level was measured using Hepcon HMS. Incremental doses of protamine [at a protamine-to-Hepcon-derived heparin ratio (PHR) of 1:1, 2:1 and 3:1] were added to patients' blood samples in vitro and four TEG coagulation parameters, including R (time to clot initiation), K (clot kinetics), alpha (clot kinetics) and maximum amplitude (ultimate clot strength), were monitored. Statistical analysis was performed using NCSS software. Protamine caused dose-dependent worsening of coagulation parameters on TEG; K was significantly elevated, whereas alpha and maximum amplitude showed significant reduction (P < 0.001) compared with baseline at a PHR of 2:1 and 3:1, respectively. R was significantly prolonged compared with baseline (P < 0.001) at a PHR of 3:1. Protamine adversely affects clot initiation time, clot kinetics and platelet function in a dose-dependent manner, which can predispose to bleeding.