Background: Ventilator-acquired pneumonia is a common complication in intensive care units. Ensuring optimal tracheal sealing might prevent this complication. Aim: To compare the effectiveness of polyvinyl chloride taper-shaped versus polyvinyl chloride cylindrical-shaped cuffed tubes in reducing the pen-cuff leak. Design: Experimental study using a sheep trachea model. The tracheal tubes were inserted into the trachea placed in a vertical position at a fixed height. The cuff of each tube was inflated until reaching a pressure ranging between 25 and 30 cm H2O. Ten milliliters of methylene blue were poured above the cuff and the volume of fluid leaking around the tube was collected and quantified at 30 min, 60 min and 360 min. Results: Sixty measurements were performed with cylindrical shaped cuffed tubes and 48 measurements were performed with the taper-shaped cuffed tubes. Repeated measures analysis of variance showed that there was a significant difference in the volume of leakage for both tubes over time (p = 0.016). Accordingly, the post hoc analysis revealed a significant decrease of the volume leaking at 30 min versus 360 min. The between subject variables assessment showed a significant decrease of leak volume with the taper-shaped cuffed tracheal tubes (p = 0.011). Conclusion: Our experimental study suggests that polyvinyl chloride taper-shaped cuffed tubes are more effective in ensuring appropriate tracheal sealing and reducing the fluid leak around the cuff of the tracheal tube. (C) 2018 Elsevier Ltd. All rights reserved.

Cardiac output (CO) monitoring is an invaluable tool for management of critically ill patients in the intensive care units (ICU) and high-risk patients undergoing surgery.Measurements of CO were not available until 1970, when Swan et al introduced the flow-directed balloon-tipped pulmonary artery catheter (PAC); this catheter is inserted at the bedside and is considered the gold standard for accurate CO measurements(1,2). Recently, minimally invasive and non-invasive alternative CO monitors have emerged that not only overcome the PAC's invasive limitations, but are also able to guide fluid optimization, which has been shown to improve the outcome after major surgery(3).This is a review of the characteristics of the PAC and compares it with other less invasive and non-invasive CO monitors currently available.We will look at issues of accuracy, dependability, complications, limitations to use, the ability to give continuous readings and how these monitoring systems could be used to guide fluid status optimization.The systems we will review include the following:Pulmonary artery catheter (as the gold standard)LiDCO Plus (TM) (LiDCO Ltd, London, UK)LiDCO Rapid (TM) (LiDCO Ltd, London, UK)PiCCO Plus (TM) (Pulsion Medical Systems, Munich, Germany)The Edwards FloTrac (TM) sensor/Vigileo (TM) monitor (Edwards Lifesciences, Irvine, USA)Oesophageal Doppler UltrasoundFinometer (TM) (Finapres Medical Systems, Amsterdam, Netherlands)Nexfin (TM) (Bmeye B.V., Amsterdam, Netherlands)

A thirty-two-year-old male patient with a history of fever presented with generalized tonic-clonic convulsions and a low Glasgow Coma Score (GCS); an endotracheal tube was inserted to secure his airway.The patient had malignant generalized tonic-clonic convulsions for six weeks, he was diagnosed as status epilepticus (SE) on the electroencephalogram (EEG). Achieving control was very difficult even with various antiepileptic medications. More than six antiepileptic drugs were used in addition to continuous infusion of anesthetic medications to control the convulsions.After four-months in the ICU, the patient became fully conscious with no residual neurological deficit and good control of convulsions but with generalized muscle weakness. The patient was eventually transferred to the regular ward and was discharged after few days.

Result: Statistical analysis showed a confidence interval overlap for flow rates in nonkinked versus kinked catheters sizes 14 G, 16 G and 18 G indicating that kinking does not significantly alter flow rate in these catheters. Ambiguity in the 20 G catheter data suggests that a greater sample size should be examined. Analysis of the 22 G catheter data showed a statistically significant decrease in flow rate when kinked.

Result: Fifty doctors completed the questionnaire; 49 (98%) of the physicians thought that a hospital should have a DNR policy, 23 (46%) of the physicians believed that the DNR decision lies in the hands of the responsible doctor, 10 (20%) of the participants thought that it is a family decision only, whilst 17 (34%) thought that it is a joint decision by the family and the physician. All of the physicians agreed that there should be no code blue activation in case of cardiopulmonary arrest of a DNR labeled patients.

A two-year-old male, a known case of bronchial asthma was admitted as a case of exacerbation of asthma. He did not improve with standard treatment and required invasive ventilator support twice during his admission. The chest x-rays only showed hyperinflation but CT scan of the thorax revealed a foreign body (a piece of Betel nut) lodged in the right main bronchus. It was removed under bronchoscopic guidance.

Background: Pediatric surgery performed in a daycare unit has become the norm in the last few years. Children need special care in terms of psychological stress during the perioperative period 1 . There are many ways to reduce stress in children scheduled for surgery, including preoperative sedative premedication, induction of anesthesia in a familiar environment and “steal” induction in the mother’s arms 2,3 . It is important to consider parental satisfaction while delivering a healthcare service to children. Objective: To assess the overall parental satisfaction throughout the patient’s journey, including the preoperative, intraoperative and the postoperative periods. Setting: Daycare Unit, Department of Anesthesia, King Hamad University Hospital, Bahrain. Design: A Prospective Study. Method: Fifty parents were consented for the questionnaire-based study. Children of these parents were posted for different types of daycare surgery. The parents were asked to fill a form either in Arabic or English, before their children were discharged from the daycare ward. The parents were given an 11-point questionnaire 4 . Scoring these questions was based on their choice of 5 options including: (1) strongly agree, (2) agree, (3) neutral, (4) disagree and (5) strongly disagree. Fifty parents had been included in the study. Patient’s CPR numbers and telephone numbers of the parents were recorded. Questions 7 and 11 demanded individual answers rather than box-ticking. Result: “Strongly agree” and “agree” were taken as positive responses. The majority of parents answered positively to the questions asked. “Strongly disagree” and “disagree” were taken as negative responses. Neutral response was taken as a parent’s wish not to comment either positively or negatively. Conclusion: The majority of the parents were in positive agreement with the questions asked. The majority of the parents were satisfied that the PAC clinic gave them enough information about the anesthetic. The majority of parents were also satisfied with the amount of pain relief given in the recovery room and in the day-care ward. ______________________________________________________________________________ * Senior Registrar ** Director of Intensive Care and Consultant Anesthetist Associate Professor of Physiology and Critical Care, RCSI-MUB *** Senior Registrar Department of Anesthesia and ICU King Hamad University Hospital Kingdom of Bahrain Email: eamon.tierney@khuh.org.bh; aashishjain29@gmail.com INTRODUCTION In a questionnaire-based study conducted in the Royal Berkshire Hospital, it was concluded that parental satisfaction is an important outcome of quality of care delivered in the pediatric daycare unit 5 . The study also concluded that the nurses play a key role in maintaining a quality service and should therefore be involved in monitoring that service. Daycare surgery is increasingly popular because it reduces the length of stay in the hospital by facilitating admission and discharge on the same day. At least 70% of procedures in the pediatric age group are performed as day cases 6 . The increase in daycare surgery has become possible as a result of the availability of shorter-acting anesthetic agents and analgesics. In addition, the use of nerve blocks such as penile blocks and caudal blocks per-operatively has become more commonplace for pain management. Proper selection of patients is of the utmost importance for daycare surgery and one of the important categories of the patients in daycare surgeries is the pediatric age group. These patients are commonly posted for tonsillectomy, adenotonsillectomy, circumcision, undescended testes, inguinal herniotomy and other similar short duration surgeries with minimal blood loss. Children are vulnerable to separation anxiety and associated perioperative stress. In our hospital, we have a policy of child-friendly and parent-friendly management of the pediatric patient coming to theatre for surgery. The parent stays with the child until the child falls asleep. Anesthesia is always induced by inhalation to avoid placing a needle into a conscious child. When the child is transferred from theatre to the recovery room after surgery, the parent is called as quickly as possible to the recovery room to be with the child. In this manner, the child is awake without the presence of a parent for a minimum period of time. In addition, we place a large emphasis on good peri-operative analgesia in pediatric patients, with good intra-operative analgesia and with a rapid response to any complaint of pain expressed by the child in the recovery room. The aim of this study is to assess the overall parental satisfaction throughout the patient’s journey including the preoperative, intraoperative and the postoperative periods. METHOD The parents of 50 patients below 10 years of age posted for daycare surgery were included in the study. The children were anesthetized by anesthetic gas inhalation in the presence of one parent. The parent left the induction room immediately when the child fell asleep. At the end of surgery, the child was transferred to the recovery room. The parent was called to the recovery room as soon as the anesthetist and recovery nurse were satisfied that the child had recovered from the anesthetic. An eleven-point questionnaire was filled out by the parents just before their children were discharged from the daycare ward, see table 1. The questionnaire included the preoperative, intraoperative and postoperative periods. In response to each question, parents were requested to select one of the options on five-point score; the options were:  strongly agree  agree  neutral  disagree  strongly disagree Identifying data on the questionnaire forms were the patient’s Central Population Registration (CPR) number and the telephone number of their parents. RESULT Table 1: Parents’ Responses Numbers and Percentages Question Number Strongly Agree Agree Neutral Disagree Strongly Disagree Not Attempted 1 Was your visit to the pre admission Clinic helpful? 31 16 0 1 1 1 2 Are you satisfied that the doctor/anesthetist gave you enough information about the anesthetic for your child? 34 10 3 2 1 0 3 Did the doctor or anesthetist answer all your questions? 37 10 2 0 0 1 4 Did the doctor/anesthetist explain enough details about the anesthetic procedure? 31 13 2 3 0 1 5 Was it helpful for you to go to operating room with your child? 42 6 2 0 0 6 If yes, was it helpful for your child? 39 9 1 0 0 1 7 Why was it helpful for your child? Discussed below 8 Were you called early enough to be with the child as he/she woke up in the recovery room? 39 9 0 0 1 1 9 Were you satisfied with the 40 8 1 0 0 1 amount of pain relief given to your child in the recovery room? 10 Were you satisfied with the amount of pain relief given to your child in the ward? 42 7 0 0 0 1 11 Do you have any suggestions as to how we can improve the anesthetic and Pain relief services for children? Discussed below

methods include, after positioning of the patient and painting of the neck with an antiseptic, local infiltration of lignocaine, followed by skin incision, and thereafter, tracheal puncture and guide wire insertion. We propose a modification of the initial surgical steps; the patient is positioned and the neck is painted with antiseptic solution, 14 gauge cannula is inserted into the trachea under bronchoscopic guidance without infiltration of local anesthetic, but with the administration of systemic sedation and potent intravenous analgesia using remifentanil, see figure 1. Traditionally, local anesthetic had been infiltrated before insertion of the cannula into the trachea. After introducing the guide wire into the trachea through the cannula, 15-20 ml of 1% lignocaine is infiltrated alongside the guide wire through the subcutaneous tissue down as far as the anterior tracheal wall creating a “pool” of local anesthetic around the guide wire, see figure 2. Thereafter, the skin is incised in the usual manner, immediately alongside the guide wire, and the incision is continued as far as the anterior tracheal wall.

Autopsy appears to have then become unfashionable or undesirable until the time of the Renaissance and afterwards. In the mid-sixteenth century, Vesalius practiced autopsy and taught it to his students 1 . In about 1543 or 1544, he published De humani corporis fabrica on the composition of the human body based on his post-mortem studies, which is probably the most important anatomy textbook ever published 1 . Of interest to intensivists, he was the first to describe artificial ventilation by attaching a pair of bellows to a post-mortem trachea-lung preparation 2 .

We present a case of deliberate self-inflicted trauma to the airway. The patient presented with a slit throat secondary to attempted suicide. The patient had a GCS score of 15 in the emergency department with an ability to maintain his own airway and phonation. A cuffed tracheostomy tube was inserted through the wound to maintain the airway. The patient had full wound exploration and repair of anterior tracheal wall. Repeat laryngoscopy and bronchoscopy was done postoperatively which revealed left vocal cord palsy which recovered completely after 2 weeks.

Cardiopulmonary resuscitation (CPR) is the emergency medical procedure used in an attempt to restart circulation and breathing in a patient after the heartbeat and/or breathing have ceased. The most basic form of CPR involves giving artificial breaths and external chest compressions while advanced CPR includes, in addition to basic CPR, placement of an advanced airway, giving electric shocks and medications 1 .

We involved the parents of paediatric patients in the first part of the three-stage WHO Surgical Safety Checklist (SSC) process. Forty-two parents took part in the study. They came to the theatre suite with their child and into the induction room. Immediately before induction of anaesthesia they were present at, and took part in, the first stage of the three-stage SSC process, confirming with staff the identity of their child, the procedure to be performed, the operating site, and the consent being adequately obtained and recorded. We asked parents and theatre staff later whether they thought that parental involvement in the SSC was beneficial to patient safety. Both parents and staff welcomed parental involvement in the WHO Surgical Safety Checklist and felt that it improved patient safety.

Objective: To evaluate the degree of communication with patients and their relatives based on a predesigned medical communication scale. Design: A Prospective random sample assessment study. Setting: Intensive Care Unit, King Hamad University Hospital. Method: We studied the scale randomly in 50 adult patients admitted to ICU. The degree of communication with the patient’s next of kin was assessed by a native English speaking intensivist according to a scale designed for the purpose. Result: Twenty-three (46%) relatives required the help of an interpreter for communication (class 4). Full communication was possible with 15 (30%) relatives (class 2). Twelve (24%) relatives did not have a full grasp of the working language or were informed to a below average level or were unwilling or uninterested in obtaining further knowledge. There was no relative with whom communication was impossible (class 5) nor was there any well-informed relative with whom communication was fully fluent (class 1). Conclusion: The medical communication scale can help the physician to objectively quantify the ease or difficulty in communication with the patient’s relatives. In the ethnically mixed workforce of our hospital, while the physician could fully communicate with many relatives, a significant percentage of the relatives were not proficient in the working language of the hospital and required the help of an interpreter to communicate with the physician.