HELP-VDL: study protocol for a multicentre, open, randomised, controlled clinical trial comparing the use of the head-elevated laryngoscopy position and the use of a videolaryngoscope to facilitate orotracheal intubation in a patient population without predictable difficulty of intubation

IntroductionTracheal intubation remains an everyday challenge for anaesthesiologists, even in patients without suspected difficult airways. The ideal positioning of the patient’s head (flat, raised a few centimetres on a cushion in the sniffing position (SP), or raised to achieve horizontal alignment between the external acoustic meatus and the sternal angle) and the use of videolaryngoscopy remain controversial. This trial aims to compare the efficacy for orotracheal intubation of the SP or the head-elevated laryngoscopy position (HELP), which has been shown to improve laryngeal visualization and the intubation condition particularly in obese patients, in combination with a McGrath Mac videolaryngoscope whose video screen is either on or off (Video or NoVideo).Methods and analysisThe HELP-VDL factorial trial is a prospective, randomised, parallel, multicentre, open study of 240 adult patients undergoing tracheal intubation under general anaesthesia. Patients will be allocated into four groups: SP-NoVideo, HELP-NoVideo, SP-Video and HELP-Video. The primary outcome is the proportion of orotracheal intubations that requires the assistance of a nurse anaesthetist. The secondary outcomes include the intubation duration, the first intubation success rate, the quality of visualisation of the glottis, the glottis visualisation score, adjunctive manoeuvres and alternative techniques used, the occurrence of oesophageal intubation, failure of tracheal intubation, the incidence of arterial oxygen desaturation, the perception of a difficult intubation, the score on the Intubation Difficulty Scale, cooperation among the members of the anaesthesia team, the evolution of vital signs and the frequency and severity of intubation complications. Data will be analysed on the intention-to-treat principle and a per-protocol basis.Ethics and disseminationEthics approval was obtained from the Ethical Committee Ile de France V (Paris, France). Participant recruitment began on 3 July 2019. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT03987009; Pre-results.

A review of literature on substance abuse among anaesthesia providers

Background Research has demonstrated that anaesthesia providers are susceptible to substance abuse. Several preventive measures are being implemented in certified registered nurse anaesthetist programmes to educate future providers about substance abuse. Given the continued prevalence and impact of the problem, more research is needed about the prevalence of substance abuse among student registered nurse anaesthetists and the implementation of preventive strategies in the educational setting. Aims The purpose of this narrative literature review was to examine the state of the science related to substance abuse among US certified anaesthesia providers. This literature review covered abuse of alcohol, tobacco, recreational drugs, opioids and anaesthetic agents. Methods This narrative review was conducted using the following search terms: anaesthesia, student, wellness, stress, substance abuse, satisfaction, personality, depression, nurse, nurse anaesthetist, propofol, isoflurane and fentanyl. References were identified using PubMed, CINAHL, Google Scholar, and the American Society of Anesthesiologists and American Association of Nurse Anesthetists websites. A total of 36 articles were identified as relevant to this literature review based on content and country of publication. This literature review was limited to articles published in the past 15 years. With one exception, our search was limited to manuscripts from the US. Results The literature underscored that various risk factors contribute to substance abuse. Board-certified anaesthesia providers fall prey to substance abuse due to ease of access, the high stress associated with administering anaesthesia, and the propensity to become addicted to opioids and other anaesthetics. A gap in the science exists about the prevalence of substance abuse among student registered nurse anaesthetists and the effectiveness of preventive strategies in the educational setting. Conclusions Anaesthesia providers are at high risk of abusing substances. To create a safer environment, future research should explore the prevalence of substance abuse among student registered nurse anaesthetists and emphasise the integration of effective preventive strategies in the educational setting.

Nurses anaesthetists’ versus patients’ assessment of anxieties in an ambulatory surgery setting

Background Failure to assess patients’ anxiety perioperatively by means of a validated instrument makes the assessment arbitrary. Studies are lacking about how well nurse anaesthetists estimate patients’ preoperative worries. Purpose To compare the nurse anaesthetists’ estimations of patients’ preoperative anxieties with the patients’ own assessment of their anxieties. Design Quantitative prospective design. Methods Eighty-five pairs of patients and nurse anaesthetists in two ambulatory surgery units in a university hospital in Sweden were included. Patients’ perioperative anxieties were graded using the Numeric Visual Analogue Anxiety Scale. Results The nurse anaesthetist overestimated the patients’ level of preoperative anxiety in 53% of patients and underestimated patients’ anxieties in 31% of the patients. Consensus was seen in 16% of the pairs. In fifty-six pairs (65%), the difference between the estimation of level of patients’ anxiety according to Numeric Visual Analogue Anxiety Scale was between −3 (overestimation) and +3 levels (underestimation). Median levels of anxiety were estimated as 3 within the patient group and 4 among the nurse anaesthetists. Conclusions Systematic assessment of patients’ level of anxiety could lead to identifying patients with severe anxiety levels and to offer more individualised treatment. The patients’ own estimation must form the basis for the discussion and treatment.

Team talk and team decision processes: a qualitative discourse analytical approach to 10 real-life medical emergency team encounters

ObjectivesExplore the function of three specific modes of talk (discourse types) in decision-making processes.DesignTen real-life admissions of patients with critical illness were audio/video recorded and transcribed. Activity-type analysis (a qualitative discourse analytical method) was applied.SettingInterdisciplinary emergency teams admitting patients with critical illness in a Norwegian university hospital emergency department (ED).ParticipantsAll emergency teams consisted of at least two internal medicine physicians, two ED nurses, one anaesthetist and one nurse anaesthetist. The number of healthcare professionals involved in each emergency team varied between 11 and 20, and some individuals were involved with more than one team.ResultsThe three discourse types played significant roles in team decision-making processes when negotiating meaning. Online commentaries (ONC) and metacommentaries (MC) created progression while offline commentaries (OFC) temporarily placed decisions on hold. Both ONC and MC triggered action and distributed tasks, resources and responsibility in the team. OFC sought mutual understanding and created a broader base for decisions.ConclusionA discourse analytical perspective on team talk in medical emergencies illuminates both the dynamics and complexity of teamwork. Here, we draw attention to the way specific modes of talk function in negotiating mutual understanding and distributing tasks and responsibilities in non-algorithm-driven activities. The analysis uncovers a need for an enhanced focus on how language can trigger safe team practice and integrate this knowledge in teamwork training to improve communication skills in ad hoc emergency teams.