SummaryAwake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta-analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our primary outcome was the time needed to intubate the patient's trachea. Secondary outcomes included: failed intubation; the rate of successful intubation at the first attempt; patient-reported satisfaction with the technique; and any complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intubation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 participants, mean difference (95%CI) À45.7 (À66.0 to À25.4) s, p < 0.0001, low-quality evidence). There was no significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI) 1.01 (0.24-4.35), p = 0.99, low-quality evidence) or the first-attempt success rate (six studies, 391 participants, risk ratio (95%CI) 1.01 (0.95-1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies, 167 participants, risk ratio (95%CI) 1.07 (0.62-1.85), p = 0.81, low-quality evidence), and low oxygen saturation (five studies, 337 participants, risk ratio (95%CI) 0.49 (0.22-1.12), p = 0.09, low-quality evidence). In summary, videolaryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a success rate and safety profile comparable to fibreoptic bronchoscopy.

Intra-articular tenoxicam improves postoperative analgesia in knee arthroscopyPurpose: Non Steroidal Anti-Inflammatory drugs have a well documented benef~ in the relief of postoperative pain. This study was designed to compare the analgesic effect of intra-articular tenoxicam 20 mg with intravenous tenoxicam on postoperative pain in 88 patients undergoing day case knee arthroscopy. Methods: A prospective, double blind, randomized trial was performed. All patients received a standard general anesthetic. Patients in group A received 20 mg tenoxicam made up to 40 ml with normal saline intra-articularly (io) and 2 ml normal saline iv. Patients in group B received 40 ml normal saline intra-articularly and 2 ml, 20 mg of tenoxicam, iv. Results: Both groups of patients were similar with respect to age, weight, sex and tourniquet inflation time. Patients receiving in tenoxicam had lower pain scores (at rest and upon movement) at 30, 60, 120 and 180 min postoperatively (0.8 _ 0.2 vs 2.5 _ 0.2 at rest and 1.24 _+ 0.2 vs 3.4 _+ 0.2 at movement at 60 min; P < 0.000 I). Fewer patients required additional analgesia in the first four hours postoperatively (33% vs 84%; P < 0.0000 I) and the time to first analgesia (23.7 + I 1.2 vs 9.4 _+ 0.6; P < 0.02) was longer in those receiving in tenoxicam. Conclusion: Intra-articular tenoxicam provides superior postoperative analgesia and reduces postoperative analgesic requirements compared with iv tenoxicam in patients undergoing day case knee arthroscopy.Objcctif: Les anti-inflammatoires non st&oi'diens sont des mddicaments bien reconnus pour le soulagement de la douleur postop&atoire. La pr&ente ~tude avait pour but de comparer reffet analg&ique de 20 mg de t6noxi-cam intra-articulaire ~ du t~noxicam intraveineux sur la douleur postop&atoire chez 88 patients admis en chirurgie ambulatoire pour une arthroscopie du genou. M&hode : On a proc6d~ ~ un essai prospectif, randomis6 et ~ double insu. Tous les patients ont re~u un anesth&ique g~n&al standard. Les patients du groupe A ont re~u une injection intra-articulaire (io) compos& de 20 mg de t~noxicam compl6t~ ~ 40 ml par une solution salve et 2 ml de solution sal& iv. Les patients du groupe B ont re~u 40 ml de solution sal& en injection intra-articulaire et 2 ml, 20 mg de t~noxicam, iv. R~sultats : Les deux groupes pr6sentaient des caract&istiques semblables quant ~ I'~ge, le poids, le sexe et le temps de gonflement du garrot. Les patients qui ont re~u du tfinoxicam io ont eu des scores de douleur plus bas (au repos et en mouvement) ~ 30, 60, 120 et 180 min apr~s I'intervention (0,8 + 0,2 vs 2,5 -0,2 au repos et 1,24 _+ 0,2 vs 3,4 _+ 0,2 en mouvement ~ 60 min; P < 0,0001). Moins de patients ont eu besoin d'analg&ie suppl~mentaire pendant les quatre premi&es heures postop&atoires (33 % vs 84 %; P < 0,0000 I) et le temps &oul~ avant la premi&e analg&ie (23,7 _+ I 1,2 vs 9,4 _+ 0,6 P < 0,02) a ~t~ plus long pour les patients qui ont re~u du t~noxicam in. Conclusion : Le t6noxicam intra-articulaire, compar~ au t~noxicam iv, fournit une anal...

SummaryWe report three experiences that illustrate the use of local anaesthesia for rigid bronchoscopy. All patients were acute emergencies, with life-threatening central airway problems. Instruments were inserted after the airway was anaesthetised using a technique that owes much to mid 20th Century methods for inserting endobronchial blockers. There is discussion about requirement to preserve and conserve self-ventilation and the securing of compromised central airways without the aid of neuromuscular blocking agents. Historical aspects of bronchoscopy are reviewed. Concomitant sedation reduced the unpleasantness of the experience in a way that in the past could only be dealt with by careful attention to the humanitarian elements of detail. Problems of oxygenation were ameliorated by periodically superimposing intermittent jetting with a Sanders injector fed from the oxygen pipeline. A need for developing and refining topical and other local anaesthetic techniques for rigid bronchoscopy is anticipated with the expansion of services for tracheobronchial stenting and lasering.

IntroductionThe first case of COVID-19 in Ireland was diagnosed on 29 February 2020. Within the same week, our Department of Anaesthesia and Critical Care at University Hospital Galway began to tackle the educational challenge by developing an  in situ interprofessional simulation programme to prepare staff for the impending outbreak.Principles and approaches used for simulation-based trainingWe describe principles applied to identify core educational and system engineering objectives to prepare healthcare workers (HCWs) for infection control, personal and psychological safety, technical and crisis resource management skills. We discuss application of educational theories, rationale for simulation modes and debriefing techniques.Development of the simulation programme3 anaesthesia (general, obstetric, paediatric) and 1 critical care silo were created. 13 simulated scenarios were developed for teaching as well as for testing workflows specific to the outbreak. To support HCWs and ensure safety, management guidelines, cognitive aids and checklists were developed using simulation. The cumulative number of HCWs trained in simulation was 750 over a 4-week period.Challenges and future directionsDue to the protracted nature of the pandemic, simulation educators should address questions related to sustainability, infection control while delivering simulation, establishment of hybrid programmes and support for psychological preparedness.

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