Cannula tracheotomy in a model comparable to the infant airway is difficult and not without complication. Cannulae of 14- and 18-gauge appear to offer similar performance. Successful aspiration is the key predictor of appropriate cannula placement. The Quicktrach Child was not used successfully in this model. Further work is required to compare possible management strategies for the CICO scenario.

At level 1, the first attempt success rate was 100% for both devices. Overall CM showed a better success rate than SB; however, both techniques were associated with significant complication rates, which were more pronounced following the scalpel bougie technique.

Background: Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy.Aims: To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates.Methods: Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique).Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt.Results: 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect).Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique. Conclusion:Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.

Editor's key points † Sleep quality is important to patients and can be disrupted by hospital admission for surgery. † Remifentanil was shown to have long-term effects on sleep quality in children. † This study aimed to use patient self-report measures to assess sleep quality 6 months after surgery. † Preoperative 'good sleepers' were affected most by remifentanil after 6 months.Background. Clinical and pre-clinical data agree that opioids disrupt sleep architecture.Recently, remifentanil has been suggested to cause possible long-term disturbances of sleep quality. This randomized controlled clinical trial was designed to substantiate or refute a possible long-term effect of remifentanil on the quality of sleep.Methods. One hundred patients undergoing elective surgery were randomized to receive either fentanyl or remifentanil-based anaesthesia. Before operation (T0) and 3 (T3) and 6 (T6) months after operation, the quality of sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI). Results.Overall, the quality of sleep for patients in the remifentanil or fentanyl group was not significantly different at any time point. Patients in the fentanyl group screened as good sleepers before operation showed no differences across time course of the study in PSQI scores. In contrast, good sleepers in the remifentanil group had significantly impaired sleep quality for at least 3 months after operation. Patients who were before operation screened as poor sleepers showed no significant changes in PSQI scores at T3 and T6 in both groups.Conclusions. The intraoperative use of remifentanil in a general patient population does not significantly alter the quality of sleep in the postoperative period. However, it may result in a significant reduction in the quality of sleep in patients before operation considered good sleepers. These changes were not observed in the group of patients receiving fentanyl. The relevance of these findings in terms of patient recovery and quality-of-life warrants further investigation.Trial Registration. ACTRN12610000362099.Anaesthesia causes distinct disturbances in the integrity of body functions that may extend beyond the acute postoperative period. It has multiple effects on the circadian rhythm and sleep-wake cycle but also affects other circadian rhythms such as cortisol, 1 melatonin secretion, 2 and temperature control. 3 A central circadian (24 h) pacemaker in the suprachiasmatic nuclei coordinates circadian oscillators in many cells of mammals in order to synchronize and organize daily rhythms in behaviour and physiology. Exactly how anaesthesia in general and, more specifically, which drugs affect these sensitive systems is not fully understood. Data from animal and human research suggest that opioids play a highly complex role: they inhibit the rapid eye movement (REM) phase of sleep and decrease acetylcholine (ACh) release at the cholinergic cell body region in the laterodorsal tegmental nuclei (LDT) and the terminal field in medial pontine reticular formation (mPRF) regions that cont...