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Background Although an emergency surgical airway is recommended in the guidelines for a paediatric cannot intubate, cannot oxygenate (CICO), there is currently no evidence regarding the best technique for this procedure. Objective To review the available literature on the paediatric emergency surgical airway to give recommendations for establishing a best practice for this procedure. Design Systematic review: Considering the nature of the original studies, a meta-analysis was not possible. Data sources MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Google Scholar and LILACS databases. Eligibility criteria Studies addressing the paediatric emergency surgical airway and reporting the following outcomes: time to tracheal access, success rate, complications and perceived ease of use of the technique were included. Data were reported using a Strengths, Weaknesses, Opportunities and Threats analysis. Strengths and Weaknesses describe the intrinsic (dis)advantages of the techniques. The opportunities and threats describe the (dis)advantage of the techniques in the setting of a paediatric CICO scenario. Results Five studies described four techniques: catheter over needle, wire-guided, cannula or scalpel technique. Mean time for placement of a definitive airway was 44 s for catheter over needle, 67.3 s for the cannula and 108.7 s for the scalpel technique. No time was reported for the wire-guided technique. Success rates were 43 (10/23), 100 (16/16), 56 (87/154) and 88% (51/58), respectively. Complication rates were 34 (3/10), 69 (11/16), 36 (55/151) and 38% (18/48), respectively. Analysis shows: catheter over needle, quick but with a high failure rate; wire-guided, high success rate but high complication rate; cannula, less complications but high failure rate; scalpel, high success rate but longer procedural time. The available data are limited and heterogeneous in terms of reported studies; thus, these results need to be interpreted with caution. Conclusion The absence of best practice evidence necessitates further studies to provide a clear advice on best practice management for the paediatric emergency surgical airway in the CICO scenario.

Background Contemporary axillary brachial plexus block is performed by separate injections targeting radial, median, ulnar and musculocutaneous nerve. These nerves are arranged around the axillary artery, making ultrasound visualisation sometimes challenging. In particular, the radial nerve can be difficult to localise deep to the artery. Objectives The primary aim of this study was to investigate which arm position optimises the visibility of the radial nerve. Secondary aims were the visibility and position of the other nerves during varying arm positions. Design A prospective observational study. Setting University teaching hospital, November 2012. Participants Twenty volunteers, recruited by an advertisement on the Department's bulletin board. Inclusion criterion age more than 18 years. Exclusion criteria refusal of ultrasound examination, restricted shoulder movement, local infection, BMI greater than 30 kg m⁻². Intervention One anaesthesiologist performed bilateral ultrasound examinations of the axillary brachial plexus on 20 volunteers. Each arm was placed in different positions [shoulder (S) 90° or 180° abduction, elbow (E) 0° or 90° extension] and scans were performed proximally in the axilla, and additionally 5 cm distally to this point [proximal (P) vs. distal (D)], resulting in eight different scans stored for off-line analysis performed by two blinded anaesthesiologists. Main outcome measures For radial, median, ulnar and musculocutaneous nerve, visibility was assessed on a six-point visibility scale. Distances and angles of the nerves relative to the axillary artery and distances relative to the skin were measured. Results No significant differences between arm positions were found in the visibility score of radial (P = 0.359) and musculocutaneous nerves (P = 0.073). Visibility of the median nerve was improved in positions S90°/E0°/D and S180°/E0°/P (P = 0.02). The ulnar nerve was more visible in position S180°/E 0°/P and D (P = 0.007). The greatest distance between artery and radial nerve was 7.4 ± 4.7 mm at an angle of 120 ± 14° in position S180°/E 0°/D. Conclusion The visibility of the radial nerve was not improved by varying positions of the arm. S180°/E0° provided the best overall visibility and accessibility of nerves. Trial registration https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm Identifier: NL42116.018.12.

Background and objectives Local neurotoxicity of local anaesthetics is a well known phenomenon which is determined by lipophilicity. Recent reports have indicated the relevance of local anaesthetic-induced cytotoxicity also in nonneuronal tissues. This study re-evaluates the role of lipophilicity in local anaesthetic cytotoxicity in nonneuronal cells. In addition, the toxicities of pipecoloxylidine S(-) enantiomers were investigated. Methods Local anaesthetic-induced cytotoxicity was investigated in vitro in T-lymphoma cells (Jurkat). Cells were incubated with each of eight different local anaesthetics, two esters and six amides. Annexin V-fluorescein isothiocyanate and 7-aminoactinomycin D double staining followed by flow cytometry were used to investigate the fraction of early apoptotic cells as well as the overall cell death. The concentrations leading to 50% cell death (LC(50)) were calculated and compared. In a second step, we compared the toxicities of S(-) bupivacaine and the racemate as well as R(R) and S(-) ropivacaine. Results Concentration-dependent cytotoxicity was observed for all investigated local anaesthetics. Apoptosis was seen at low concentrations, whereas necrosis was observed at higher concentrations. LC(50) values of the different local anaesthetics yielded the following decreasing order of toxicity: tetracaine, bupivacaine, ropivacaine, prilocaine, procaine, lidocaine, articaine and mepivacaine. Toxicity correlated with octanol/buffer partition coefficients, but was independent of the ester or amide linkage. There was no effect of stereoisomerism on apoptosis and necrosis. Conclusion Moderate correlations for cytotoxicity with lipophilicity and clinical potency of local anaesthetics can be found in nonneuronal cells that are less than those reported previously with neuronal cells. Structural factors such as ester or amide linkage or stereospecificity do not have any influence on cytotoxicity. Although S(-) enantiomers may be advantageous with regard to systemic toxicity, they have no advantage in respect of local cytotoxicity in vitro. Eur J Anaesthesiol 2012;29:35-41 Published online 19 October 2011