3 research outputs found
Airway management in emergency anaesthesia
No full textBackgroundAirway management in critically ill patients, particularly rapid sequence induction and intubation (RSI) for emergency anaesthesia, remains a high-stakes and time-critical procedure associated with significant morbidity and mortality. Maximizing first-pass success (FPS) is a critical quality target, as multiple intubation attempts correlate with increased adverse events. Current global guidelines stress the need for a systematic approach to technical execution, patient physiology, operational logistics, and human factors to refine safe practices. The Scandinavian Helicopter Emergency Medical Service (HEMS) system, which is staffed by highly experienced anaesthesiologists, operates under challenging constraints, necessitating research that validates adaptable techniques and effective team dynamics. Historically, prehospital guidelines have advocated for 360-degree access outside the vehicle, potentially increasing critical on-scene time. Furthermore, contemporary practice has explored the use of alternative adjuncts for emergency anaesthesia, such as high-flow nasal oxygen (HFNO) for preoxygenation and prolonging the safe apnoea time, that can further mitigate these risky procedures. However, robust, multicentre evidence supporting operational changes, such as in-cabin intubation or quantifying the influence of the airway assistant, has been sparse. This thesis sought to contribute empirical evidence across these domains. The first phase of this doctoral project focused on evaluating the safety profile of HFNO as an alternative preoxygenation strategy within the emergency surgical population. The next trial addressed logistical constraints in prehospital care, specifically testing whether intubating within the confined space of a vehicle could match the success rates of traditional exterior procedures. Finally, we utilized the same dataset to explore human factors, specifically analysing whether the professional designation of the assisting provider correlated with procedural outcomes.MethodsThis thesis comprises three clinical studies, Study I ("PRIOR2"), a prospective, randomized controlled, international multicentre trial conducted across six centres in Sweden and Switzerland (n=349). Patients who underwent RSI for emergency surgery were randomized 1:1 to receive preoxygenation with HFNO or a tight-fitting facemask. The primary outcome was the incidence of oxygen saturation (SpO2) less than 93% from the start of preoxygenation until one minute after tracheal intubation. Study II ("PHASTER"), a prospective, observational, international multicentre study involving 12 HEMS bases across Scandinavia (n=422 drug-assisted tracheal intubations). This study was designed as a noninferiority trial to compare FPS and complication rates when intubation was performed in-cabin (in a helicopter or ambulance) versus outside. The primary outcome was the FPS rate. Noninferiority was defined by a margin (Δ) of -4.5%. Propensity score matching was used to adjust for confounding factors related to the observational nature of the location choice. Study III (PHASTER Subgroup Analysis), a retrospective subgroup analysis of Study II data (n=422) investigating the influence of the airway assistant's professional background, anaesthetist (anaesthesiologist or nurse anaesthetist) vs. nonanaesthetist (e.g., other physician, other nurse or paramedic), on FPS and complication rates. Binary logistic regression was used to calculate adjusted odds ratios (aORs) for the outcomes, adjusting for covariates such as initial patient condition, VL use, and operator experience.ResultsStudy I: No difference was detected in the primary outcome, desaturation within one minute of intubation. Five patients (2.9%) in the HFNO group desaturated below 93%, whereas six patients (3.4%) in the facemask group desaturated (p=0.77). No difference was detected in the incidence of gastric regurgitation or desaturation between office hours and on-call hours. There was a greater incidence of desaturation in the Switzerland cohort (7%) than in the Sweden cohort overall (1.6%) (p = 0.009).Study II: The FPS rate was 89.2% for in-cabin procedures and 86.3% for outside procedures. The confidence interval for the difference did not include the noninferiority margin (Δ= -4.5) and therefore successfully met the predefined criteria for noninferiority. Intubations performed in the helicopter cabin resulted in a significantly shorter mean on-scene time (27 minutes vs. 32 minutes, p=0.004).Study III: FPS was nearly identical between the anaesthetist-assisted (88.1%) and nonanaesthetist-assisted (87.8%) groups. The assistant profession was not independently associated with FPS (aOR 1.05, 95% CI 0.54-2.12) or overall complication rates (aOR 1.79, 95% CI 0.66-5.39).ConclusionsThis thesis validates essential strategies for increasing the standard of emergency airway management. The results of Study I support technical efficacy and flexibility. HFNO is deemed a functionally equivalent and as good alternative to facemask preoxygenation during RSI, offering crucial technical flexibility, particularly for physiologically compromised patients, by supporting the strategy of continuous apneic oxygenation. Study II highlights logistical efficiency since the in-cabin intubation procedure is noninferior to outside intubation in terms of FPS and safety while achieving a significantly shorter on-scene time. This provides evidence-based justification for adapting HEMS SOPs to maximize logistical efficiency without compromising core safety metrics. Study III adds perspectives on team resilience. In highly experienced, protocol-driven emergency medical systems, team performance and system governance are dominant predictors of success, as the professional background of the airway assistant does not independently influence outcomes. Taken together, these results support a flexible, patient- and context-tailored approach to RSI, prioritizing FPS through meticulous techniques, optimized logistics, and sustained investment in multidisciplinary team processes and systemic governance.List of scientific papersI. Preoxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction. A. Sjöblom, J. Broms, M. Hedberg, Å. Lodenius, A. Furubacke, R. Henningsson, A. Wiklund, S. Nabecker, L. Theiler, M. Jonsson Fagerlund. Anaesthesia, 2021; 76: 1159-62. https://doi.org/10.1111/anae.15426II. Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study. J. Broms, C. Linhardt, E. Fevang, F. Helliksson, G. Skallsjö, H. Haugland, J. Knudsen, M. Bekkevold, M. Tvede, P. Brandenstein, T. Hansen, A. Krüger, L. Rognås, HM. Lossius, M. Gellerfors. British Journal of Anaesthesia, 2023 1;131(6):1102-11. https://doi.org/10.1016/j.bja.2023.09.013III. The impact of airway assistants on prehospital endotracheal intubations - a subgroup analysis of data from anaesthesiologist-staffed helicopter critical care teams. J. Broms, M. Günther, C. Svensén, A. Krüger, L. Rognås, M. Gellerfors. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2025, Nov 25. https://doi.org/10.1186/s13049-025-01515-y</p
Population genetic structuring of methicillin-resistant Staphylococcus aureus clone EMRSA-15 within UK reflects patient referral patterns.
No full textAntibiotic resistance forms a serious threat to the health of hospitalised patients, rendering otherwise treatable bacterial infections potentially life-threatening. A thorough understanding of the mechanisms by which resistance spreads between patients in different hospitals is required in order to design effective control strategies. We measured the differences between bacterial populations of 52 hospitals in the United Kingdom and Ireland, using whole-genome sequences from 1085 MRSA clonal complex 22 isolates collected between 1998 and 2012. The genetic differences between bacterial populations were compared with the number of patients transferred between hospitals and their regional structure. The MRSA populations within single hospitals, regions and countries were genetically distinct from the rest of the bacterial population at each of these levels. Hospitals from the same patient referral regions showed more similar MRSA populations, as did hospitals sharing many patients. Furthermore, the bacterial populations from different time-periods within the same hospital were generally more similar to each other than contemporaneous bacterial populations from different hospitals. We conclude that, while a large part of the dispersal and expansion of MRSA takes place among patients seeking care in single hospitals, inter-hospital spread of resistant bacteria is by no means a rare occurrence. Hospitals are exposed to constant introductions of MRSA on a number of levels: (1) most MRSA is received from hospitals that directly transfer large numbers of patients, while (2) fewer introductions happen between regions or (3) across national borders, reflecting lower numbers of transferred patients. A joint coordinated control effort between hospitals, is therefore paramount for the national control of MRSA, antibiotic-resistant bacteria and other hospital-associated pathogens
Formação política dos integrantes de uma associação de usuários de um serviço de saúde mental
No full textDissertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde. Programa de Pós-Graduação em Enfermagem.Trata-se de estudo que faz análise crítica e reflexiva de uma prática assistencial que propõe a formação política de integrantes de uma associação de usuários de um serviço de saúde mental. Os integrantes do estudo foram pessoas que participam da associação de usuários, que convivem diariamente com o transtorno mental, cuja história de vida é marcada pela experiência da crise. Apóia-se no referencial teórico metodológico de Paulo Freire e nas teorias que informam o processo da Reforma Psiquiátrica Brasileira. Utilizou-se a metodologia problematizadora cujo objetivo visa aumentar a capacidade do indivíduo em se tornar um participante e um agente de transformação social, desenvolver no e com o indivíduo a capacidade de observar a realidade imediata ou circundante, detectar suas problemáticas, bem como recursos disponíveis e encontrar formas de organização para uma ação coletiva de resposta. Foram obedecidos os passos do Arco da Problematização de Maguerez: observação da realidade, situação problema, pontos chave, teorização, hipóteses de solução e as aplicações da realidade. Estes passos permitiram a aproximação com o contexto e a realidade individual e do grupo, contribuiram para a troca de informações, reflexões e construção de propostas de ações para as situações problemas encontrados. Foram abordadas as seguintes situações problemas: Formação Política; Direitos e Legislação no campo da Saúde Mental; Reforma Psiquiátrica; Controle Social; Relações de Poder; Organização Política de Usuários no Contexto da Saúde Mental; Teoria e Prática no campo da Saúde Mental. Nesta perspectiva, a construção de uma proposta de formação política em saúde mental baseia-se na premissa do respeito a sua especificidade, na clareza que o conceito deste processo tem para o grupo envolvido e de que forma este faz sentido na vida dos participantes. Para a formulação do processo da formação política é indicado planejá-la esta diante dos objetivos que se pretenda alcançar. Formação Política em Saúde Mental é uma prática reflexiva que busca desenvolver a consciência crítica por parte do usuário ou cidadão para objetivos a serem desenvolvidos de acordo com sua necessidade ético-político e existencial, contribuindo para militância e participação política, para o exercício da cidadania inventiva, da defesa de direitos e na intervenção no serviço de saúde mental, entre outros. This study refers to a critical and reflexive analysis of an assistential practice that provides a political formation of the integrants of an association of a mental health service. The study's participants were users of the association who have had daily experiences related to mental disorders and which histories are scared by the experiences originated by the crisis. It has its base on the theoretical methodological reference of Paulo Freire and the theories that inform the process of the Brazilian Psychiatric Reform. It was used the problematical methodology which objective is to reinforce the individual's capacity of become a participant and an agent of social transformation, to develop in and with the individual the capacity to observe the immediate reality, to detect his difficulties, as well as available tools and find ways of organization to promote a group action of response. The steps of the Arco da Problematizacao of Maguerez were followed: reality observation, problem situation, key points, theorization, solution hypothesis and reality applications. These steps allowed the approximation among the context and the individual and group's reality, contributed to exchanging of information, reflexions and construction of action proposals related to the problem-situation found. The following problem-situations were approached: Political Formation; Rights and Legislation in the Mental Health Segment; Psychiatric Reform; Social Control; Relationships of Power; Political Organization of Users in the Mental Health Context, Theory and Practice in the Mental Health Segment. Looking through this perspective, the construction of a proposal of political formation in mental health is based on the respect for its specificity, the clarity that the concept of this process has to the group involved and how it makes sense in the participant's life. To stimulate the process of political formation it is indicated to create a solid plan and be aware of the objectives that are aimed to achieve. Political Formation in Mental Health is a reflexive practice that aims to develop critical consciousness by the user or citizen towards the objectives that will be developed according to the ethical-political and existential necessity, contributing to political dedication and participation, the implementation of citizenship, defense of rights and intervention in the mental health service, and others
