SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 ... more SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l−1) allowing resolution of transient incr...
Impingement of the tracheal tube on upper airway structures occurs commonly during advancement ov... more Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90° counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90° counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.
We describe the management of acute upper airway obstruction, secondary to haematoma, following t... more We describe the management of acute upper airway obstruction, secondary to haematoma, following the insertion of a central venous catheter in a patient who had recently received tissue plasminogen activator (TPA) followed by heparin infusion for the treatment of myocardial infarction.
The difficult airway can be challenging to deal with in any setting. In resource-poor environment... more The difficult airway can be challenging to deal with in any setting. In resource-poor environments pathologies are often advanced, specialist equipment may be absent and trained assistance may be lacking, adding to the challenge. The chapter offers practical advice on assessment, planning, and management of difficult airways under these circumstances. Useful techniques considered include spontaneously breathing ketamine anaesthesia, airway topicalization for awake airway management techniques, blind nasal intubation, and awake tracheostomy. Common airway pathologies that may be encountered are described. Practical considerations regarding decision making for tracheostomy, care of tracheostomy on the ward, and management of tracheostomy emergencies are also discussed.
BackgroundThe Clavien–Dindo classification is perhaps the most widely used approach for reporting... more BackgroundThe Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs).MethodsThis was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparin...
Cancellation of planned surgery impacts substantially on patients and health systems. This study ... more Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate be...
The surgical safety checklist is widely used to improve the quality of perioperative care. Howeve... more The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (1...
Introduction to field anaesthesia - When to give an anaesthetic - Know your limits - Local infilt... more Introduction to field anaesthesia - When to give an anaesthetic - Know your limits - Local infiltration anaesthesia - Peripheral nerve blocks - Spinal anaesthesia - Ketamine anaesthesia - Sedation - Suggested minimum equipment and drugs for field anaesthesia
SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 ... more SummaryThe potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l−1) allowing resolution of transient incr...
Impingement of the tracheal tube on upper airway structures occurs commonly during advancement ov... more Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90° counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90° counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.
We describe the management of acute upper airway obstruction, secondary to haematoma, following t... more We describe the management of acute upper airway obstruction, secondary to haematoma, following the insertion of a central venous catheter in a patient who had recently received tissue plasminogen activator (TPA) followed by heparin infusion for the treatment of myocardial infarction.
The difficult airway can be challenging to deal with in any setting. In resource-poor environment... more The difficult airway can be challenging to deal with in any setting. In resource-poor environments pathologies are often advanced, specialist equipment may be absent and trained assistance may be lacking, adding to the challenge. The chapter offers practical advice on assessment, planning, and management of difficult airways under these circumstances. Useful techniques considered include spontaneously breathing ketamine anaesthesia, airway topicalization for awake airway management techniques, blind nasal intubation, and awake tracheostomy. Common airway pathologies that may be encountered are described. Practical considerations regarding decision making for tracheostomy, care of tracheostomy on the ward, and management of tracheostomy emergencies are also discussed.
BackgroundThe Clavien–Dindo classification is perhaps the most widely used approach for reporting... more BackgroundThe Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs).MethodsThis was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparin...
Cancellation of planned surgery impacts substantially on patients and health systems. This study ... more Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate be...
The surgical safety checklist is widely used to improve the quality of perioperative care. Howeve... more The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (1...
Introduction to field anaesthesia - When to give an anaesthetic - Know your limits - Local infilt... more Introduction to field anaesthesia - When to give an anaesthetic - Know your limits - Local infiltration anaesthesia - Peripheral nerve blocks - Spinal anaesthesia - Ketamine anaesthesia - Sedation - Suggested minimum equipment and drugs for field anaesthesia
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Papers by Rachael Craven