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No One’s Safe Until Everybody’s Safe

5.4.2021

It’s unclear who first made this comment about the Covid-19 pandemic, but it is being used by health care leaders around the world to encourage their people to get the Covid-19 vaccination. Vaccines have played an important role throughout history in keeping us well.

Evidence exists that early attempts to inoculate people against smallpox were reported in China as early as the 16th Century. Smallpox scabs could be ground up and blown into the recipient’s nostrils or scratched into their skin. The practice, known as “variolation”, came into fashion in Europe in 1721, with the endorsement of English aristocrat Lady Mary Wortley Montagu.

The next development which turned out to be much safer than variolation, originated from the observation that dairy farmers did not catch smallpox. The 18th Century English physician, Edward Jenner, hypothesised that prior infection with cowpox, which is a mild illness spread from cattle, might be responsible for the suspected protection against smallpox.

In 1796, Jenner inoculated an eight-year-old boy by taking pus from the cowpox lesions on a milkmaid’s hands and introducing the fluid into a cut he made in the boy’s arm. Six weeks later, Jenner exposed the boy to smallpox, but he did not develop the infection then, or on 20 subsequent exposures. The origin of the term comes from the Latin for cow or “vacca”.

Edward Jenner vaccinating his child against smallpox; coloured engraving.  Image: Wellcome Library, London (CC BY 4.0)
Edward Jenner vaccinating his child against smallpox; coloured engraving. Image: Wellcome Library, London (CC BY 4.0)

In 1881 French microbiologist Louis Pasteur demonstrated immunisation against anthrax by injecting sheep with a preparation containing forms of the organism that causes the disease. Four years later he developed a protective suspension against rabies. Jenner’s approach was to use a virus similar to, but safer than, smallpox to prevent disease. Pasteur on the other hand developed a weakened or attenuated form of the virus or bacteria to treat the patient.  

This was the birth of vaccinations and heralded a new era in the treatment of diseases around the world using injections containing live, weakened, or killed viruses to produce immunity against an infectious disease. In the early 20th century, we saw the development of vaccines to protect against whooping cough (1914), diphtheria (1926), tetanus (1938), influenza (1945) and mumps (1948). Later vaccines were developed for polio (1955), measles (1963) and rubella (1969) with the world being announced smallpox free in 1980.

Vaccine technology still uses the approaches developed by Jenner and Pasteur but has developed enormously in recent years with a number of new approaches. These include:

  • A subunit vaccine, which is made from proteins found on the surface of infectious agents e.g. Influenza, Hepatitis B.
  • Inactivated toxins of infectious organisms e.g., Tetanus, Diphtheria, Whooping cough.
  • Gene sequencing and editing has allowed the mass production of antigens that are used in vaccines and made the production of attenuated vaccines safer and more effective.
  • Recombinant DNA technology has also been used effectively to develop vaccines e.g., Human papillomavirus.

Today there are around 30 diseases around the world that are treated and controlled by vaccination programmes making us all healthier and allowing us to live longer.

So here we are in 2021 and vaccines will once again help us fight against another highly infectious disease, Covid-19. There are currently 10 vaccines licensed around the world that offer protection against Covid-19. Staggeringly, there are 88 vaccines in clinical development and 184 in pre-clinical development.

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The speed of development of these vaccines has been nothing short of remarkable and their efficacy rates are equally impressive. However, public attitudes to vaccines appears to have shifted markedly to what it was when this type of treatment was introduced. People either trust vaccines or they don’t. Then we have the antivaxxers who believe vaccines are unsafe and infringe their human rights. Antivaxxers also use social media to actively spread misinformation to persuade people to their point of view. Antivaxxers have been pumping out misinformation for a number of years now, so it’s useful to see if they have had any success.

Claims about the Covid-19 vaccine made by the antivaxxer community include:

  • The vaccine alters your DNA.
  • The vaccine causes infertility.
  • Bill Gates is inserting microchips into people.
  • The virus is being used as a ploy to move a country to a “police state”.
  • Don’t be a guinea pig for pharmaceutical companies.

A number of surveys have been conducted assessing public reaction to having a Covid-19 vaccination. The Imperial College London YouGov Covid-19 Behaviour Tracker Data Hub gathers global insights on people’s behaviours in response to COVID-19. Data represents the share of respondents who have not received a COVID-19 vaccine and who agree with the following statement: “If a COVID-19 vaccine were made available to me this week, I would definitely get it.” Respondents were presented with a 1 to 5 scale, ranging from “Strongly agree” (1) to “Strongly disagree” (5). The following chart shows monthly data on the willingness of unvaccinated individuals to receive the COVID-19 vaccine. They asked this question in November 2020 with the following results:

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You can see that in those countries surveyed there is a wide variation in the willingness to be vaccinated ranging from 67% in the U.K. to only 40% in France. A study conducted by Ipsos on behalf of the World Economic forum found similar results.

Is this vaccine hesitancy the result of antivaxxer misinformation? There is no doubt that some of the claims made by antivaxxers will have resonated with some people. However, when you ask people objectively about vaccine hesitancy the reasons are quite straight forward. “Side effects”, “long term effects on health” and “how well the vaccine works” were the top three reasons for reporting negative sentiment towards the vaccine and this was consistent across all population groups. These concerns are not unreasonable. It is important to note that as more and more people are vaccinated, vaccine hesitancy is declining. In fact, in England 95% of the over 50’s have been vaccinated which is way higher than scientists thought could be achieved.

To ensure high rates of vaccination so that a population can gain “herd” immunity, health care leaders need to target vaccine hesitancy messaging very carefully. This is because hesitancy rates vary by population sub-group.

A survey carried out by the Office of National Statistics in the U.K. in early 2021 revealed that vaccine hesitancy was highest in:

  • 16–29 year olds.
  • Black or Black British adults.
  • Parents with child aged 0-4 years.
  • Adults living in the most deprived area.

It’s pretty clear that as vaccine programmes are rolled out around the world, governments and health care workers will have to work hard to ensure the majority of their people are vaccinated. Only then can we stop saying no one’s safe until everybody’s safe and we can start getting back to a normal life and fix some of the other issues this pandemic has caused.

  • We need to be more vigilant against infections, particularly with vulnerable hospitalised patients. That’s why sterile EyePro™ should be the only eyelid cover used to maintain eyelid closure during general anaesthesia or deep sedation.
  • As surgery returns and we start to reduce the huge backlog of patients waiting for routine surgery, hospitals must ensure they deliver a great patient experience by protecting patients’ eyes from trauma by using NoPress™, our foam and rigid plastic shield designed specifically to protect anaesthetised patient’s eyes from externally applied pressure.
  • Enhance the patient experience further, by guarding against dental damage and/or negative pressure oedema through the use of BiteMe™ our purpose designed, air-filled, soft plastic bite block.

So, no one’s safe until everybody’s safe and although vaccines will help the world recover, it’s important we do our utmost to protect patients from infection as well as non Covid-19 complications that can be easily avoided. By using our products, you will optimise your care and ensure your patients have the best experience they can possibly receive.

Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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Doctor There’s a Problem in the Recovery Room

The operation had been a long, but it had been a success. The patient had been taken into the recovery room and was being looked after by theatre staff as they were slowly woken up. In theatre the anaesthetist was talking with colleagues about the operation.

Suddenly, a member of staff put their head through the door of the recovery room and looking at the anaesthetist said, “doctor there’s a problem in the recovery room.”

Upon entering the recovery room, the anaesthetist found that the patient, had started to recover but was biting down on the reinforced laryngeal mask airway (LMA). The anaesthetist tried to encourage the patient to stop biting, but that didn’t work. The patient bit right through the LMA and this part was removed from his mouth. Remarkably the patient could still breathe through the bitten off end. A few minutes later the patient had recovered enough to spit the remnants of the LMA out. The photographs below clearly show the aftermath. 

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Thankfully, that was a good outcome both for the patient and the anaesthetist and their team. But there are two other scenarios that could have occurred:

  • The patient could have broken their teeth and suffered dental damage. I wrote about this last year and pointed out the consequences both from a repair perspective and a financial one for the patient and the hospital.
  • Another more serious scenario is that the patient obstructs the lumen of the LMA or the LMA blocks the upper airway. There is a real risk of desaturation and negative pressure pulmonary oedema. This is a dangerous and potentially fatal condition. Negative pressure pulmonary oedema (NPPE) or post obstruction pulmonary oedema (POPE) is a clinical entity of great relevance in anaesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.(1)

So, what do we know about negative pressure pulmonary oedema or Post Obstruction Pulmonary Oedema?

There are few studies in the public domain that look at the incidence of NPPE. The incidence of NPPE has been reported to be 0.05%–0.1% of all anaesthetic practices. However, it is suggested that it occurs more commonly than is generally documented. According to one estimate, NPPE develops in 11% of all patients requiring active intervention for acute upper airway obstruction (2) . In a small review of case reports where laryngeal mask is cited, 60% reported that the patient bit through the LMA and of that group ⅔ reported that the patient developed a pulmonary oedema (3) .

The review concluded, ”The vast majority of the papers found are case reports, though a single survey suggests that biting of an unguarded laryngeal mask airway (LMA) is not an uncommon event. Complications of biting include airway obstruction and the development of negative pressure pulmonary oedema, neither of which would be welcome events in the resuscitation area.”

In a U.K. national survey of the use of bite guards and critical incidents involving the laryngeal mask airway (3) a postal questionnaire was sent to 451 anaesthetists with a 42% response rate. 63% of consultants, 45% of SpRs and 43% of recovery staff never used a bite guard in conjunction with a laryngeal mask airway of any sort. However, biting of a laryngeal mask airway by a patient, resulting in airway obstruction, had been experienced by 18 users of the flexible laryngeal mask airway (7.3%) and 71 users of the standard laryngeal mask airway (18.8%).

The recovery staff reported an average of two incidents per month of laryngeal mask airway obstruction. The authors concluded that the use of a bite guard with a laryngeal mask airway is an uncommon practice but the occurrence of airway obstruction with the laryngeal mask airway is high.

An upper airway obstruction is the cause of negative pressure pulmonary oedema. A blocked or broken LMA caused by biting is one cause. Others include hanging, strangulation, upper airway tumours, foreign bodies, croup, choking, migration of Folly’s catheter balloon used to tamponade the nose in epistaxis, near drowning, goitre mononucleosis, big tonsils, hypertrophic adenoids, or a redundant uvula.

Once the upper airway is obstructed a very large, negative, intrathoracic pressure is generated by the patient’s increased effort to breathe. This causes pulmonary oedema or fluid build-up in the lungs resulting in acute respiratory failure. The onset of pulmonary oedema is usually rapid (within a few minutes after signs of upper airway obstruction). The patient will become agitated, may look frightened, will breathe rapidly, may become tachycardic, crackling sounds or rales may be heard with a stethoscope and pulmonary secretions become frothy and pink as progressive oxygen desaturation occurs.

Quick thinking and action are required to remove the blockage causing this emergency. If the blockage were caused by a broken LMA the patient would need to be rapidly re-anaesthetised and paralysed to allow the LMA to be removed. This would also allow reoxygenation to occur if the patient were desaturated. This intervention not only exposes the patient to more drugs but if desaturation carries on for long enough the situation can become an anaesthetic emergency. The Difficult Airway Society Guidelines for the management of tracheal extubation(4) recommend the following for the management of negative pressure oedema.

  1. Treat the cause: relieve the airway obstruction.
  2. Administer 100% O2 with full facial CPAP mask. In addition to relieving upper airway obstruction, CPAP may reduce oedema formation by increasing mean intrathoracic pressure and minimise alveolar collapse by increasing functional residual capacity, improving gas exchange, and reducing the work of breathing.
  3. Nurse the patient sitting upright.
  4. If there is fulminant pulmonary oedema with critical hypoxaemia, tracheal intubation and mechanical ventilation with PEEP are necessary. Less severe hypoxia responds to supplemental oxygen and ⁄ or non-invasive ventilation, or CPAP.
  5. Intravenous opioids may help reduce subjective dyspnoea.
  6. Chest radiography may exclude other complications of difficult airway management and causes of hypoxia (gastric aspiration, pre-existing infection, pneumothorax, barotrauma, pulmonary collapse).
  7. Frank haemoptysis may necessitate direct laryngoscopy and ⁄ or flexible bronchoscopy.
  8. Diuretics are often administered, but their efficacy is unproven.

The Difficult Airway Society also comment,” Post-obstructive pulmonary oedema may be prevented through use of a bite block during emergence.”

And so, let us finally consider the economics of managing a patient who develops negative pressure oedema from biting through their LMA. The first thing to say is that the patient would probably need to spend more time recovering in hospital either in the recovery room, on a ward, HDU or even ICU. Further investigations such as a chest x-ray or blood gas analysis might be needed. Interventions as described in the Difficult airway Society Guidelines may also be required.

Uncovering the daily cost of a hospital bed is not easy and the data is quite old. A stay in a hospital bed without factoring in investigations and/or interventions would cost approximately $1800/day in the USA, $AUD1000/day in Australia and £400/day in the UK. Private healthcare charges would be higher. In most health care systems around the world the daily cost of an ICU bed is in 4 figures. In the USA it is approximately $6000/day, Australia approximately $AUD4000/day and the UK approximately £2000/day. A bite block such as BiteMe™ costs $1.48 per patient and would reduce the incidence of negative pressure pulmonary oedema resulting in fewer patients needing to spend extra time in ICU.

I leave you to make your own mind up when it comes to cost effectiveness.

So, what can we determine from this article?

  • The incidence of NPPE is poorly understood and probably under reported.
  • NPPE can result in acute respiratory failure which is a dangerous and potentially fatal condition.
  • Biting through a laryngeal mask airway (LMA) is not an uncommon event.
  • Despite being recommended by the Difficult Airway Society the use of a bite block with a laryngeal mask airway is not a common practice.
  • Using a bite block in conjunction with an LMA would reduce the incidence of potentially fatal negative pressure pulmonary oedema caused by a patient biting through their LMA.
  • Using a bite block such as BiteMe™ to prevent NPPE caused by the patient biting through the LMA and the upper airway becoming blocked is a more cost-effective option than having the patient spend extra time in ICU.

By using a specifically designed bite block such as BiteMe™. Which is made of a very strong, but soft, plastic that resists the shear forces of a human bite very well reduces the risk of desaturation and/or Negative pressure pulmonary oedema if the patient’s airway device becomes obstructed.

The combination of the soft plastic surrounding a closed air-filled space means that when a patient bites down, there are two forces opposing the bite. This means BiteMe™ has a spongy recoil and therefore reduces the risk of the patient severing the LMA if they start biting during emergence.

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References

  1. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth. 2011 Jul-Sep; 5(3): 308–313.
  2. Tami TA, Chu F, Wildes TO, Kaplan M. Pulmonary edema and acute upper airway obstruction. Laryngoscope. 1986;96:506–9.
  3. Heptinstall E, Heptinstall L. Should Bite Guards Be Used with Laryngeal Mask Airways In Adults? Best Evidence Topics Database (BestBETS). March 2015.
  4. Popat M (Chairman),Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012, 67, 318–340
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Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

Original Post Here

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The face mask that could end the pandemic

By Keri Enriquez

Updated 10:24 AM ET, Sat January 23, 2021

 (CNN)Getting Americans masked up is a top priority for the Biden administration.

Biden, who calls wearing masks “a patriotic act,” signed an executive order Wednesday — his very first as President — to ask Americans to wear masks of their choice for the first 100 days of the new administration. The executive order also requires mask use on all federal property, though in this case, not just any old mask will do.

On Wednesday, after the inauguration, White House press secretary Jen Psaki showed off her bright white N95 mask in the press briefing room. “I wore it out, of course, here today and will continue to do that,” Psaki said after removing her medical-grade mask and before turning to questions.

CDC reports record number of daily Covid-19 vaccinations as states struggle with supply

N95 masks are considered the gold standard in personal protective equipment because they block 95% of large and small particles utilizing a unique electrostatic filter.

The filter works by trapping neutral particles like bacteria and viruses before they pass through the mask, protecting the wearer and those around them. It’s similar to how socks might get stuck to a blanket in the dryer. The N95 mask, which costs roughly $5, also fits securely to the face, eliminating most of the leakage that may occur with a loose-fitting cloth or paper mask.

Studies have shown that masks significantly decrease the chances of transmitting or contracting the coronavirus. But not all masks provide equal protection. Depending on the fabric and number of layers, homemade and simple cloth masks have a range of effectiveness that can be as low as 26%, which leaves the wearer vulnerable.

Some experts like Brigham and Women’s Hospital and Harvard Medical School physician Dr. Abraar Karan have been advocating for public use of N95 masks from the start of the pandemic. In an interview with CNN Chief Medical Correspondent Dr. Sanjay Gupta, Karan outlined why N95s are critical at this stage of the pandemic.

“If for four weeks the country essentially wore these masks in those risky settings like that indoors, what kind of difference do you think it would make?” Gupta asked.

“This would stop the epidemic,” Karan responded.

Dr. Gupta on Covid-19: This is the worst it’s ever been 05:46

The quality of protection a face mask can provide is crucial. A respiratory illness like the coronavirus is transmitted through aerosols, tiny particles that waft and hang in the air. Some virus-carrying particles are small enough to travel through or around lower-quality masks, making the wearer vulnerable to inhalation of viral particles.

“We know now that aerosols spread best when there is poor ventilation, crowding and close contact that’s prolonged,” Karan told Gupta in an interview. “So we were arguing that actually in those settings, cloth masks alone are not going to block aerosols.”

Karan is not the only expert who has been vocal in support of better quality masks for the general public. Former US Food and Drug Administration Commissioner Dr. Scott Gottlieb wrote in an op-ed in the Wall Street Journal that “encouraging Americans to wear higher-quality masks is a simple step that might make a difference.”

The biggest problem is lack of supply. This week marked a full year of the coronavirus, and the Biden administration has committed to invoking the Defense Production Act more often to boost manufacture of N95 masks and other critical supplies. Experts hope manufacturing will hit a speed to be able to sufficiently supply the population.

“An N95 that’s well-fitted clearly is the best that you can do,” National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci told CNN Friday. “You could get production of that at a much higher rate now.”

Karan believes N95 masks could be an essential asset in reopening the economy as the vaccine rollout remains sluggish and quarantine fatigue soars.

The huge stakes of Biden’s new Covid-19 plan

“If we have better personal protection for people, they can more safely go back to work. They can more safely re-engage, especially if testing and tracing is not where we need it to be,” Karan said.

“This was going to be one way to get people back in and get the economy back up.”

Some European countries are already taking that step to prevent coronavirus spread within their borders. Earlier this week, Germany and France mandated that all citizens wear high filtration masks like the N95 in all public places.

After months of treating coronavirus patients, Karan says it’s time to invest in making sure masks people wear are even more effective. “Focus on getting better masks to as many people as possible, focus on the messaging around masks, be consistent with your messaging, make masks part of American culture to stop the epidemic.”

The key here is to always wear a mask whenever you’re in public. One study in Lancet Digital Health found that a 10% increase in mask-wearing could lead to a three-fold increase in the odds of maintaining control over virus transmission in a community. The ability to control the spread of the coronavirus is in our hands — and on our faces.

Original Article Viewed Here

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AANA 2019 Annual Congress

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Bell Medical will feature six new and innovative products at the AANA 2019 Annual Congress in Chicago. Come see us at Booth 710 for FREE label samples, a demonstration, or a trial.


EyePro

The EyePro is a sterile dressing that keeps the eyelid closed during procedures.


NoPress

The NoPress is a mask shield that protects the eyes.


BiteMe

BiteMe tooth protectors.


Total Control Introducer

Total Control Introducer takes the “difficult” out of “difficult airways”.


Stimpod 450X Quantitative TOF Monitor

The Stimpod 450X is a quantitive Train-of-Four monitor that requires no calibration.


Click-To-Comply Syringe Labeling System

Two-Clicks, Two Seconds. The Vigilant Labeling System is USP 797 compliant.