The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique.

Background: Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia.

Methods: Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.

Humidicare - an implementation study of a novel HME safety device designed to prevent ventilator circuit occlusion due to inadvertent dual humidification.

Mechanical ventilation bypasses the protective mechanisms of the upper respiratory tract which are designed to heat and humidify inspired air to 37 °C and 44 mg HO/L respectively. Artificial humidification systems are therefore incorporated into ventilation circuits to condition cold and dry medical gases before they reach the lower respiratory tract and cause patient harm. Commonly either a heat and moisture exchanger (HME) or a heated humidifier (HH) are utilised for this purpose, however the inadvertent simultaneous use of both devices within the same circuit can cause critical airway occlusion within 24 h.

Central Venous Catheter Guidewire Retention: Lessons From England's Never Event Database.

Objectives: Guidewire retention during central venous catheter (CVC) insertion is considered a "never event." We analyzed the National Health Service England Never Event database (2004-2015) to explore the process of guidewire retention and identify potential preventative measures.

Methods: We performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique.

Background: Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level.

A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration.

Objective: Leakage of fluid from the subglottic space to the lungs occurs along the longitudinal folds within the wall of an inflated high-volume, low-pressure (HVLP) cuff. The low-volume, low-pressure (LVLP) cuff does not have these folds yet allows for convenient and reliable control of tracheal wall pressure. Pulmonary aspiration during anesthesia has been linked with postoperative pneumonia and during critical illness causes ventilator-associated pneumonia.