B. McGuire

Sugammadex, airway obstruction, and drifting across the ethical divide: a personal account

Editors have long argued over the merits and otherwise of publishing case reports, and the power of the anecdote, despite their lowly ranking in the hierarchy of evidence. Indeed, case reports remain ever popular; as journals have shied away from a regular case report section, so has grown an increasing number of online case report resources (see for example http:// www.anaesthesiacases.org/). The following account [1] by McGuire and Dalton is a case report in which the ‘case’ is not a clinical curiosity or challenge, but a project that started innocently enough but illustrates how easy it is for clinicians, keen to explore ways of improving the quality of care they provide, to run into trouble without realising it. McGuire and Dalton’s tale should serve as a lesson to all those embarking on a clinical project, however it might be labelled, and emphasises how important it is to have: i) an understanding of the basic ethical principles involved in even the simplest study; ii) proper governance oversight of projects within organisations; and iii) awareness of the local regulatory processes and mechanisms. I commend McGuire and Dalton for their openness and willingness to share their experience and the lessons learnt, after what was evidently a rather unpleasant experience – after all, that’s the whole point of case reports, isn’t it? Competing interests No external funding and no competing interests declared. I was the Editor-in-Chief to whom McGuire and Dalton refer in their editorial.

A comparison of the ease of tracheal intubation using a McGrath MAC(®) laryngoscope and a standard Macintosh laryngoscope.

We compared the McGrath MAC® videolaryngoscope when used as both a direct and an indirect laryngoscope with a standard Macintosh laryngoscope in patients without predictors of a difficult tracheal intubation. We found higher median Intubation Difficulty Scores with the McGrath MAC as a direct laryngoscope, 1 (0–3 [0–5]) than when using it as an indirect videolaryngoscope, 0 (0–1 [0–5]) or when using the Macintosh laryngoscope, 0 (0–1 [0–5]), p = 0.04. This was mirrored in the subjective user reporting, scored out of 10, of difficulty for each method 3.0 (2.0–3.4 [0.5–80]); 2.0 (1.0–3.9 [0–70]) and 2.0 (1.0–3.3 [0–70]), respectively (p = 0.01). This difficulty is in part explained by the poorer laryngeal views recorded using the Cormack and Lehane classification system (p < 0.001) and reflected in the higher than normal operator force required (25%, 4%, 8% for each method, respectively, p < 0.001) and the increased use of rigid intubation aids (21%, 6%, 2%, respectively, p < 0.001). There was no difference between the groups in time taken to intubate or incidence of complications. There was no statistical difference in the performances as measured between the McGrath MAC used as an indirect videolaryngoscope and the Macintosh laryngoscope. We cannot recommend that the McGrath videolaryngoscope be used as a direct laryngscopic device in place of the Macintosh.

A randomised cross‐over trial comparing the McGrath® Series 5 videolaryngoscope with the Macintosh laryngoscope in patients with cervical spine immobilisation

We compared the performance of the McGrath® Series 5 videolaryngoscope with the Macintosh laryngoscope in 49 patients without suspected cervical spine pathology, whose cervical spine was immobilised using a semi‐rigid collar. The primary outcome was the view obtained at laryngoscopy. Secondary outcomes included time to tracheal intubation, rates of successful intubation and incidence of complications. In all patients, the view was better (92%) or the same (8%) in the McGrath group versus the Macintosh group (p < 0.01). There were no failed intubations in the McGrath group and seven (28%) in the Macintosh group (p < 0.02). There was no statistical difference in time taken to intubate or incidence of complications. We conclude that the McGrath® Series 5 is a superior laryngoscope when cervical spine immobilisation is maintained during tracheal intubation.

Postoperative management of the airway with a Ravussin cricothyroid cannula in head and neck surgery

p c i i ostoperative loss of the airway is a serious concern with axillofacial patients. Oedema or haematoma in the head nd neck region can impinge upon and threaten the upper irway. In “high risk” patients, a formal tracheostomy is ommonly done pre-emptively. This procedure has an assoiated morbidity1 and hence performing a tracheostomy on atients with less of a risk to the airway is often a difficult ecision. We present a technique that is established,2,3 but arely used within maxillofacial surgery. In patients where it s perceived that there is less risk of compromising the airay postoperatively, a Ravussin cricothyroid cannula3 can be sed in preference to a pre-emptive tracheostomy. This allows or transtracheal rescue of the airway if it is compromised ostoperatively. The cannula is placed (usually by the anaesthetist) at nduction and can be removed once the airway is under no otential threat, usually after 24 h. In an emergency it can be onnected to high frequency jet ventilation to provide immeiate oxygenation, and provided that the upper airway is not ompletely obstructed to exhalation, then ventilation is posible. Manoeuvres to open the airway such as a jaw thrust ay be required to ensure upper airway exhalation. Whether entilation or oxygenation is achieved, we still recommend ubsequent conversion to a tracheostomy. The latter can be ompleted as a “controlled” procedure.

Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute ‘Never Events’ as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

Did sugammadex cause, or reveal, laryngospasm? A reply

1. McGuire B, Dalton AJ. Sugammadex, airway obstruction, and drifting across the ethical divide: a personal account. Anaesthesia 2016; 71: 487–92. 2. Curtis R, Lomax S, Patel B. Use of sugammadex in a ‘‘can’t intubate, can’t ventilate’’ situation. British Journal of Anaesthesia 2012; 108: 612–4. 3. Paton L, Gupta S, Blacoe D. Successful use of sugammadex in a ‘‘can’t ventilate’’ scenario. Anaesthesia 2013; 68: 861–4. 4. Yentis SM. A different kind of case report: I. Anaesthesia 2016; 71: 487. 5. Yentis SM. A different kind of case report: II. Anaesthesia 2016; 71: 492–3. 6. Gale E. GLP-1 based gents and acute pancreatitis: drug safety falls victim to the three monkey paradigm. British Medical Journal 2013; 346: f1263.

Standardising airway management documentation - a reply.

a Macintosh laryngoscope. In a recent survey of Canadian anaesthetists, for example, over 90% choose to use a videolaryngoscope in situations of ‘cannot intubate and cannot ventilate’ [2]. However, we suggest that documentation by anaesthetists has not kept pace with advances in what equipment or techniques they used for difficult airway management, and that this leads to potentially avoidable airway problems during subsequent anaesthesia. We would like to invite the Difficult Airway Society to comment on whether they have considered modifying their airway alert document [3], or recommending a standardised anaesthetic chart section for airway management to this end, by including specific details of equipment used and sequential management?