I. Smith

Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation

Two hundred and ten obstetric anaesthetists completed a questionnaire assessing how they would perform a rapid sequence induction of anaesthesia for a Caesarean section and their continued management during a failed tracheal intubation. The survey revealed considerable variation in the timing and application of cricoid pressure, the choice and dose of drugs used and the timing of their administration. The management of a difficult intubation also varied. This variability was independent of both grade of anaesthetist and frequency of practice. There appear to be at least two distinct techniques in current practice, characterised by ‘fast’ or ‘slow’ rapid sequence induction. Rapid sequence induction is clearly not a standard technique and debate is necessary to clarify the risks and benefits of its components. In particular, the rapidity of the technique and the application of cricoid pressure may contribute to the increased incidence of difficult tracheal intubation in obstetric anaesthesia.

Rising to the challenges of achieving day surgery targets

Day surgery provides high quality and efficient care for a wide variety of surgical procedures. Patients appreciate the rapid recovery and effective analgesia, while the health service benefits from a streamlined service with lower costs. Despite the numerous advantages, day surgery practices vary enormously and many patients are still denied this excellent form of care. Fundamental to improving this situation is a change in emphasis, with day surgery becoming the default option for many surgical procedures – rather than being applied selectively – with inpatient care being used only where specifically indicated. Appropriate patient preparation is facilitated by consultant‐led, nurse‐run preassessment using modern selection criteria; only conditions which will still cause problems a few hours beyond the end of the operation should be barriers to day surgery. Preassessment also provides an excellent opportunity to begin patient education and ensures that pre‐existing pathology is optimally treated. Efficient day surgery is best delivered by a specialised, dedicated, multi‐disciplinary team, but consultant anaesthetists have a major role to play in co‐ordinating policies and providing leadership. Individual anaesthetists should develop techniques that allow their patients to undergo day surgery with minimum stress, maximum comfort and the optimal chance of early discharge. Improving day surgery rates is a win–win situation, with both clinical and financial benefits.

A multi centre telephone survey of compliance with postoperative instructions.

Summary Patients undergoing procedures under general anaesthesia as day cases are routinely given a set of instructions regarding activities to avoid in the first 24 h after discharge. Day surgery units generally specify the need for a responsible carer from time of discharge for a period of 24 h. This study looks at the compliance of 240 patients with postoperative instructions. Of the patients studied, 4.1% drove, 1.7% made important decisions, 3.3% drank alcohol, 0.8% took sedatives and 10% cooked, ironed or looked after children. All patients were discharged into the care of a responsible adult. However, 13.3% failed to have a carer with them for 24 h and 1.3% spent the night alone at home. Of our cohort, 25% were unable to comply with the postoperative instructions in full. The majority of non‐compliance occurred on the day following surgery, suggesting that patients may feel that the advice is excessively cautious.

Virtual training in research methods

Recent experience of a cerebrovascular accident following inadvertent carotid arterial catheterisation leads us to question a recommendation in the comprehensive AAGBI safe vascular access 2016 guidelines [1]. A 52-year-old man was admitted to ICU with status epilepticus, following inadvertent insertion of an 8.5-F quadruple lumen catheter into his right common carotid artery. In line with the current guidelines, the catheter was left in situ and the vascular surgical team contacted. A computerised tomography (CT) angiogram of the neck was performed, a heparin infusion was commenced, and the catheter was removed surgically 11 hours later. No thrombus was seen on the catheter or within the vessel intraoperatively or on post-operative duplex ultrasound. Postoperatively, the patient was noted to have reduced power in the left upper and lower limbs, and a CT revealed acute, right anterior and middle cerebral artery territory infarction. Reviewing the preoperative CT angiogram, the patient was noted to have an abnormally narrow origin of the common carotid artery, such that the 8.5-F catheter could have caused intermittent rheological compromise, contributing to the infarction (Fig. 1). Current evidence for the management of inadvertent arterial catheterisation supports the superior safety profile of emergent surgical exploration over immediate catheter removal with pressure application at the bedside. This case emphasises the need to consider the rare possibility that a large diameter catheter may compromise distal blood flow when left in an abnormally narrow artery. If surgical exploration cannot be performed immediately, we suggest CT angiography may help decide whether the catheter can be safely left in situ, withdrawn to the widest segment of the vessel, or requires further consultation about immediate removal.

Could 'safe practice' be compromising safe practice? More evidence

I congratulate Calder and Yentis [1] for questioning conventional wisdom regarding the ‘safe practice’ of confirming adequate face mask ventilation prior to administering neuromuscular blocking drugs. In the third of their five perceived defects with established practice, the authors suggest face mask ventilation becomes easier after neuromuscular blockers have been given, but acknowledge that they can only provide anecdotal evidence to substantiate this. Several years ago, we demonstrated that tracheal intubation could be performed sooner and with better conditions after rocuronium compared with vecuronium when the timing of laryngoscopy was judged solely by clinical criteria [2]. In this blinded investigation, two experienced anaesthetists were able to begin direct laryngoscopy an average of 21 s sooner after rocuronium than after an equivalent dose of vecuronium. The decision to commence tracheal intubation was based on a clinical assessment of jaw and upper airway tone and, predominantly, by the ease of bag and mask ventilation. Since all other aspects of anaesthesia induction were standardised, this provides definitive evidence that the improvement in ease of bag and mask ventilation is due to the onset of neuromuscular block. As further confirmation, the degree of neuromuscular block, although not known to the intubating anaesthetist, was indeed more profound at the time of laryngoscopy in the rocuronium group than in the patients who had received vecuronium. I hope this small piece of additional evidence will help strengthen the case made by Calder and Yentis and aid in the discussion for which they call.

Peri-operative management of diabetes.

The review of the peri-operative management of the diabetic patient by Robertshaw and Hall [1] was a useful overview, but we were disappointed by the very cursory account of intraoperative management. The blanket statement ‘in Type 1 diabetics, a GIK regimen should be used in the perioperative period’ is an oversimplification and needs qualification. Many Type 1 diabetics can successfully have short day-case procedures without resorting to GIK infusions as long as they are first on the list. Even patients on afternoon lists don’t necessarily need a GIK infusion if control is good and a management plan is followed. The key elements are good peri-operative assessment with the formulation of a plan and the avoidance of excessive periods of starvation on the day. We have recently introduced new peri-operative guidelines for diabetics taking into account the new generation of insulins (both ultra shortand ultralong-acting), and now only use GIK infusions for major surgery when the patient is not expected to eat and drink for more than 12 h or when control has been difficult in the past. The ultra-long acting insulins Lantus and Levemir are given as usual the evening before surgery and help to achieve acceptable blood sugar control without the need for GIK infusions. Other statements about regional blockade such as an increase in infection and the possible exacerbation of peripheral neuropathy should, we believe, have been referenced as these will concern many anaesthetists who regard regional anaesthesia as the technique of choice in diabetics.