Kathy Wilkinson

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

Diabetes mellitus and the pediatric anesthetist

Diabetes mellitus (DM) is a relatively common problem in the perioperative period in adults. It also occurs in childhood and there is evidence that the prevalence is increasing. Children may present for minor surgery unrelated to their diabetes, often to the nonspecialist center. Even in the most ideal circumstances, children with DM experience marked fluctuations in blood glucose levels. Added to this, the stresses of illness and surgery and their glucose control can be challenging. The rule during the perioperative period is to avoid hypoglycemia or marked hyperglycemia. Therefore, a well thought out scheme of management is essential. An updated review of this important problem is presented in this article.

The NCEPOD study: on the right trach? lessons for the anaesthetist

Patients managed in our hospitals with temporary or permanent tracheostomies are exposed to awide range of healthcare professionals and specialities, with the anaesthetist often pivotal in their inpatient journey. Since the widespread adoption of percutaneous procedures in the critically ill, the population of hospitalised patients with tracheostomy has changed. It is surprisingly difficult to find national data on the number of patientsmanaged with tracheostomy. What detailed data there are suggests that 7–19% of all patients admitted to an Intensive Care Unit (ICU) will be managed with a tracheostomy, and that up to 90% of these tracheostomies are currently performed by percutaneous routes. 3 This figure varies with the admission diagnosis, individual units, and to some extent, the country. The spotlight has turned onto tracheostomy care, after reports from around the world highlighting measurable harm in up to 30% of all acute hospital admissions involving temporary or permanent tracheostomy. 8–12 The requirement for tracheostomy marks the patient out as one with high risk for morbidity and mortality. This is borne out by studies which demonstrate mortality rates during the index hospital admission ranging from 17–20%, rising to 40% in groups with significant comorbidities. 11 Harm may occur that can be directly associated with the management of the airway device. 9 Analysis of severe incidents has revealed common underlying themes, which include a lack of staff training, of basic bedside equipment, and inadequate environments and support mechanisms, compounded by poorly thought out care pathways and response to incidents. These findings were reinforced by the 2011 4th National Audit Project of the UK Royal College of Anaesthetists (NAP4), which reported similar problems in a subset of major tracheostomy incidents, that occurred in the UK’s critical care units. Eleven out of the 14 dislodged ICU tracheostomies reported to NAP4 led to death or severe hypoxic brain injury. Competency deficiencies and a lack of capnography were consistent factors in these patients. Anaesthetists will usually have first hand experience of dealing with routine and emergency care of neck breathing patients. They are also the professional group most likely to be involved acutely when care does not go well, as airway specialists, resuscitation experts and intensivists. These varied experiences alongside increasing awareness of avoidable harm, prompted the Association of Anaesthetists of Great Britain & Ireland (AAGBI) to propose a study specifically on tracheostomy care. The survey-based study was undertaken by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and is the largest study of its type to date.

Notes from a Small Island: Lessons from the UK NCEPOD Tracheotomy Report.

The spotlight in the care of tracheotomy patients has turned in recent years onto multidisciplinary care, scrutinizing the patient journey from initial treatment decisions through tracheotomy to postprocedural care. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) conducted a national study into tracheostomy care in the United Kingdom, reporting the most comprehensive analysis of in-patient care to date. Key findings highlight recurrent deficiencies in the organization of care, staff training, and support and the inconsistent use of monitoring and safety equipment. The NCEPOD study findings are translatable to Western health care systems and serve to highlight important safety initiatives from exemplar institutions and national and international quality improvement projects. This commentary provides a forum to disseminate this essential information internationally.

Should physicians routinely be involved in the care of elderly surgical patients? Yes

Standards of care for elderly people in hospital have come under the spotlight. Kathy Wilkinson and Helen Wilson believe that geriatricians can help improve the management of surgical patients, but Barbara Herd (doi:10.1136/bmj.d1072) is concerned that the dilution of resources will harm those who most need specialist attention

Safeguarding children: why an issue for pediatric anesthetists?

Child maltreatment and the responsibility of heath care professionals to assist in prevention and diagnosis is currently center stage in the United Kingdom. This subject has a very large literature base. Anesthetists were one of the first groups to have specific guidance on this subject, and key competencies are now part of the core curriculum for our trainees. This article seeks to briefly define maltreatment and provide statistics that outline the scale of the problem, and includes discussion of risk factors and recognition. We have focused on physical abuse and have provided a separate section on abusive head trauma, which is of particular importance to anesthetists. We also discuss the process of management, with some detail around Child Death Review procedures.

Response to Dr A Snoek - 'Useful as a point-of-care algorithm?'.

SIR—I read with interest the paper containing guidelines for management of the unanticipated difficult airway (1) and commend the authors for tackling a difficult task. There are three points worth adding. First, though the paper does contain the Delphi group (DG) results for many guideline steps, inconsistent use of terminology, employing phrases such as ‘favored’ or ‘recommended’, rather than the predefined Delphi levels of consensus terms, means that not all DG results are clearly presented. In addition, it is unclear if some statements in the text were considered by the DG, and whether these were subsequently included in the guideline (e.g., adjusting cricoid pressure) or not (e.g., use of the lateral position if tonsils are enlarged). The reader would have benefited from a summary table of each guidelineconsidered step with its respective DG result. This would clarify which parts of the final guideline had been more rigorously tested via the larger 27-person DG rather than those that only went through the smaller sixperson Working Group (WG). Second, the complex deliberations of the WG on what ultimately to include or exclude in the final guidelines have not been presented. Some statements appear in the guidelines without having achieved DG consensus agreement (e.g., use of a nasopharyngeal airway) and other statements that did achieve DG consensus were not incorporated (e.g., use of cuffed tubes). Filtering of guideline steps by the WG weakens the DG contribution and ultimately compromises the validity of the method. The discussion section in the paper could have been better utilized to elucidate reasons for such decisions. Third, the aim was to produce simple guidelines in keeping with a ‘less is more’ principle. In the setting of a rapidly deteriorating situation of downward spiraling saturations, it may be that these guidelines are too prolix to follow, for example when compared to the vortex approach (2). On the flip side, there are aspects of the guideline where the goal for simplicity has excessively dominated detail, for example in the omission of intramuscular suxamethonium for laryngospasm without intravenous access. Consequently, the guideline is not comprehensive enough without having read the background text in the paper. In a state of panic it is questionable whether the target group for these guidelines will think of such steps without a detailed directive. Not only that but the use of the word ‘consider’ implies a necessity to weigh up risks and benefits. In the heat of the moment, when it says ‘consider a nasopharyngeal airway’, will some do so even if mouth opening is adequate and at best waste time, or at worst cause a nosebleed with resultant worsening of airway conditions? In its use as a point-of-care algorithm I fear that many will fall short in appreciating such complexities, especially without having conscientiously developed a deeper understanding for all relevant factors. As with any other emergency algorithm, an overarching comprehension of the foundations from which the algorithm has been developed, underpins its effective use. We should caution against solely relying on these guidelines without having wrestled with the accompanying background.