Martin Beed

Updating our approach to the difficult and failed airway: time to “stop and think”

The Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults provocatively include deliberate instructions to ‘‘stop and think’’ (Figure). In so doing, they remind us that management of the difficult and failed airway is as much cerebral and situational as it is procedural and anatomical. The new guidelines are established on a growing evidence base. Accordingly, from a technical point of view, the authors recommend limiting intubation attempts, performing earlier scalpel cricothyrotomy, and avoiding blind techniques. More pertinent to this review, the authors also promote the evidence base supporting the importance of psychological factors, structured communication, and regular practice. Non-technical skills, such as the ability to step back and think, the ability to give and take instructions, and the aptitude to function within a high-stakes team, are increasingly recognized as part of what elevates experts above novices. These guidelines advance the field in many ways, not the least of which is the implicit message that successful difficult airway management requires the use of our hands, brains, and voices. It is important not to oversimplify the technical aspects of airway management. Similarly, the discussion of nontechnical factors, including analogies to other highreliability industries such as aviation, should not be oversimplified. After all, planes often do not take off during particularly inclement weather, whereas practitioners confronted by patients with a difficult or failed airway frequently have to ‘‘fly into the storm’’. Nevertheless, approximately a half-century of research from psychology, anthropology, sociology, and engineering has interrogated the factors that affect behaviour. Despite being leaders in medicine, the subspecialties of anesthesia and critical care are still in their infancy compared with other high-stakes systems. If we agree with the Institute for Healthcare Improvement that ‘‘every system is designed to achieve the results it gets’’, then new guidelines offer fresh impetus to create systems where practitioners are ‘‘fit for task’’ and ‘‘safety is no accident’’. The instruction to ‘‘stop and think’’ applies on many levels.

I. Adult cardiopulmonary resuscitation: ‘who’ rather than ‘how’

Cardiopulmonary resuscitation (CPR) can be a wonderful medical intervention. After all, it can prevent premature death, and save ‘hearts too good to die’. However well intentioned, CPR can also prolong inevitable death, increase family duress, extend patient suffering, and squander scarce resources. 3 Like other aspects of contemporary anaesthesia and intensive care unit (ICU), CPR has the power to be both the best and worst of what we do. 4 ‘Resuscitation’ is central to what defines anaesthesia and ICU, and to what concerns medical ethics. However, much of our literature still focuses on ‘how’ to perform CPR, rather than ‘who’ benefits. CPR has also morphed from a targeted intervention (only for those with reversible disease), to a default (an expectation for all without contrary documentation), to a near ‘societal right’ (if families insist enough we usuallyacquiesce). When supported by robust data, resuscitation is an important investment. When in opposition to robust data, it is often a tragic waste. In the USA, there are now over half-a-million annual CPR attempts, and over 1 billion dollars spent on unsuccessful attempts. 8 ICU already exceeds 80 billion dollars per annum, consumes over 20% of the total hospital budget, and is approaching 1% of that nation’s entire GDP. 10 One-third of Medicare costs are accrued during the last month of life, and at least 70% of North Americans now die in hospital. With over 130 million annual cardiovascular deaths worldwide, indiscriminate CPR is something we cannot afford—in any sense of the word—to ignore. Anaesthesia played a key in the birth of resuscitation. It needs to guide its growth and maturity. CPR: fulfilling our medical duty None of CPR’s pioneers ever argued for it to be universal. – 14 Approximately 60 yr on, CPR is increasingly excused the justification of treatments that are similarly invasive, expensive, or unsuccessful. With more elderly now alive than through all human history, resuscitation is also increasingly performed on the infirm and the terminal. Of course, prognostication is imperfect, but it is not impossible. ‘Frailty’, as the complex, but predictable, cumulative effect of ageing, illness, and inadequate recovery, can be quantified and qualified. It should become a key determinant of whether full resuscitation is offered. If not, then social forces will dominate. Perhapsmodern healthcare is sosubspecializedthatthe path of least resistance (‘just do it’) wins out. Perhaps, it is really the fear of litigation, or merely a convenient excuse to avoid difficult conversations. Maybe ‘progress’ is interpreted as ‘more’ but never ‘less’. Perhaps we prefer thinking in ‘black and white’ (do ‘everything’ or do ‘nothing’). Perhaps we find it difficult to distinguish limits from ‘giving-up’, and perhaps a do not resuscitate (DNR) order is still misinterpreted as a ‘do not respond’. Other reasons might include the single patient who unexpectedly survived, encouraging survival from select subgroups, or the promise of new therapies. Regardless, if contemporary CPR reflects the complex interaction of science, psychology, and litigation, then we should be leading a similarly multidisciplinary debate: whether practitioner, patient, or policymaker, CPR matters to all those with a heart. In a 2012 review of CPR after in-hospital arrest (IHA), the multidisciplinary National Confidential Enquiry into Patient Volume 112, Number 5, May 2014

Publication of surgical outcomes-data: whose team are we on?

In 2013, the Royal College of Surgeons of England (RCS), in partnership with the National Health Service of England (NHSE) began public disclosure of outcomes-data for individual hospitals and named surgeons. Data have been published for the following surgical disciplines: adult cardiac, bariatric, colorectal, headandneck,thyroidandendocrine,gastrointestinal,urological, vascular (plus interventional cardiology). Politicians may argue that this is a ‘revolution in transparency’. The public might applaud this as a way to empower patients and facilitate their decision-making. Surgeons might, albeit with trepidation, welcome the opportunity for comparison with peers. Those of us in anaesthesia and intensive care, however, might want to ask: ‘what does it mean to us?’ and ‘are we on the team or not?’

Emergencies in critical care

1. Assessment / Stabilisation 2. Airway 3. Breathing 4. Circulation 5. Neurology 6. Metabolic and Endocrine 7. Renal 8. Gastro-intestinal and hepatic 9. Haematology 10. Infections 11. Surgical patients 12. Trauma and burns 13. Obstetric critical care 14. Poisoning and Overdose 15. Miscellaneous Conditions 16. Transfers, retrievals, and major incidents 17. Organ Donation and coroner referrals APPENDICES 1. Common emergency procedures 2. Reference values 3. Useful Information

The association between prior statin use and long-term outcomes after critical care admission

BACKGROUND Statins may have immunomodulatory effects that benefit critically ill patients. Therefore, we retrospectively examined the association between survival and the prescription of statins prior to admission to an intensive care unit (ICU), or high dependency unit (HDU), as a result of major elective surgery or as an emergency with a presumed diagnosis of sepsis. METHODS We retrospectively studied critical care patients (ICU or HDU) from a tertiary referral UK teaching hospital. Nottingham University Hospitals have more than 2200 beds, of which 39 are critical care beds. Over a 5-year period (2000-2005), 414 patients were identified with a presumed diagnosis of sepsis, and 672 patients were identified who had planned ICU/HDU admissions following elective major surgery. Patients prescribed statins prior to hospital admission were compared with those who were not. Demographics, medical history, drug history, and Acute Physiology and Chronic Health Evaluation II scores were examined. Univariate and multivariate analyses were applied using the primary end point of survival at 5 years after admission. RESULTS Patients prescribed statins prior to critical care admission were, on average, older and had higher initial Acute Physiology and Chronic Health Evaluation II scores and more preexisting comorbidities. Statins were almost invariably stopped following admission to critical care. Statin use was not associated with significantly altered survival during hospital admission, or at 5 years, for either patients with sepsis (9% vs 15%, P=.121; 73% vs 84%, P=.503, respectively) or postoperative patients (55% vs 58%, P=.762; 57% vs 63%, P=.390). CONCLUSIONS Prior statin use was not associated with improved outcomes in patients admitted to critical care after elective surgical cases or with a presumed diagnosis of sepsis.

Comparing the socioeconomic status of critical care doctors and patients

To the Editor, Efforts have been made to increase the diversity of medical doctors, including encouraging females, visible minorities, and rural residents to pursue a career in medicine. However, socioeconomic status (SES) may have a greater impact upon clinician empathy, patientadherence, and health outcome than gender, ethnicity, or geography. Trainees from lower SES may be especially under-represented in critical care medicine (CCM) or whenever medical training is very expensive, specialisttraining is lengthy, or subspecialist employment is uncertain. For these reasons, we conducted the first study comparing income and education levels for parents of CCM trainees and parents of pediatric critically ill patients. We consented Canadian senior CCM trainees in 2010, 2011, and 2012 and reported their parents’/guardians’ education levels and best employment descriptor using the Blishen index. We compared these against the distribution of highest educational achievement published in the 2006 Canadian census. Next, we prospectively accessed similar data on pediatric intensive care unit (ICU) patients at the University of Alberta Hospital, along with parental satisfaction scores, whereby parents rated the doctors caring for their children in terms of overall care, sympathy, and parental engagement in decision-making. We obtained 134 complete responses from senior trainees (89%) and 80 from pediatric ICU parents (73%). Results are summarized in the Table. Median paternal SES was significantly higher for trainees vs patients (68 vs 41; P \ 0.001). Median maternal SES score was also significantly higher (62 vs 42; P \ 0.001). A larger proportion of CCM trainee parents had completed college, graduate, or higher education compared with pediatric parents ([ 80% vs\ 50%). More pediatric parents were ‘‘stay at home mothers’’ (60% vs 27%; P = 0.05). When compared against the 2006 Canadian census data, parents of CCM trainees were even less representative of the general population because of their higher average educational achievements. There was no correlation between SES and satisfaction scores from the parents of critically ill patients. Our data—albeit with limitations—suggest overall that critical care doctors from more advantaged backgrounds look after patients from comparatively more disadvantaged backgrounds. For some this will confirm common sense; for others it may be an uncomfortable realization. Fortunately, there was no gross evidence of lower satisfaction from the parents of patients, though with the caveat that satisfaction scoring was more tied to interactions with the attending physician than with senior trainees. We are certainly not proposing punitive redress, simply that more objective data could facilitate mature and empathic debate. Following these pilot data, we could P. G. Brindley, MD, FRCPC (&) Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, AB, Canada e-mail: peter.brindley@albertahealthservices.ca

Improving Chest Compressions Following Cardiac Arrest: Pushing Ahead

In Canada there are in excess of 40,000 annual cardiac arrests. Unfortunately, survival remains low following both out-of-hospital and in-hospital cardiac arrest, and many premature deaths are believed to be preventable. Studies have shown that high-quality chest compressions are key to survival, and the American Heart Association has summarized the need for: 1) adequate compression depth 2) adequate compression rate 3) avoiding leaning 4) minimizing interruptions 5) and minimizing chest rise. However, both laypersons and professionals are failing to reliably achieve these recommendations. Several devices (which provide real-time visual and audio feedback) have been developed with the goal of improving performance. Voice advisory manikins and motion capture technology utilize accelerometer technology and infrared sensors. Portable devices- including the CPREzyTM, PocketCPRTM, and CPRmeterTM- use accelerometer or pressure sensor technology. A number of defibrillators have been modified to provide real-time feedback. Recently, two applications, iCPR and PocketCPR, have been developed to capitalize on the ubiquity and familiarity of smartphones. These novel devices have shown the potential to improve the quality of chest compressions. What is needed is further research (and development) into how to translate these exciting opportunities into improved survival following cardiac arrest.