Role of the anaesthetist during cataract surgery under local anaesthesia in the UK: a national survey.

BACKGROUND: Recent advances in cataract surgery techniques have enabled these to be performed under less invasive local anaesthetic techniques. As a result, ophthalmic surgeons are increasingly prepared to give the local anaesthesia to the patient themselves without the need for the presence of an anaesthetist. METHODS: A national postal survey was conducted in 2008, asking all consultant ophthalmic surgeons for their choice of local anaesthetic technique, whether an anaesthetist or a surgeon performs the block, the current level of anaesthetic cover for the ophthalmic operating sessions, and the need for anaesthetists for phacoemulsification under local anaesthesia in future. No reminders were sent to the non-respondents. RESULTS: The response rate was 62%. The choice of local anaesthetic technique was sub-Tenon's 47%, topical 33%, peribulbar 16%, retrobulbar 2%, and others 2%. Twenty-eight per cent of sub-Tenon's blocks were given by the surgeons and 47% by the anaesthetists. Of peribulbar blocks, 9% were given by the surgeons and 85% by the anaesthetist. Seventy-five per cent of ophthalmic operating sessions had allocated anaesthetic cover. Ophthalmic surgeons felt that in their judgement, only 10% of the phacoemulsifications under local anaesthesia would necessitate the presence of an anaesthetist. CONCLUSIONS: The consultant eye surgeons, based on their judgement, are prepared to undertake a bigger proportion of cataract surgeries under local anaesthesia without the presence of an anaesthetist. This development is bound to have a significant impact on manpower planning for ophthalmic anaesthetists.

Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema.

We report two cases of severe upper airway obstruction caused by supraglottic oedema secondary to adult epiglottitis and Ludwig's angina. In the former case, attempts to intubate with a direct laryngoscope failed but were successful once percutaneous transtracheal jet ventilation (PTJV) had been instituted. In the case with Ludwig's angina, PTJV was employed as a pre-emptive measure and the subsequent tracheal intubation with a direct laryngoscope was performed with unexpected ease. In both cases recognition of the glottic aperture was made feasible with PTJV by virtue of the fact that the high intra-tracheal pressure from PTJV appeared to lift up and open the glottis. The escape of gas under high pressure caused the oedematous edges of the glottis to flutter, which facilitated the identification of the glottic aperture. We believe that the PTJV should be considered in the emergency management of severe upper airway obstruction when this involves supraglottic oedema.

Emergency use of the laryngeal mask airway in severe upper airway obstruction caused by supraglottic oedema.

We report two cases of severe upper airway obstruction caused by supraglottic oedema which developed rapidly at the time of anaesthesia. Conventional methods to relieve the obstruction failed and it was only overcome when a laryngeal mask airway (LMA) was inserted and positive pressure applied manually during inspiration. In one case a fibrescope was passed via the LMA and this revealed two cushions of oedematous false vocal cords protruding into the bowel of the LMA which were pushed out of the way when positive pressure was applied during inspiration. We believe that the LMA should be considered in the emergency management of severe upper airway obstruction even when this involves supraglottic oedema.