Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia.

Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

Intra-articular local anaesthetic on the day after surgery improves pain and patient satisfaction after Unicompartmental Knee Replacement: a randomised controlled trial.

Intra-operative local anaesthetic infiltration provides good early pain relief after Unicompartmental Knee Replacement (UKR). However, appreciable pain may occur on the day after surgery. The purpose of this double-blinded, prospective randomised controlled trial was to evaluate the effectiveness of a bolus of local intra-articular anaesthetic given early on the day after surgery. Forty-four patients were randomised to receive an intra-articular injection, via an epidural catheter inserted at operation, of either 20 ml 0.5% plain bupivacaine or 20 ml normal saline. All patients received a femoral nerve block with 20 ml prilocaine 1% and local anaesthetic infiltration by the surgeon. Patients injected with bupivacaine had significantly less (p<0.001) pain than control patients immediately (mean pain score 1.82 v 6.1) and 6 hours (2.5 v 5.7) after injection. Patient satisfaction was also significantly greater (p<0.001) in the local anaesthetic group. We conclude that a bolus dose of intra-articular bupivacaine early on the day after surgery dramatically improves pain control after UKR and improves patient satisfaction.

The Difficult Airway Society 'ADEPT' guidance on selecting airway devices: the basis of a strategy for equipment evaluation.

Faced with the concern that an increasing number of airway management devices were being introduced into clinical practice with little or no prior evidence of their clinical efficacy or safety, the Difficult Airway Society formed a working party (Airway Device Evaluation Project Team) to establish a process by which the airway management community within the profession could itself lead a process of formal device/equipment evaluation. Although there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (i.e. purchased). The Airway Device Evaluation Project Team's first task was to formulate such advice, emphasising evidence-based principles. Team discussions led to a definition of the minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. The Team concluded that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. We describe how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained. Essential elements are that: (i) the Difficult Airway Society facilitates a coherent national network of research-active units; and (ii) individual anaesthetists in hospital trusts play a more active role in local purchasing decisions, applying the relevant evidence and communicating their purchasing decisions to the Difficult Airway Society.

Nasotracheal fibreoptic intubation: a randomised controlled trial comparing the GlideRite® (Parker-Flex® Tip) nasal tracheal tube with a standard pre-rotated nasal RAE™ tracheal tube.

In a randomised controlled study, we compared the ease of railroading a GlideRite® nasal tracheal tube over a fibrescope with that of a pre-rotated RAE™ nasal tracheal tube. We studied 110 anaesthetised patients with no known airway difficulties undergoing elective dental or maxillofacial surgery. Impingement was more common with the GlideRite tubes (11/55 (20%)) compared with the pre-rotated RAE tubes (3/55 (5%); p=0.02). The median (IQR [range]) time to intubation (GlideRite 7.6 (4.7-10.8 [3.0-46.2]) s; RAE 8.0 (6.2-10.7 [2.4-30.0]) s) and postoperative sore throat numerical ratings (GlideRite 2 (0-3 [0-10]); RAE 2 (0-5 [0-8])) were similar. A 90° anticlockwise pre-rotation of a standard nasal RAE tube has a higher initial rate of successful railroading at first attempt and is therefore superior to a GlideRite nasotracheal tube during nasal fibreoptic intubation.

A comparison of a flexometallic tracheal tube with the intubating laryngeal mask tracheal tube for nasotracheal fibreoptic intubation using the two-scope technique.

We compared the incidence and site of impingement of a flexometallic tracheal tube with those of the re-usable intubating laryngeal mask (ILMA) tube in 60 anaesthetised patients undergoing nasotracheal fibreoptic intubation for oral surgery. A two-scope technique was used, observing the site of impingement with one scope whilst intubating with the other. The tubes were 6.0-mm in females and 6.5-mm in males. Impingement occurred with 10 (33%) flexometallic and 2 (7%) ILMA tubes (p < 0.032). In all but one case, the impingement was posterior to the right arytenoid cartilage. When impingement was observed, a single disempaction with a 90 degrees anticlockwise rotational manoeuvre overcame impingement in every case except one, allowing successful intubation. We conclude that the incidence of impingement of the tracheal tube, and therefore of potential laryngeal trauma from nasotracheal fibreoptic intubation, is significantly greater with the flexometallic tube than with the ILMA tube.

Regional anaesthesia for limb surgery: a review of anaesthetists' beliefs and practice in the Oxford region.

We conducted a postal survey of 210 anaesthetists in the Oxford region to determine their views and practice regarding the timing of regional anaesthesia when combined with general anaesthesia for adults undergoing limb surgery and to compare the results with those obtained in a similar survey conducted in 2001. Of the 151 respondents (72% response rate), 102 (68%) regularly combined regional and general anaesthesia for adult limb surgery. Over 80% believed that central neuraxial blocks should be performed before general anaesthesia. This matched their current practice, marking a change from 2001. Significantly fewer anaesthetists believed it necessary to perform peripheral nerve blocks before general anaesthesia than in 2001, marking another significant change in practice. Overall, the results indicate an increased popularity of regional blocks in combination with general anaesthesia when compared with 2001 practice, which we believe is related to high quality advanced training modules now on offer to senior trainees in the Oxford region.

Pain relief after knee replacement in patients with a bleeding disorder.

Peripheral nerve blocks can be safely used on patients with bleeding disorder, to achieve peri-operative amalgesia.

A comparison of an anterior jaw lift manoeuvre with the Berman airway for assisting fibreoptic orotracheal intubation.

This study compared the efficacy of an anterior jaw lift manoeuvre with that of the Berman airway in clearing the upper airway during oral fibreoptic tracheal intubation in anaesthetised, paralysed patients. Fifty patients were randomly assigned to undergo fibreoptic-assisted intubation with one method, followed by crossover to the alternative method. The time taken to view the vocal cords was the primary endpoint, and we also noted the rate of failure to view the cords, i.e. cords not seen after 120 s of endoscopy. Anterior jaw lift yielded significantly shorter times to view the vocal cords (median [interquartile range; range]: 22 [17-46; 7-120] s vs 40 [29-67; 21-120] s, p = 0.001) and a higher success rate (49/50 vs 42/50, p = 0.014). We conclude that the anterior jaw lift is more effective than the Berman device for achieving airway clearance in this setting.

Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation.

This study examines the incidence and site of tracheal tube impingement during nasotracheal fibreoptic intubation, and the efficacy of anticlockwise tube rotation to overcome the problem. Forty-three patients underwent fibreoptic-assisted nasotracheal intubation using a preformed nasal tube, and a second fibrescope was used to observe any obstruction to passage of the tracheal tube. Impingement occurred in 10 cases, with the most common site being the right arytenoid cartilage. Rotation resulted in successful intubation in all 10 cases, but proximal rotation did not always result in an equal degree of rotation at the tube tip. We conclude that the site of impingement for nasotracheal intubation with preformed nasal tubes is located at the posterior structures of the laryngeal inlet and that anticlockwise rotation is a simple and effective solution.

Comparison of fibreoptic-guided orotracheal intubation through classic and single-use laryngeal mask airways.

We compared times to intubate the trachea orally and success rates using two fibreoptically assisted techniques in 42 healthy patients with normal airways using (a) a 6.0-mm nasal RAE tracheal tube passed through a classic laryngeal mask airway (CLMA group) or (b) a 6.0-mm nasal RAE tracheal tube passed through a new disposable Portex Soft Seal laryngeal mask airway (PLMA group). The mean (SD) total intubation times were 82 (14) and 80 (17) s, respectively (p = 0.55). The success rates for intubation at the first attempt were similar (17/21 in the CLMA vs. 16/21 in the PLMA group; p = 0.50). We conclude that there is no clinically significant difference between the times to intubate the trachea or success rates using these two devices, but there may be other more subtle measures which might influence the choice of device in clinical practice. Finally, in the course of this study we developed a grading scale to describe the laryngeal views obtained when using a fibrescope passed through supraglottic airway devices.

Difficult Airway Society guidelines for management of the unanticipated difficult intubation.

UNLABELLED: Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. DISCLAIMER: It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.

Management of unanticipated difficult intubation: a survey of current practice in the Oxford region.

BACKGROUND AND OBJECTIVE: Unanticipated difficulty in tracheal intubation in an anaesthetized patient has always been a cause of concern to anaesthesiologists. This difficulty may lead to morbidity and mortality. This survey was carried out to determine the technique commonly favoured in centres in the Oxford region in the UK for the management of unanticipated difficult intubation. METHODS: We conducted a clinical scenario-based questionnaire survey of 181 anaesthesiologists in the Oxford region. In this scenario, difficulty in endotracheal intubation is recognized only after induction of anaesthesia. A number of options were available to deal with this situation. We used this scenario as a tool to gain insight into the training and the training needs of anaesthesiologists at various levels of training. RESULTS: Of the 181 questionnaires sent, we received 143 (79%) completed replies. The vast majority (141/143 (99%)) of anaesthesiologists would use a gum-elastic bougie together with head and neck positioning and optimal external laryngeal manipulation to gain the best attempt at intubation. If intubation still failed, overall 129/143 (90%) had a back-up plan, while 14/143 (10%) had no plan. Flexible fibreoptic techniques were more commonly planned by 92/143 (64%) anaesthesiologists compared to blind techniques which were less commonly planned by 37/143 (26%) anaesthesiologists. Differences in choice of technique among anaesthesiologists in teaching and district general hospitals were not significant (P = 0.87). Overall, trainees were less likely to choose fibreoptic techniques compared to consultants (P = 0.0009) and would use blind techniques or ask a more experienced colleague to take over. The main reason for the choice was previous experience with the technique. CONCLUSIONS: Although fibreopric techniques were most commonly planned, these were less often chosen by trainees than consultants due to lack of experience/training, while unavailability of intubating laryngeal mask airway (Intavent) was an additional issue precluding its use as an adjunct to intubation.

Use of the bougie in simulated difficult intubation. 1. Comparison of the single-use bougie with the fibrescope.

We studied the success rates for tracheal intubation in 64 healthy patients during simulated grade III laryngoscopy after induction of anaesthesia, using either the single-use bougie or oral flexible intubating fibrescope, both in conjunction with conventional Macintosh laryngoscopy. Patients were randomly allocated to either simulated grade IIIa or grade IIIb laryngoscopy, and also to one of the two study devices. Success rates for tracheal intubation (primary outcome measure) and times taken to achieve intubation (secondary outcome measure) were recorded. For the simulated grade IIIa laryngoscopy group, the fibreoptic scope was more successful than the bougie (16/16 successful intubations vs. 8/16; p = 0.02). For the simulated grade IIIb laryngoscopy group, the fibreoptic scope was also more successful than the bougie (8/16 successful intubations vs. 1/16; p = 0.02), but clearly use of the fibreoptic scope was not as successful as it had been in simulated grade IIIa laryngoscopy (p = 0.04). With either device, median (range) total tracheal intubation times for successful attempts with either grade of laryngoscopy were less than 60 s (19-109) and there were no clinically important differences. We conclude that the fibrescope used in conjunction with Macintosh laryngoscopy is a more reliable method of tracheal intubation than the single-use bougie in both types of grade III laryngoscopy. This finding has implications for the management of patients in whom grade III laryngoscopy is encountered unexpectedly after induction of anaesthesia, and also for the management of patients previously known to have grade III view at laryngoscopy.

Use of the bougie in simulated difficult intubation. 2. Comparison of single-use bougie with multiple-use bougie.

We studied the success rates for tracheal intubation in 32 healthy, anaesthetised patients during simulated grade IIIa laryngoscopy, randomised to either the multiple-use or the single-use bougie. Success rates (primary end-point) and times taken (secondary end-point) to achieve tracheal intubation were recorded. The multiple-use bougie was more successful than the single-use one (15/16 successful intubations vs. 9/16; p = 0.03). With either device, median [range] total tracheal intubation times for successful attempts were < 54 [24-84] s and there were no clinically important differences between these times. We conclude that the multiple-use bougie is a more reliable aid to tracheal intubation than the single-use introducer in grade IIIa laryngoscopy.

Orotracheal fibreoptic intubation for rapid sequence induction of anaesthesia.

We assessed whether flexible fibreoptic-guided orotracheal intubation could be rapidly and successfully achieved during a simulated rapid sequence induction in 30 anaesthetised and paralysed patients. Rapid sequence induction was simulated by applying practised cricoid pressure. Using a flexible fibreoptic laryngoscope with camera and closed circuit television, an anaesthetist experienced with the technique performed orotracheal endoscopy and intubation with a cuffed 7.0-mm Portex tracheal tube through a VBM Bronchoscope Airway. Fibreoptic intubation was successful at the first attempt in 28 patients (93%); two patients required two attempts. Mean (SD) time from removal of the facemask from the patient's face to the appearance of carbon dioxide in the expired breath after intubation was 111 (46) s (median 100 s; range 54-195 s). There were one or more difficulties in 13 patients (43%). These difficulties were largely avoidable and included problems with fibreoptic equipment, the Bronchoscope Airway, copious secretions, cricoid pressure or railroading of the tracheal tube. Flexible fibreoptic-guided orotracheal intubation may have a place in the management of failed intubation during a rapid sequence induction.

Comparison of times to achieve tracheal intubation with three techniques using the laryngeal or intubating laryngeal mask airway.

We compared the times to intubate the trachea using three techniques in 60 healthy patients with normal airways: (i) fibreoptic intubation with a 6.0-mm reinforced tracheal tube through a standard laryngeal mask airway (laryngeal mask-fibreoptic group); (ii) fibreoptic intubation with a dedicated 7.0-mm silicone tracheal tube through the intubating laryngeal mask airway (intubating laryngeal mask-fibreoptic group); (iii) blind intubation with the dedicated 7.0-mm silicone tracheal tube through the intubating laryngeal mask airway (intubating laryngeal mask-blind group). Mean (SD) total intubation times were significantly shorter in the intubating laryngeal mask-blind group (49 (20) s) than in either of the other two groups (intubating laryngeal mask-fibreoptic 74 (21) s; laryngeal mask-fibreoptic group 75 (36) s; p < 0.001). However, intubation at the first attempt was less successful with the intubating laryngeal mask-blind technique (15/20 (75%)) than in the other two groups (intubating laryngeal mask-fibreoptic 19/20 (95%) and laryngeal mask-fibreoptic 16/20 (80%)) although these differences were not statistically significant. We conclude that in this patient group, all three techniques yield acceptable results. If there is a choice of techniques available, the intubating laryngeal mask-blind technique would result in the shortest intubation time.

Regional anaesthesia for limb surgery--before or after general anaesthesia. A survey of anaesthetists in the Oxford region.

We conducted a postal survey of 221 anaesthetists in the Oxford region to determine their views and actual clinical practice regarding regional anaesthesia in adult patients undergoing limb surgery, when a combined regional and general anaesthetic was planned. Of the 162 respondents (73.3%), 142 (87.6%) regularly practised regional blocks for limb surgery in adult patients. For all the regional anaesthetic techniques in question, more anaesthetists felt it was safer to perform these blocks before induction of general anaesthesia than after induction. However, their actual practice varied markedly from their views, with more anaesthetists performing these blocks after general anaesthesia. Overall, trainees performed blocks before induction of general anaesthesia more often than consultants (p = 0.047).

Lingual nerve injury after use of a cuffed oropharyngeal airway.

The cuffed oropharyngeal airway is a modified Guedel airway and is recommended for anaesthesia in spontaneously breathing patients. To our knowledge this is the first report of transient unilateral lingual nerve palsy after the use of a cuffed oropharyngeal airway to maintain anaesthesia during arthroscopy of an ankle. The aetiology of lingual nerve damage is multifactorial. The possible mechanisms involved include anterior displacement of the mandible during insertion of the cuffed oropharyngeal airway (as in the jaw thrust manoeuvre), compression of the nerve against the mandible, or stretching of the nerve over the hyoglossus by the cuff of the cuffed oropharyngeal airway. We recommend gentle airway manipulation with the use of the cuffed oropharyngeal airway, avoidance of excessive cuff inflation and early recognition of such a complication if it occurs.