Should ongoing airway education be a mandatory component of continuing professional development for College of Intensive Care Medicine Fellows?

This study aimed to determine whether airway education should be introduced to the continuing professional development (CPD) program for College of Intensive Care Medicine (CICM) Fellows. A random representative sample of 11 tertiary intensive care units (ICUs) was chosen from the list of 56 units accredited for 12 or 24 months of CICM training. All specialist intensive care Fellows (n=140) currently practising at the eleven ICUs were sent the questionnaire via email. Questionnaire data collection and post-collection data analysis was used to determine basic respondent demographics, frequency of certain airway procedures in the past 12 months, confidence with advanced airway practices in ICU, participation in airway education in the past three years, knowledge of can't intubate, can't oxygenate (CICO) algorithms, preference for certain airway equipment/techniques, and support for required airway education as a component of the CICM CPD program. All responses were tabled for comparison. Data was analysed to establish any significant effect of another specialty qualification and current co-practice in anaesthesia on volume of practice, confidence with multiple airway procedures, use of airway equipment, and support for airway education. In total, 112 responses (response rate 80%) to the questionnaire were received within four weeks; 107 were completed in full (compliance 96%). All results were tabled. There is currently widespread support amongst CICM Fellows for airway skills education as a CPD requirement for CICM Fellows. Volumes of practice and confidence levels with different airway procedures vary amongst Fellows and further support the need for education.

Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand.

BACKGROUND: There is growing evidence that airway complications are relatively common in critical care. Strategies have been suggested to decrease their incidence. METHODS: We conducted a telephone survey of all adult intensive care units (ICUs) in Australia and New Zealand to establish the current practice regarding strategies used to reduce airway complications in five key areas: (i) use of capnography; (ii) care of oral tracheal tubes; (iii) care of tracheostomy tubes; (iv) difficult and failed intubation; and (v) training and medical staffing. RESULTS: Of 176 ICU meeting inclusion criteria, 171 agreed to participate. Capnography is used during tracheal intubation in 88% of ICUs and for continuous monitoring in 64%. Protocols for advancing or partially withdrawing malpositioned tracheal tubes are used by 54% of units, with most allowing repositioning by unaccredited nurses. A small minority of ICUs use bed head signs to identify patients with 'critical airways' or laryngectomy, while only 8% have specific protocols for the care of these high-risk patients. Tracheostomy emergency algorithms are available in 13% of ICUs. At night, a doctor is exclusively assigned to 73% of units, although in 72%, the night doctor is not required to have prior anaesthetic/airway training. In 97% of the institutions surveyed, the senior doctor relied upon for airway emergencies at night is either non-resident or working elsewhere in the hospital. CONCLUSIONS: Our data suggest that several possible strategies for avoiding airway complications in ICU patients dependent on an artificial airway are poorly implemented. This may expose these patients to avoidable risk.

Evaluation of the LMA Supreme in 100 non-paralysed patients.

We studied the LMA Supreme in 100 elective, anaesthetised, healthy patients assessing: ease of use, airway quality, anatomical and functional positioning, airway leak and complications. Insertion was successful on first, second or third attempt in 90, nine and one patient respectively. Thirty manipulations were required in 22 patients to achieve a clear airway. Median [interquartile (range)] insertion time was 18 [10-25 (5-120)] s. During ventilation, an expired tidal volume of 7 ml x kg(-1) was achieved in all patients. Median [interquartile (range)] airway leak pressure was 24 [20-28 (13-40)] cmH(2)O. On fibreoptic examination via the device, vocal cords were visible in 83 patients (85%). During maintenance, five patients (5%) required 13 airway manipulations. There was one episode of minor regurgitation, without aspiration. Other complications and patient side-effects were mild and few. The LMA Supreme is easily and rapidly inserted, providing a reliable airway and good airway seal. Further studies are indicated to assess safety and performance compared to other supraglottic airway devices.

Myocardial infarction associated with the administration of intravenous ephedrine and metaraminol for spinal-induced hypotension.

A 31-year-old female with no risk factors for cardiac disease suffered a peri-operative myocardial infarction during an elective gynaecological procedure under spinal anaesthesia. The timing and nature of cardiac symptoms suggest that the myocardial infarction was caused by coronary artery vasospasm secondary to ephedrine and/or metaraminol, which were administered to treat spinal-induced hypotension. We review the recent literature and case reports on myocardial infarction attributed to sympathomimetic drugs, and recommend the use of sublingual or intravenous nitrates when signs or symptoms of coronary arterial vasospasm become evident during their use.

Evaluation of the size 4 i-gel airway in one hundred non-paralysed patients.

We studied the i-gel in 100 elective, anaesthetised patients (55:45 male:female, median age 53 years) assessing: ease of use, airway quality, positioning, seal and complications. First insertion attempt was successful in 86 patients, second attempt in 11 patients, and third attempt in three patients. Fifty three manipulations were required in 26 patients (median 1) to achieve a clear airway. Median insertion time was 15 s. During ventilation, expired tidal volume of 7 ml x kg(-1) was achieved in 96 (96%) patients. Median airway leak pressure was 24 cmH(2)O. On fibreoptic examination via the device, vocal cords were visible in 87 patients (91%). During maintenance, six patients (6%) required 12 airway manipulations. There was one episode of regurgitation, without aspiration. Other complications and patient side-effects were mild and few. The i-gel is easily and rapidly inserted, providing a reliable airway in over 90% of cases. Further studies are indicated to assess safety and performance compared to other supraglottic airway devices.

Renal replacement therapy for acute renal failure: a survey of practice in adult intensive care units in the United Kingdom.

This study surveyed current practice in adult intensive care units in the United Kingdom in three key areas of renal replacement therapy when used for acute renal failure: type of therapy used, typical treatment dose and anticoagulation. Responses were received from 303 (99%) of the 306 intensive care units. 269 units (89%) provide renal replacement therapy for acute renal failure. Most (65%) use continuous veno-venous haemofiltration as first-line therapy in the majority of patients, though continuous veno-venous haemodiafiltration is used by 31% of units. For haemofiltration, the median typical treatment dose (interquartile range [range]) is 32 ml.kg(-1).h(-1) (28.6-35.7 [14.3-85.7]), with 49% using a treatment dose of 35 ml.kg(-1).h(-1) or greater. For haemodiafiltration, the median typical treatment dose (interquartile range [range]) is 44 ml.kg(-1).h(-1) (28.6-57.1 [21.4-120.7]), with 67% using a treatment dose of 35 ml.kg(-1).h(-1) or greater. The vast majority of intensive care units use intravenous unfractionated heparin (96%) or epoprostenol (88%) for anticoagulation. Dosage and monitoring of these two agents vary markedly between units. No units use citrate anticoagulation. These results reveal a wide variety of practice in the delivery of renal replacement therapy between intensive care units in the United Kingdom.

Effect of chest compressions on the time taken to insert airway devices in a manikin.

BACKGROUND: Resuscitation guidelines recommend that chest compressions should continue throughout attempts to place airway devices. Few data support the use of the tracheal tube over supraglottic airway devices (SADs) during cardiopulmonary arrest. This study was designed to evaluate the speed with which different airway devices could be placed with and without interrupting chest compressions. METHODS: Forty volunteer doctors regularly involved in cardiopulmonary resuscitation (CPR) were timed inserting four different airway devices [tracheal tube (TT), LMA Classic (cLMA), LMA ProSeal (PLMA), and igel] into a manikin, with and without stopping chest compressions. RESULTS: Chest compressions delayed the placement of the TT only (3.3 s, P<0.0001). Comparison of the speed of insertion of the different airway devices during CPR enabled ranking of the devices: igel (fastest), PLMA (second), and TT and cLMA (joint slowest). The igel was inserted approximately 50% faster than the other devices. Doctors who had previously inserted more than 50 tracheal tubes were significantly faster at intubating the trachea, but no faster at inserting SADs. CONCLUSIONS: Our results show that continuing chest compressions has a minor effect on time for tracheal intubation and until clear human data are available the recommendation to intubate without interrupting CPR is therefore justified. The PLMA and igel (SADs with a gastric drain tube) were both faster to insert than the cLMA and offer additional benefits. They should be considered for use in CPR.