Preventing major airway complications

Every anaesthetist fears the moment they might become faced with a ‘can’t intubate, can’t oxygenate’ (CICO) scenario, but thankfully such events are exceedingly rare. They nevertheless receive much attention in the academic literature. The results from this online survey of Australian and New Zealand anaesthetists finds that most hospitals keep CICO equipment in every anaesthetic room in dedicated packs. As this is probably not common practice elsewhere, maybe it is probably about time we all caught up. Kelly and Duggan discuss preparing for and preventing CICO events, and call for clinicians’ worldwide to examine the design of their working environment. At the same time, the need to prepare for CICO events is superseded, arguably, by the need to prevent them from happening in the first place. Perhaps it is good timing then, that Chrimes, Higgs and Sakles write in this month’s issue to welcome us to the era of universal airway management. Their guidelines are anticipated eagerly.

This new pilot study from Deng et al. is an excellent example of how such a study should be designed and reported. They present important data that will hopefully allow for a larger, definitive randomised controlled trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomyWiles discusses the relevant literature on the relationship between anaesthetic technique, blood pressure monitoring and outcomes for patients undergoing mechanical thrombectomy after ischaemic stroke. He argues a greater focus on precision medicine is required, which includes individualised objectives and attention to detail. Is it time for bespoke haemodynamic targets? Such an aim might seem more biologically plausible than a simple choice between general anaesthesia and conscious sedation (Table 1).

AdvantagesDisadvantages
Airway protection with reduced risk of pulmonary aspiration of gastric contents (most patients do not present fasted).Slower door‐to‐groin puncture time and thus may delay vessel recanalisation.
Less patient movement which is desirable from the perspective of the interventional radiologist and may reduce procedural time and complications.Potential for a greater degree of iatrogenic hypotension
Lower potential for patient discomfort.Unable to monitor neurological status intra‐operatively.
Ensures direct anaesthetic involvement in the procedure which may secondary benefits such as: dedicated intra‐operative clinical monitoring; assessment and correction of volaemic status; and assistance with postoperative care destination (e.g. critical care admission).Risk of postoperative hangover effect with potential for POCD/POD.
Table 1 Advantages and disadvantages of general anaesthesia (including tracheal intubation) for mechanical thrombectomy.

This new editorial is extremely timely, even though it was written at the end of 2019. Kelly et al. discuss resilience in the context of lessons learnt from the military. They remind us that resilience is more than ‘toughness’, and involves the ability to manage the breadth, depth, intensity and chronicity of the demands placed upon us. In the wake of passing the peak of COVID-19 cases in the UK and elsewhere, the messages contained, such as strategies to improve team resilience, are essential reading for all. In early March, we received our first COVID-19 paper from a group of Italian authors documenting their clinical experiences and recommendations. It has since been cited 32 times and achieved an Altmetric score of > 340! We then went on to publish these consensus guidelines for managing the airway in patients with COVID-19, which has now been cited 34 times and has an Altmetric score of > 500! We hope these and other publications, such as this simulation study to evaluate the operational readiness of a high-consequence infections disease intensive care unit, have contributed to better clinical care during what has been an extremely difficult time for us all.

This new review from Lindsay et al. examines representation of patients in peri-operative randomised controlled trials in terms of age, sex, race and ethnicity. They found included trials were insufficiently representative, with race and ethnicity seldom reported. Overall, study populations were younger (Fig. 1), which perhaps presents issues in areas such as orthopaedic and trauma surgery research. They recommend that unnecessary age discriminatory exclusion criteria, including age limits, should be avoided. This systematic review by Heesen et al. pits phenylephrine and noradrenaline against each other for the management of hypotension associated with spinal anaesthesia in women undergoing caesarean section. They found that noradrenaline may preserve haemodynamic stability to a better extent than phenylephrine. They also conclude that an effect of noradrenaline on the rate of fetal acidosis cannot be excluded, which could be due to the β‐stimulating properties of noradrenaline. However, they warn of a lack of data as these conclusions come from single trials only. It looks like this one is far from over!

Figure 1 Bubble plots for each surgical category showing the difference between the mean or median age of the randomised controlled trial population and the mean age of the equivalent populations in the English hospital registry, according to the middle year of study recruitment. Marker radius is proportional to the number of study participants.

Elsewhere this month, we have: a sub-analysis of pooled data from two prospective studies on 10 kHz spinal cord stimulation for the treatment of non-surgical refractory back painan analysis of patient and surgery factors associated with the incidence of failed and difficult intubation; and a randomised controlled trial of the effect of low-dose naloxone infusions on the incidence of respiratory depression after intrathecal morphine administration for major open hepatobiliary surgery. Over in Anaesthesia Reports, we have a report of airway obstruction during general anaesthesia in a patient with a vagal nerve stimulator. Make sure you send your reports today for an efficient and friendly peer review service, together with the chance to get a publication in a well-read PubMed listed publication!

Keep your eyes out for new about our next TweetChat, which we hope to bring to you very soon, and make sure you check out our complete free to access COVID-19 collection!

Mike Charlesworth and Andrew Klein

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