The anaesthetic robotic revolution?

The July issue is now available online and next month will see a return to the distribution of printed copies of the journal to our readers. You can read all about the reasons for this, along with how we have adapted to the pandemic, in our new editorial which now features in our ‘accepted articles’ section. In this month’s issue, Biro et al. describe robotic endoscope-automated laryngeal imaging for tracheal intubation. A prototype robotic endoscope device was inserted into the trachea of an airway manikin by seven anaesthetists and seven novice participants. There was little difference between the groups in terms of success rate and duration of insertion (Fig. 1). Ahmad et al. list the many limitations of this study, such as the fact that tracheal intubation was not performed. That said, the device recognised glottic features and was able to steer the endoscope tip into the trachea automatically. This is truly novel. Will robots take our jobs? We only need to look to surgery to tell us that robots have made good surgeons better, and although anaesthesia might be an innovative specialty, we have not fully embraced the robotic revolution, just yet.

Figure 1 User interface composed of the tip camera video (a) and the device configuration feedback (b), and anatomical features detection (c to e). The square indicates the successful recognition of the laryngeal inlet. The white dot represents the detected entrance of the glottis, while the white cross aims into the direction the tip is pointing. This difference triggers the proposal to ‘move the device to the left’, which appears in the left upper corner of the screen. The entire larynx (double line square), the corniculate cartilages (dotted small square), glottis (full line square) and subglottic trachea (segmented square). On the video screen (a), these squares are colour coded for better differentiation.

This month’s issue contains several high impact papers on various aspects of caring for patients with COVID-19. First, Lyons and Callaghan discuss the use of high-flow nasal oxygen (HFNO) for such patients. We use it commonly for patients with respiratory failure, but there are theoretical concerns around the potential for aerosol generation. This is all challenged by the authors, who point to a lack of evidence on aerosol generation and the risk of infection with HFNO, and call for clinicians to remain open minded. The question is, do alternatives have a better risk-benefit profile, for both patients and healthcare workers? Ventilator splitting has received much attention, and this new paper describes how it might be achieved with standard hospital equipment. Lee et al. report their experiences of battling COVID-19 from a tertiary academic medical centre in Singapore. Strategies included: containment; avoidance of health resource overburdening; optimisation of healthcare resources; and factoring in welfare and logistics. This can be compared with hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Milan, Italy. They issued an early warning (in late March) that hospitals should be prepared to face severe disruptions to their routine, and that it was very likely that protocols and procedures might require re-discussion and updating daily. The care of patients with chronic pain has been significantly impacted by the pandemic, and these new consensus recommendations from an international expert panel provide guidance on: the immune response; steroids; psychological, physical and social functions; in-person visits; telemedicine; biopsychosocial management; opioid prescriptions; anti-inflammatory drugs; and procedural precautions. Of course, no discussion of COVID-19 is complete without talking about personal protective equipment, and this review by Tim Cook is arguably the best there is. The infographic below contains all the key messages, but the full paper is well worth a read for everyone. You can also listen to a podcast on the topic from last month here. 

We also have a number of high-quality ‘NO-VID’ papers this month, including this narrative review of the anticipated difficult airway during obstetric general anaesthesia from Mushambi et al. They provide generic recommendations as well as updated decision aids for: the time and mode of delivery for a pregnant woman with an anticipated difficult airway; the general anaesthetic approach to such a patient; and an overview of all the included practice recommendations. This new safety guideline, jointly produced between the Obstetric Anaesthetic Association and the Association of Anaesthetists, describes practices around neurological monitoring associated with obstetric neuraxial block. Four main recommendations are given, which include: triggers to alert the anaesthetist; the use of straight-leg raise as a screening method; the likely timescale for resolution of neuraxial blockade; and the guidelines and policies maternity units should be expected to have in place (Fig. 2).

Figure 2 Summary of postpartum neurological deficits.

Elsewhere we have a study of the association of pre-operative anaemia with morbidity and mortality after emergency laparotomy; a prospective cohort study of clinician perception of long-term survival at the point of critical care discharge; and a retrospective observational study of variables associated with survival in patients with invasive bladder cancer with and without surgery. Over in Anaesthesia Reports, this new report of a junior doctor’s experience of critical illness due to COVID-19 now had an Altmetric score of > 1000! It was featured by > 100 news organisations, including the mainstream media, and has won acclaim from doctors and patients alike. Other reports include: local anaesthetic resistance in a patient with Ehlers-Danlos; intra-abdominal nasogastric tube placement; paratracheal abscess formation following tracheal intubation; the anaesthetic management of a patient with an isolated cortical vein thrombosis for emergency caesarean section; transient paraplegia due to subarachnoid haemorrhage following spinal anaesthesia; and unexpected difficult airway management in a transgender female patient. 

Join us over on Twitter as we discuss every paper from the issue in detail, with each made free for a day for all!

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Mike Charlesworth and Andrew Klein