Sanders, R.D. et al. (2017) Anesthesiology 2(126) pp. 214-222.
Background: The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice.
Although difficult airways occur frequently in emergency medicine, few studies have investigated the incidence, management and outcomes of these patients, according to the investigators.
“We’ve been collecting airway data at our institution for many years, and this past year we decided to focus on the difficult airway,” said John C. Sakles, MD, professor of emergency medicine at the University of Arizona College of Medicine, in Tucson. Dr. Sakles presented the study at the 2016 annual meeting of the Society for Airway Management.
The study examined 348 nonarrest intubations between July 1, 2015, and March 31, 2016, at Banner University Medical Center, in Tucson. Operators performed a difficult airway assessment and classified the airway into one of three categories: routine, challenging or difficult.
A new research paper, jointly published today by the British Journal of Anaesthesia and Clinical Otolaryngology, recommends the scalpel-bougie cricothyroidotomy technique as the most efficient and reliable method of obtaining emergency front of neck access to the trachea in a situation where the patient’s airway is blocked and routine methods fail.
Without this rescue technique many of these patients would die. The technique, which involves placing a tube into the windpipe using a scalpel and a small guide, is recommended by a working group of anaesthetists and ear, nose and throat surgeons, led by the Royal College of Anaesthetists, which is working to spread this information to clinicians across the country.
Patients who are unconscious, either through illness or during anaesthesia, require a tube to be placed into the trachea to enable oxygen to reach the lungs. Although anaesthetists are able to manage the vast majority of difficult airways, some may rapidly develop into ‘can’t intubate, can’t oxygenate’ (CICO) events, which are one of the most feared emergencies in clinical medicine. These life-threatening situations, occurring approximately 100 times per year in the UK, often take place after instances of failed airway management and, if not managed correctly will lead to death or brain damage from lack of oxygen.
Anaesthetists and surgeons must work quickly and collaboratively to place a tube in the front of the neck (a front of neck airway, FONA). Good team communication, correct choice of FONA techniques and timing of interventions are all critical to the survival of the patient suffering from life-threatening breathing problems.
Prediction in airway management: what is worthwhile, what is a waste of time and what about the future?
Teoh, W.H. & Kristensen, M.S. British Journal of Anaesthesia (2016) 117 (1): 1-3.
Nørskov and colleagues1 randomized Danish anaesthesia departments in two groups, in order to investigate the effect of a structured airway examination on the ability to predict difficult intubation by direct laryngoscopy. The departments either continued with the pre-anaesthetic airway evaluation that they were used to, or applied the structured evaluation that consisted of five parameters (mouth opening, thyromental distance, Mallampati classification, neck movement and ability to prognath) and two questions (weight, previous difficult intubation) that culminated in the calculation of the Simplified Airway Risk Index (SARI).2This study found that clinicians were able to predict between nine and 50% of the patients where intubation with direct laryngoscopy was or would have been difficult. This success-rate in prediction difficulty was NOT different between the departments that continued with business-as-usual, and the departments where the evaluation of the seven predictive parameters was implemented.