Rapid Sequence

A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal

The WHO has developed a list of aerosol-generating procedures that healthcare organisations throughout the world have used as a framework for development of their guidelines. Supraglottic airways are used in the majority of the approximately 2.7 million general anaesthetics performed in the UK each year. In a UK survey in October 2020, 40% of responding hospitals reported that supraglottic airway removal, even in low COVID-19 risk pathways, is restricted exclusively to the operating theatre (rather than being performed in a recovery area), indicating the presence of policies that assume it is an aerosol-generating procedure. However, uncertainty remains as to whether insertion or removal of a supraglottic airway generates aerosols.

Given the uncertain balance of potential risks and benefits associated with the protective strategies put in place to limit airborne viral transmission, this new paper from Shrimpton et al. aimed to directly assess airborne particle emission during insertion and removal of supraglottic airways. They used real-time measures of aerosol generation with an optical particle sizer in a working operating theatre environment and compared the measured levels with reference to those generated by a volitional cough and the patient’s own breathing.

Joining two of the authors was our fellow, Craig Lyons as well as Laura Duggan who is an Editor of Anaesthesia.

Treatment threshold for intra-operative hypotension in clinical practice—a prospective cohort study in older patients in the UK

Intra-operative hypotension frequently complicates anaesthesia and has been extensively associated with myocardial injury, acute kidney injury, stroke and death. The iHypE study aimed to describe the incidence of intra-operative hypotension in older patients and define both the intended blood pressure treatment threshold, and the clinically applied treatment threshold for intra-operative hypotension in UK anaesthetic practice.

The main finding was that intra-operative hypotension is documented in the majority of patients aged ≥ 65 y undergoing surgery in the UK using any of the applied definitions. Prolonged intra-operative hypotension was also prevalent in most patients.

This podcast discusses the how the study was done as well as its key clinical implications. It is essential listening for anyone interested in conducting a trainee network research project and the story of how such a study was coordinated and run is fascinating.

Regional analgesia for lower leg trauma and the risk of acute compartment syndrome

Tonight’s discussion is all about a new Association of Anaesthetists guideline on regional analgesia for lower leg trauma and the risk of acute compartment syndrome.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. There is, however, very little high quality evidence to inform practice. These guidelines were developed, therefore, to provide pragmatic guidance to enable optimal analgesia and to highlight the need for careful observation for acute compartment syndrome in any patient at risk.

With us today to discuss this new paper we have one of the authors, Dr Matt Wiles from Sheffield, who is also an Editor of Anaesthesia. With us also we have Mr Simon Fleming who is a trainee Trauma and Orthopaedic surgeon who has developed a national, and growing international reputation, for his campaigning work to drive cultural change in the NHS and other healthcare organisations. Last but by no means least we have Dr Sally El-Ghazali who is a London based anaesthetist and intensive care doctor, and the immediate past chair of the Association of Anaesthetists Trainee committee

The impact of COVID-19 on anaesthesia and critical care services in the UK

During the COVID-19 pandemic, there has been considerable focus on the escalation of critical care capacity, capability and delivery. Early in the first wave, NAP7 was postponed and, as part of assessing when anaesthetic and peri-operative services might have returned to a stable baseline and thus be ready for starting NAP7, the authors of this new paper undertook a series of national surveys in order to track activity during the second wave of the pandemic.

Their work describes and quantifies the huge pressures on the anaesthesia and critical care workforce during the winter wave of the pandemic, and the devastating drop in surgical activity.

Joining us today we have Dr Emira Kursumovic and Professor Tim Cook. Their work was published just last week, is highly relevant to hospitals, healthcare staff and patients alike, and was featured in the mainstream media.

Recommendations for standards of monitoring during anaesthesia and recovery 2021

This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the UK and Ireland, but it is recognised that these guidelines may also be of use in other areas of the world.

For this podcast, Tanya Selak joined us from Australia with authors Andrew Klein, Tim Meek and Tei Sheraton. This one is not to be missed! Enjoy!

The 7th UK National Audit Project (NAP7). The challenges of defining, studying and learning from peri‐operative cardiac arrest

Welcome to this Anaesthesia Journal Podcast which is all about the the 7th UK National Audit Project (NAP7), and more specifically, the challenges of defining, studying and learning from peri‐operative cardiac arrest.

With the discovery of general anaesthesia came the issue of cardiac arrest during anaesthesia. It is thought to occur rarely, ranging from 2-13 per 10,000 anaesthetics and there is much that remains incompletely understood. As such, peri-operative cardiac arrest has been chosen as the topic for the 7^th National Audit Project of the Royal College of Anaesthetists.

With us today we have the NAP7 clinical lead, Dr Jasmeet Soar, as well as NAP7 fellows Dr Andrew Kane and Dr Emira Kursumovic.

Awake tracheal intubation with the ProVu™ video stylet: a case series

Welcome to the first ever Anaesthesia Reports live broadcast – what will hopefully be the first of many - where we chat with the authors of their reports about the interesting scenarios they have encountered in their own clinical practice. This session was chaired by Dr Maryann Turner, who is an editor of Anaesthesia Reports and a paediatric anaesthetist based in Sydney.

Dealing with a predicted difficult airway is a common challenge in anaesthesia. There are several different devices on the market that are designed to facilitate tracheal intubation in these patients and traditionally, a bronchoscope or a video laryngoscope would be used. But today, we are going to discuss the use of the ProVu™ video stylet as an alternative device for use in these patients.

We were joined by Dr Imran Ahmad and Dr Siew-Ling Harrison, who are the authors the paper. Imran is a consultant anaesthetist at Guy’s and St Thomas’ and the director of the Guy’s Airway Management Course, as well as the honorary secretary of the Difficult Airway Society. Siew-ling is a senior trainee in the south east of London who is the outgoing airway fellow under Imran and the current thoracic fellow at Guys Hospital.

The Great Aerosol Debate 2!

There is much debate over the role of respiratory particles in guidelines for preventing transmission of COVID-19. Larger particles are traditionally called ‘droplets’ and are deemed to travel only 1-2 metres from an infected patient before falling to the ground. Aerosols are smaller particles and stay floating in the air for prolonged periods, spread further, may accumulate in poorly ventilated spaces, can be inhaled deep into the lungs and bypass looser fitting facemasks. Much current guidance is designed to protect from droplets and infection spread by aerosols is only considered a risk when caused by medical therapies. In this new study, the volunteers produced up to 100 times more aerosol particles with activities such as coughing than they did during treatment with oxygen therapies.

This challenges the current guidelines which state healthcare staff looking after patients with COVID-19 who are coughing and have breathing difficulty only need PPE that protects against the larger droplets. ‘Droplet protection’ includes surgical masks but does not prevent  aerosol particles passing around the edges of the masks and being inhaled. N95/FFP3 respirators which are tightfitting and filter better, block more aerosols but guidelines currently recommend these only for staff looking after patients receiving the advanced oxygen therapies.

This new study from Wilson et al. challenges the guidance that special aerosol precautions are only needed when using oxygen therapies for COVID-19 patients, and raises concerns about safety of staff and patients on hospital wards, if they are not protected from infectious aerosols. We were joined by authors Dr Nick Wilson and Professor Tim Cook, as well as expert Professor Tony Pickering and Editor Laura Duggan. The broadcast has already been viewed over 10k times!

The need for safe, stable and sustainable resumption of planned surgery in an era of COVID‐19

Today we published a new editorial which outlines the principles laid out in the recently released document from the Royal College of Anaesthetists, the Association of Anaesthetists and the Faculty of Intensive Care Medicine on resumption of planned surgical services.

The resumption of planned healthcare in 2021 is both a necessity and an opportunity, but it will require co‐ordination at all levels and acknowledgement and planning that accommodates the physical and psychological needs of those who have worked throughout the pandemic in order to deliver the safe, stable and sustainable service that will be required in the years to come.

Authors Professor Tim Cook and Dr Tei Sheraton are joined by Dr Kariem El-Boghdadly to go through the many issues raised in the paper.

Malignant hyperthermia guideline from the Association of Anaesthetists

Malignant hyperthermia (MH) is a rare anaesthetic emergency. It has been estimated to occur in between 1:10,000 and 1:150,000 general anaesthetics, though there is much uncertainity about the precision of these estimates.

The Association of Anaesthetists has not previously published full MH guidelines. In the absence of any recent guidelines published in a peer reviewed journal, rather than simply updating the 2011 crisis management laminates, a Working Party was established to produce these formal comprehensive guidelines. Importantly, the scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed.

With us today we have the lead author of the paper, Professor Phil Hopkins from the Malignant Hyperthermia Unit at St. James’ University Hospital and the University of Leeds. We are also delighted to be joined by Connor Philips, an award-winning television presenter, BBC radio presenter, writer and live event host whose broadcasting work includes sport, entertainment, current affairs, film, music, travel, comedy and property. Connor and several family members have been affected by MH, and his insights and experiences of this rare condition will be of interest to all.