The Westmead Anaesthesia Blog

Lipid rescue for treatment of delayed systemic ropivacaine toxicity from a continuous thoracic paravertebral block. BMJ Jun 2016.

2016-09-13T21:38:00.001+10:00

This case report describes a 66-year-old man who underwent a left minithoracotomy for pleural biopsies and thoracentesis of a left-sided lesion involving the T3 and T4 vertebral bodies and pedicles. He developed local anaesthetic systemic toxicity (LAST) 37 hours after placement and initiation of a left T3 paravertebral catheter. Patient had symptoms of convulsions without loss of consciousness, a burning sensation in his legs and penis and agitation. Ropivacaine infusion was ceased and bolus of intralipid 20% was administered, followed by an infusion. His symptoms resolved within an hour of cessation of local anaesthetic infusion. The total serum concentration of ropivaciane during the event was 2.1mg/L compared with a published toxic level of 2.2 mg/L in healthy human volunteers. As the infusion rate of ropivacaine was reasonable based on pharmacokinetics, it is postulated that systemic local anaesthetic uptake may have been increased by the proximity of the block to areas with more vascularity such as tumour and pleural biopsy sites. Another possible cause could be intravascular migration of the paravertebral catheter.

Anaesthesia on the Western Front – perspectives a century later. AAIC Jul 2016.

2016-09-13T21:37:00.005+10:00

This interesting article by Dr McDonald takes us back in time to the battles of World War I and the significant effects on the development of anaesthesia that occurred as a result. In particular, the challenges of the Western Front, with its massive numbers of injured, saw progress in the understanding and management of trauma and shock, and significant improvement in the provision of anaesthesia and the training of anaesthesia providers. The result was increased anaesthetic safety for the civilian population after the war and further development of anaesthesia and resuscitation as a specialised area of medicine.

Gas: the greatest terror of the Great War. AAIC Jul 2016.

2016-09-13T21:37:00.003+10:00

“To an anaesthetist the word ‘gas’ refers to our ‘everyday tools of the trade’. Just over 100 years ago, the world ‘gas’ has an entirely different and sinister meaning. Gas was to become synonymous with an almost inescapable form of agonising death of painful injury on a scale never before seen in human history.” In this illustrative article, Dr Padley outlines the development of the gas warfare – the first weapon of mass terror – during World War I. From the development of chlorine, phosgene and then mustard gas, to trench warfare and management of gas casualties, this article takes us through a journey and shows us the destructive effects innovations can bring when applied as a weapon.

Advances in the diagnosis of shock, its assessment and resuscitation during the Great War. AAIC Jul 2016.

2016-09-13T21:37:00.001+10:00

On a different note, the Great War did bring about an accelerated understanding of physiology and medical treatment of shock and trauma patients. In this intriguing article Dr Bullingham discusses the history of management of haemorrhagic shock, multi-trauma, sepsis, oxygen therapy and blood transfusion during the Great War. It is fascinating to learn that much of the knowledge gained during this period is integral in our anaesthetic practice today.

The effect of intrathecal morphine dose on outcomes after elective caesarean delivery: a meta-analysis. AA Apr 2016.

2016-09-13T21:36:00.001+10:00

This meta-analysis compared low dose (LD 50-100microg) spinal morphine to high dose (HD >100-250microg) as part of spinal anaesthesia for elective Caesarean section. 11 Articles found including 480 patients. Primary outcome found HD (>100-250) spinal morphine prolonged mean time to first request for supplemental morphine equivalent by 4.5 hrs (CI 1.85–7.13 hours; P = 0.0008, Moderate heterogeneity) compared to LD (50-100). Secondary outcomes - incidence of pruritis and PONV was significantly lower in LD group (OR 0.34 p =0.0001, OR 0.44 p = 0.002 respectively) but pain scores at 12 hours, morphine equivalent consumption at 24 hours and APGAR scores <7 at 1 min was not significantly different. This meta-analysis shows that higher dosage (>100-250) of spinal morphine compared with lower dose (50-100) will prolong time to first analgesic request by 4.5hrs but at the cost of increased chance of side effects (pruritis and PONV).
Summarised by: Brenton Sanderson

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. BMJ Feb 2016.

2016-09-13T21:35:00.001+10:00

Adrenaline has been used for resuscitation after cardiac arrest for decades in both shockable and non-shockable rhythm. It has been previously shown that delay in the first administration of adrenaline is associated with a decreased chance of good outcomes in both adults and children in hospital who experience cardiac arrest with an initial non-shockable rhythm. There is however a lack of published studies in such patients presenting with a shockable rhythm (pulseless ventricular tachycardia or ventricular fibrillation). This is a prospective observational cohort study which attempts to address this. This study included 2978 patients who experienced cardiac arrest with an initial shockable rhythm. 51% of patients received adrenaline within 2 minutes after the first defibrillation, which is contrary to current American Heart Association (and also Australian Resuscitation Council) guidelines. Adrenaline given within the first 2 minutes after the first defibrillation was associated with decreased odds of survival (OR 0.70, 95% CI 0.59 to 0.82; P<0.001). Early adrenaline administration was also associated with decreased odds of return of spontaneous circulation (OR 0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83: P<0.001). The biggest limitation is that being an observational study, no strong causal effect of early adrenaline administration can be made. These findings may still be of relevance to future guidelines and studies.

Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. NEJM May 2016.

2016-09-13T21:33:00.000+10:00

This double-blind, randomised trial compared amiodarone, lidocaine and placebo in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. Paramedics enrolled patients at 10 North American sites. 3026 patients were randomly assigned to amiodarone, lidocaine or placebo; of those 24.4%, 23.7% and 21.0% respectively survived to hospital discharge. There were no significant differences in the survival rate or neurological outcomes between the 3 groups. This study concluded that neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favourable neurological outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory VF or pulseless VT.

Stopping vs continuing aspirin before coronary artery surgery. NEJM May 2016.

2016-09-13T21:32:00.001+10:00

This randomised controlled trial is a part of the ATACAS trial (Aspirin and Tranexamic Acid for Coronary Artery Surgery), to help answer whether aspirin should be stopped before coronary artery surgery. Only results regarding aspirin were presented in this paper. 1047 patients were randomly assigned to receive 100mg aspirin 1 to 2 hours before surgery and 1053 to receive placebo. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days of surgery. There was no significant difference in the primary outcome events in aspirin (19.3%) vs placebo group (20.4%) (RR 0.94, 95% CI 0.80-1.12; P=0.55). There was also no difference in major haemorrhage events leading to reoperation (1.8% vs 2.1%, P=0.75) and cardiac tamponade rates (1.1% vs 0.4%, P=0.08) in the 2 groups.

Factors associated with vancomycin nephrotoxicity in the critically ill. Anaesth Intensive Care Sept 2015.

2016-09-13T21:31:00.003+10:00

Vancomycin is commonly used to treat methicillin-resistant Staphylococcus aureus (MRSA). Recently there has been an increase in the prevalence of MRSA with reduced susceptibility to vancomycin. Serum concentrations of <10mg/l is associated with the emergence of vancomycin-resistant Staphylococcus aureus. Current consensus guidelines recommend a target serum vancomycin trough concentration between 15 and 20 mg/l, compared to a historical target of 5 to 10mg/l. Vancomycin related nephrotoxicity is common and has been reported in up to 40% of recipients. This single centre retrospective study of 159 patients who received vancomycin showed that 8.8% manifested new onset AKI. Multivariate logistic regression analysis showed mean trough concentration, APACHE II score and simultaneous aminoglycoside prescription as significant predictors of AKI. These data suggest high trough vancomycin serum concentrations are associated with greater odds of AKI in the critically ill.

Obstetric Anaesthetists’ Association/Difficult Airway Society difficult and failed tracheal intubation guidelines – the way forward for the obstetric airway. BJA Oct 2015.

2016-09-13T21:31:00.001+10:00

Last year a joint working group from Obstetric Anaesthetists’ Association (OAA) and the Difficult Airway Society (DAS) published the first obstetric-specific difficult airway guideline in UK. This editorial discusses the major points in difficult obstetric airway management. I have also included the OAA/DAS guideline for your review.
Summary of important points:

‘Worst case’ is category 1 Caesarean section.
Use airway assessment to predict global airway management difficulty, not just laryngoscopy and intubation problems.
Before induction, make provisional plan should intubation fail – either awaken or proceed with surgery – communicate this with the team.
Head up position and apnoeic oxygenation can prolong safe apnoea time.
Gentle mask ventilation with cricoid pressure after administering induction agents is recommended.
Cricoid pressure should be reduced or released if there is a poor view at laryngoscopy.
Supraglottic airway device or facemask ventilation are valid first options after failed tracheal intubation. A second-generation supraglottic airway device is recommended.
After failed intubation, the immediate situation will determine the decision to awakening or proceed with surgery.
Unless it is safe or essential to proceed, the patient should be awakened.
Safety – strong indications for waking the patient after failed intubation include one or more of: obstructed airway, inadequate capnogram, hypoxaemia secondary to hypoventilation; a relative indication is if the patient has eaten recently.
Essential to proceed – strong indications to proceed are maternal compromise or fetal indications with an identified sentinel event (review current status), difficulty with providing alternatives (regional anaesthesia, awake securement of the airway).
Awakening – during failed intubation at category 1 Caesarean section for fetal indications without an identified sentinel event, there is a high chance that fetal condition will remain the same or even improve.
Proceed with surgery – if there is adequate airway/ventilation, further intubation attempts are discouraged unless a new factor presents that significantly increases the chance of success, or there is an indication for prolonged airway control.
Can’t intubate can’t oxygenate – if this occurs, ensure muscle paralysis before performing front-of-neck access procedure.
After failed intubation at Caesarean section, there is increased risk of neonatal admission to the neonatal intensive care unit; the neonatologist should be informed about the problem.

The changing face of malignant hyperthermia: less fulminant, more insidious. Anaesth Intensive Care Jul 2015.

2016-03-14T16:25:00.002+11:00

Due to modern anaesthetic techniques, the clinical presentation of malignant hyperthermia is becoming increasingly insidious. The 4 case reports in this article highlight such presentations. Fulminant MH is characterised by a combination of rapidly evolving signs of hypermetabolism (hypercapnia, tachycardia, hypertension, hyperthermia), muscular symptoms (masseter spasm, rigidity) and rahdbdomyolysis. As anaeshtetists we should be aware of the more subtle signs of MH which include:

Foremost: persistent, unexplained and difficult-to-correct hypercapnia
Rapidly increasing and/or inappropriately elevated body temperature
Masseter spasm following suxamethonium
Clinical or biochemical evidence of rhabdomyolysis: increased postoperative CK level, voiding of cola-coloured urine (myoglobinuria), with or without hyperkaelamia

Cardiac complications in patients undergoing major noncardiac surgery. NEJM Dec 2015.

2016-03-14T16:24:00.005+11:00

Perioperative deaths are common. If perioperative death were considered as a separate category, it would rank as the third leading cause of death in the US. Major perioperative cardiac complications are important because they account for at least one third of perioperative deaths. This detailed review article discusses the current evidence for preoperative coronary revascularization, noninvasive cardiac testing, preoperative use of aspirin and clonidine, and post operative monitoring of haemodynamics and troponin.

A randomized trial comparing skin antiseptic agents at cesarean delivery. NJEM Feb 2016.

2016-03-14T16:24:00.002+11:00

This single-centre, randomised controlled trial compared the use of chlorhexidine-alcohol and iodine-alochol for preoperative skin antisepsis for prevention of surgical-site infection after cesarean delivery. 572 patients were assigned to chlorhxidine-alcohol and 575 to iodine-alcohol. Surgical-site infection was diagnosed in 23 patients (4%) in the chlorhexidine-alcohol group and 42 (7.3%) in the iodine-alcohol group (RR 0.55, 95% CI 0.34–0.90; p=0.02). These results are consistent with those of prior studies that suggest the superiority of chlorhexidine-based antiseptics over iodine-based antiseptics for the prevention of surgical-site infection. Although these previous studies suggested the superiority of chlorhexidine-based antiseptics, it remained unclear whether the superiority was attributable to the chlorhexidine, the alcohol, or the combination and whether these results would apply to cesarean delivery.

Perioperative thermoregulation and heat balance. The Lancet Jan 2016.

2016-03-14T16:23:00.007+11:00

This is a well-written review article which revisits the topic of thermoregulation under anaesthesia.
Important points to note include:

General anaethetic agents – volatiles, nitrous oxide and propofol – all reduces vasoconstriction and shivering threshold in a concentration-dependent manner, but has minimal effect on sweating threshold
Sedatives such a midazolam even combined with typical opioid doses do not appreciably impair thermoregulatory control
Neuraxial anaesthesia impairs thermoregulatory control such that patients are as hypothermic as those given a GA for similar operations. Effects of neuraxial and general anaesthesia on thermoregulatory control are additive
Peripheral nerve blocks do no have substantive thermoregulatory effects beyond preventing local thermoregulatory responses
Consequences of hypothermia include

coagulopathy – 1°C of hypothermia significantly increases blood loss by about 20%
delays wound healing
increases risk of wound infection
prolongs drug action – vecuronium, atracurium, propofol
prolongs recovery stay and hospital stay

Measures to maintain normothermia

Prewarming – prewarmed patients stay 0.4°C warmer
Most surgical patients will be hypothermic from passive insulation alone, forced air warmer is recommended
Fluid warming should be used if being given to patients in large volume (>1L/h). Each litre of room temperature fluid and each unit of blood reduces mean body temperature by 0.25°C in a 70kg patient

Temperature monitoring is recommended for general anaesthesia case over 30 minutes and substantial neuraxial cases

Best sites to monitor core temperature include the pulmonary artery, distal oesophagus, nasopharynx with the probe inserted 10-20cm and tympanic membrane,

Liberal transfusion strategy improves survival in perioperative but not in critically ill patients. A meta-analysis of randomised trials. BJA Oct 2015.

2016-03-14T16:23:00.004+11:00

This meta-analysis of RCTs investigates the influence of liberal and restrictive blood transfusion strategies on mortality in perioperative (17 trials) and critically ill (10 trials) adult patients. Patients in the perioperative period receiving a liberal transfusion strategy had lower all-cause mortality when compared with a restrictive transfusion strategy. There was no difference in mortality in critically ill patients receiving liberal vs restrictive transfusion strategies. This is the first meta-analysis to focus on the perioperative setting.

Time to shut down the acute care conveyor belt? MJA Dec 2015.

2016-03-14T16:23:00.001+11:00

End of life care has recently been an active issue raised within our department as well as in healthcare across Australia. The author, distinguished anaesthetist/intensivist Ken Hillman, compared the current medicalisation of dying with medicalisaion of birthing in 1950s. End of life care is not being well managed in the hospital setting. Most admitting teams do not have the level of training to carry out a lengthy and complex discussion with patients and their carers, and they are often busy caring for the more conventional aspects of medical care. He suggests a strategy to manage this would be an end-of-life care team similar to the rapid response team, where patients in the at-risk group are identified and a clinician with appropriate skills, knowledge and experience to carry out end of life discussions. This is likely to be a palliative care nurse until more training is provided in the undergraduate and postgraduate levels for nurses and doctors.

Is ketamine ready to be used clinically for the treatment of depression? MJA Dec 2015.

2016-03-14T16:22:00.006+11:00

To date, 8 randomised placebo-controlled trials involving almost 200 participants with depression showed antidepressant effects after a single dose of ketamine of 0.5mg/kg over 40 minutes IV. A major drawback is that the antidepressant effects typically last for only several days after a single treatment. Recently Australian health authorities have curtailed medical practitioners offering a course of ketamine treatments to patients with depression. http://www.abc.net.au/news/2015-05-30/ketamine-offered-to-patients-with-depression-in-take-home-packs/6508232 A new trial is underway to assess the effects of a four week course of ketamine on patients with depression who have not responded to existing medications. http://www.abc.net.au/news/2015-11-09/grant-of-$2m-awarded-for-ketamine-depression-treatment-trial/6923788

Let’s watch this space.

The paternalism preference – choosing unshared decision making. NEJM August 2015.

2016-03-14T16:22:00.003+11:00

This article discusses the medical informed consent process and how much information is adequate to give patients. The last paragraph of the articlesummarises the points well… ”The doctors I admire most are characterized not by how much they know but by a sophisticated intuition about how best to share it. Sometimes they tell their patients what to do; sometimes they give them a choice. Sometimes, when discussing treatment options, they cover all seven tenets of informed consent. Sometimes, instead, seeing the terror of uncertainty in a patient’s face, they make their best recommendation and say, “I don’t know how things are going to turn out, but I promise I’ll be there with you the whole way.””

Teaching and learning in undergraduate anaesthesia: a quantitative and qualitative analysis of practice at the University of Auckland. Anaesthe Intensive Care Nov 2015

2016-03-14T16:22:00.000+11:00

This is a survey article, covering multiple sources, examining anaesthetic teaching of medical students in a New Zealand University. It highlights some of the significant discrepancies between medical student expectations and actual learning experiences in anaesthesia. One of the key findings was the surprisingly limited exposure to IV cannulation, which has subsequently been de-emphasised in the University of Auckland learning objectives for the Anaesthesia rotation. Definitely worth a read.

AE

Neurodevelopmental outcome at 2 years of age after general anaestehsia and awake-regional anaesthesia in infancy (GAS): an international multicenter, randomised controlled trial. Lancet October 2015.

2016-03-14T16:21:00.002+11:00

This is the first randomised controlled trial assessing the effect of general anaestheisa in infancy on neurodevelopmental outcome. This study randomised 363 infants (younger than 60 weeks) to receive awake-regional anaesthesia and 359 to general anaesthesia for inguinal herniorrphaphy. The primary outcome will be WPPSI-III Full Scale Intelligence Quotient score at 5 years (data is yet to be collected). The secondary outcome is reported here a composite cognitive score of Bayley Scales of Infant and Toddler Development III assess at 2 years. There is no difference in the cognitive composite score between the 2 groups at 2 years. The median duration of anaesthsia was 54 minutes. It should be noted that this is an analysis of secondary outcome, and reassessment at 5 years is necessary before definitive conclusions can be drawn.

An overview of the American College of Cardiology / American Heart Association 2014 Valve Heart Disease Practice Guidelines: What is its relevance for the anaesthesiologist and perioperative medicine physician? AA November 2015.

2016-03-14T16:20:00.006+11:00

This is an excellent summary article by 3 of the most influential US cardiac anaesthetists. It covers the 2014 ACC/AHA guidelines on the management of valvular heart disease. The original article is very lengthy, but this summarises the pertinent points for anaesthetic practice in non-cardiac and cardiac surgery.

AE

PS60 Guidelines on the perioperative management of patients with suspected or proven hypersensitivity to chlorhexidine. ANZCA 2015.

2016-03-14T16:20:00.003+11:00

Chlorhexidine is a broad spectrum antiseptic that is extensively used in healthcare environments. It is observed that incidence of anaphylaxis has been increasing in recent years. There is no centralized database in Australia for reporting chlorhexidine allergery. However in Royal North Shore Hospital Anaesthetic Allergy Clinic alone, there are 29 cases of confirmed chlorhexidine anaphylaxis between 2007 to 2015. This is the third most common allergen after neuromuscular blockers and antibiotics

Issues include:

Difficulty in identifying products containing chlorhexidine

Chlorhexidine is increasingly incorporated in antiseptic handrub solutions, gels, pastes, dressings and devices (including central venous catheters and drape).
There is inconsistent labeling of products that contain chlorhexidine

Difficulty avoiding contact with chlorhexidine products once identified

Suggested perioperative management of patients with chlorhexidine allergy include:

development of a chlorhexidine product register throughout each hospital
development of a “chlorhexidine free box” in operating theatres – containing chlorhexidine free laternative for common procedures such as skin antisepsis, lubrication jelly for IDC insertion, chlorhexidine free central venous access device

Intravascular complications of central venous catheterization by insertion site. NJEM September 2015.

2016-03-14T16:20:00.000+11:00

In this multicenter trial, 3471 central venous catheters were assigned to ICU patients to the subclavian, jugular or femoral vein. The primary outcome was a composite of major catheter-related bloodstream infection and symptomatic DVT.

Key points for this article:

Subclavian line is associated with less bacterial bioburden (longer subcutaneous course to the entry of vein); less likelihood of disruption of dressing) - i.e. less colonisation, which is also associated with less catheter related infection and LESS deep vein thrombosis. This is most important when the catheter is going to be used for longer term.
Mechanical complications of pneumothorax was higher in subclavian approach.
Considering infectious, thrombotic and mechanical complications all together – there is little difference between the three approaches. Mechanical complications can be reduced by improved skills and ultrasound use for subclavian approach.

Evaluation of perioperative medication errors and adverse drug events. Anesthesiology November 2015.

2016-03-14T16:19:00.003+11:00

One in 20 perioperative medications given was an error. More than one third of the errors led to observed adverse events, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys.

Specific solutions exist that have the potential to decrease the incidence of perioperative medication errors.

In summary: We give a lot of drugs and could do a better job of making sure we're doing it right.

MD

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. BJA December 2015.

2016-03-14T16:19:00.000+11:00

This is the revised version of the DAS guidelines for management of the unanticipated difficult airway, originally published in 2004.

The majority of the changes have come about from the findings of NAP4. Analysis of the adverse airway events in the UK from 2008-2009 showed that human factors were directly responsible for poor outcomes in 40% of the cases reported, and a contributing factor for all cases. The authors acknowledge that this was occurring despite the DAS guidelines being published and widely available.

One of the factors that they attribute this to is the confusing nature of the original DAS algorithm. They acknowledge that the original guidelines had too many choices or options at each level and this could lead to paralysis of indecision. In view of this the new guidelines are much simpler.

A brief over view of the new algorithm for the unanticipated difficult airway:
During assessment of the patient’s airway consider ease of BMV, LMA insertion, intubation and front of neck access for all patients. Have a plan that will give you the best likelihood of first attempt success for all possible interventions.

Plan A:

BMV and direct laryngoscopy using optimum equipment and positioning, pre-oxygenation etc as dictated by your assessment of the patient.
No more than 3 attempts at direct laryngoscopy (one more allowed if more senior anesthetist available)
No repeat attempts at laryngoscopy without changing something in your approach learned by the experience gained in previous intubation attempts.
If fail to intubate move to Plan B

Plan B:

Plan B is always a supraglotic device
Supraglotic device should be chosen and available prior to induction
2nd generation are preferred
If failed then no more than 3 attempts at insertion, consider changing size or type
If succeed STOP and THINK: Wake patient? Intubate via LMA? Proceed with procedure under LMA? Tracheostomy or cric?
If fail proceed to Plan C

Plan C:

One final attempt at rescuing situation by BMV
Be aware that this is highly unlikely to be successful after multiple airway interventions
Use knowledge of BMV gained during plans A and B to optimize attempt at BMV during Plan C
Prepare for Plan D
If fail proceed to plan D

Plan D:

Surgical airway
Position patient appropriately for surgical airway
Advocate either scalpel bougie or needle cric, operators choice
More emphasis on scalpel bougie due to support from literature including NAP4
STOP and Think – proceed with case or postpone surgery?

Other changes

Cricoid:

Still advocated in 10N/30N form but now advocates removal if difficulty intubating rather than waiting till failed ventilation via LMA to remove as per old guidelines

Choice of muscle relaxant for RSI:Rocuronium or sux supported for RSI
BMV should not be deemed to be impossible unless the patient is fully paralysed

Apneoic oxygenationApnoeic oxygenation using normal NP or HFNP is recommended for the expected difficult intubation

CICO
Regular practice is the best way to prepare for this, ANZCA’s efforts to ensure regular CICO training was acknowledged in the paper

There is a large emphasis on human factors in this publication. Particularly they note the importance in calling for help, ensuring someone maintains situational awareness and the importance of announcing when a particular intervention has failed so that the team is aware that we are proceeding to the next step.

Overall these guidelines are a massive improvement over the 2004 version. They also more accurately reflect current practice and provide a better framework with in which to operate.

I have included an editorial by Professor Keith Greenland that discuss the role of human factors in more detail. Several other editorials and articlesrelated to airway management are also published in this months BJA.

DD