Anaesthesia 2015, 70, 502–510
2.
3.
4. 5. 6.
7.
8.
9.
tists’ Association, Regional Anaesthesia UK and Association of Paediatric Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279–86. Maddock A, Ball DR, Jefferson P. Aseptic precautions for caudal anaesthesia. Anaesthesia 2015; 70: 233–4. West SJ, Pawa A. Continuing to use 2% chlorhexidine applicators. Anaesthesia 2015; 70: 234–5. Plaat F, Campbell J. A reply. Anaesthesia 2015; 70: 235–6. Bogod D. The truth, the whole truth? Anaesthesia News 2010; 271: 7–8. Killeen T, Kamat A, Walsh D, Parker A, Aliashkevich . Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. Adams D, Quayum M, Worthington T, Lambert P, Elliott T. Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant. Journal of Hospital Infection 2005; 61: 287–90. Crowley L, Preston R, Wong A, et al. What is the best skin disinfectant solution for labour epidural analgesia? A randomized, prospective trial comparing Chloroprep, Duraprep and chlorhexidine 0.5% in 70% alcohol. Anesthesia and Analgesia 2008; 106: AA221. The 3rd National Audit Project of the RCoA. Major complications of central neuraxial block in the United Kingdom. London: Royal College of Anaesthetists, 2009. doi:10.1111/anae.13046
Cricoid cartilage compression devices We were interested to read the recent article by Taylor et al. describing their cricoid compression device [1] because it validated the results of our description of a visually interactive guidance device for applying cricoid presure, published in 2013 [2]. Whereas Taylor et al. used the mechanical deformation of their device as a gauge of applied force, ours was a simple electronic 504
Correspondence
device with a thin-film force sensor that allows the anaesthetist to feel and apply force more directly to the patient’s cricoid cartilage than is possible with Taylor et al.’s device, which necessarily separates the anaesthetist’s fingers from the patient’s neck by some distance. Further, our device indicates the correct amount of applied force by illuminating a green light, while too much or too little pressure results in different warning colours. Were cricoid pressure to be applied by a trainee or nurse in clinical practice, Taylor et al.’s device provides little external feedback to the anaesthetist that the procedure is being correctly performed. The independent development of these devices implies a clinical need and suggests that a commercial cricoid pressure guidance device could be a viable medical product. We empathise with the lack of commercial manufacturing interest in Taylor et al.’s design; we were similarly unsuccessful in that regard. However, we have since turned our experimental efforts towards using disposable thin-film force sensors as a means of monitoring for the onset of tissue ischaemia and decubitus ulcers in prolonged surgery, intensive care units and long-term care. R. Saffary E. Feliz C. W. Connor Boston Medical Center, Boston, MA, USA Email: [email protected] Patent applied for by Anaesthesia Associates of Massachusetts. No
external funding or authors’ competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Taylor RJ, Smurthwaite G, Mehmood I, Kitchen GB, Baker RD. A cricoid cartilage compression device for the accurate and reproducible application of cricoid pressure. Anaesthesia 2015; 70: 18–25. 2. Connor CW, Saffary R, Feliz E. Performance of the Sellick maneuver significantly improves when residents and trained nurses use a visually interactive guidance device in simulation. Physiological Measurement 2013; 34: 1645–56. doi:10.1111/anae.13056
Regional service evaluation of echocardiography trainers Sharma et al. are to be congratulated for their comprehensive overview of the current state of training in echocardiography in anaesthesia and intensive care [1]. With the potential for ‘focused intensive care echocardiography’ (FICE) accreditation to become incorporated as a compulsory module into the Faculty of Intensive Care Medicine syllabus, our group (South Yorkshire Hospitals Audit and Research Collaborative – SHARC) had concerns that this would be unachievable in South Yorkshire owing to a lack of suitable mentors. We therefore conducted a service evaluation of echocardiography training and practice in consultants working on intensive care units across all five trusts in the South Yorkshire region. Data were collected using ‘bring your own device technology’
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
pioneered in a previous study by SHARC [2]. A commercially available application on trainees’ smartphones was used both to collect and to transmit data securely to an encrypted central database. Over a three-month period from November 2013, 65/69 (94%) consultants participated (44 general intensivists, 11 cardiothoracic intensivists and 10 neurointensivists). Forty-three (66%) had attended a basic echocardiography workshop, but only 16 (25%) had started formally logging scans they had performed. Only two consultants (both cardiac anaesthetists and FICE-registered supervisors) were certified in basic transthoracic echo. Six (9%) consultants (all cardiac anaesthetists) had full British Society of Echocardiography accreditation or equivalent. In total, only six (9%) of the consultants surveyed (all cardiac anaesthetists) had any level of echocardiography qualification. Thirty-eight (58%) used echocardiography unsupervised in their practice, and made clinical decisions based on information obtained from the scans, 23 of these (35%) doing so on a weekly basis. Of the 43 consultants who had attended a basic echocardiography workshop, the most common barriers to training included the time to perform studies (21, 49%), access to a suitable echocrdiography machine (16, 37%) and access to a suitable supervisor/mentor (12, 28%). Our results have several implications. Firstly, there is a potential patient safety issue with the regular and widespread use of echocardiography by consultant intensivists lack-
Anaesthesia 2015, 70, 502–510
ing formal qualifications in the tool. Though some consultants may be experienced practitioners, if a patient was to come to harm from misinterpretation of a scan – for example thrombolysis for incorrectly diagnosed pulmonary embolus – the medicolegal position of an unqualified practitioner is uncertain. Secondly, there are likely to be significant shortfalls in personnel able to act as mentors and supervisors should basic echocardiography qualifications become mandatory for trainee intensivists. Finally, consultants are struggling to complete the logbook of 50 scans for basic echocardiography qualifications, despite the high proportion attending practical workshops. The process of accreditation may need to be redesigned. J. Rosser K. Bauchmuller M. Faulds D. Miller A. Parnell Northern General Hospital, Sheffield, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Sharma V, Fletcher N. A review of echocardiography in anaesthetic and perioperative practice. Part 2: training and accreditation. Anaesthesia 2014; 69: 919–27. 2. Bauchmuller K, Faulds M, Rosser J, Miller D, Mills GH, Wrench I. Communication within operating theatres – a multicentre service evaluation. British Journal of Anaesthesia 2014; 112: 181.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
doi:10.1111/anae.13047
Clarifying the indications for difficult airway alert forms We read with interest the letter by Cassells and Ball concerning the importance of communicating information about difficult airways, particularly in avoiding future risk for patients and legal liability [1, 2]. Several publications have previously contained examples of airway alert notifications [3, 4], but non-standardised notification practices are still common [5] and no formalised approach to notification has been published so far. Currently, the definition of a difficult airway event varies widely among different anaesthesia providers. It may include factors such as difficult or impossible mask ventilation, difficulty or inability to see the larynx directly and secure the airway, or even just a non-rational, personal feeling of a potential airway difficulty. Triggers for when to communicate and document a difficult airway event, therefore, depend on both whether any defined criteria are encountered and any subsequent action by the particular anaesthetist involved. When a patient with a difficult airway presents for future surgery, however, airway assessment is the poorer for not having access to contemporaneous reports of previous difficulties. Indiscriminate or ‘blanket’ use of airway alert forms can also be problematic, decreasing the ability of future anaesthetists to detect potential problems with previously difficult airways. To improve the quality of notification at our hospital, we have developed empirical criteria about when 505
2.
3.
4. 5. 6.
7.
8.
9.
tists’ Association, Regional Anaesthesia UK and Association of Paediatric Anaesthetists of Great Britain and Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014; 69: 1279–86. Maddock A, Ball DR, Jefferson P. Aseptic precautions for caudal anaesthesia. Anaesthesia 2015; 70: 233–4. West SJ, Pawa A. Continuing to use 2% chlorhexidine applicators. Anaesthesia 2015; 70: 234–5. Plaat F, Campbell J. A reply. Anaesthesia 2015; 70: 235–6. Bogod D. The truth, the whole truth? Anaesthesia News 2010; 271: 7–8. Killeen T, Kamat A, Walsh D, Parker A, Aliashkevich . Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia 2012; 67: 1386–94. Adams D, Quayum M, Worthington T, Lambert P, Elliott T. Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant. Journal of Hospital Infection 2005; 61: 287–90. Crowley L, Preston R, Wong A, et al. What is the best skin disinfectant solution for labour epidural analgesia? A randomized, prospective trial comparing Chloroprep, Duraprep and chlorhexidine 0.5% in 70% alcohol. Anesthesia and Analgesia 2008; 106: AA221. The 3rd National Audit Project of the RCoA. Major complications of central neuraxial block in the United Kingdom. London: Royal College of Anaesthetists, 2009. doi:10.1111/anae.13046
Cricoid cartilage compression devices We were interested to read the recent article by Taylor et al. describing their cricoid compression device [1] because it validated the results of our description of a visually interactive guidance device for applying cricoid presure, published in 2013 [2]. Whereas Taylor et al. used the mechanical deformation of their device as a gauge of applied force, ours was a simple electronic 504
Correspondence
device with a thin-film force sensor that allows the anaesthetist to feel and apply force more directly to the patient’s cricoid cartilage than is possible with Taylor et al.’s device, which necessarily separates the anaesthetist’s fingers from the patient’s neck by some distance. Further, our device indicates the correct amount of applied force by illuminating a green light, while too much or too little pressure results in different warning colours. Were cricoid pressure to be applied by a trainee or nurse in clinical practice, Taylor et al.’s device provides little external feedback to the anaesthetist that the procedure is being correctly performed. The independent development of these devices implies a clinical need and suggests that a commercial cricoid pressure guidance device could be a viable medical product. We empathise with the lack of commercial manufacturing interest in Taylor et al.’s design; we were similarly unsuccessful in that regard. However, we have since turned our experimental efforts towards using disposable thin-film force sensors as a means of monitoring for the onset of tissue ischaemia and decubitus ulcers in prolonged surgery, intensive care units and long-term care. R. Saffary E. Feliz C. W. Connor Boston Medical Center, Boston, MA, USA Email: [email protected] Patent applied for by Anaesthesia Associates of Massachusetts. No
external funding or authors’ competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Taylor RJ, Smurthwaite G, Mehmood I, Kitchen GB, Baker RD. A cricoid cartilage compression device for the accurate and reproducible application of cricoid pressure. Anaesthesia 2015; 70: 18–25. 2. Connor CW, Saffary R, Feliz E. Performance of the Sellick maneuver significantly improves when residents and trained nurses use a visually interactive guidance device in simulation. Physiological Measurement 2013; 34: 1645–56. doi:10.1111/anae.13056
Regional service evaluation of echocardiography trainers Sharma et al. are to be congratulated for their comprehensive overview of the current state of training in echocardiography in anaesthesia and intensive care [1]. With the potential for ‘focused intensive care echocardiography’ (FICE) accreditation to become incorporated as a compulsory module into the Faculty of Intensive Care Medicine syllabus, our group (South Yorkshire Hospitals Audit and Research Collaborative – SHARC) had concerns that this would be unachievable in South Yorkshire owing to a lack of suitable mentors. We therefore conducted a service evaluation of echocardiography training and practice in consultants working on intensive care units across all five trusts in the South Yorkshire region. Data were collected using ‘bring your own device technology’
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
pioneered in a previous study by SHARC [2]. A commercially available application on trainees’ smartphones was used both to collect and to transmit data securely to an encrypted central database. Over a three-month period from November 2013, 65/69 (94%) consultants participated (44 general intensivists, 11 cardiothoracic intensivists and 10 neurointensivists). Forty-three (66%) had attended a basic echocardiography workshop, but only 16 (25%) had started formally logging scans they had performed. Only two consultants (both cardiac anaesthetists and FICE-registered supervisors) were certified in basic transthoracic echo. Six (9%) consultants (all cardiac anaesthetists) had full British Society of Echocardiography accreditation or equivalent. In total, only six (9%) of the consultants surveyed (all cardiac anaesthetists) had any level of echocardiography qualification. Thirty-eight (58%) used echocardiography unsupervised in their practice, and made clinical decisions based on information obtained from the scans, 23 of these (35%) doing so on a weekly basis. Of the 43 consultants who had attended a basic echocardiography workshop, the most common barriers to training included the time to perform studies (21, 49%), access to a suitable echocrdiography machine (16, 37%) and access to a suitable supervisor/mentor (12, 28%). Our results have several implications. Firstly, there is a potential patient safety issue with the regular and widespread use of echocardiography by consultant intensivists lack-
Anaesthesia 2015, 70, 502–510
ing formal qualifications in the tool. Though some consultants may be experienced practitioners, if a patient was to come to harm from misinterpretation of a scan – for example thrombolysis for incorrectly diagnosed pulmonary embolus – the medicolegal position of an unqualified practitioner is uncertain. Secondly, there are likely to be significant shortfalls in personnel able to act as mentors and supervisors should basic echocardiography qualifications become mandatory for trainee intensivists. Finally, consultants are struggling to complete the logbook of 50 scans for basic echocardiography qualifications, despite the high proportion attending practical workshops. The process of accreditation may need to be redesigned. J. Rosser K. Bauchmuller M. Faulds D. Miller A. Parnell Northern General Hospital, Sheffield, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Sharma V, Fletcher N. A review of echocardiography in anaesthetic and perioperative practice. Part 2: training and accreditation. Anaesthesia 2014; 69: 919–27. 2. Bauchmuller K, Faulds M, Rosser J, Miller D, Mills GH, Wrench I. Communication within operating theatres – a multicentre service evaluation. British Journal of Anaesthesia 2014; 112: 181.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
doi:10.1111/anae.13047
Clarifying the indications for difficult airway alert forms We read with interest the letter by Cassells and Ball concerning the importance of communicating information about difficult airways, particularly in avoiding future risk for patients and legal liability [1, 2]. Several publications have previously contained examples of airway alert notifications [3, 4], but non-standardised notification practices are still common [5] and no formalised approach to notification has been published so far. Currently, the definition of a difficult airway event varies widely among different anaesthesia providers. It may include factors such as difficult or impossible mask ventilation, difficulty or inability to see the larynx directly and secure the airway, or even just a non-rational, personal feeling of a potential airway difficulty. Triggers for when to communicate and document a difficult airway event, therefore, depend on both whether any defined criteria are encountered and any subsequent action by the particular anaesthetist involved. When a patient with a difficult airway presents for future surgery, however, airway assessment is the poorer for not having access to contemporaneous reports of previous difficulties. Indiscriminate or ‘blanket’ use of airway alert forms can also be problematic, decreasing the ability of future anaesthetists to detect potential problems with previously difficult airways. To improve the quality of notification at our hospital, we have developed empirical criteria about when 505
