Anaesthesia 2015, 70, 628–635
References 1. Pandit JJ, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089–101. 2. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318–40. 3. Association of Anaesthetists of Great Britain and Ireland. Immediate postanaesthesia recovery 2013. Anaesthesia 2013; 68: 288–97. doi:10.1111/anae.13095
Safe general anaesthesia without secure intravenous access It is standard practice for all patients to have intravenous access secured before general anaesthesia is administered. However, intravenous cannulation can be difficult in certain patients, e.g. those with a history of intravenous drug abuse. Central venous cannulation avoids the discomfort of repeated cannulation attempts, but is not without risk, which may exceed the benefit of venous access for short, low-risk procedures that could be carried out under inhalational anaesthesia only. We suggest that an alternative to pre-induction central venous access might be to ensure the immediate availability of an EZ-IOâ Intraosseous Vascular Access System (Teleflex, Shavano Park, TX, USA) for rapid intraosseous access, as required. Using this device in emergency situations [1, 2], fluids and anaesthetic and resuscitation drugs [1, 2] can be administered as rapidly into the circulation as occurs with 634
Correspondence
intravenous injection [3, 4]. For elective surgery, we advocate good patient selection and pre-operative communication with the patient, with appropriate skin preparation before induction of anaesthesia.
layers. Simply spraying and allowing to dry does not achieve this penetration. Spraying needs to occur with abrasion, which combination is most easily achieved using 2% chlorhexidine in 70% alcohol swabsticks.
A. Dobson C. Tennuci Wythenshawe Hospital, Wythenshawe, UK Email: [email protected]
D. Stanley Russell’s Hall Hospital, Dudley, UK Email: [email protected]
No external funding and no competing interests declared.
References 1. Day MW. Intraosseous devices for intravascular access in adult trauma patients. Critical Care Nurse 2011; 31: 76–89. 2. Anson JA. Vascular access in resuscitation: is there a role for the intraosseous route? Anesthesiology 2014; 120: 1015–31. 3. Day MW. Intraosseous devices for intravascular access in adult trauma patients. Critical Care Nurse 2011; 31: 76–89. 4. Watson R, Ryan DM, Dubick MA, Simmons DJ, Kramer GC. High-pressure delivery of resuscitation fluid through bone marrow. Academic Emergency Medicine 1995; 2: 402. doi:10.1111/anae.13087
Are current skin antisepsis guidelines too superficial? Like Parsons and Saha [1], I too am concerned about the effectiveness of asepsis for ‘rapid sequence spinal’ when using of a spray to apply 0.5% chlorhexidine in 70% alcohol for central neuraxial block [2]. Fifteen percent of epidermal bacteria are found deeper than the first six corneocyte layers of the outermost epidermis [3]. Abrasion of the outer skin layers is therefore required to allow penetration of any antiseptic solution into the deeper epidermal
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Parsons B, Saha S. Skin antisepsis guidelines - time to rethink the ‘rapid sequence spinal’?. Anaesthesia 2015; 70: 366. 2. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ 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. 3. Lange-Asschenfeldt B, Marenbach D, Lang C, et al. Distribution of bacteria in the epidermal layers and hair follicles of human skin. Skin Pharmacology and Physiology 2011; 24: 305–11. doi:10.1111/anae.13094
Tea trolleys and infection control We read O’Farrell et al.’s ‘Snippet’ about ‘tea trolley’ difficult airway training with great interest [1]. Whilst we agree that NAP4 highlighted the importance of maintaining airway skills, we think that there is a significant infection control risk involved in handling or consuming hot food and drink in the anaes-
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
thetic room, in close proximity to clinical equipment, patients and staff [2]. Furthermore, we suggest that moving training equipment between active theatre anaesthetic rooms could act as a vector for the dissemination of infection. We believe that incentivised opportunities are an excellent method for increasing trainee participation, but should occur in a
Anaesthesia 2015, 70, 628–635
suitable venue where the risk to patient and staff is minimal. N. Pradhan M. Davison Stoke Mandeville Hospital, Aylesbury, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corre-
spondence website: www.anaesthesia correspondence.com.
References 1. O’Farrell G, McDonald M, Kelly FE. ‘Tea trolley’ difficult airway training. Anaesthesia 2015; 70: 104. 2. Association of Anaesthetists of Great Britain and Ireland. Infection control in anaesthesia. Anaesthesia 2008; 63: 1027–36. doi:10.1111/anae.13063
Visit the Anaesthesia Correspondence website at http://www.anaesthesiacorrespondence.com and comment on any article or letter in this issue of the Journal.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
635
References 1. Pandit JJ, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089–101. 2. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318–40. 3. Association of Anaesthetists of Great Britain and Ireland. Immediate postanaesthesia recovery 2013. Anaesthesia 2013; 68: 288–97. doi:10.1111/anae.13095
Safe general anaesthesia without secure intravenous access It is standard practice for all patients to have intravenous access secured before general anaesthesia is administered. However, intravenous cannulation can be difficult in certain patients, e.g. those with a history of intravenous drug abuse. Central venous cannulation avoids the discomfort of repeated cannulation attempts, but is not without risk, which may exceed the benefit of venous access for short, low-risk procedures that could be carried out under inhalational anaesthesia only. We suggest that an alternative to pre-induction central venous access might be to ensure the immediate availability of an EZ-IOâ Intraosseous Vascular Access System (Teleflex, Shavano Park, TX, USA) for rapid intraosseous access, as required. Using this device in emergency situations [1, 2], fluids and anaesthetic and resuscitation drugs [1, 2] can be administered as rapidly into the circulation as occurs with 634
Correspondence
intravenous injection [3, 4]. For elective surgery, we advocate good patient selection and pre-operative communication with the patient, with appropriate skin preparation before induction of anaesthesia.
layers. Simply spraying and allowing to dry does not achieve this penetration. Spraying needs to occur with abrasion, which combination is most easily achieved using 2% chlorhexidine in 70% alcohol swabsticks.
A. Dobson C. Tennuci Wythenshawe Hospital, Wythenshawe, UK Email: [email protected]
D. Stanley Russell’s Hall Hospital, Dudley, UK Email: [email protected]
No external funding and no competing interests declared.
References 1. Day MW. Intraosseous devices for intravascular access in adult trauma patients. Critical Care Nurse 2011; 31: 76–89. 2. Anson JA. Vascular access in resuscitation: is there a role for the intraosseous route? Anesthesiology 2014; 120: 1015–31. 3. Day MW. Intraosseous devices for intravascular access in adult trauma patients. Critical Care Nurse 2011; 31: 76–89. 4. Watson R, Ryan DM, Dubick MA, Simmons DJ, Kramer GC. High-pressure delivery of resuscitation fluid through bone marrow. Academic Emergency Medicine 1995; 2: 402. doi:10.1111/anae.13087
Are current skin antisepsis guidelines too superficial? Like Parsons and Saha [1], I too am concerned about the effectiveness of asepsis for ‘rapid sequence spinal’ when using of a spray to apply 0.5% chlorhexidine in 70% alcohol for central neuraxial block [2]. Fifteen percent of epidermal bacteria are found deeper than the first six corneocyte layers of the outermost epidermis [3]. Abrasion of the outer skin layers is therefore required to allow penetration of any antiseptic solution into the deeper epidermal
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Parsons B, Saha S. Skin antisepsis guidelines - time to rethink the ‘rapid sequence spinal’?. Anaesthesia 2015; 70: 366. 2. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ 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. 3. Lange-Asschenfeldt B, Marenbach D, Lang C, et al. Distribution of bacteria in the epidermal layers and hair follicles of human skin. Skin Pharmacology and Physiology 2011; 24: 305–11. doi:10.1111/anae.13094
Tea trolleys and infection control We read O’Farrell et al.’s ‘Snippet’ about ‘tea trolley’ difficult airway training with great interest [1]. Whilst we agree that NAP4 highlighted the importance of maintaining airway skills, we think that there is a significant infection control risk involved in handling or consuming hot food and drink in the anaes-
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
thetic room, in close proximity to clinical equipment, patients and staff [2]. Furthermore, we suggest that moving training equipment between active theatre anaesthetic rooms could act as a vector for the dissemination of infection. We believe that incentivised opportunities are an excellent method for increasing trainee participation, but should occur in a
Anaesthesia 2015, 70, 628–635
suitable venue where the risk to patient and staff is minimal. N. Pradhan M. Davison Stoke Mandeville Hospital, Aylesbury, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corre-
spondence website: www.anaesthesia correspondence.com.
References 1. O’Farrell G, McDonald M, Kelly FE. ‘Tea trolley’ difficult airway training. Anaesthesia 2015; 70: 104. 2. Association of Anaesthetists of Great Britain and Ireland. Infection control in anaesthesia. Anaesthesia 2008; 63: 1027–36. doi:10.1111/anae.13063
Visit the Anaesthesia Correspondence website at http://www.anaesthesiacorrespondence.com and comment on any article or letter in this issue of the Journal.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
635
