Acquiring skills of airway management: The grandpa–granddaughter model! Rakesh Kumar Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):287-288

Optimal position for laryngoscopy – Time for individualization? Sheila Nainan Myatra Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):289-291

Digital future in perioperative medicine: Are we there yet? Umakanth Panchagnula, Mohan Shanmugam, Biyyam Meghna Rao Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):292-294

Beyond the borders: Lessons from various industries adopted in anesthesiology Subramanyam S Mahankali, Priya Nair Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):295-301 Since the first public demonstration of anaesthesia in Boston, USA which happened around 172 years back, the field of anesthesiology has rapidly progressed, with many developments that have improved the quality and safety of anesthesia care. This has enabled tremendous advances in the surgical disciplines and increasing the life expectancy and quality of life of humans. This is a result of learning and constantly evolving. There are several similarities between healthcare and other industries, though there are several distinguishing characteristics that set it apart from other industries. There are a number of safety and quality improvement measures in healthcare which have been influenced by safety practices in other industries. Anaesthesia has been the leader among the medical specialities in adoption of innovative practices from various industries in an effort to advance patient safety, enhance quality of care, reduce waste & inefficiency, and improve customer service and satisfaction. This article emphasises on learnings from other industries in the recent decades, focusing on aviation, high-reliability organizations, car manufacturing, telecommunication, car racing, entertainment, and retail. Learning and implanting the best practices from these industries can bring about a paradigm shift in health care industry. It has a potential to improve efficiency and make anaesthesia safer than ever before in the history of human kind.

Anesthetic considerations for extracranial injuries in patients with associated brain trauma Ankur Khandelwal, Parmod Kumar Bithal, Girija Prasad Rath Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):302-311 Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

Comparative evaluation of laryngeal view and intubating conditions in two laryngoscopy positions-attained by conventional 7 cm head raise and that attained by horizontal alignment of external auditory meatus - sternal notch line – using an inflatable pillow - A prospective randomised cross-over trial Anant V Pachisia, Kavita R Sharma, Jaspal S Dali, Mona Arya, Neha Pangasa, Rakesh Kumar Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):312-317 Background and Aims: We compared the laryngoscopy position attained by a 7-cm-high pillow (Sniffing position-SP) with that attained by horizontal alignment of external auditory meatus-sternal notch (AM-S) line-using variable height inflatable pillow. Material and Methods: This prospective-randomised-cross-over study included 50 patients in each group. Group-AM-S: A 7 cm uncompressible pillow was used for attaining first laryngoscopy position, followed by horizontal alignment of external auditory meatus-sternal notch (AM-S) line-using an inflatable pillow for attaining second laryngoscopy position followed by intubation. Group-SP: Horizontal alignment of external auditory meatus-sternal notch (AM-S) line-was done using an inflatable pillow for attaining first laryngoscopy position, followed by using 7 cm uncompressible pillow for second laryngoscopy position followed by intubation. The CL-grade, Intubation Difficulty Score (IDS) and time to intubation were compared in both positions. The head raise (in cm) required for attaining AM-S alignment was noted. Results: CL-grade-I was obtained in significantly larger number of patients with AM-S alignment position than with 7 cm head raise (P = 0.004). CL-grade-III was obtained in significantly lesser number of patients with AM-S alignment (P = 0.002). Mean IDS with AM-S alignment (1.18 ± 1.69) was significantly less than with 7cm head raise (2 ± 1.59; P = 0.007) and time to intubation with AM-S alignment (17.33 ± 4.52 s) was significantly less than that with 7cm head raise (18.94 ± 4.64 s; P = 0.041). The mean head rise required to achieve AM-S line alignment was 4.920 ± 1.460 cm. Conclusion: External Auditory Meatus-Sternal notch (AM-S) line alignment provides better laryngeal view, better intubating conditions and requires lesser time to intubate as compared to a conventional 7-cm-head raise. The size of pillow used for head raise should be individualised.

Emergency front of neck airway: What do trainers in the UK teach? A national survey Ilyas Qazi, Cyprian Mendonca, Achuthan Sajayan, Adam Boulton, Imran Ahmad Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):318-323 Background and Aims: Front of neck airway (FONA) is the final step to deliver oxygen in the difficult airway management algorithms. The Difficult Airway Society 2015 guidelines have recommended a standardized scalpel cricothyroidotomy technique for an emergency FONA. There is a wide variability in the FONA techniques with disparate approaches and training. We conducted a national postal survey to evaluate current teaching, availability of equipment, experienced surgical help and prevalent attitudes in the face of a can't intubate, can't oxygenate situation. Material and Methods: The postal survey was addressed to airway leads across National Health Service hospitals in the United Kingdom (UK). In the anesthetic departments with no designated airway leads, the survey was addressed to the respective college tutors. A total of 259 survey questionnaires were posted. Results: We received 209 survey replies with an overall response rate of 81%. Although 75% of respondents preferred scalpel cricothyroidotomy, only 28% of the anesthetic departments considered in-house FONA training as mandatory for all grades of anesthetists. Scalpel-bougie-tube kits were available in 95% of the anesthetic departments, either solely or in combination with other FONA devices. Conclusion: The survey has demonstrated that a majority of the airway trainers in the UK would prefer scalpel cricothyroidotomy as emergency FONA. There is a significant variation and deficiency in the current levels of FONA training. Hence, it is important that emergency FONA training is standardized and imparted at a multidisciplinary level.

Emergency surgical access in complete ventilation failure or CICO: The right time! Rakesh Garg Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):324-325

Advanced airway training in the UK: A national survey of senior anesthetic trainees Adam J Boulton, Sunita R Balla, Aleksandra Nowicka, Thomas M Loka, Cyprian Mendonca Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):326-334 Background and Aims: High-quality training in advanced airway skills is imperative to ensure safe anesthetic care and develop future airway specialists. Modern airway management skills are continually evolving in response to advancing technology and developing research. Therefore, it is of concern that training provisions and trainee competencies remain current and effective. Material and Methods: A survey questionnaire based on the airway competencies described in the Royal College of Anaesthetists' curriculum and Difficult Airway Society guidelines was posted to all United Kingdom (UK) National Health Service hospitals to be completed by the most senior anesthetic trainee (ST 5–7, resident). Results: A total of 149 responses were analyzed from 237 hospitals with eligible anesthetic trainees (response rate 63%), including 53 (36%) and 39 (26%) respondents who had completed higher and advanced level airway training respectively. Although clinical experience with videolaryngoscopy was satisfactory, poor confidence and familiarity was identified with awake fiberoptic intubation, high frequency jet ventilation, at risk extubation techniques, and airway ultrasound assessment. Only 26 (17%) respondents had access to an airway skills room or had regular airway emergency training with multidisciplinary theater team participation. Reported barriers to training included lack of training lists, dedicated teaching time, experienced trainers, and availability of equipment. Conclusions: This national survey identified numerous deficiencies in airway competencies and training amongst senior anesthetic trainees (residents) in the UK. Restructuring of the airway training program and improvements in access to training facilities are essential to ensure effective airway training and the capability to produce future airway specialists.

Efficacy of surface landmark palpation for identification of the cricoid cartilage in obstetric patients: A prospective observational study Fatemah Qasem, Roy Khalaf, Ilana Sebbag, Ronit Lavi, Philip M Jones, Sudhu Indu Singh Journal of Anaesthesiology Clinical Pharmacology 2019 35(3):335-339 Background and Aims: Rapid sequence induction, with the application of cricoid pressure is an accepted practice during induction of general anesthesia in pregnant patients to prevent pulmonary apiration. We found no prior studies assessing the accuracy of locating the cricoid cartilage by professional caregivers, and therefore conducted an observational study to assess the ability of different caregivers – anesthesia consultants, anesthesia residents, respiratory therapists (RTs), and nurses, in the obstetric care unit, to correctly identify the cricoid cartilage of parturients. We hypothesized that anesthesia consultants would be most accurate. Material and Methods: Institutional REB approval was obtained, as was written informed consent from all participants in the study. The subjects were made up of thirty healthy obstetric patients scheduled for elective cesarean delivery. Their cricoid cartilages were assessed by 53 caregivers (assessors). Localization of the cricoid cartilage by assessors was considered accurate if it was within 5 mm of the sonographically identified mark. The difficulty in localization was reported on a VAS scale and the time taken for localization was recorded. Results: Data from 30 subjects and 53 assessors (13 anesthesia consultants, 12 residents, 13 RTs, and 15 nurses) performing a total of 60 evaluations (some assessors evaluated 2 subjects) were analyzed. About 60% of RTs, 53% of anesthesia residents, 40% of anesthesia consultants, and 13% of nurses correctly identified the cricoid cartilage. No differences in caregivers'perception of difficulty were found, but RTs were the quickest at identification (P < 0.001 vs anesthesia consultants; P = 0.002 vs residents; P = 0.071 vs nurses). Conclusion: RTs were the most successful and accurate in identifying the cricoid cartilage of parturients among the different groups of professional caregivers.