Universal C-MAC® videolaryngoscope use in adult patients: a single-centre experience.

Universal use of Storz C-MAC® videolaryngoscopes was implemented for adult tracheal intubations in the operating theatres, intensive care unit and emergency department at Royal United Hospitals Bath NHS Foundation Trust in 2017. We report data from 1099 intubations from March 2020 to March 2022, collected contemporaneously and anonymously using a smartphone app, representing an estimated 18% of intubations in operating theatres and 30% of intubations in other locations during this period. Intubation success was 100%. The first-pass success rate was 87.3% overall: 87% with a Macintosh videolaryngoscope, 92% with a hyperangulated videolaryngoscope and 81% for users with ≤ 20 previous uses. First-pass success without complications was 87% overall: 87% in operating theatres (836/962), 93% in the emergency department (38/41) and 83% in the intensive care unit (73/88). Complications occurred during 0.6% of intubations: 0/962 in operating theatres and 7/137 in non-theatre locations. The rate of complications was unaltered by blade type (Macintosh 5/994 vs. hyperangulated 2/105, p = 0.14); intubator experience with the device (≤ 20 previous clinical uses 2/260 vs. > 20 previous uses 5/832, p = 0.67) and use of airborne personal protective equipment (PPE 6/683 vs. no-PPE 1/410, p = 0.27). Complication rates increased outside theatres (theatres 0/963 vs. non-theatre 7/136, p < 0.001) and during rapid sequence induction (RSI 6/379 (1.6%) vs. non-RSI 1/720 (0.1%), p = 0.008).

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia.

Human factors in anaesthesia: a narrative review.

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care Society.

The need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.

A trial comparing emergency front of neck airway performance in a novel obese-synthetic neck, meat-modified obese neck and conventional slim manikin.

Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have described previously a pork belly-modified manikin that more realistically simulated an obese patient's neck. In this study, we compared a novel obese-synthetic manikin (obese-synthetic manikin) with a pork belly-modified manikin (obese-meat manikin) and a conventional slim manikin (slim manikin). Thirty-three experienced anaesthetists undertook simulated emergency front of neck airway procedures on each manikin (total 99 procedures). Time to ventilation was longer on both obese manikins compared with the slim manikin (median (IQR [range]) time to intubation 159 (126-243 [73-647]) s in the obese-synthetic, 105 (72-138 [43-279]) s in the obese-meat and 58 (47-74 [30-370]) s in the slim manikin; p < 0.001 between each manikin). Cricothyroidotomy success rate was similar in the both obese manikins but lower when compared with the slim manikin (15/33 obese-synthetic vs. 14/33 obese-meat vs. 27/33 slim manikin). Participant feedback indicated performance difficulty was similar between both obese manikins, which were both more difficult than the slim manikin. The tissues of the obese-meat manikin were judged more realistic than those of either other manikin. Overall, the obese-synthetic manikin performed broadly similarly to the obese-meat manikin and was technically more difficult than the conventional slim manikin. The novel obese-synthetic manikin maybe useful for training and research in front of neck airway procedures.

Videolaryngoscope-assisted flexible intubation tracheal tube exchange in a patient with a difficult airway.

An 88-year-old woman presented with acute airway obstruction caused by a large retrothyroid bleed following anterior neck trauma. Her airway was secured in the operating theatre with an awake nasal flexible optical bronchoscope tracheal intubation using an Intubating Laryngeal Mask Airway tracheal tube. Haemostasis was achieved following surgical ligation and the patient was transferred to the critical care unit. Postoperatively, a large leak around the tracheal tube was noted and a decision was made to change to an orotracheal tube with a subglottic drainage port. Our exchange technique required two experienced operators. The first operator used videolaryngoscopy with a hyperangulated blade to establish an optimal view of the larynx. The second operator placed an airway exchange catheter through the existing nasal tracheal tube to ensure airway control. The trachea was then intubated orally using a flexible optical bronchoscope observed under direct vision using the videolaryngoscope. The technique combined several simple and well-documented approaches, but importantly, the airway remained secure and visible throughout the procedure.