Equipment to manage a difficult airway during anaesthesia.

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

Out-of-hours surgery--a snapshot in time.

Anaesthesia in Australia is amongst the safest in the world. This record of safety is under threat from increasing pressures to operate at times of poor human performance, particularly late at night. Our institution has a policy mandating the prioritisation of surgery based on clinical need while minimising the risks associated with after-hours surgery. The policy states that "only Category 1 (urgent, needing immediate surgery) and Category 2 cases which cannot wait until the morning should be done between 2230 and 0800". From 5 March 2007 we performed an eight-week prospective audit of all cases where surgery occurred in this time period. The anaesthetic senior registrar on duty recorded the clinical priority of the case. There were 95 cases commenced between 2230 and 0800 hours during the audit period, of which 28 (30%) were in clear breach of this policy, in some cases delaying urgent surgery. The potential implications of such breaches are significant in the context of worse outcomes for patients undergoing surgery in the after-hours period. When non-urgent cases occupy resources, the capacity of the system to deal with the truly urgent case is significantly impaired. Adequate 'in-hours' resourcing, capacity and appropriate scheduling may be key to maintaining the excellent safety record of anaesthesia. A large study prospectively examining morbidity, error and outcomes of after-hours operating would serve to further elucidate the risk benefit ratio of after-hours operating.