Airway management guidance for the endemic phase of COVID-19.

It is now apparent that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) will remain endemic for some time. Improved therapeutics and a vaccine may shorten this period, but both are far from certain. Plans must be put in place on the assumption that the virus and its disease will continue to affect the care of patients and the safety of staff. This will impact particularly on airway management due to the inherent risk to staff during such procedures. Research is needed to clarify the nature and risk of respiratory aerosol-generating procedures. Improved knowledge of the dynamics of SARS-CoV-2 infection and immunity is also required. In the meantime, we describe the current status of airway management during the endemic phase of the COVID-19 pandemic. Some controversies remain unresolved, but the safety of patients and staff remains paramount. Current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management. Theatre efficiency and training issues are a challenge that must be addressed, and new information may enable this.

Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland.

Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions about the utility of surgery and/or resuscitation. The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.

Immediate post-anaesthesia recovery 2013: Association of Anaesthetists of Great Britain and Ireland.

1. After general, epidural or spinal anaesthesia, all patients should be recovered in a specially designated area (henceforth 'post-anaesthesia care unit', PACU) that complies with the standards and recommendations described in this document. 2. The anaesthetist must formally hand over the care of a patient to an appropriately trained and registered PACU practitioner. 3. Agreed, written criteria for discharge of patients from the PACU to the ward should be in place in all units. 4. An effective emergency call system must be in place in every PACU and tested regularly. 5. No fewer than two staff (of whom at least one must be a registered practitioner) should be present when there is a patient in a PACU who does not fulfil the criteria for discharge to the ward. 6. All registered practitioners should be appropriately trained in accordance with the standards and competencies detailed in the UK National Core Competencies for Post Anaesthesia Care. 7. All patients must be observed on a one-to-one basis by an anaesthetist or registered PACU practitioner until they have regained control of their airway, have stable cardiovascular and respiratory systems and are awake and able to communicate. 8. All patients with tracheal tubes in place in a PACU should be monitored with continuous capnography. The removal of tracheal tubes is the responsibility of the anaesthetist. 9. There should be a specially designated area for the recovery of children that is appropriately equipped and staffed. 10. All standards and recommendations described in this document should be applied to all areas in which patients recover after anaesthesia, to include those anaesthetics given for obstetric, cardiology, imaging and dental procedures, and in psychiatric units and community hospitals. Only registered PACU practitioners who are familiar with these areas should be allocated to recover patients in them as and when required. 11. Patients' dignity and privacy should be respected at all times but patients' safety must always be the primary concern. When critically ill patients are managed in a PACU because of bed shortages, the primary responsibility for the patient lies with the hospital's critical care team. The standard of nursing and medical care should be equal to that in the hospital's critical care units. Audit and critical incident reporting systems should be in place in all PACUs.

Fifteen years of ultrasound guidance in regional anaesthesia: part 1.

Ultrasound guidance for regional anaesthesia has gained enormous popularity in the past decade. The use of ultrasound guidance for many regional anaesthetic techniques is common in daily clinical practice, and the number of practitioners using it is increasing. However, alongside the enthusiasm, there should be a degree of informed scepticism. The widespread use of the various techniques of ultrasound-guided regional blocks without adequate training raises the danger of malpractice and subsequent impaired outcome. Adequate education in the use of regional block techniques under ultrasound guidance is essential. This review article addresses ultrasound guidance for regional anaesthesia, and is divided into two parts because of the size of the topic and the number of issues covered. This first part includes a review and preview of ultrasound guidance in regional anaesthesia and discusses all aspects of ultrasound for regional anaesthesia with a focus on recent technical developments, the positive implications in economics, further potential advantages (e.g. detection of anatomical variants, painless performance of blocks) and education. It also attempts to define a 'gold standard' in regional anaesthesia with the most recent findings in adequate volumes of local anaesthetics for peripheral nerve blocks. This standard should include an extraneural needle position, a high success rate, and wide application of ultrasound guidance in regional anaesthesia. The second part describes the impact of ultrasound on the development of nerve block techniques in the past 5 yr.

Fifteen years of ultrasound guidance in regional anaesthesia: Part 2-recent developments in block techniques.

The use of ultrasound guidance for regional anaesthesia has gained enormous popularity in the last 10 yr. The first part of this review article provided information on safety, technical developments, economic aspects, education, advantages, needle guidance techniques, and future developments in ultrasound. The second part focuses on practical and technical details of individual ultrasound-guided nerve blocks in adults. We present a comprehensive review of the relevant literature of the last 5 yr with a commentary based on our own clinical experience in order to provide information relevant to patient management. Upper limb blocks, including interscalene, supra- and infraclavicular, and axillary approaches, are described and discussed. For the lower limb, psoas compartment, femoral, obturator, sciatic, and lateral cutaneous nerve blocks are described, as are some abdominal wall blocks. The potential role of ultrasound guidance for neuraxial block is addressed. The need for further large-scale studies of the role of ultrasound is emphasized.

Upper limb blocks.

This article discusses recent innovations and changes in practice in upper limb regional anaesthesia, dividing the blocks into those performed above the clavicle, those performed in the area of the clavicle and those performed below it. It offers a critical appraisal of the current status with regard to the use of ultrasound nerve location for upper limb regional anaesthesia and, while accepting that the use of ultrasound in this way has many theoretical advantages and will therefore continue to grow, concludes that there is currently insufficient published evidence to determine conclusively that the use of this technique is associated with nerve blocks that are more successful or safer.

Achieving good-quality consent: review of literature, case law and guidance.

BACKGROUND: Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self-determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent-based discussions with competent patients undergoing elective procedures. METHODS: Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer-reviewed literature and case law, was considered in the formulation of this review. RESULTS: A framework for obtaining consent is presented that is informed by the key tenets of shared decision-making (SDM), a model that advocates the contribution of both the clinician and patient to the decision-making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process. CONCLUSION: This SDM-centric framework provides structure, detail and suggestions for achieving meaningful consent.

ANTECEDENTES: El consentimiento informado es una parte integral de la práctica clínica. Existe un acuerdo generalizado entre los profesionales de la salud en que lograr el consentimiento del procedimiento no debe ser una transferencia unidireccional de información, sino un proceso de apoyo a los pacientes en la toma de decisiones informadas y autodeterminadas. Esta revisión tiene como objetivo identificar procesos y medidas que deban ser considerados al hablar sobre el consentimiento con pacientes autosuficientes sometidos a procedimientos quirúrgicos electivos. MÉTODOS: Al planear esta revisión se tuvo en cuenta la recomendación formal por escrito del Consejo Médico General y del Royal College of Surgeons of England, además de la literatura revisada por pares y de la jurisprudencia. RESULTADOS: Se presenta un marco para lograr el consentimiento que se basa en los principios clave de la toma de decisiones compartida (Shared Decision-Making, SDM); un modelo que aboga por la contribución, tanto del médico como del paciente, al proceso de toma de decisiones a través del énfasis en la participación del paciente, el análisis de la evidencia empírica y el intercambio efectivo de información. Además, se destacan áreas de contención en las que se necesitan más recomendaciones y más investigación para mejorar aún más el proceso del consentimiento. CONCLUSIÓN: Este marco centrado en la SDM proporciona estructura, detalles y sugerencias sobre cómo se puede lograr un consentimiento informado satisfactorio.

Guidelines and the adoption of 'lipid rescue' therapy for local anaesthetic toxicity.

Gathering evidence from animal experiments, an editorial in this journal and published human case reports culminated in the Association of Anaesthetists of Great Britain and Ireland recommending in August 2007 that lipid emulsion be immediately available to all patients given potentially cardiotoxic doses of local anaesthetic drugs. This development offered an opportunity to track the adoption of an innovation by anaesthetists in the UK and to gauge the effects of guidelines. Two surveys, each of 66 NHS hospitals delivering acute care within London and its penumbra, examined the adoption of lipid emulsion therapy. After the publication of the editorial in autumn 2006, the spread of 'lipid rescue' was rapid. The timing of the adoption and the impetus for innovation varied substantially between the sampled hospitals. When the formal guidelines were published, approximately half of the hospitals surveyed did not have lipid rescue. Of those that subsequently adopted it, half attributed their decision to the guidelines. At the end of 2007, there remained a small number of hospitals that had yet to adopt lipid rescue. Lipid rescue's adoption by anaesthetists in the UK offers a rare example of swift uptake of an innovation. National guidelines accelerated the adoption of innovation by some hospitals.

Interscalene brachial plexus block: assessment of the needle angle needed to enter the spinal canal.

Attempts were made to place 8-cm 22G needles into the spinal canals of four preserved cadavers using the skin entry point most commonly associated with the lateral interscalene brachial plexus block or Winnie approach (that is, at the level of the cricoid cartilage). Eleven successful attempts were confirmed by computed tomography. Needle angles that were cephalad, transverse or slightly caudad were associated with entry into the spinal canal at depths of 5.0 cm or less from the skin. The only needle entry into the spinal canal with a needle angle of > 50 degrees to the transverse plane (< 40 degrees to the sagittal plane) entered the intervertebral foramen at a depth of 7.7 cm from the skin. We conclude that the use of markedly caudad angulations of needles no longer than 5.0 cm may minimise the chances of spinal canal entry and spinal cord damage.