A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex.

A 'can't intubate, can't oxygenate' airway crisis is a rare event which most anaesthetists will never experience during their career(1,2). This report highlights the outcome of time-critical decisions in a potential airway catastrophe. Rocuronium was used as an alternative muscle relaxant for rapid sequence induction. The use of sugammadex in 'can't intubate, can't oxygenate' crises is discussed and highlights how, despite adequate reversal of neuromuscular blockade, the 'can't intubate, can't oxygenate' situation failed to resolve. An asymptomatic vallecular cyst was the causal factor in this scenario. Anaesthetic issues surrounding this pathology are discussed.

Difficult double-lumen tube placement due to laryngeal web.

We present a case of difficult intubation in a patient with a laryngeal web. A 33-year-old male patient presented for open thoracotomy and had a previously undiagnosed laryngeal web, which complicated the placement of a double-lumen tube. A single-lumen tube was placed with the use of a bougie through the narrowed airway. With the subsequent use of an airway exchange catheter a double-lumen tube was positioned. Techniques for managing narrowing of the supraglottic airway are presented and the literature dealing with laryngeal webs is reviewed. In the setting of an unusual airway and thoracic surgery, ventilation via simpler techniques takes precedence over insertion of more complex tubes.

Survey of airway skills of surgeons in Western Australia.

Our objective was to survey all consultant surgeons, including obstetricians/gynaecologists, in the State of Western Australia to assess their experience with, and readiness to assist anaesthetists with a difficult or failed airway. Survey questionnaires were mailed to all surgeons registered in Western Australia (n = 445). A total of 238 responses (53%) were received, mostly from general surgeons, obstetrician/gynaecologists and orthopaedic surgeons. Forty percent had provided non-surgical assistance with a difficult airway and 60% had assisted with a surgical airway. All ear nose and throat surgeons who responded to the survey had assisted with an emergency surgical airway and 47 surgeons reported having performed six or more surgical airways. However 26% of respondents had never performed a surgical airway and 37% did not feel confident in performing an urgent surgical airway Seven percent of respondents reported witnessing a failed airway that resulted in death or neurological damage. Seventy percent of respondents had undergone formal training in tracheostomy and 26% had advanced trauma life support or early management of severe trauma training. These findings indicate that surgeons in Western Australia perform surgical airways infrequently and only occasionally assist anaesthetists with difficult airway management. However, some surgeons lack confidence and training in surgical airway management. Because anaesthetists cannot always rely on their surgical colleagues to provide a surgical airway during a crisis, we recommend that anaesthetists discuss airway management with their surgical colleagues for all patients with identified difficult airways and that anaesthesia training should include surgical airway management.

A survey of anaesthetists' perspectives of communication in the operating suite.

We surveyed 222 anaesthetists attending a University of Western Australia conference (n = 110) and two public hospitals in Perth (n = 112) by anonymous questionnaire in March 2006 regarding communication issues in the operating suite. Forty-one percent (n = 92) responded. Questions concerned communication skills, experiences of good and poor communication and relationship to outcome, attitudes to music and communication courses. Stress in anaesthetists due to poor communication, staff naming practices, information on courses with communication content attended and attitudes to non-verbal communication were also surveyed. Anaesthetists' communication skills were self-rated as "very good" by 52% and "average" by 39% of respondents. It was strongly agreed that good verbal communication leads to better patient outcome (57%) and was important between surgeons and anaesthetists (76%). Regarding the current state of surgeon/anaesthetist communication, 25% (23/92) agreed this was acceptable, 33% (30/92) were undecided and 42% (39/92) regarded this as poor. Silence in theatre was generally not desired, 71% preferring background music. Ninety-nine percent of respondents believed good communication decreased stress and 89% felt personally stressed in situations where poor communication occurred. Email/text communication was not preferred to spoken language regarding case information. Sixty-four percent of respondents would attend a communications course voluntarily, with implementation of a compulsory communications course supported by 45%. Most anaesthetists surveyed used staff first names and 94% believed poor communication caused procedural delay. The data suggest that further work is required to improve communication in the stressful operating room environment, particularly at the surgeon/anaesthetist interface.

Prevalence of obesity in surgical patients: a comparative survey in the United States and Australia.

STUDY OBJECTIVE: To determine and compare the prevalence of obesity in adult patients undergoing surgery in an Australian and a United States teaching hospital. DESIGN: Retrospective and prospective surveys. SETTING: Operating theatres at two university hospitals. INTERVENTIONS: Patients scheduled for surgery during two consecutive months at Royal Perth Hospital (RPH) in Perth, Western Australia, and Montefiore-University Hospital (MUH) in Pittsburgh, Pennsylvania, were studied. Age, sex, American Society of Anesthesiologists class, height, and weight data were collected from anaesthesia records. Body mass index (BMI) was calculated according to the formula: BMI = weight/height2 (kg m-2). Obesity was defined as BMI > or = 30, morbid obesity as BMI > or = 35, and overweight as BMI = 25-30. RESULTS: Data from 1604 patients were analysed. Patients ranged in age from 15 to 93 years (mean +/- SD = 52.4 +/- 20). The RPH group was slightly older (RPH = 54 +/- 20 years; MUH = 50 +/- 19 years). Men from MUH were significantly taller (MUH = 176 +/- 8 cm; RPH = 174 +/- 9 cm) and MUH women were also significantly taller (MUH = 162 +/- 8 cm; RPH = 160 +/- 8 cm) than Australian patients. Mean weight was significantly different between hospitals (RPH = 73.5 +/- 16 kg; MUH = 77.9 +/- 20 kg). Mean BMI was also significantly different between hospitals (RPH = 25.8 +/- 5; MUH = 27.3 +/- 7). The proportion of obese men (RPH = 15.7%; MUH = 21.0%), obese women (RPH = 21.9%; MUH = 30.2%), morbidly obese men (RPH = 2.1%; MUH = 6.8%), and morbidly obese women (RPH = 7.8%; MUH = 15.1%) was significantly greater in the MUH study population. However, the proportion of overweight patients was similar between countries. A greater proportion of women were found to be obese or morbidly obese in both hospitals. CONCLUSION: Obesity is more prevalent among surgical patients at MUH than at RPH, and is more common among women. The proportion of obesity seen in this survey is greater than results from general population surveys.

Effects of caffeine or diphenhydramine on visual vigilance.

The effects of two drugs having opposite effects on the central nervous system were investigated using a newly developed visual vigilance task. Twenty-four male volunteers (median age = 20) performed the task on three separate occasions; after consuming placebo, caffeine (200 mg), or diphenhydramine (25 mg), in a double-blind, Latin Square design. At least 2 days intervened between drug administrations. Caffeine use was restricted for 10 h and smoking for 3 h before drug administration. When compared with placebo, caffeine significantly increased the number of correct responses and decreased response times, whereas diphenhydramine decreased the number of correct responses and increased response times. Low habitual consumers of caffeine (< 100 mg/day) and non-smokers had more correct responses than did high habitual caffeine consumers (> 100 mg/day) and smokers, but only in the placebo condition. Non-smokers had faster response times than smokers only in the placebo condition. Both caffeine and diphenhydramine altered certain aspects of mood.

Arterial oxygen saturation in anaesthetised patients during transfer from induction room to operating room.

There is no published study that examines oxygenation of anaesthetised patients during transport from anaesthesia induction room to operating room. Arterial oxygen saturation (SaO2) was measured in twenty-five anaesthetised patients before and during transfer to an adjacent operating room and continuously recorded on a calibrated chart recorder. A telemetry ECG recorder was used to detect cardiac dysrhythmias. All anaesthetists followed their usual anaesthetic practice. Patients ventilated via face-mask and via endotracheal tube were studied. During transfer patients were either apnoeic (n = 8) or breathing room air spontaneously (n = 17). Mean SaO2 before induction was 95.4 (SD 2.5)%, was higher after induction of anaesthesia, 98.5 (SD 1.4)% and fell after transfer, 95.7 (SD 2.6)%. A fall in SaO2 was recorded for 21 patients. No SaO2 value below 90% was seen. The decrease in SaO2 was related to the time taken to transfer the patients and spontaneous ventilation (Multiple regression analysis); it was not related to the body mass index although two of the greatest decreases were seen in obese patients. Transfer time averaged 51 seconds (range: 24-97 s). No changes in cardiac rhythm were seen. Transfer of anaesthetised patients was accompanied by variable falls in SaO2 which related to duration of transfer and spontaneous breathing of room air and which were not associated with new dysrhythmias.