Emergency Tracheal Intubation in Patients with COVID-19: Experience from a UK Centre.

This retrospective observational case series describes a single centre's preparations and experience of 53 emergency tracheal intubations in patients with COVID-19 respiratory failure. The findings of a contemporaneous online survey exploring technical and nontechnical aspects of airway management, completed by intubation team members, are also presented. Preparations included developing a COVID-19 intubation standard operating procedure and checklist, dedicated airway trolleys, a consultant-led mobile intubation team, and an airway education programme. Tracheal intubation was successful in all patients. Intubation first-pass success rate was 85%, first-line videolaryngoscopy use 79%, oxygen desaturation 49%, and hypotension 21%. Performance was consistent across all clinical areas. The main factor impeding first-pass success was larger diameter tracheal tubes. The majority of intubations was performed by consultant anaesthetists. Nonconsultant intubations demonstrated higher oxygen desaturation rates (75% vs. 45%, p=0.610) and lower first-pass success (0% vs. 92%, p < 0.001). Survey respondents (n = 29) reported increased anxiety at the start of the pandemic, with statistically significant reduction as the pandemic progressed (median: 4/5 very high vs. 2/5 low anxiety, p < 0.001). Reported procedural/environmental challenges included performing tasks in personal protective equipment (62%), remote-site working (48%), and modification of normal practices (41%)-specifically, the use of larger diameter tracheal tubes (21%). Hypoxaemia was identified by 90% of respondents as the most challenging patient-related factor during intubations. Our findings demonstrate that a consultant-led mobile intubation team can safely perform tracheal intubation in critically ill COVID-19 patients across all clinical areas, aided by thorough preparation and training, despite heightened anxiety levels.

A guide to epidural management.

Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. To non-anaesthetists, or those not versed in their usage, epidurals can appear complex and intimidating, and the potential complications, although rare, can be catastrophic if not picked up on in a timely fashion. This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.