AAGBI Foundation CPoDcasts

Andrew Hartle discusses the implications of pandemic flu for hospitals, intensivists, anaesthetists, trainees and the public.

When Ellen O'Sullivan describes a patient with a dental abscess whose trachea proves difficult to intubate, a discussion is sparked about what airway skills all anaesthetists should have and what airway equipment all hospitals should have. Ellen O'Sullivan, Chandra Kumar, Steve Yentis and Alastair Chambers also discuss problems with maintaining difficult airway skills.

Yentis SM, Lee D.
Evaluation of an improved scoring system for grading tracheal intubation. Anaesthesia 1998; 53: 1041-4.

Henderson J J, Popat M T, Latto I P, Pearce A C.
Difficult Airway Society guidelines for management of the unanticipated difficult intubation.
Anaesthesia 2004; 59: 675-94

Cormack RS, Lehane J.
Difficult tracheal intubation in obstetrics.
Anaesthesia 1984; 39: 1105-11

Cook TM.
A new practical classification of laryngeal view.
Anaesthesia 2000; 55: 274-9

When Chandra Kumar describes a patient who presents a potentially difficult tracheal intubation, our panel of experts disagree on whether formal airway assessment is of real value. Steve Yentis, Ellen O'Sullivan, Chandra Kumar and Alastair Chambers address this unresolved dilemma.

Samson GLT, Young JRB.
Difficult tracheal intubation: a retrospective study.
Anaesthesia 1987; 42: 487-90.

Mallampati SR, GattSP, Gugino LD et al.
A clinical sign to predict difficult tracheal intubation: a prospective study.
Canadian Anaesthetists Society Journal 1985; 32: 429-34.

Yentis SM.
Predicting difficult intubation--worthwhile exercise or pointless ritual?
Anaesthesia 2002; 57:105-9

When Dr Valerie Bythell is asked to have a “quick look” at a chest X-ray on the Labour Ward, her suspicions are quite correctly aroused. David Bogod, Mike Wee and Paul Clyburn discuss the management of an acutely septic woman in labour, the use of remifentanil PCA for analgesia, autonomy in decision-making and even the best form of anaesthesia for rescue cervical cerclage.

Reference
Blair JM, Dobson GT, Hill DA, McCracken GR, Fee JPH. Anaesthesia 2005; 60: 22-7

When an 82-year-old diabetic with severe aortic stenosis and chronic lung disease presents for amputation of a gangrenous leg, no anaesthetic option seems without significant risks. Andrew Hartle, Will Harrop-Griffiths, Nick Denny and Chandra Kumar discuss the pros and cons of the various options, coming to a conclusion that may well surprise those who know their passion for regional anaesthesia.

When a severely demented woman is admitted to hospital with a fractured neck of femur, her estranged daughter intervenes and tries to refuse treatment on her mother’s behalf. Who decides whether surgery should be performed under these circumstances: the demented patient, the estranged daughter, the anaesthetist, the surgeon or an independent mental capacity advocate? David Bogod, Stuart White, Steve Yentis, Les Gemmell and Andrew Hartle discuss this knotty problem.

Although a plan for the management of a pregnant woman with a mechanical mitral valve replacement is decided in advance by a multidisciplinary team, spontaneous rupture of her membranes and the start of premature labour disrupt the plan, forcing the obstetricians and anaesthetists to contemplate an urgent caesarean section in an anticoagulated patient. How long can the operation be delayed? What tests of coagulation for a patient on low molecular weight heparin would be appropriate? What form of anaesthesia should be used? David Bogod, Paul Clyburn, Valerie Bythell and Mike Wee debate this difficult clinical problem.

When a woman who cannot speak English is admitted in labour, those caring for her start to doubt the accuracy of her husband's translation of her wishes. When it becomes evident that she is needlephobic and her labour becomes complicated, matters get even worse. David Bogod, Mike Wee, Paul Clyburn and Val Bythell discuss the problems associated with interpretation and needlephobia in high-risk labour.

David Bogod, Steve Yentis, Les Gemmell, Stuart White and Andrew Hartle discuss the problems associated with providing anaesthetic care for a patient who is the subject of a Do Not Attempt Resuscitation order. Is tracheal intubation resuscitation? Is intravenous fluid therapy resuscitation? How about a milligram or two of ephedrine? Our resident ethical experts unpick this potentially knotty ethical situation.

Reference

McBrien ME. Heyburn G. 'Do not attempt resuscitation' orders in the 
peri-operative period Anaesthesia 2006; 61: 625-7

When a 32-year-old man suffers significant nerve damage after plating of the clavicle performed under regional and general anaesthesia, the surgeon is all too ready to blame the interscalene brachial plexus block. How common is significant nerve damage? What can you do to minimise the risks of this feared complication? Do the benefits of this technique outweigh its risks? In this session, four experts in regional anaesthesia - Andrew Hartle, Will Harrop-Griffiths, Nick Denny and Chandra Kumar - explore the controversial topic of regional anaesthesia and nerve damage.

References

Benumof JL. Permanent loss of cervical cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000; 93: 1541-4.

Koff MD, Cohen JA, McIntyre JJ, Carr CF, Sites BD. Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis. Anesthesiology 2008; 108: 325-9.

You are in an anaesthetic room preparing to anaesthetise a patient when a trainee paramedic enters the room and asks you whether he can intubate the patient's trachea in order to complete the 10 intubations he needs to be "signed off". Should you agree to this because it is in society's interest to have skilled paramedics or refuse on the grounds that the patient is not in a position to give - or refuse to give - informed consent? In this session, five leading experts in clinical ethics - David Bogod, Les Gemmell, Andrew Hartle, Steve Yentis and Stuart White - debate the ethical considerations of this all-too-common situation.

References

Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia 2006.