Some photos of the action at the Nairobi Surgical Skills Centre this week. Many thanks to the local faculty from the University of Nairobi and other institutions, the companies that supported use of the facilities and equipment, and the enthusiastic delegates!
A short presentation on a selection of airway themes and some of the papers from 2016 for our FCA Part 2 candidates. Definitely not intended to be a systematic or exhaustive review! Click the image to download a PDF of the slides, or the link below for the resources.
Another quick training video, on the basic techniques of driving a flexible scope (fibreoptic or video) for intubation. This was made specifically as a primer for people in our own department taking part in a training study, but hopefully it is useful to a larger audience!
Please put your comments and (hopefully constructive) critique below. As always, you’re welcome to use with attribution!
Despite making a previous post and video to explain the way to make sure the device switches on, I regularly get told that the Pocket Monitor (PM) for our C-MAC video laryngoscope is not working/charging/switching on. This is in fact a design feature to prevent accidental activation or discharge. Watch here to find out more:
Thanks to the lovely Sam Adams for playing along…good career in acting if anaesthesia were to ever become boring!
The guidelines are presented as a ‘Master Algorithm’ and several sub-algorithms to deal with specific aspects of obstetric airway management, and a guide to making the decision to awake the patient or continue with surgical delivery after an airway event:
Some thoughts (COI – the author did provide feedback on the draft algorithms):
Stressing good positioning for airway management is absolutely critical in this population, and especially in practice environments where patients tend to have a high BMI (a common situation in our South African setting). The guidelines include ramping and the ear-to-sternal-notch (E2SN) position.
The inclusion of cricoid pressure will inevitably spark the usual debate, but it is this author’s contention that this is likely an appropriate use until more evidence to the contrary emerges. The guidance to consider CP reduction or release in the event of difficulty is apt.
The inclusion of gentle face-mask assisted ventilation during RSI is a welcome inclusion. Will we see NPO2 or HFNC included in later editions as more outcomes evidence emerges?
Advocating the use of VL in obstetrics certainly sounds like a good idea, but is not attainable for most of the developing world. This is a huge area for growth/research – the development of low-cost VL solutions.
This is a great step forward in promoting safe airway management and guiding training in a particularly dangerous corner of our practice.
For some more thoughts and images, here is a Prezi on the subject presented at the SASA Difficult Airway workshop in 2014:
The newest edition of the Anaesthesia Tutorial of the Week (ATOTW #321) covers the much underestimated but critically important topic of predicting and managing difficulty in face mask ventilation. Irish anaesthetists Jonathan Holland and Will Donaldson have created a useful resource for anyone studying or performing airway management, or refreshing for exam purposes.
The authors discuss the predictors of difficult mask ventilation and report/propose another two mnemonics, to add to the existing stable (MOANS, BONES, etc):
I’ve always used MOANS for mask factors (like I use LEMON for laryngoscopy), but all these mnemonics cover the same ground. MOANS, for instance, stands for
M Mask seal factors, like beards, NGTs, odd shaped faces
O Obesity and causes of Obstruction, like tumours/angioedema
A Age extremes (the elderly and very young)
N No teeth (or nasty dentition)
S Snoring and Stiff lungs (the latter being issues like inhalation burns and acute bronchospasm, where the higher pressures required increase the risk of gastric insufflation and Splinting of the diaphragm)
As you can see, they are all much the same, although there are a few things that are not covered by every algorithm. The purist would point out that obesity is defined as a BMI of >30 kg/m2, not 26 as stated in the table.
The authors then present a useful flowchart for addressing unexpected difficulty, which is quite sensible. It is much in line with the DAS guidelines and other algorithms for general airway difficulty, and useful for instruction. Of course, in a dire emergency, using a cognitive aid such as the Vortex would be effective.
This month’s edition of Anesthesiology News features a worthwhile piece from Prof John Doyle, in which he poses 7 questions on the current state of airway management to 6 airway experts from around the world (Abdelmalak, Cooper, Frova, Rosenblatt, Spiegel and Doyle himself), and collates their responses into a dialogue. Definitely worth reading to determine what some (certainly not all) of the biggest names in the world are thinking on:
Herewith the presentation that Ross cobbled together for the candidates preparing for anaesthesia finals, to give an idea of the trends and new tools in airway management at the current time. Mostly pictures, but the lecture notes (with all the references) can be downloaded as a PDF here: