Anaesthesia 2015, 70, 229–239 chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant. Journal of Hospital Infection 2005; 61: 287–90. 5. Crowley L, Preston R, Wong A, et al. What is the best skin disinfectant solution for labour epidural analgesia? A randomized, prospective trial comparing ChloroprepTM, DuraprepTM and chlorhexidine 0.5% in 70% alcohol. Anesthesia and Analgesia 2008; 106: A-A-221.
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concerned that these do not necessarily equate with improvements – or indeed, any change – in practice. I would like to suggest that future projects concentrate specifically on how simple messages can be best disseminated both to the public and to clinicians.
doi:10.1111/anae.13004
NAP5 and consent Despite extensive traditional and social media coverage of the NAP5 project on accidental awareness under general anaesthesia (AAGA), I am yet to experience any curiosity from, or increased questioning by, patients about AAGA. The vast majority of my colleagues whom I have questioned have not received any increased questioning about AAGA, and none was intending to inform patients about AAGA in the light of NAP5, excepting the fifth of those who would now inform obstetric patients about the risk. I wonder then, how much of a need NAP5 has created for changing the current consent process or altering practice [1]? Additional comments from colleagues indicated concerns about anaesthetists in future using opioids during rapid sequence induction, limiting the use of neuromuscular blocking drugs, foregoing total intravenous anaesthesia and abandoning depth of anaesthesia monitoring, in order to avoid AAGA, at the expense of patient safety. Although national audit projects provide fundamental objective data and sensible guidelines, I am 236
R. Tighe St. Richard’s Hospital, Chichester, UK Email:
[email protected] No external funding and conflicts of interest declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
Reference 1. Cook TM, Andrade J, Bogod D, et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. Anaesthesia 2014; 69: 1102–16. doi:10.1111/anae.12985
Safety and efficacy of laryngeal mask airways during tracheostomy We read Price et al.’s report discouraging use of the laryngeal mask (LMA) during percutaneous dilatational tracheostomy with interest [1], as we have used a LMA UniqueTM for this technique as standard practice for over a year. None of the 32 unselected critically ill patients that we have treated so far have experienced significant deterioration of cardiorespiratory function, and we have only experienced prob-
lems with the airway seal in one patient, who had a body mass index of over 30 kg.m 2 and required high ventilatory pressures, for whom tracheal intubation was required. We have used the correct size of LMA according to the manufacturer’s instructions, but stabilise it by routinely inserting a cylinder of gauze on each side and securing it with tape. This reduces air leak, avoiding any clinically relevant derecruitment during tracheostomy. Subsequent fibreoptic bronchoscopy enables transillumination of soft tissue and tracheal structures at the tracheostomy site, as previously identified by clinical and ultrasonographic examination, and confirms correct placement of the PercuTwist tracheostomy tube, under direct vision. We suggest, therefore, that the problems Price et al. report may be due to either their choice of the LMA SupremeTM or their patient selection. Furthermore, we disagree with the authors that positioning the tracheal tube above the vocal cords during tracheostomy is safe, because this ‘traditional’ method does not guarantee airway protection, can facilitate complete tracheal tube dislodgment with potentially severe consequences, and could lead to cuff-related damage to the laryngeal structures. Price et al. are to be congratulated on adding valuable evidence to the published data in this area, but as our experience shows, it is too early to discount LMA-assisted percutaneous dilational tracheostomy as a safe alternative to ‘traditional’ tracheostomy.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia 2015, 70, 229–239
G. Consales G. Michelagnoli L. Zamidei D. Bettocchi Santo Stefano Hospital, Prato, Italy Email:
[email protected] No external funding and conflicts of interest declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
Reference 1. Price GC, McLellan S, Paterson RL, Hay A. A prospective randomised controlled trial of the LMA Supreme vs cuffed tracheal tube as the airway device during percutaneous tracheostomy. Anaesthesia 2014; 69: 757–63. doi:10.1111/anae.12981
The expense of unnecessary videolaryngoscopy We read with interest Sandu and Higgs’s letter [1], reporting the routine use of an AirtraqTM optical laryngoscope to assess vocal cord function after thyroid surgery. However, we have two reservations regarding this practice. Most importantly, the British Association of Thyroid and Endocrine Surgeons states that accurate assessment of vocal cord movement can only be obtained by formal indirect nasendoscopy in the conscious patient [2]. It is unlikely that a suboptimal assessment of vocal cord function during anaesthesia at the end of surgery would alter materially the patient’s immediate clinical care, and it is therefore difficult to justify. Medicolegal concerns would also be
better addressed by more formal assessment after surgery. The Academy of Medical Royal Colleges has recently reminded doctors about the ethical imperative of saving money by avoiding unnecessary investigations where possible and if safe [3]. The Airtraq is not designed to be, or validated as, a diagnostic device and has a singleuse unit cost of £56 (€72; $88) in our hospital. We would argue that it is difficult to justify such expense solely for this use, particularly if the result will not alter clinical management. L. Bishop D. Bush R. Dawson Z. Makura Leeds Teaching Hospitals NHS Trust, Leeds, UK Email:
[email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspon-
dence website: www.anaesthesia correspondence.com.
References 1. Sandu R, Higgs A. Extended roles for videolaryngoscopy. Anaesthesia 2014; 69: 1293–4. 2. British Association of Endocrine and Thyroid Surgeons, 2003. Guidelines for the surgical management of endocrine disease and training requirements for endocrine surgery. http://www.baets. org.uk/wp-content/uploads/2013/02/ BAETS-Guidelines-2003.pdf (accessed 13/11/2014). 3. The Academy of Medical Royal Colleges, 2014. Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care. http://www.aomrc.org. uk/doc_download/9793-protecting-reso urces-promoting-value.html (accessed 13/11/2014). doi:10.1111/anae.12997
Ulnar ‘dive’ may not always identify the median nerve in the forearm I congratulate Singh et al. in identifying the median nerve in the forearm by following the course of the
Figure 1 Short-axis ultrasound image of the forearm, showing the superficial ulnar artery (SUA) lying anterior to flexor carpi ulnaris (FCU) muscle in the forearm. The ulnar nerve (UN) is normally positioned between FCU and flexor digitorum profundus (FDP) muscles. T is the tendon of FCU. Published with the written consent of the patient.
© 2015 The Association of Anaesthetists of Great Britain and Ireland
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