AUSTRALASIAN ANAESTHESIA 2013 AUSTRALASIAN ANAESTHESIA 2013 Invited papers and selected continuing education lectures Editor: Richard Riley Department of Anaesthesia and Pain Medicine Royal Perth Hospital Pharmacology and Anaesthesiology Unit, School of Medicine and Pharmacology University of Western Australia Contents Evolution of airway training at a large metropolitan teaching hospital 1 Jon Graham, Samantha Leung, Parameswaran Pillai, David A Story, Francis Parker and Daryl Jones Videolaryngoscopes and the ‘Fremantle score’ 13 Mei-Mei Westwood, Alex D Swann and James D English Urine output: To chase or not to chase? 23 Peter McLoughlin Monoclonal antibody therapy – Implications for anaesthesia, intensive care and pain medicine 29 Subhashini Nadarajah, Michal Kluger and Aravind Chandran Onco-anaesthesia – an emerging sub-specialty defining a ‘cancer anaesthetic’? 45 Jonathan G Hiller, Hilmy Ismail and Bernhard Riedel Novel oral anticoagulants: Implications for the anaesthetist 57 Rafal Bacajewski, David J Sturgess and Jeffrey J Presneill Spinal ultrasound: The superior way? 69 Nico Terblanche Caesarean haemodynamics 79 Dane Blackford Torrential peripartum haemorrhage 87 Stephen P. Gatt and Andre Van Zundert Carbetocin in the prevention and management of post partum haemorrhage: 95 A review of current evidence for obstetric anaesthesia Graham Langerak, David J Sturgess and David McCormack Can I TAP that? Review of the use of transversus abdominis plane (TAP) block 103 Raviram Ramadas and Krishna Boddu Acute compartment syndrome and anaesthesia 117 Rob Glasson and Krishna Boddu Pre-filled emergency drugs: The introduction of pre-filled metaraminol and ephedrine 127 syringes into the main operating theatres of a major metropolitan centre Nathan Goodrick, Torben Wentrup, Geoffrey Messer, Patricia Gleeson, Martin Culwick and Genevieve Goulding Increasing efficiency through an evidence-based framework of volatile agent use 137 Stanley Tay, Laurence Weinberg and David Story Cardiopulmonary exercise testing for preoperative assessment of surgical risk 143 CPH Kalinowski Orphan outcomes, risk and ethical collaboration 155 Jo Sutherland and Elisabeth Shaw Royal Dental Hospital Day Surgery Unit – The same as other day surgery units, but different 165 Tony Bajurnow Anaesthesia in Australia’s Top End 173 Published in 2013 by: Jamahal Luxford and Brian Spain Australian and New Zealand Informed choice and consent in anaesthesia: Are we there yet? 183 College of Anaesthetists Grant Brace 630 St Kilda Road Melbourne VIC 3004 Propofol misuse among anaesthetists 187 Lisa Zuccherelli ISSN 978-0-9775174-9-7 Where oh where has your Endone script gone? The oxycodone epidemic 193 Copyright © 2013 by the Australian and Ngaroma Steele and Jennifer Stevens New Zealand College of Anaesthetists, all rights reserved. None of the contents of Fear and loathing in the operating room 199 this publication may be reproduced, stored Diarmuid McCoy in a retrieval system or transmitted in any Are urine drug tests useful in management of pain patients? 203 form, by any means without the prior written Benjamin Davies and Rhys Henning permission of the publisher. Pain assessment in animals 209 Please note that any views or opinions expressed in this publication are solely those Gabrielle C Musk of the author and do not necessarily represent The impact of culture on simulation based medical education. 215 those of ANZCA. Timothy Brake Printed by: DigitalHouse Research integrity: what is it and why does it matter? 221 70 Wirraway Drive, Port Melbourne, VIC, 3207 Paul M Taylor and Daniel P Barr Faculty and Regional Sub-Editors AUSTRALASIAN Dr Dane Blackford Tasmania ANAESTHESIA Professor Thomas Bruessel Australian Capital Territory, Canberra Hospital, Canberra Dr Doug Campbell 2013 New Zealand, Auckland City Hospital, Auckland Dr Brenda Cassidy Faculty of Pain Medicine, Women’s and Children’s Hospital, North Adelaide Clinical Associate Professor Richard Riley Western Australia, Royal Perth Hospital, Perth Professor David Story Victoria, Austin Health, Melbourne Dr David Sturgess Queensland, Mater Health Services, South Brisbane Dr Sharon Tivey New South Wales, St George Hospital, Sydney Dr Gerald Toh South Australia, Royal Adelaide Hospital, Adelaide Preface Welcome to the 2013 edition of Australasian Anaesthesia. This edition is available in digital and hard copy versions. There has been much discussion by Fellows about these changes and I thank those who have made contact to express their views. Publishing is undergoing massive change and traditional media are being replaced by electronic formats. Newspapers are disappearing, or sacking staff; e-zines and other on-line resources are thriving. One colleague let me know that he used the internet as his principal resource to prepare for the Part II examination. I hope that you will take advantage of the immediacy and flexibility of the digital edition and let ANZCA know how this publication can match your requirements in the future. Please know that bonus material, such as video files or brochures, can be found on the ANZCA website (http://www.anzca.edu.au/resources/college-publications or use the QR code with your smartphone). The authors have generously allowed their articles to be distributed in this way to maximise the educational impact of their work. Finally, this issue of the Blue Book once again provides a diverse range of topics for your interest. I thank the authors, the regional editors and Katherine Hinton, Laura Foley, and Chriss Marinoni for the work and support in producing this edition. Please take the opportunity to thank our authors personally when you can and also consider writing yourself for a future edition. Richard Riley Evolution of airway training at a large metropolitan teaching hospital 1 Evolution of airway training at a large metropolitan teaching hospital JON GRAHAM, MBBS, FANZCA Staff anaesthetist, Department of Anaesthesia, Austin Health, Melbourne, Australia Dr Jon Graham is the airway training co-ordinator at Austin Health. His other interests include cardiothoracic anaesthesia, cardiovascular physiology and simulation education. SAMANTHA LEUNG, MBBS (HONS), BMEDSCI (HONS), FANZCA Fellow, Mercy Hospital for Women, Melbourne, Australia Dr Samantha Leung is a visiting medical officer at the Northern Hospital Melbourne. She has an interest in obstetric anaesthesia and is completing a further obstetric anaesthesia fellowship at the Mercy Hospital for Women. PARAMESWARAN PILLAI, MBBS, MD (ANAESTHESIA), FRCA Staff anaesthetist, Department of Anaesthesia, Austin Health, Melbourne, Australia Dr Parameswaran Pillai’s other interests include airway teaching and quality and safety in anaesthesia. His clinical interests include anaesthesia for cardiac surgery and liver transplantation. DAVID A STORY, MBBS (HONS), MD, BMEDSCI (HONS), FANZCA Professor and Chair of Anaesthesia and head of the Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Australia Professor David Story facilitates research teaching and engagement in anaesthesia perioperative and pain medicine at the 14 hospitals affiliated with the University of Melbourne. He has a passion for evidence based practice. FRANCIS PARKER, MBBS, M.EPID, FANZCA Visiting anaesthetist, Department of Anaesthesia, Austin Health, Melbourne, Australia Dr Francis Parker has co-authored a number of papers in the fields of anaesthesia, gastroenterology and urology. He has a particular interest in the management of difficult airways. DARYL JONES, BSC (HONS), MBBS, FRACP, FCICM, MD Consultant intensive care specialist, Austin Health; adjunct senior research fellow and PhD student DEPM Monash University; Associate Professor Department of Surgery, University of Melbourne, Melbourne, Australia Associate Professor Daryl Jones has research interests including recognition and response to clinical deterioration, the medical emergency team and care for at-risk surgical patients in the perioperative period. INTRODUCTION In an editorial in 1998 entitled “Education and training in airway management”, Mason lamented that: “In what other profession would untrained teachers, with little time and fewer facilities, be expected to provide comprehensive education for trainees with such widely different levels of experience.”1 Within the Department of Anaesthesia at Austin Health we have developed an airway-teaching program that, we think, has addressed some of these problems. This article describes some of the features of our airway program and how it was developed. Table 1. Features of the Austin Training Program • Designated anaesthesia department airway co-ordinator. • Airway co-ordinator provided with adequate out of theatre time. • Core instructor group developed with airway and simulation expertise. • Ongoing review of educational resources and attendance at external courses. • Review of unexpected difficult airway algorithms including approach to surgical airway for anaesthetists. • Department airway manual provided. • Dedicated airway training room and access to wet lab and simulation room. • Both technical and non-technical skills taught. • Anaesthesia nurses involved in simulation to emphasise team approach. • Attendance at ENT clinics and respiratory medicine bronchoscopy lists. • Collaboration with ICU and emergency medicine. • Collaboration with broader hospital education services. • Airway refresher and fibreoptic program run as separate entities. • Audit and governance. • Network with other centres. 2 Australasian Anaesthesia 2013 Evolution of airway training at a large metropolitan teaching hospital 3 There is increasing recognition of the importance of airway training.1-3 The authors of the “4th National Audit Training facilities Project of the Royal College of Anaesthetists and the Difficult Airway Society: Major complications of airway Dedicated airway training rooms have been identified as important training resources.1,6 In 2006 the Austin redeveloped management in the United Kingdom” (NAP4) identified poor judgement, and education and training, as the second the operating theatres. At that time we were able to secure an area of the old day surgery unit, which is very close and third most frequent causal and contributory factors in the reported anaesthesia events.4 to the operating theatres, to establish an airway training room. The airway training room contains; a DAT resembling The 2013 Australian and New Zealand College of Anaesthetists (ANZCA) curriculum revision included a requirement those in the operating theatre stocked with expired equipment; a number of fibreoptic scopes and several light for more structured airway training.5 While the clinical environment remains the most important learning ground for sources; a fibreoptic dexterity trainer (DexterTM, Replicant, Wellington, New Zealand);25 a trolley containing tubes airway expertise, there is strong support for dedicated airway training outside the operating room.1,2 External and blockers for lung isolation; a simulated tracheal bronchial tree for lung isolation training and several manikins. workshops are partially able to address this training requirement but should be complemented by comprehensive The room has a whiteboard and a dozen chairs for interactive teaching and a large cupboard to store expired teaching in the training hospital.1,6 Only half of the 60% of training programs in the United States and Canada who equipment as it becomes available for teaching. responded to a 2008 survey had formal airway rotations.7 In 2008 the Austin opened its own simulation centre. This is an additional resource for airway training which includes Expert opinion recommends that such hospital airway training could include: airway assessment and planning; a simulation room, equipped with a sophisticated mannequin (SimmanR, Laerdal, Stavanger, Norway), and viewing approaches to the expected and unexpected difficult airway; specific airway equipment training including new and debriefing rooms. There is also a wet lab in which the surgical airway sessions can be taught. devices; surgical airway training; development of fibreoptic skills and development of human factor expertise.1-3, 6 The Australasian College of Surgeons Skills Laboratory, which is half an hour journey by car or train, is equipped with a bronchoscopy simulator (Accutouch endoscopy simulator, Immersion Medical, San Jose, USA). Such AIRWAY TRAINING RESOURCES simulators have been demonstrated to improve fibreoptic skills at other centres.26,27 Airway training co-ordinator and instructors The Austin is a large metropolitan hospital affiliated with the University of Melbourne, undertaking surgery in all Simulation specialties except obstetrics. In 2004 a staff anaesthetist (JG) was appointed as airway training co-ordinator (airway Simulation allows participants to practise leadership in crises and other challenging clinical situations and to receive co-ordinator) and provided with out of theatre time to perform this role. The airway co-ordinator’s task was to feedback regarding their management of these events.28 Human factor training and the opportunity for multidisciplinary harness the considerable airway expertise in the department into a cohesive training program for the department’s teams to train together within simulated difficult airway scenarios were recommendations of NAP4.29 trainees. Creating such a role is considered important to the success of airway training.1,2,8 Formal airway training Simulation has formed part of airway training at Austin since its inception; in recent years nursing staff have commenced in 2006 and has evolved each year since then. During that time, 12 anaesthesia consultants have participated in addition to anaesthesia trainees. In 2009, five consultants attended a two-day workshop on simulation provided instruction in the operating room or in airway training outside the operating room. Our anaesthesia trainees education at the Southern Health Simulation Centre in Melbourne. In 2011, two consultants, a provisional fellow are rostered to receive five hours per week for out of theatre education. Approximately 45 anaesthesia trainees and two nurse educators completed the week-long Co-ordinated Approach to Simulation Training course at Southern rotate through our department annually for periods of three to 12 months. Typically trainees are attached to the Health Simulation Centre. Two of the consultants attended both training opportunities. Most of these staff remain training program which includes the Austin for three to four years and would spend some time in our hospital in involved in the simulation component of Austin airway training. each of those years. An additional 15 doctors, including intensive care trainees, emergency trainees and junior resident medical officers, work in our department for similar periods to the anaesthesia trainees. Surgical airway The airway co-ordinator has been an instructor on the Effective Management of Anaesthesia Crises (EMAC) There is uncertainty about the best approach to the emergency surgical airway for anaesthetists and this is course since 2006.9 This has provided exposure to the EMAC emergency airway approach,10 and an opportunity reflected in the DAS and ASA guidelines, which suggest options rather than a definitive instruction as to how to to develop expertise in simulation. The airway co-ordinator has completed the Royal Melbourne Fibre-optic Workshop proceed.17, 18 Surgical airways were generally poorly performed by anaesthetists in the NAP4, most frequently a in 2004;11 the Difficult Airway Course for Anesthesia (Airway Management Education Center) in 200812 and has cannula approach was chosen.30 Delay in performing an emergency surgical airway has been implicated in adverse twice attended the Airway Skills Course in 2007 and 2012 (AirwaySkillsTM).13 Attendance at each of these courses, outcomes.31 The authors of NAP4 recommend that all anaesthetists should be trained and maintain expertise in discussions with experienced colleagues and academic sources have all contributed towards the development of cannula and surgical cricothyroidotomy and recommend that further research be pursued into reasons for needle Austin airway training.1, 2,14-16 cricothyroidotomy failure.32 Strong support for surgical airway training for anaesthetists has also been expressed in Australia and New Zealand, with particular emphasis on the importance of human factor training.33 The Royal Unexpected difficult airway pathway Perth Hospital can’t intubate, can’t oxygenate (CICO) algorithm incorporates a cannula approach, a Seldinger Mason emphasised the importance of an agreed simplified department-wide approach to the unexpected difficult approach (5.0 cuffed melkerTM) and a surgical approach (scalpel bougie and scalpel finger cannula) in a logical airway, with the intention that this be used as a guide to teaching and the arrangement of difficult airway equipment.1 progression.34,35 A recent publication using these guidelines has emphasised the importance of prepared equipment Soon after the airway co-ordinator’s appointment, he and a colleague revised the department’s suggested and a rehearsed team strategy in the management of the CICO scenario.36 The airway co-ordinator has visited the pathway for unexpected difficult intubation. This revision included detailed consideration of the Difficult Airway Royal Perth Hospital to observe a training session led by Dr Andrew Heard and remains in contact with him so that Society (DAS) guideline, the American Society of Anesthesiologists (ASA) guideline and the airway section in the modifications to that hospital’s approach are taught at the Austin. The equipment to perform a surgical airway EMAC Instructors Manual.10,17,18 After a consultation process with key department staff, the unexpected difficult following the Royal Perth Hospital approach is available in the emergency department, intensive care and at multiple airway pathway was developed and is attached to all anaesthesia machines and to the difficult airway trolleys (DATs). locations in the operating theatre in our hospital. The Royal Perth CICO algorithm is attached to all the anaesthesia machines and the DATs on the reverse side of the unexpected difficult airway pathway placard. Airway equipment The contents of the DATs were revised after development of the unexpected difficult airway pathway and have Collaborative relationships subsequently been revised to comply with the ANZCA guideline.1,19,20 In a 2007 Auckland survey, 20% of respondents Key relationships with other departments have been gradually developed. Each fortnight for several years, an had never been orientated to the DAT in the place in which they were working.21 In recent years on the orientation anaesthesia trainee has attended the ear nose and throat (ENT) outpatient clinic to gain experience with day at the start of the training year, trainees have been shown the location of: the DAT; Royal Perth surgical airway nasendoscopy.37 Anecdotally, these interactions have improved communication between the ENT unit and the bags; the grab bag for off the floor (that is, outside of the operating theatre suite) airway emergencies and the airway anaesthesia department about patients presenting for surgery with expected difficult airways. Once a week an training room.1 Unfortunately this does not include all trainees and, from 2013, trainees who are not present at the anaesthesia trainee attends a clinical bronchoscopy list under the supervision of respiratory physicians. At these orientation day will be personally oriented to these locations by the airway co-ordinator, or a colleague, when their sessions the anaesthesia trainees perform the initial part of the bronchoscopy until the scope is past the vocal rotation commences at the Austin. cords.38 Anaesthesia trainees attend only about one third of the ENT clinics and bronchoscopy lists, which minimises In the operating theatre at Austin we have access to 11 video intubation bronchoscopes of varying external the burden of training anaesthetists on these separate specialty groups. diameters between four and six mm,22 which we share with our thoracic surgery and respiratory medicine colleagues. Fibreoptic training is also undertaken on maxillofacial and thyroid elective theatre lists. These lists were chosen It has been suggested that using intubation bronchoscopes via a screen rather than an eyepiece provides benefit as these two patient groups often require intubation and not infrequently require fibreoptic intubation. In usual for trainees.23 circumstances one patient on the list is intubated fibreoptically for clinical reasons or for educational purposes. Hospital legal opinion was sought before commencing this part of the airway program. If it is planned that airway Airway manual management is to be altered for teaching purposes, patient consent is sought during the anaesthetic pre assessment We have developed an extensive department manual incorporating all of the material covered during the airway on the day of surgery.6,16 training. This manual is provided in hard copy to trainees at the commencement of the training year. This manual is constantly updated and from 2013 will be provided in electronic form. The manual has been used by other providers of airway training to assist with preparation of participant reading material.24 4 Australasian Anaesthesia 2013 Evolution of airway training at a large metropolitan teaching hospital 5 The same consultant anaesthetists are rostered to each of these lists and are committed to the educational (2) Simulation opportunities they provide. This continuity also ensures that there is no effect on the efficiency of the list. The Five or six participants at a time undertake this session. The session commences with a short film followed by an surgeons on these lists were personally approached when this part of the program was established and value the interactive conversation emphasising the importance of human factors in airway management.58,59 Following this experience gained by their anaesthetic colleagues. A paralysed apnoeic approach is typically used when fibreoptic there is a discussion about how to optimise attempts at bag mask ventilation and intubation. Emphasis is placed intubation is performed in anaesthetised patients for educational purposes.16 on the importance of distinguishing between patients who are unable to be intubated but able to be bag mask With the assistance of anaesthesia and intensive care colleagues the airway co-ordinator has provided airway ventilated, from those who are unable to be intubated or bag mask ventilated. The surgical airway is presented as training to ICU trainees for the past four years. This training delivers the material that is covered in the airway the final step for patients with a failed airway who are not awakening. It is emphasised that the surgical airway must refresher for anaesthesia trainees in an abbreviated form and includes simulation and practical instruction in the be preceded by optimised attempts to bag mask ventilate, intubate and insert a supraglottic device.10,60 These use of airway equipment. The airway co-ordinator also has regular contact with the lead airway consultants in the principles are used to explain the unexpected difficult airway pathway. Participants are then introduced to simulation emergency department, so that each is aware of the teaching being provided in both departments. Difficult airway principles and to the simulation room. equipment has become standardised across the departments.39 A hospital airway group was established in 2012 Typically, five scenarios are completed. One of the participants acts as primary responder for an airway scenario, to ensure that in the future there is a regular forum to discuss shared airway concerns. with a second participant available to attend as help. Anaesthesia nurses are also immersed in the scenario and The Austin’s airway training has included teaching relating to tracheostomy emergencies for several years and are full participants. Facilitated debriefing is performed in a separate room after each scenario, with the pause and the need for this was reinforced in NAP4.39 The teaching material was developed after a review of the literature and discuss technique occasionally also being used during scenarios.61 consultation with the directors of ENT and thoracic surgery, two of the senior intensive care consultants and with Within the five scenarios, different participants are expected to demonstrate: optimised attempts at bag masking; the Austin’s Tracheostomy Review and Management Service (TRAMS).40-42 TRAMS is an integrated service of optimised attempts at intubation including when to desist; recognition that a laryngeal mask is a reliable rescue doctors, nurses, physiotherapists and speech pathologists, which manages inpatients and outpatients with when bag masking and intubation fails; be prepared to perform a surgical airway when required; manage the tracheostomy and trains other staff who care for these patients. apparently displaced or blocked tracheostomy tube; manage an apparently blocked endotracheal tube and lead or act as an effective team member. STRUCTURE OF AIRWAY TRAINING Airway training at the Austin has two components. The airway refresher is incorporated into the planned department (3) Expected difficult airway teaching program and is intended to involve all trainees once a year. The second component is the fibreoptic This is an interactive discussion of clinical cases from our institution and from the literature. It is led by the airway program, which is an option available to 16 trainees annually. It involves two trainees for four weeks. It is intended co-ordinator and a senior anaesthetist and incorporates clinical histories, photographs and radiological investigations that each trainee completes this program once early in their training and once towards the end of their training. (see table 2). Participation is limited to anaesthetic trainees and priority is given to the most senior. Trainees who complete the fibreoptic program would also be expected to complete the airway refresher that year. Table 2. Expected difficult airway scenarios discussed Airway refresher • Obese patient with expected difficult airway. The airway refresher is made up of three three-and-a-half hour sessions using the regular weekly department training • Ankylosing spondylitis requiring intubation. time. It is undertaken as close as possible to the beginning of the training year to assist with trainee orientation and • Bleeding tongue tumour for biopsy. perhaps improve patient safety.1,43 Considerable effort is made to include trainees who are at the Austin near the • Retropharyngeal abscess with airway obstruction. beginning of the training year and those who will rotate to the Austin later in the year. It is intended that all attend • Submandibular abscess for drainage. the airway refresher annually, as this has been validated as a realistic retention interval for complex procedural skills • Laryngeal cancer presenting with airway obstruction. reinforced in a simulation environment.44 • Laser microlaryngeal surgery. (1) Surgical airway and equipment session • When, where and how to extubate a patient with a difficult airway. This session is made up of four different components, which the trainees rotate through in two groups. The first • Fractured unstable cervical spine for fixation. component is an interactive hands-on exposure to fibreoptic scopes, laryngoscopes, lung isolation devices and • Severe rheumatoid arthritis. other airway equipment. Trainees are able to practise the use of airway equipment on simple mannequins.1 The • Neck swelling post carotid endarterectomy. fibreoptic scopes available at our institution are presented and the relative merits of the endotracheal tubes available • Airway burns. for fibreoptic intubation are discussed. Measures to improve the view for fibreoptic intubation and to improve the • Quinsy. likelihood of successfully passing the endotracheal tube over the fibreoptic bronchoscope and through the glottis • Angioedema with upper airway obstruction. without impingement are also considered.22 A number of airway devices and techniques are demonstrated and • Adult acute epiglottitis. then practised including: the Berman airway45 (Vital signs, Totowa, USA); the endoscopy mask46 (VBM Medizintechnik, • Neck dissection with past neck radiotherapy. Sulz a.N., Germany); techniques of blind and fibreoptic intubation via the intubating laryngeal mask18 (LMA, Jersey, • Maxillofacial fractures. UK); intubation with the Aintree catheter18,47 (Cook Medical, Bloomington, USA); use of the straight blade • Laryngeal injury. laryngoscope,48 McCoy laryngoscope49 (Penlon, Abingdon, England); the Airtraq50 (Prodrol, Vizcaya, Spain); the • Goitre. Pentax airway scope51 (Pentax corporation, Tokyo, Japan) and airway exchange catheters (Cook Medical, Bloomington, USA) including discussion of safe techniques of using these devices for endotracheal tube exchange and difficult extubation.14,52,53 Emphasis is placed on the importance of a comprehensive airway assessment that addresses the likelihood of In the second component in the wet lab, the Royal Perth Hospital CICO algorithm is presented. The trainees success with all modalities of airway management including bag mask ventilation, laryngeal mask placement, observe and then practise performing a surgical airway using a pig larynx mounted on a board, and delivering intubation and a surgical airway.17,62 Participants are encouraged to consider systematically the possible methods oxygen via a cannula on a mannequin. of securing the airway in patients with anticipated airway difficulty17 and to plan airway management for the duration The third component covers principles of lung isolation. Anatomical models are used to focus on the anatomy of the patient’s care.14 The relative indications and contraindications to fibreoptic intubation are discussed.63,64 Use of the trachea and main bronchi relevant to lung isolation with emphasis on the variable anatomy of the right upper of gas induction in a patient with an expected difficult airway is considered, including strategies to manage airway lobe.54,55 Clinical and fibreoptic methods of placement and confirmation of position of double lumen tubes, bronchial obstruction if it occurs during gas induction. There is comprehensive discussion of assessment and management blockers and endobronchial tubes are presented.56 The features of the different styles of double lumen tubes are of patients with upper airway obstruction, with particular emphasis on the importance of having a surgeon present considered, particularly the variability in the design of right sided tubes. Effective methods of ventilation using the to perform rigid bronchoscopy or a surgical airway if required.65 Approaches to airway management during micro rigid bronchoscope are demonstrated.57 laryngeal surgery are presented with particular emphasis on patients requiring jet ventilation and/or laser surgery The final component involves an interactive discussion about the apparently blocked endotracheal tube and (Richard Barnes, consultant anaesthetist, Monash Medical Centre, personal communication). tracheostomy emergencies. A systematic approach is presented for the management of a patient with an endotracheal tube, which requires very high ventilatory pressures or is apparently obstructed.10,58 The discussion regarding tracheostomy emergencies covers equipment and tubes and immediate information required when managing a patient with a problematic tracheostomy. Suggested pathways for management of accidental decannulation and the apparently obstructed tracheostomy tube are presented. 6 Australasian Anaesthesia 2013 Evolution of airway training at a large metropolitan teaching hospital 7 Fibreoptic program Table 3. Analysis of change in response to eight key questions compared to commencement Limited opportunity to practise fibreoptic intubation has been previously identified as a problem for trainees. The questionnaire expressed as medians and interquartile range in brackets. median number of fibreoptic intubations performed by trainees in a New Zealand survey was four per year.66 The intention of the fibreoptic program is to provide a period of concentrated exposure to increase expertise and After After confidence. surgical expected The fibreoptic program is composed of four educational sessions, using the training time that is normally allocated After airway and difficult At 4 to trainees, and four normal theatre clinical sessions, which have opportunities for fibreoptic intubation. Question Baseline simulation equipment airway months How would you rate your ability to manage 1 3 3 Four three-and-a-half hour out-of-theatre educational sessions are devoted to the following: a patient who was unexpectedly difficult to (1-2) (3-3) (3-3) (i) Self-guided endoscopy dexterity training using Dexter. intubate? N=9 P=0.011 P=0.011 (ii) ENT outpatient clinic. (iii) Two respiratory medicine bronchoscopy lists. How would you rate your ability to manage 1 3 3 a patient who was unexpectedly difficult to (1-2) (3-3) (3-3) Theatre clinical sessions which have opportunities for fibreoptic intubation drawn from: intubate and unexpectedly difficult to bag P=0.008 P=0.011 (i) Two maxillofacial lists. and mask ventilate? N=9 (ii) Two thyroid surgery lists. These sessions constitute 64 elective operating lists a year used for this teaching purpose. Do you feel confident that you would know 2 4 3 4 when it is appropriate to perform a surgical (2-3) (3-4) (2-3) (3-4) Trainees are also encouraged to use the bronchoscopy simulator at the skills laboratory at the Australasian College airway on an anaesthetised patient? N=9 P = 0.012 P=0.026 P = 0.008 of Surgeons, however specific training time is not allocated to this. If you had to perform a surgical airway, how 2 3 3 AUDIT SURVEY competent would you feel to do it? N=14 (1-2) (3-4) (2-4) As part of audit for the airway refresher6 we developed a brief survey (table 3). Trainees who completed the airway P=0.001 P = 0.001 refresher in the first part of 2011 were asked eight questions assessing their confidence at managing important airway situations before commencing the program, immediately after the relevant education session and then four How well could you manage a patient 2 2 3 3 months later (see table 3). Questions were designed for the participant to choose a discrete numbered box response who can’t breathe or be ventilated via (1-3) (2-4) (3-3) (2-4) from one to five, with one indicating a beginner and five an expert. All forms were completed voluntarily and their tracheostomy tube? N=9 P = 0.015 P = 0.011 P=0.008 anonymously. The hospital ethics committee approved the survey. Changes in confidence scores were analysed Do you feel confident you would choose an 2 3 4 as ordinal categorical data using the Wilcoxon matched pairs signed-rank test, with a p-value of 0.05 considered appropriate management plan for a patient (1-4) (2-4) (3-4) to be statistically significant. The group scores are presented as medians. who presented with a difficult airway? N=11 P = 0.052 P=0.026 Twenty three trainees were eligible to complete the survey. To make comparisons meaningful, only the responses of the participants who completed the commencement form, the relevant session audit form and the form four How well could you manage a patient who 2 4 4 months post-training were included in the analysis. In all eight questions there was a significant increase in the presented with acute upper airway (1-3) (3-4) (3-4) trainees self perceived confidence levels after four months. In seven of the eight questions there was also a significant obstruction? N=11 P = 0.006 P = 0.010 increase in the trainees self-perceived confidence levels immediately following the session. Our survey demonstrates a persisting one-step improvement of median response in the participants’ self-perceived ability. We recognise that How well could you perform an awake 1 2.5 2 this is not the same as an objective assessment of competence. As part of ongoing quality and governance we will fibreoptic intubation? N=14 (1-3) (2-4) (2-4) repeat the survey on future participants in our airway training. P = 0.004 P = 0.011 Comparisons were performed using the Wilcoxon matched pairs signed-rank test. N = number analysed (completed both relevant session and four month form). CONCLUSION Our airway training program contains features (table 1) derived from the available literature as well as from direct communication with those with a particular interest in airway education. While we cannot comment on benefits to patient safety, our audit suggests trainees may benefit from the airway refresher component of the program. The Austin airway training program undergoes constant change to meet the needs of our trainees and their training body5. We think our airway training has features that may interest other centres. No author has a conflict of interest. ACKNOWLEDGEMENTS Dr Will Howard edited the manuscript and provided valuable feedback. Thanks to all contributors to airway training at Austin Health since 2006. Special thanks to Drs G Brace, H Deifuss, C Fiddes, R Gebert, J Geertsema, G Godsall, E Kayak, J Kok, W Howard, L Ellard, L Aykut, J Colin- Thome, J Cornes, J Fernandes, T Kelly, C Kolivas, C Lai, P Laverty, I Letson, E Mariampillai, S Matzelle, M McDonald, A Nanuan, L O’Shea, and to M Dunstan, F Nasra. Special thanks also to: the Department of Anaesthesia, anaesthesia nursing staff, theatre technical staff, Austin Simulation Centre, Department of Respiratory Medicine staff, Radiology Department, Ear Nose and Throat Unit, Thoracic Surgical Unit, Intensive Care Unit, Medical Engineering and the Australasian College of Surgeons Skills Laboratory. For airway training sessions: Cook supplied some airway disposables, Covidien a Manujet ventilator, and CR Kennedy a Pentax AWS laryngoscope. 8 Australasian Anaesthesia 2013 Evolution of airway training at a large metropolitan teaching hospital 9 REFERENCES 27. Colt HG, Crawford SW, Galbraith O, 3rd. Virtual reality bronchoscopy simulation: a revolution in procedural 1. Mason RA. Education and training in airway management. Br J Anaesth 1998;81(3):305-7. training. Chest 2001;120(4):1333-9. 2. Baker PA, Weller JM, Greenland KB, Riley RH, Merry AF. Education in airway management. Anaesthesia 2011;66 28. Byrne A. What is simulation for? Anaesthesia 2012;67(3):219-25. (Suppl 2):101-11. 29. Shaw J, Frerk C, Russell J. A commentary on human factors aspects of cases reported to NAP4. In: Cook T, 3. Gibbs N, Borton C. Safety of anesthesia in Australia: a review of anaesthesia related mortality 2000-2002. Woodall N, Frerk C, editors. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Report of the Committe convened under the auspices of the Australian and New Zealand College of Airway Society: Major complications of airway management in the United Kingdom: the Royal College of Anaesthetists 2006. Anaesthetists and the Difficult Airway Society; 2011. pp. 193-201. 4. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth 30. Frerk C, Cook T. Management of the ‘can’t intubate can’t ventilate situation and the emergency surgical airway’. National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. In: Cook T, Woodall N, Frerk C, editors. 4th National Audit Project of the Royal College of Anaesthetists and the Br J Anaesth 2011;106(5):617-31. Difficult Airway Society: Major complications of airway management in the United Kingdom: the Royal College 5. ANZCA. Australian and New Zealand College of Anaesthetists Curriculum Revision 2013. 2013 From: of Anaesthetists and the Difficult Airway Society; 2011. pp. 105-13. http://www.anzca.edu.au/training/curiculum-revision-2013. Accessed April 2012. 31. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a 6. Cook TM. (Still) time to organise training in airway management in the UK. Anaesthesia 2006;61(8):727-30. closed claims analysis. Anesthesiology 2005;103(1):33-9. 7. Pott LM, Randel GI, Straker T, Becker KD, Cooper RM. A survey of airway training among US and Canadian 32. Mulligan M. NAP4 Report (reply to ANZCA Bulletin September 2011, p48-49). ANZCA Bulletin March 2012:59. anesthesiology residency programs. J Clin Anesth 2011;23(1):15-26. 33. Greenland KB, Acott C, Segal R, Goulding G, Riley RH, Merry AF. Emergency surgical airway in life-threatening 8. Gemmell L, Huggins D, Coates T. Organisation and equipment. In: Cook T, Woodall N, Frerk C, editors. 4th acute airway emergencies – why are we so reluctant to do it? Anaesth Intensive Care 2011;39(4):578-84. National Audit Project of The Royal College of Anaesthetists and the Difficult Airway Society: Major complications 34. Heard AM, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm of airway management in the United Kingdom: The Royal College of Anaesthetists and the Difficult Airway into clinical practice. Anaesthesia 2009;64(6):601-8. Society; 2011. p. 187-92. 35. Massey S, Blackford D, Murray D. Royal Perth Hospital solution for managing the ‘can’t intubate, can’t ventilate’ 9. Weller J, Morris R, Watterson L, Garden A, Flanagan B, Robinson B, et al. Effective Management of Anaesthetic crisis. Br J Anaesth 2011;107(4):636; author reply -8. Crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education 36. Watterson L. Preparedness to manage the ‘can’t intubate-can’t oxygenate’ event. ANZCA Bulletin 2012:56-9. in Australia and New Zealand. Simul Healthc 2006;1(4):209-14. 37. Burke LP, Osborn NA, Smith JE, Reid AP. Learning fibreoptic skills in ear, nose and throat clinics. Anaesthesia 10. Watterson L. Effective Management of Anaesthesia Crises; instructors manual ANZCA. 2003. 1996;51(1):81-3. 11. Fibreoptic airway workshop. The Royal Melbourne Hospital; From:http://www.anaesthesia.mh.org.au/ 38. Mason RA. Learning fibreoptic intubation: fundamental problems. Anaesthesia 1992;47(9):729-31. www/560/1001127/displayarticle/1001246.html. Accessed 30 July 2013. 39. Harper J, Rangasami J, Cook T. Major airway events in patients with a tracheostomy. In: Cook T, Woodall N, 12. The airway site. From:http://www.theairwaysite.com/pages/page_content/Airway_home.aspx. Accessed Frerk C, editors. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society: 30 July 2013. Major complications of airway management in the United Kingdom: the Royal College of Anaesthetists and the 13. Airway skills. From: http://www.airwayskills.co.nz/page.php?1. Accessed 30 July 2013. Difficult Airway Society; 2011. pp. 121-8. 14. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the 40. Hooper L. Tracheostomy management in the intensive care unit. In: Russell C, Matta B, editors. Tracheostomy management of tracheal extubation. Anaesthesia 2012;67(3):318-40. a multiprofessional handbook. Cambridge: Greenwich Medical; 2004. pp. 115-42. 15. Cook T, Woodall N, Frerk C. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult 41. TRAMS Service. Tracheostomy Care Resources: a guide to the creation of site specific tracheostomy procedures Airway Society: Major complications of airway management in the United Kingdom: the Royal College of and education. Austin Health;2006. Anaesthetists and the Difficult Airway Society; 2011. From: http://www.rcoa.ac.uk/nap4. Accessed 30 July 2013. 42. Russell C. Tracheostomy tubes. In: Russell C, Matta B, editors. Tracheostomy a multiprofessional handbook. 16. Stringer KR, Bajenov S, Yentis SM. Training in airway management. Anaesthesia 2002;57(10):967-83. Cambridge: Greenwich Medical; 2004. pp. 85-114. 17. Practice guidelines for management of the difficult airway: an updated report by the American Society of 43. Myles P, Haller G. Using an incident reporting system to improve anaesthetic care: a study on undesireable Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98(5):1269-77. events at the beginning of a new year. ANZCA Bulletin. December 2009:50-1. 18. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the 44. Boet S, Borges BC, Naik VN, Siu LW, Riem N, Chandra D, et al. Complex procedural skills are retained for a unanticipated difficult intubation. Anaesthesia 2004;59(7):675-94. minimum of 1 yr after a single high-fidelity simulation training session. Br J Anaesth. 2011;107(4):533-9. 19. Australian and New Zealand College of Anaesthetists. PS56 ANZCA Guidelines on Equipment to Manage a 45. Smith JE, Mackenzie AA, Scott-Knight VC. Comparison of two methods of fibrescope-guided tracheal intubation. Difficult Airway During Anaesthesia. 2012. From: http://www.anzca.edu.au/resources/professional-documents. Br J Anaesth 1991;66(5):546-50. Accessed January 2012. 46. Mallios C. A modification of the Laerdal anaesthesia mask for nasotracheal intubation with the fiberoptic 20. Baker PA, Flanagan BT, Greenland KB, Morris R, Owen H, Riley RH, et al. Equipment to manage a difficult airway laryngoscope. Anaesthesia 1980;35(6):599-600. during anaesthesia. Anaesth Intensive Care 2011;39(1):16-34. 47. Higgs A, Clark E, Premraj K. Low-skill fibreoptic intubation: use of the Aintree catheter with the classic LMA. 21. Baker PA, Hounsell GL, Futter ME, Anderson BJ. Airway management equipment in a metropolitan region: an Anaesthesia. 2005;60(9):915-20. audit. Anaesth Intensive Care 2007;35(4):563-9. 48. Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 22. Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and 1997;52(6):552-60. solutions. Br J Anaesth 2004;92(6):870-81. 49. Chisholm DG, Calder I. Experience with the McCoy laryngoscope in difficult laryngoscopy. Anaesthesia 23. Wheeler M, Roth AG, Dsida RM, Rae B, Seshadri R, Sullivan CL, et al. Teaching residents pediatric fiberoptic 1997;52(9):906-8. intubation of the trachea: traditional fiberscope with an eyepiece versus a video-assisted technique using a 50. Dhonneur G, Abdi W, Amathieu R, Ndoko S, Tual L. Optimising tracheal intubation success rate using the Airtraq fiberscope with an integrated camera. Anesthesiology 2004;101(4):842-6. laryngoscope. Anaesthesia. 2009;64(3):315-9. 24. National Airway Training Course for Anaesthesia Trainees. From: http://www.anaesthesia.mh.org.au/about- 51. Asai T, Liu EH, Matsumoto S, Hirabayashi Y, Seo N, Suzuki A, et al. Use of the Pentax-AWS in 293 patients with natcat/w1/i1001250/. Accessed 23 February 2013. difficult airways. Anesthesiology 2009;110(4):898-904. 25. Martin KM, Larsen PD, Segal R, Marsland CP. Effective nonanatomical endoscopy training produces clinical 52. Duggan LV, Law JA, Murphy MF. Brief review: Supplementing oxygen through an airway exchange catheter: airway endoscopy proficiency. Anesth Analg 2004;99(3):938-44. efficacy, complications, and recommendations. Can J Anaesth 2011;58(6):560-8. 26. Rowe R, Cohen RA. An evaluation of a virtual reality airway simulator. Anesth Analg 2002;95(1):62-6. 53. Law J, Duggan L. Extubation guidelines: use of airway exchange catheters. Anaesthesia 2012;67(8):918-9. 54. Ellis H, Feldman S, Lawson A. Anatomy for Anaesthetists. 7th ed: Blackwell Science, 1997.