BACKGROUND:There is no national or international consensus or guideline on recommended dosing of lidocaine for airway topicalization in children. Doses quoted in the literature vary substantially.AIMS:The primary aim of the study was to ascertain current international dosing practices (mg.kg-1 and concentration of solution) for lidocaine airway topicalization in children. The secondary aims included examining aftercare instructions for those receiving lidocaine airway topicalization and instances of local anesthetic systemic toxicity secondary to the use of lidocaine for airway topicalization in pediatric patients.METHODS:This cross-sectional study consisted of 11-20 questions across three domains-population demographics, clinical practice, and local anesthetic systemic toxicity. It adhered to the consensus-based checklist for reporting of survey studies. Responses were collected over 14 weeks using a combination of probability (cluster and simple random) and nonprobability (purposive, convenience and snowball) sampling. Data were analyzed based on the response rate per question with proportions expressed as percentages and nonparametric data expressed as median (interquartile range [range]) in an effort to minimize nonresponse error. No weighting of items or propensity scoring was applied.RESULTS:After initial exclusions, 1501 participants from 69 countries, across six continents, were included. Consultant anesthetists or those with an equivalent level of experience accounted for 1262/1501 (84.1%) of responses. Results showed heterogeneity in dosing and timing regimens and evidence that dosing may contribute to adverse outcomes. The maximum dose reported by participants who use lidocaine for airway topicalization as part of their normal practice was 5 mg.kg-1 (4-6 mg.kg-1 [0.5-50]) median (interquartile range [range]) over 2 h (1-4 h [0-30]).CONCLUSION:The results support the need for further research and consensus in this area, in order to provide safe provision of lidocaine airway topicalization in children. It is hoped the results of this study can support future collaborative work in this area.

Background and aims Bystanders should be protected against aerosols, droplets, saliva, blood and vomitus during resuscitation after cardiac arrest The SARUS (safer - airway - resuscitation) CPR airway hood™ is a clear plastic cover and integrated mask that envelopes the head and torso. Our objectives were to test leakage using saline aerosol generation tests, then assess the performance of the hood during mock cardio-pulmonary resuscitation on a manikin. Methods A checklist was validated by comparing the performance of 10 novices against 10 experts during mock resuscitation. Thereafter, 15 novices were tested with and without the hood, in a randomised cross-over study, one week apart. Results Laboratory analysis showed a > 99% reduction of saline particles detected 5 cm, 75 cm and 165 cm above volunteers wearing the hood. On manikins, experts scored better compared to novices, 8.5 (0.7) vs 7.6 (1.2), difference (95%CI) 0.9 (0.4–1.3), P = 0.0004. Novice performance was equivalent using the hood and standard equipment, 7.3 (1.4) vs 7.3 (1.1) respectively, difference (90%CI) 0.0 (−0.3 - 0.3), P = 0.90. Conclusion Aerosol transmission reduced in the breathing zone. Simulated resuscitation by novices was equivalent with and without the hood.

INTRODUCTION:Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy.METHODS:We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation.RESULTS:Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients.CONCLUSIONS:Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

It is now apparent that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) will remain endemic for some time. Improved therapeutics and a vaccine may shorten this period, but both are far from certain. Plans must be put in place on the assumption that the virus and its disease will continue to affect the care of patients and the safety of staff. This will impact particularly on airway management due to the inherent risk to staff during such procedures. Research is needed to clarify the nature and risk of respiratory aerosol-generating procedures. Improved knowledge of the dynamics of SARS-CoV-2 infection and immunity is also required. In the meantime, we describe the current status of airway management during the endemic phase of the COVID-19 pandemic. Some controversies remain unresolved, but the safety of patients and staff remains paramount. Current evidence does not support or necessitate dramatic changes to choices for anaesthetic airway management. Theatre efficiency and training issues are a challenge that must be addressed, and new information may enable this.

Alongside the dramatic increase in caesarean section rates in the UK over the last 40 years, there has been a significant trend away from general anaesthesia, with neuraxial anaesthesia now the preferred mode. General anaesthesia, with the attendant risks of failed intubation, hypoxaemia and pulmonary aspiration, is infrequently performed and is a significant source of anxiety for anaesthetists working on the labour ward 1, 2. In contrast to other areas of anaesthetic practice, obstetric general anaesthesia has been slow to evolve 3, 4. A significant development in this area of practice came in 2015, with the publication of the Obstetric Anaesthetists’ Association (OAA) and Difficult Airway Society (DAS) joint guidelines on the management of the unpredicted difficult airway in obstetric patients 5. These guidelines included three algorithms to support practice in: planning airway management in obstetrics; acute management of failed intubation; and management of a ‘can't intubate, can't oxygenate’ scenario. However, the issue of the predicted difficult airway in obstetrics was deliberately not tackled in these guidelines. In this issue of Anaesthesia, Mushambi et al. address this subject and offer guidance on how to manage such patients 6. This document, produced outside the OAA and DAS guidelines processes, is not a guideline per se, but instead a series of practice recommendations and algorithmic decision aids, based on an extensive literature review. This aims to offer a consistent approach to identifying and managing the pregnant woman with an at-risk airway. Such guidance is welcomed but will only be beneficial if readers are convinced of its validity and practicality. Historically, airway guidelines have been criticised for being based on low-quality evidence, having variable clinical uptake and failing to demonstrate a causal relationship between guideline adherence and outcome 7. The evidence presented is in the form of case reports, covering almost 40 years, describing the management of difficult obstetric airways in terms of approach – neuraxial anaesthesia or general anaesthesia with advanced airway techniques. This is low-level evidence by any classification but is all that is currently available. In the UK, a case series such as this is level-4 Oxford Centre for Evidence-based Medicine level of evidence. It will be debatable whether this evidence is sufficient to justify recommendations for practice, even when coupled with the known expertise of the authors. Certainly, demonstration of a causal relationship between following the recommendations and clinical outcomes appears challenging. The authors have chosen not to match their recommendations to a graded level of evidence. The pattern of publication of the included case reports is notable, with an almost equal number having been published between 2010 and 2019 as between the years 1980 and 2009. We respect the desire of the authors to provide an exhaustive case series but would question the relevance of some of the more historical data. Both obstetric and anaesthetic management have evolved hugely since 1981, and in particular, the progress of advanced airway techniques and devices. Management strategies that were undertaken in the 1980s and 1990s, at a time when supraglottic airways were regarded as novel devices and videolaryngoscopes were but a distant dream, are now of limited relevance. Many different techniques have been reported for the management of the challenging obstetric airway. These include those performed awake and those after the induction of general anaesthesia. A wide variety of rigid and flexible indirect laryngoscopy techniques have been employed, as have emergency and elective tracheostomy. A lack of consistency of approach reflects differing skill sets and preferences within individuals and departments, arguably justifying the need for guidance on a consistent approach in such scenarios. However, could such variability in practice simply reflect the management of the predicted difficult airway in all patients, not just those who are pregnant? Furthermore, the heterogeneity of the data makes its translation to the formulation of a guideline extremely difficult. There is insufficient information on individual cases to evaluate the relative success or failure of a particular technique. The authors of the fourth National Audit Project on serious complications of airway management assessed the quality of the airway management in their reported cases 8, a process that could not happen here with the methodology employed. The published cases in this series mostly present successful outcomes and not complications. However, the authors do reflect on what lessons we can learn regarding effective approaches to the challenging obstetric airway. Airway assessment is likely to be of benefit as it starts the process of antenatal airway planning, but we know how our assessment tools do not serve us well in predicting difficulty 9. Multidisciplinary discussion and strategy agreement involving anaesthetists, with regard to when and how to facilitate safe delivery, will promote best practice in airway management. In terms of airway techniques, videolaryngoscopy after induction of general anaesthesia may become commonplace and probably first line in obstetric general anaesthesia, but the term covers a gamut of devices and techniques, making a recommended approach difficult. Choice of Macintosh or hyperangulated blades, and channelled or non-channelled devices are currently more influenced by local factors rather than published evidence. Videolaryngoscopy may have a high success rate in the obstetric population, both when used as the primary device and when required as a rescue device following failed Macintosh intubation 10. The recently published Difficult Airway Society guidelines for awake tracheal intubation in adults recommend that awake tracheal intubation must be considered in the presence of predictors of difficult airway management 11. Awake videolaryngoscopy is likely to increase in popularity, perhaps to the detriment of awake flexible bronchoscopic intubation, which we know takes time when delays can be critical 12 and requires rehearsed proficiency that may not always be available 13. The challenges for obstetric anaesthesia are firstly, to ensure that those who need to use videolaryngoscopy are suitably trained and, secondly, to identify which videolaryngoscope devices are most effective in the obstetric population. This need is highlighted by the finding that one third of reported cases in this review did not reach their planned date for delivery and urgent contingency plans had to be implemented. This aspect, the unpredictability of labour and delivery, may be a weakness of the suggested algorithms. The role of high-flow nasal humidified oxygenation as a peri-intubation technique in obstetrics has yet to be defined. Studies evaluating the impact of high-flow nasal humidified oxygenation in obstetric patients found that it did not confer an advantage in pre-oxygenation, and performed worse than standard face mask techniques 14, 15. In these studies, the success of pre-oxygenation was assessed using end-tidal oxygen concentration as the primary outcome, and no patients received general anaesthesia. Currently, there are no clinical studies looking at the time to desaturation in the obstetric patient having general anaesthesia. However, in a computational model, the positive effect on oxygen saturation of increasing oxygen concentration at the open glottis during apnoea in the term parturient has been demonstrated 16. This, coupled with numerous case reports and work in the non-obstetric population, would strongly imply that high-flow nasal humidified oxygenation has an important role in maintaining oxygenation in the apnoeic period during obstetric general anaesthesia 17. Research in this patient group is fraught with difficulties, but evidence is required to answer this question. However, work on this topic is ongoing (Personal communication with R Hofmeyr). Airway rescue techniques also need to be considered. Pre-emptive neck ultrasound and marking of the cricothyroid membrane in cases of predicted difficulty have a role to play 18, and the high efficacy of supraglottic airway devices in airway rescue must not be forgotten 8. Mushambi's paper is less about airway management per se but highlights the need for evidence on the relative success of devices, approaches and techniques to truly inform clinical practice in obstetric anaesthesia. This will require prospective research or ‘big data’ retrospective collections. Arguably, the most controversial aspect of the recommendations in this paper surrounds the advice that planning during pregnancy should take account of the airway skills and equipment available out-of-hours and that, when these cannot be guaranteed, an elective caesarean section is advised. Regarding the ‘requisite advanced airway equipment’ referred to in Fig. 2 of the guidelines by Mushambi et al. 6, this predominantly describes videolaryngoscopes, flexible bronchoscopes and equipment for front-of-neck access. Despite the unanswered questions about videolaryngoscopy, we believe these devices should be mandatory equipment for any obstetric theatre. Furthermore, the issue of availability of the ‘appropriate skills for the airway plan’ raises an interesting point about clinical practice within our specialty. As sub-specialisation in anaesthesia has progressed, airway specialists have emerged. The Difficult Airway Society has been pivotal in developing standardised approaches to airway management in a variety of clinical situations. Part of this ethos centres around maintaining a set of skills that encompasses the ability to manage difficult tracheal intubation, requisite for all anaesthetists. The decision to undertake an elective caesarean section ‘for airway indication’ in a woman where there is no obstetric or fetal indication is, in our view, contentious. We would suggest that, in all but the most extreme cases, anaesthetic or airway reasons should not routinely be an indication for elective caesarean section. We acknowledge that this requires departments to ensure the presence of the appropriate equipment and skill provision to deliver advanced airway management at the time of need. The presumption that an elective caesarean section undertaken with neuraxial anaesthesia will avoid the risks of general anaesthesia and airway control is erroneous, as demonstrated by several cases in Mushambi et al.'s literature review where general anaesthesia had to be undertaken when the neuraxial technique failed. Similarly, half of the obstetric cases described in NAP4 occurred when general anaesthesia was administered after an inadequate neuraxial technique 8. An analogous clinical situation to planning delivery for a woman with an anticipated difficult airway might be a woman with an elevated body mass index (BMI). A UK national cohort study compared outcomes in pregnant women with BMI ≥ 50 kg.m−2 between those who planned to deliver vaginally and those who planned to deliver by caesarean section 19. The authors of this study found there were no significant differences in anaesthetic, postnatal or neonatal complications between the two groups, with the exception of shoulder dystocia. It could be argued that a department that cannot provide out-of-hours advanced airway management in obstetrics should consider the transfer of such cases to another unit, rather than offering elective caesarean section. The paper emphasises the important role of neuraxial analgesia in the care of a woman with an anticipated difficult airway. An oft-cited advantage of labour epidural analgesia is the ability to convert reliably to an anaesthetic block, should caesarean section be required. The authors highlight that there is evidence that the reliability of epidural analgesia is enhanced when a combined spinal-epidural approach is used. One of the most critical indicators of an effective epidural, apart from analgesia, is the absence of a requirement for clinician intervention with additional top-ups. Our final point is to stress that labour epidurals must be actively reviewed, particularly in a patient with an anticipated difficult airway, and managed with early recourse to resiting if concern exists about a lack of efficacy. In summary, this paper tackles an important issue and should be commended. While some may have reservations on the evidence base used in making their recommendations, others will find such recommendations extremely informative. Expert opinion on retrospective data is the basis for most published airway guidelines and, although not considered to be a high level of evidence, should not be ignored. These recommendations may raise further debate on the matter, but it seems highly unlikely that future authors will produce guidance with stronger evidence, at least not until prospective national data in obstetric anaesthesia are collected, along the lines of the Royal College of Anaesthetists National Audit Projects. No external funding or competing interests declared.

................................................................................................................................................................. Correspondence to: B.McGuire Email: president@das.uk.com Accepted: 9 July 2020

Severe acute respiratory syndrome-corona virus-2, which causes coronavirus disease 2019 (COVID-19), is highly contagious. Airway management of patients with COVID-19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID-19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID-19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID-19. The advice in this document is designed to be adapted in line with local workplace policies.

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

to produce desired changes [2], so convened a group of enthusiastic anaesthetists with an interest in trauma and hip fracture anaesthesia to address these issues. We have achieved significant improvement in structure, process and outcome measures [3], building on those reported in the 2014 National Anaesthesia Sprint Audit of Practice (ASAP) [4]. Robust, local, data-based information has been an essential component for demonstrating continuous improvement as part of our quality improvement programme. We introduced a consultant ‘anaesthetist of the week’ to provide consistent day-time care over a 7-day period, to assist standardisation, reduce operative delay/cancellation and ensure continuity of communication with the orthogeriatrics services; specialist orthopaedic surgeons undertake a similar rota pattern, enabling continuity of care and consistent decision-making. The ‘anaesthetist of the week’ is paired with a second anaesthetist for at least one session Monday to Friday, enabling them to undertake regular ward rounds, and co-ordinate peri-operative care, particularly analgesia, fluid management, consent issues and pre-operative optimisation. Anaesthetic techniques and peri-operative care were standardised into standard operating procedures, based on the best evidence and guidance available. Continual feedback and multidisciplinary standardised care has been key to our improvement, and I commend these processes to other clinicians and hospitals. S. Sivasubramaniam Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK Email: s.sivasubramaniam@nhs.net

Laryngo-tracheal surgery presents the anaesthetist with numerous challenges including a shared airway with potential for airway compromise pre-, intra- or postoperatively. Surgical desire for a tubeless field in patients with acute or chronic laryngeal or tracheal pathology can be a daunting prospect for anaesthetists unfamiliar with these techniques. With careful preoperative planning and multidisciplinary communication, the most appropriate strategy for oxygenation and anaesthesia can be agreed.

We compared the performance of the McGrath® Series 5 videolaryngoscope with the Macintosh laryngoscope in 49 patients without suspected cervical spine pathology, whose cervical spine was immobilised using a semi-rigid collar. The primary outcome was the view obtained at laryngoscopy. Secondary outcomes included time to tracheal intubation, rates of successful intubation and incidence of complications. In all patients, the view was better (92%) or the same (8%) in the McGrath group versus the Macintosh group (p < 0.01). There were no failed intubations in the McGrath group and seven (28%) in the Macintosh group (p < 0.02). There was no statistical difference in time taken to intubate or incidence of complications. We conclude that the McGrath® Series 5 is a superior laryngoscope when cervical spine immobilisation is maintained during tracheal intubation.

We and two colleagues (one senior trainee, three consultants, with a combined anaesthetic experience of 74 years) recently embarked on what we considered to be a service evaluation relating to a tracheal extubation technique used in our head and neck surgery theatres. As clinicians with a special interest in anaesthesia for head and neck surgery, we aim to provide the best conditions for our surgical colleagues and we commonly evaluate drugs, equipment and techniques involved within this sub-specialty. The Difficult Airway Society (DAS) extubation guidelines 1 refer to advanced techniques in the management of the perceived ‘at-risk’ extubation. As a group, we felt that these techniques are not always as straightforward as the literature might suggest. Hence, we viewed that exploring one of the techniques described, namely supraglottic airway device (SAD) exchange (Bailey's manoeuvre 2), was justified. We decided to perform an evaluation of this specific technique in clinical practice as we felt there were very limited published data to support this as a good technique. The aim was to examine the efficacy and safety of the exchange. An essential component of performing a SAD exchange is to ensure an adequate depth of anaesthesia and/or neuromuscular blockade. Hence, we proposed to perform the exchange under deep general anaesthesia and full neuromuscular blockade using routinely used drugs, including desflurane, remifentanil and rocuronium, before reversal of paralysis with neostigmine or sugammadex. The aim was the demonstration of safe, smooth emergence from anaesthesia following head and neck surgery, without airway excitation. We wrote to the Local Research Ethics Committee (LREC), seeking approval for the project without needing formal NHS ethical review. This was duly granted. We also sought and obtained approval by the Caldicott Guardian to use routinely recorded and patient/procedure-specific (non-identifiable) data to support the evaluation. We did not register the project with the Clinical Governance Department as it was our understanding that this was not a formal requirement, although we have subsequently learnt that the Research and Development Department does recommend such registration and that it was documented in the LREC literature (we, and colleagues we have since asked, were unaware of this at the time). In an attempt to obtain the most reliable data from the evaluation, we were advised to record a recommended technique including general anaesthetic drugs (Table 1) and SAD exchange according to the DAS extubation guidelines (Table 2). This was not deemed to be a ‘protocol’: the drugs were all routinely used for such cases, and it was not felt that there was rigidity regarding their administration. The SAD exchange technique is used on occasion in our institution, but is not our ‘routine practice’ for the majority of cases. Suction airway under direct vision; place LMA Unique® and inflate cuff; deflate tracheal tube cuff and withdraw tube; attach breathing system to LMA Unique and ventilate using anaesthetic circuit, then Mapleson-C system Give sugammadex 200 mg or neostigmine 2.5 mg Observe accelerometer return to TOF ratio 90% and concurrently switch off remifentanil/desflurane Hand/machine ventilate lungs to confirm correct LMA Unique position Transfer to recovery area with LMA Unique and Mapleson-C system using spontaneous/assisted ventilation Remove LMA on awakening The first two patients in the evaluation were given sugammadex following successful SAD exchange. Both developed apparent upper airway obstruction around 120 s after sugammadex 200 mg, having previously demonstrated an entirely patent airway with a square wave capnography trace and cuff seal pressures > 15 cmH2O. Both resolved spontaneously over 2-3 min with positive end-expiratory pressure (and without arterial desaturation). At this stage, we discussed the pathogenesis of this and reflected on the techniques and drugs used. We agreed to continue the evaluation and decided that, in subsequent patients, examination of the larynx with a flexible fibreoptic endoscope was indicated after sugammadex to help ascertain the likely cause of the apparent obstruction. We were uncertain of the reasons for the airway obstruction – was it simply related to inadequate depth of anaesthesia? In deciding to examine the glottis endoscopically in subsequent patients (something we do occasionally as part of our anaesthetic technique in head and neck surgery), we were unconsciously straying from the proposed project and technique. We did not discuss with subsequent patients any potential risk of the technique following the adverse event in the first two cases. At the time, this did not feel like an irresponsible decision, nor was it an attempt to disregard our ethical responsibilities. We proposed to continue the evaluation, with what we considered to be meticulous airway management, involving two senior head and neck anaesthetists planning the technique and present at all times, delivering smooth, safe anaesthesia with optimally maintained oxygenation throughout and quantitative neuromuscular monitoring to ensure complete reversal of paralysis. We proceeded with the evaluation, curious to explain our unexpected finding. Patient 3 had the same anaesthetic as the previous two, with the same pattern of airway obstruction after sugammadex administration. A fibrescope was inserted and we noted that the vocal cords were completely closed. This again self-resolved without arterial desaturation. We then made subtle variations to the anaesthetic drugs administered. Patient 4 had fentanyl rather than remifentanil; patient 5 received sevoflurane maintenance rather than desflurane; patient 6's neuromuscular blockade was reversed with neostigmine rather than sugammadex; patient 7 underwent SAD exchange ‘unparalysed’ (train-of-four (TOF) ratio > 90%); patient 8 had a volatile-free anaesthetic with propofol by target-controlled infusion (TCI), and patient 9 had propofol, rocuronium, fentanyl, sevoflurane and sugammadex. All patients who received sugammadex experienced very similar transient upper airway obstruction following administration, regardless of any changes in other anaesthetic drugs. One patient experienced arterial desaturation to 90% which resolved rapidly; no other patients experienced any desaturation. The patient receiving TCI propofol rather than volatile agent appeared to have less airway obstruction, while those receiving neostigmine or no reversal had no obstruction. Three patients underwent fibreoptic examination of the glottis after sugammadex and all demonstrated powerful adduction of the vocal cords, commencing ~2 min after sugammadex and coinciding with a return of TOF ratio > 90%, i.e. confirmed full muscle power. This resolved spontaneously and entirely after a further 3 min. We concluded that the administration of sugammadex was resulting in a rapid increase in upper airway tone. At this point, we decided to cease the evaluation, now convinced that we had indeed unearthed an adverse effect of sugammadex in patients with unintubated tracheas. We proceeded to write up our findings and submitted what we termed a ‘case series audit’ to Anaesthesia. After a slightly protracted wait for a reply (the reason for which soon became clear), we received a disappointing, but detailed letter from the Editor-in-Chief of Anaesthesia; ‘disappointing’ because, on reading the first paragraph, we realised that we had a (big) problem. The editorial team had raised some ‘serious ethical issues’; a number of not unreasonable concerns were listed and several key questions were asked. These included: whether we had halted the study and sought advice from the LREC after the initial three patients; whether we had discussed with them the change in ‘protocol’; whether we had reported the adverse findings locally; whether the risks of Bailey's manoeuvre were discussed with patients; and whether patients had given consent for fibreoptic examination of the glottis. There was also concern whether this technique was genuinely ‘routine’ practice for such surgery. What exactly constitutes routine practice is a moot point. Anaesthetists in our institution do use Bailey's manoeuvre for some ‘at-risk’ extubations, but we accepted that it was not routine enough in our unit to justify this project as a ‘service evaluation’ for this group of patients. All of these concerns and queries were reasonable and we all felt contrite and somewhat naïve in equal measure. Our patients had given written consent for fibreoptic examination, but otherwise we had a negative response to the remainder of the aforementioned queries. However, we also felt that we had given extremely safe anaesthesia throughout, with optimal patient care, and that our finding may be of significant clinical relevance to the general anaesthetic community. Documentation was requested – all the correspondence leading to the LREC's waiver of the need for a formal ethical application and all other communications with the Research and Development Department, Clinical Governance Department and Caldicott Guardian. We had a very helpful telephone conversation with the Editor-in-Chief, who, by that stage, had already spoken with the LREC chairperson in our Trust. The issue of patients’ consent was again raised. One could argue that the LREC's opinion was that formal ethical review was not required. However, the reviewers felt that consent was still indicated in this case, particularly if their care was not considered ‘routine’. This issue became more acute once complications had arisen and in retrospect, it was apparent that at this stage it had been unwise of us to continue without seeking ethical advice. We attempted to answer all the questions asked, but our failings remained evident and concerning, perhaps now more for our Trust rather than the Journal. Our LREC chairperson voiced similar concerns to those of the editors, centred on what was deemed routine practice in our patient group and failings in communication with them and the LREC. In our defence, we cited our absolute commitment to safe anaesthesia, but also our comfort dealing with all of the complexities of anaesthesia for head and neck surgery, including challenging airway management scenarios such as these. However, we acknowledged that we had become distracted by the unexpected clinical finding. We also felt that there was a lack of clarity regarding the exact processes and regulations that come under the academic umbrella of research/audit/service evaluation. Arguably, this uncertainty extends into issues of consent, risk evaluation and explanation, particularly for academic work not deemed to be research. Was this project service evaluation, case series audit or scientific research? Despite attempts to provide clear guidance, there are many grey areas and it can be difficult to define what some have described as indefinable 3. Were we unwise to formulate a ‘protocol’ for general anaesthesia and SAD exchange, i.e. did this essentially make our project research? We didn't consider at any stage that we were in fact performing research. It was agreed that a Local Adverse Event Review (LAER) would take place involving the clinicians concerned, our Anaesthesia Clinical Director, representatives from the LREC, Risk Management and Clinical Governance Departments and two local, non-anaesthetic consultant colleagues. The resultant report criticised our failure to seek consent or provide written information of the procedure and any potential risks, our failure to stop the evaluation once a problem had been observed, and our decision to alter the proposed technique without discussion with the LREC. However, the panel acknowledged that we felt we were working under the umbrella of service evaluation. We received support from our non-anaesthetic colleagues, who stressed that our desire to improve clinical practice by developing skills and techniques was evident and has been a part of our practice for many years. There was also acknowledgement that, unlike research projects within the remit of the LREC, where stringent supervision takes place, there was no such facilitation of our project and that perhaps this could be more explicit in future work of this ilk. The LAER concluded with the recommendation to proceed to a Significant Clinical Event Analysis (SCEA). The SCEA was chaired by the Trust's Medical Director. The stated aims were to: establish the background and sequence of events surrounding the case; identify the underlying contributory factors in Trust management and organisational systems; identify lessons learned; and develop a list of recommendations to prevent similar, future incidents. Finally, the SCEA required communication of any findings and recommendations amongst relevant individuals and the organisation as a whole. The process began with positive aspects. These included our completing a British National Formulary ‘yellow alert’ card and informing the producers of sugammadex of our findings before submitting the original manuscript. Despite our failed local communication of the adverse finding, our initial contact with the Caldicott Guardian and LREC was commended, as were our regular discussions within the project team and liaison with clinical colleagues. As clinicians, we were all up-to-date with our personal appraisals and Good Clinical Practice training, and it was noted that patient safety had been paramount in our clinical conduct throughout the evaluation. The criticisms had largely been covered during the LAER and were summarised before agreement of the key learning points and actions required. The main learning point related to our transition from evaluation/improvement project to what was essentially clinical research: all that we failed to do should have been done! We agreed to design an online module for education within the Trust to help others avoid our mistakes; this would clarify the distinction between service evaluation, audit and research, and stress what is required for each in terms of ethics, governance, consent and communication. The SCEA also asked our Clinical Governance Department to review its processes of project surveillance, support and guidance in order to prevent similar mistakes by overzealous clinicians. Finally, we were requested to write to the patients we had evaluated, explaining what had happened and offering each the opportunity for further discussion. All consented to the publication of this article. As two of the clinicians involved in this whole process, we have to stress that we all felt extremely supported throughout, both locally and by the Editor-in-Chief on behalf of Anaesthesia. The submitted manuscript to Anaesthesia, titled ‘Unexpected airway obstruction following sugammadex’, described our nine cases in sequence and our perception of the accumulating evidence that we had witnessed laryngospasm secondary to sugammadex administration. We included ‘before and after’ photographs as the glottis changed from full patency to opposed vocal cords. Video footage, via the fibrescope through the SAD, was the most compelling of all the evidence. The apparent clarity of our finding and our interpretation of its potential significance further blinkered us. At the outset, it had never been our intention to publish our data. It had been planned as a small service evaluation project that might have provided data that could be presented locally or perhaps nationally. Our decision to publish subsequently, as a case series, related to our desire to share an unexpected and potentially significant finding with the anaesthetic community. A case report by Curtis et al. 4 describes use of sugammadex in a ‘can't intubate, can't ventilate’ scenario. They stated that “rocuronium induced neuromuscular block was successfully reversed by sugammadex as evidenced by the restoration of diaphragmatic movement, the ability of the patient to move her limbs, and the presence of a train-of-four nerve stimulation with no fade; however, ventilation was still not possible”. An emergency cricothyroid puncture was required for rescue oxygenation. Another case report by Paton et al. 5, in which sugammadex was used following a failure to ventilate, states: “Approximately 1 minute after receiving sugammadex (3-4 minutes post induction), the patient began to show signs of spontaneous respiratory effort. Eye opening occurred shortly thereafter. Throughout this period, oxygen saturation remained 100%. There then followed a difficult few minutes with improving spontaneous effort against a degree of upper airway obstruction.” We consider that both these cases fitted into the timescale we observed for laryngospasm secondary to sugammadex, with the latter a contributing factor to the problems encountered. Finally, the purpose of this article is two-fold: to lay bare the perils of performing small scale academic work; and, once again, to raise the possibility that a drug used relatively commonly in anaesthetic practice may have a serious unwanted effect. We wish to thank our colleagues Drs Grant Rodney and Pavan Raju for their work with the clinical project and original paper. We also wish to thank Drs Carol Macmillan (LREC chair), Edward Wilson (Anaesthesia Clinical Director) and Andrew Russell (Medical Director) for their support and help throughout the process, and for granting permission to publish this article. Finally, we thank the patients involved who all kindly agreed to the publishing of this article. No external funding and no competing interests declared.

We compared the McGrath MAC(®) videolaryngoscope when used as both a direct and an indirect laryngoscope with a standard Macintosh laryngoscope in patients without predictors of a difficult tracheal intubation. We found higher median Intubation Difficulty Scores with the McGrath MAC as a direct laryngoscope, 1 (0-3 [0-5]) than when using it as an indirect videolaryngoscope, 0 (0-1 [0-5]) or when using the Macintosh laryngoscope, 0 (0-1 [0-5]), p = 0.04. This was mirrored in the subjective user reporting, scored out of 10, of difficulty for each method 3.0 (2.0-3.4 [0.5-80]); 2.0 (1.0-3.9 [0-70]) and 2.0 (1.0-3.3 [0-70]), respectively (p = 0.01). This difficulty is in part explained by the poorer laryngeal views recorded using the Cormack and Lehane classification system (p < 0.001) and reflected in the higher than normal operator force required (25%, 4%, 8% for each method, respectively, p < 0.001) and the increased use of rigid intubation aids (21%, 6%, 2%, respectively, p < 0.001). There was no difference between the groups in time taken to intubate or incidence of complications. There was no statistical difference in the performances as measured between the McGrath MAC used as an indirect videolaryngoscope and the Macintosh laryngoscope. We cannot recommend that the McGrath videolaryngoscope be used as a direct laryngscopic device in place of the Macintosh.

In 1958, aspiration was credited as the largest cause of anaesthesia-related death by Snow and Nunn. Surprisingly, this remains the case in 2011. The Royal College of Anaesthetists National Audit Project (NAP4) calculated the incidence of fatal aspiration during general anaesthesia as one in 340 000, but acknowledging that as a probable underestimate, reported that it may be as common as one in 45 000. The risk of aspiration itself is estimated at one in 2–3000 during elective surgery and one in 6–800 during emergency surgery. Potential consequences of aspiration include chemical pneumonitis, bacterial aspiration pneumonia, acute respiratory distress syndrome, and death. While recognizing the lack of a clear definition, NAP4 recommended that, in those patients at risk of regurgitation and subsequent aspiration, a rapid sequence induction (RSI) with cricoid pressure should be the technique of choice to induce anaesthesia. However, RSI as a practice is not without risk, particularly in the critically ill population. Risks include hypoxia, failed intubation, oesophageal trauma, cardiovascular compromise, and awareness. We will describe how modern practice has deviated from the traditional, standardized RSI to an approach where management of the patient at increased risk of aspiration involves an assessment of all risks to identify suitable techniques designed to minimize those risks for that individual.

Almost 20% of adverse airway events reported to the Royal College of Anaesthetists 4th National Audit Project (NAP4) occurred in the ICU [1]. NAP4 commented that the failure to use capnography probably contributed to 77% of the ICU airway mortality. NAP4 subsequently made a number of recommendations pertaining to capnography use. We designed a survey to describe practice with regards to these.