AbstractObjectiveThis study aimed to compare the cost per use of video-rhinolaryngoscopy using reusable and disposable devices in a tertiary referral centre.MethodsA cost-comparison study was performed that utilised retrospective cost data and prospective utilisation data to compare the total costs of using reusable video-rhinolaryngoscopes versus a single-use alternative.ResultsIt was estimated that 4776 and 1821 procedures were performed annually with reusable and disposable video-rhinolaryngoscopes, respectively. The cost per use was £66.61 for reusable devices versus £150.00 for disposable devices. The break-even point (i.e. when cost per use was equal, occurred at 1374 procedures per year). Thereafter, it was cheaper to use reusable devices.ConclusionDisposable rhinolaryngoscopes may present a cheaper solution to services with low rates of rhinolaryngoscope utilisation. However, for larger services considering replacement of their reusable rhinolaryngoscopes with disposable units, it is likely that the recurring costs will be prohibitive in the medium to long term.

Background There is an association between video game practice and laparoscopic expertize in trainee surgeons. Ultrasound-guided regional anesthesia has many parallels with laparoscopic surgery. The aim of this study was to explore whether video game experience is associated with enhanced performance in a simulated ultrasound-guided task in novice operators. Methods In this prospective observational study, 60 medical student volunteers were recruited. Following characterization of video game experience, they underwent an assessment of visuospatial abilities. Following standardized teaching, the recruits' technical performance of an ultrasound-guided needle task was assessed for overall quality by global rating scale (GRS). Results Out of a total possible GRS score of 35, gamers compared with non-gamers demonstrated 5.2 (95% CI 1.9 to 8.4) units of better performance. Gamers also performed better in mental rotation test scores (difference 4.1, 95% CI 1.2 to 7.0). Conclusion Video game practice is associated with increased mental rotation ability and enhanced technical performance in a simulated ultrasound-guided task.

BACKGROUND:The effect of mental rotation training on ultrasound-guided regional anaesthesia (UGRA) skill acquisition is currently unknown. In this study we aimed to examine whether mental rotation skill training can improve UGRA task performance by novice operators.METHODS:We enrolled 94 volunteers with no prior experience of UGRA in this randomised controlled study. After a baseline mental rotation test, their performance in a standardised UGRA needling task was independently assessed by two raters using the composite error score (CES) and global rating scale (GRS). Volunteers with low baseline mental rotation ability were randomised to a mental rotation training group or a no training group, and the UGRA needling task was repeated to determine the impact of the training intervention on task performance. The study primary outcome measure was UGRA needling task CES measured before and after the training intervention.RESULTS:Multivariate analyses controlling for age, gender, and previous performance showed that participants exposed to the training intervention made significantly fewer errors (CES B=-0.66 [standard error, se=0.17]; P<0.001; 95% confidence interval [CI], -0.92 to -0.26) and displayed improved overall performance (GRS B=6.15 [se=2.99], P=0.048, 95% CI=0.06 to 12.13) when undertaking the UGRA needling task.CONCLUSIONS:A simple training intervention, based on the manipulation and rotation of three-dimensional models, results in improved technical performance of a UGRA needling task in operators with low baseline mental rotation skills.

In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.

Prediction of the difficulty of an airway is unreliable, and failure of one technique of management increases the likelihood of failure of subsequent interventions. Part 2 of this review describes strategies to avoid or mitigate the impact of failure, and the associated airway-related morbidity and mortality.

BACKGROUND:We examined the validity and reliability of the previously developed criterion-referenced assessment checklist (AC) and global rating scale (GRS) to assess performance in ultrasound-guided regional anaesthesia (UGRA). METHODS:Twenty-one anaesthetists' single, real-time UGRA procedures (total: 21 blocks) were assessed using a 22-item AC and a 9-item GRS scored on 3-point and 5-point Likert scales, respectively. We used one-way analysis of variance to compare the assessment scores between three groups (Group 1: ≤30 blocks in the preceding year; Group 2: 31-100; and Group 3: >100). The concurrent validity was evaluated using Pearson's correlation (r). We calculated Type A intra-class correlation coefficient using an absolute-agreement definition in two-way random effects model, and inter-rater reliability using an absolute agreement between raters. The inter-item consistency was assessed by Cronbach's α. RESULTS:The greater UGRA experience in the preceding year was associated with better AC [F (2, 18) 12.01; P<0.001] and GRS [F (2, 18) 7.44; P=0.004] scores. There was a strong correlation between the mean AC and GRS scores [r=0.73 (P<0.001)], and a strong inter-item consistency for AC (α=0.94) and GRS (α=0.83). The intra-class correlation coefficient (95% confidence interval) and inter-rater reliability (95% confidence interval) for AC were 0.96 (0.95-0.96) and 0.91 (0.88-0.95), respectively, and 0.93 (0.90-0.94) and 0.80 (0.74-0.86) for GRS. CONCLUSIONS:Both assessments differentiated between individuals who had performed fewer (≤30) and many (>100) blocks in the preceding year, supporting construct validity. It also established concurrent validity and overall reliability. We recommend that both tools can be used in UGRA assessment.

In this review we describe the evidence base for postoperative analgesia after maxillofacial surgery. We discuss the implications of poorly managed pain, risk factors for the development of severe pain, and pharmacological and non-pharmacological analgesic strategies to manage it.

Editor'We would like to comment on two recent manuscripts that compared the performance of videolaryngoscopes in manikins and simulated difficult laryngoscopy in patients.1Kleine-Brueggeney M Greif R Schoettker P Savoldelli GL Nabecker S Theiler LG Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial.Br J Anaesth. 2016; 116: 670-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar2Pieters BMA Wilbers NER Huijzer M Winkens B van Zundert AAJ Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel.Anaesthesia. 2016; 71: 556-564Crossref PubMed Scopus (37) Google Scholar Both manuscripts provided useful steps in our understanding of the variability of intubation performance using videolaryngoscopes. Ultimately, they suggested that differences in performance between devices relate to their design, the nature of the airway difficulty, or indeed, the type of user. Anaesthetists quite rightly consider themselves expert in all matters airway. However, as a result we believe there is an unsupported assumption that somehow expertise in Macintosh laryngoscopy equates to similar levels of performance with novel laryngoscopes. Indeed, Kleine-Brueggeney and colleagues1Kleine-Brueggeney M Greif R Schoettker P Savoldelli GL Nabecker S Theiler LG Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial.Br J Anaesth. 2016; 116: 670-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar allowed their group of airway experts to self-assess their competence with videolaryngoscopes before study commencement. However, it is known that self-assessment of performance is subject to many confounders and is unreliable.3David DA Mazmanian PE Fordis M Harrison V Thorpe KE Perrier L Accuracy of physician self-assessment compared with observed measures of competence: a systematic review.JAMA. 2006; 296: 1094-1102Crossref PubMed Scopus (1574) Google Scholar Therefore, we believe that a major consideration in device performance is the current expertise of the user and the efficacy of any teaching intervention on skill acquisition. If we consider the two studies in question, the recruits had little opportunity to learn and practise with videolaryngoscopes, which they had seldom if ever used, thus maintaining an expertise gap. It is unsurprising then, that airway experts performed best with non-channelled, Macintosh-like videolaryngoscopes.1Kleine-Brueggeney M Greif R Schoettker P Savoldelli GL Nabecker S Theiler LG Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial.Br J Anaesth. 2016; 116: 670-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar At the end of the day, what both studies have provided is a snapshot of expertise along the respective learning curves of each videolaryngoscope. We believe that it would be more useful and reliable to measure performance during learning and practise with new devices until there is a flattening of the learning curve, and for comparisons to be made at this point. A major clinical driver for the proliferation of videolaryngoscopes is the successful intubation of the difficult airway, which thankfully is not a daily occurrence for most anaesthetists. As such, expertise decay is an important consideration in the successful use of novel videolaryngoscopes in the context of unanticipated difficult laryngoscopy. In the ideal world, skill decay can be avoided with regular, deliberate practice. However, in the real world this ideal is currently out of reach for many anaesthetists for a variety of reasons. Therefore, we believe that a more useful and pragmatic line of study would be to measure skill decay associated with the different videolaryngoscopes. Ultimately, we believe that the ideal videolaryngoscope should be intuitive to the user. The clinical significance of both studies’ findings is debatable. Ultimately, the vast majority of patients will be intubated in a reasonable time frame and with little morbidity regardless of the device used. We believe that a great deal of the variability in intubation time and successful intubation rates described by these two studies is down to a variable lack of expertise with the individual devices. Anaesthetists would do well to remember the adage, ‘the more I practise, the luckier I get’. None declared.

We thank Dr. Jain for commenting on our recent study of laryngoscopy skill retention in medical students 1. Before addressing Dr Jain's two queries, I would like to address the point raised about acquisition of skills in laryngoscopy. Whilst I agree that the rate of skill acquisition for each laryngoscope can vary, what is more important is that learning should ultimately culminate in similar levels of performance during laryngoscopy. Unfortunately, a failure to appreciate this concept continues to permeate the literature in the domain of skill acquisition in videolaryngoscopy. For example, in three recent studies, there is scant attention to the videolaryngoscopy learning needs of the participant anaesthetists, which we believe reflects a subconscious assumption by anaesthetists that expertise in Macintosh laryngoscopy somehow equates to similar levels of proficiency with novel videolaryngoscopes 2-4. As such, an expertise gap between traditional Macintosh laryngoscopy and novel videolaryngoscopy will continue to exist until anaesthetists acknowledge their unwitting lack of competence in this area of practice 5. In response to Dr. Jain's specific queries, we chose the C-MAC® and A.P. Advance™ difficult airway blades over their conventional counterparts because we had simulated potential airway difficulty by reducing cervical flexion and atlanto-occipital extension. Pragmatically, we chose the difficult airway blades for the two devices, because this is precisely what they are marketed and sold for. Ultimately, though, we demonstrated that intubation times after the initial, comprehensive learning phase were broadly comparable between all devices for this sample of medical students. We are slightly confused by Dr Jain's second question, in that we studied novice laryngoscopists (medical students). However, we believe that it is likely that a similar pattern of performance would have been observed in postgraduate novice anaesthetists with little or no experience of Macintosh laryngoscopy; this is apparent from the literature, and is considered in our manuscript. A more interesting prospect might be to examine what is required to close the expertise gap between Macintosh laryngoscopy and videolaryngoscopy for more experienced anaesthetists.

Background: Visuospatial ability correlates positively with novice performance of simple laparoscopic tasks. The aims of this study were to identify whether visuospatial ability could predict technical performance of an ultrasound-guided needle task by novice operators and to describe how emotional state, intelligence, and fear of failure impact on this.Methods: Sixty medical student volunteers enrolled in this observational study. The authors used an instructional video to standardize training for ultrasound-guided needle advancement in a turkey breast model and assessed volunteers' performance independently by two assessors using composite error score (CES) and global rating scale (GRS). The authors assessed their visuospatial ability with mental rotation test (MRT), group embedded figures test, and Alice Heim group ability test. Emotional state was judged with UWIST Mood Adjective Checklist (UMACL), and fear of failure and general cognitive ability were judged with numerical reasoning test.Results: High CES scores (high error rate) were associated with low MRT scores ( = -0.54; P < 0.001). Better GRS scores were associated with better MRT scores ( = 0.47; P < 0.001). Regarding emotions, GRS scores were low when anxiety levels were high ( = -0.35; P = 0.005) and CES scores (errors) were low when individuals reported feeling vigorous and active ( = -0.30; P = 0.01).Conclusions: An MRT predicts novice performance of an ultrasound-guided needling task on a turkey model and as a trait measure could be used as a tool to focus training resources on less-able individuals. Anxiety adversely affects performance. Therefore, both may prove useful in directing targeted training in ultrasound-guided regional anesthesia.

In addition to being effective and easy to learn how to use, the ideal laryngoscope should be associated with minimal reduction in skill performance during gaps in practice over time. We compared the time taken to intubate the trachea of a manikin by novice medical students immediately after training, and then after 1 month, with no intervening practice. We designed a two-period, four-group, randomised, cross-over trial to compare the Macintosh, Venner(™) A.P. Advance(™) with difficult airway blade, C-MAC(®) with D-Blade and Airtraq(®) with wireless video-viewer. A bougie was used to aid intubation with the Macintosh and the C-MAC. After training, there was no significant difference in median (IQR [range]) intubation time using the videolaryngoscopes compared with the Macintosh, which took 30 (26.5-35 [12-118])s. One month later, the intubation time was longer using the C-MAC (41 (29.5-52 [20-119])s; p = 0.002) and A.P. Advance (40 (28.5-57.5 [21-107])s; p = 0.0003)m compared with the Macintosh (27 (21-29 [16-90])s); there was no difference using the Airtraq (27 (20.5-32.5 [15-94])s; p = 0.258) compared with the Macintosh. While skill acquisition after a brief period of learning and practice was equal for each laryngoscope, performance levels differed after 1 month without practice. In particular, the consistency of performance using the C-MAC and A.P. Advance was worse compared with the Macintosh and the Airtraq. While the clinical significance of this is doubtful, we believe that reliable and consistent performance at laryngoscopy is desirable; for the devices that we tested, this requires regular practice.

Introduction: There are distinct effects on nasal morphology after various movements of the maxilla in Le Fort-1 osteotomies. Corresponding change in nasal volume may have important surgical and anaesthetic implications. Some movements such as superior repositioning of the maxilla may have a significant influence on nasal airflow. The purpose of our study was to investigate the effect of maxillary Le-Fort 1 impaction, advancement or a combination of both on nasal airflow before and after Le Fort-1 osteotomy.

Applying human factors principles to the design of clinical emergency guidelines is important. The UK Civil Aviation Authority uses a Checklist Assessment Tool for evaluating the content and usability of emergency drills before introduction into service on aircraft. We hypothesised that this model could be used to develop a generic medical tool. A three-stage modified Delphi process was used to adapt the above tool for use in designing medical emergency guidelines. The resulting Cognitive aids in Medicine Assessment Tool was then used to score and rank seven published difficult airway guidelines; the scores were used to assess its validity and reliability. Pearson's rank coefficient between these scores and scores from independent assessors was 0.89 (p=0.007). Internal consistency, as assessed by Cronbach's alpha, was 0.74, 0.96 and 0.72 for the tool's three constituent domains of physical characteristics, content and layout/format, respectively. Inter-rater reliability, as assessed by Cohen's kappa, ranged from 0.33 to 0.72. The adoption of our tool has the potential to improve the usability of medical emergency guidelines.

A number of studies in the U.S.A. and mainland Europe have described the costs of fibreoptic tracheal intubation. However, no such data from the UK appear available. We performed a cost assessment of fibreoptic intubation, using re-usable (various devices from Olympus, Acutronic and Karl Storz) and single-use (Ambu aScope) fibrescopes, at the Queens Medical Centre, Nottingham, U.K., between 1 January 2009 and 31 March 2014. The total annual cost of fibreoptic intubation with re-usable fibrescopes was £46,385. Based on 141 fibreoptic intubations per year, this equated to £329 per use, an average dominated by repair/maintenance costs (43%) and capital depreciation costs (42%). In comparison, the total annual cost of using single-use fibrescopes for the same work would have been around £200 per use. The analysis enabled us to develop a generic model, wherein we were able to describe the relationship between total cost of use vs number of uses for a fibrescope. An 'isopleth' was identified for this relationship: a line that joined all the points where the cost of re-usable vs single-use fibrescopes was equal. It appears cheaper to use single-use fibrescopes at up to 200 fibreoptic intubations per year (a range commensurate with normal practice) even when the repair rate for re-usable fibrescopes is low. Any centre, knowing its fibrescope use and repair rate, can plot its data similarly to help ascertain which of the re-usable or single-use fibrescope represents better value.

Concern that laryngoscopy and intubation might create or exacerbate a spinal cord injury has generated extensive research into cervical spinal movement during laryngoscopy. We performed a randomised trial on six cadavers, using three different laryngoscopes, before and after creating a type-2 odontoid peg fracture. Our primary outcome measure was the change in the space available for the spinal cord at the C1/2 segment measured by cinefluoroscopy. Tracheal intubation was performed using a minimal view of the glottis, a bougie, and manual in-line stabilisation. In a cadaveric model of type-2 odontoid fracture, the space available for the cord was preserved in maximum flexion and extension, and changed little on laryngoscopy and intubation.

Airway management is the foundation upon which anaesthesia is built, and fibreoptic intubation (FOI) is a key facet of this skill. Despite this, many trainee anaesthetists in the UK have been unable to perform sufficient FOIs to gain competence. We aimed to establish the incidence of FOI in adult patients, in a UK teaching hospital, in order to determine what FOI training opportunities actually exist. During the study period (from October 1st, 2008, to September 30th, 2009) an estimated 11 712 general anaesthetics were undertaken that necessitated tracheal intubation. In 141 of these cases FOIs were performed giving an incidence of FOI of 1.2% (95% confidence interval 1%–1.4%). Of these, 86 (61%) were in awake and 55 (39%) in anaesthetised patients. Only 16 (11%) of the FOIs were done solely for the purposes of training. We suggest that a greater number of FOIs should be undertaken to allow trainees to gain and consultants to maintain the FOI expertise necessary for the provision of safe anaesthesia.

Plasma expanders are used to restore the circulating volume of a hypovolaemic patient. Typically, colloids are used to expand the plasma volume, although combinations of hypertonic crystalloid and colloid have recently been used. The currently available colloids vary in their physico-chemical, pharmaco-dynamic and pharmaco-kinetic properties. In particular, they differ in molecular weight, which partly determines their duration of action, and in their ability to expand the plasma volume. Dextran, hydroxyethyl starch and hypertonic colloid solutions improve oxygen flux within the microcirculation. Despite their benefits, the use of dextran and high molecular weight starches is limited by their negative impact on coagulation. In addition, these macro-molecules may also induce acute renal failure in susceptible patients. Current research focuses on the development of artificial oxygen carriers as plasma expanders. These substances, which include modified stromal-free haemoglobin and perfluorocarbon emulsions, are undergoing clinical trials.

We wish to congratulate Kathirgamanathan et al. on their well-conducted study of the time taken for surgical readiness in category-1 caesarean section 1. While we do not disagree with their finding that spinal anaesthesia is slower than general anaesthesia, we believe that in actual category-1 caesarean section the median (range) time of 8:52 (3:31–17:22) min:s for spinal anaesthesia may be much greater. The authors have studied the performance of a group who were probably experts in obstetric anaesthesia practice and the study participants may not have been representative of resident obstetric anaesthesia cover, at least not in the UK, which typically relies on basic and intermediate level trainees who are competent, but neither proficient nor expert 2-4. Attendance at a category-1 caesarean section is acutely stressful, and typically occurs out of hours when experts are not immediately available. The negative impact of acute stress, distraction and fatigue on cognitive capacity and psychomotor performance are well known 5-7, and we believe that this further widens the performance gap between the study participants and actual practice. With this is mind, we feel that the authors' pessimistic estimation of total time for spinal anaesthesia (17 min 22 s) is perhaps closer to the mark. Although the total spinal time reported in this manuscript may appear to strengthen the case in favour of spinal anaesthesia for category-1 caesarean section, we advise caution in its interpretation. As the authors rightly point out, category-1 caesarean section is a process with a number of predictable, well-recognised steps to achieving that end. We believe that improvements in the decision-delivery time may be more reliably and safely achieved by focusing on interventions to modify systems within the maternity suite and to improve non-technical skills within the multidisciplinary team.

OBJECTIVE:To compare the responsiveness of the EuroQol five-dimensional questionnaire (EQ-5D) generic quality-of-life instrument with that of specific instruments-the Brief Pain Inventory (BPI) and the Oswestry Disability Index (ODI)-in assessing low back pain.METHODS:Data were obtained from a group of patients receiving epidural steroid injections. We assessed responsiveness by using correlation, by estimating standardized response means, by receiver operating characteristic curve analysis, and by comparing the minimum clinically important differences peculiar to each of the instruments.RESULTS:ODI, BPI, and EQ-5D index scores, and changes in scores, were found to be correlated. Estimated standardized response means and receiver operating characteristic curve analysis suggested lower responsiveness for the EQ-5D index score. Clinically significant categories of mild, moderate, and severe BPI pain intensity translated into progressively and significantly lower mean EQ-5D index scores. An increase or a decrease in severity level reported on any of the five EQ-5D dimensions was associated with significant changes (with appropriate signs) in the condition-specific scores. No change in severity in any EQ-5D dimension was associated with no change in the specific scores. Significant changes in the EQ-5D index scores were associated with clinically important changes in the ODI and BPI scores. Correlation between index scores and responses on EQ-5D's visual analogue scale was only moderate.CONCLUSIONS:The EQ-5D index is less responsive than instruments specific to pain measurement, although it is capable of indicating clinically important changes. The lower responsiveness arises from EQ-5D's more limited gradation of severity and its multidimensionality.