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      A national survey of practical airway training in UK anaesthetic departments. Time for a national policy?

      1 , 1 , 1

      Anaesthesia

      Wiley

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          Abstract

          The Fourth National Audit Project (NAP4) recommended airway training for trainee and trained anaesthetists. As the skills required for management of airway emergencies differ from routine skills and these events are rare, practical training is likely to require training workshops. In 2013, we surveyed all UK National Health Service hospitals to examine the current practices regarding airway training workshops. We received responses from 206 hospitals (62%) covering all regions. Regarding airway workshops, 16% provide none and 51% only for trainees. Of those providing workshops, more than half are run less than annually. Workshop content varies widely, with several Difficult Airway Society (DAS) guideline techniques not taught or only infrequently. Reported barriers to training include lack of time and departmental or individual interest. Workshop-based airway training is variable in provision, frequency and content, and is often not prioritised by departments or individual trainers. It could be useful if guidance on workshop organisation, frequency and content was considered nationally.

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          Most cited references 11

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          Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.

          This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events. Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgical airway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. An expert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated a denominator of 2.9 million general anaesthetics annually. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38-54] or one per 22,000 (95% CI 1 per 26-18,000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8-8.3): one per 180,000 (95% CI 1 per 352-120,000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is 'room for improvement'.
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            Difficult Airway Society guidelines for management of the unanticipated difficult intubation.

             M Popat,  ,  I Latto (2004)
            Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.
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              Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation.

              There is little doubt that these guidelines incorporate advances made in airway management since 2004. They will change day-to-day practice of anaesthesia, as outlined above, from pre-operative airway assessment, to integrating the WHO team briefing, to the use and provision of equipment and drugs, and the recording of information on the anaesthesia chart. They will inform the later analysis of any critical airway incidents, especially as documentation and postoperative management are addressed, and they will encourage training in a range of techniques. Taken together, not quite a revolution but certainly a very 'radical evolution'.Assessment of the utility of the new guidelines should consider if they can be used as tools to enhance knowledge and training, or in addition as a prosthesis to bridge the gap between the requirements of and our abilities during emergencies. Formal testing may reveal which aspects of their design, complex as it is, may distract from, rather than enhance, airway management during crises.All guidelines represent a standard of care or a normative approach to a clinical problem. As such, they not only help guide clinicians, but they also provide the broader community with the opportunity to improve standards, to ensure equipment is available, and that training for the skills and processes required are in place to ensure successful adoption.
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                Author and article information

                Journal
                Anaesthesia
                Anaesthesia
                Wiley
                00032409
                November 2016
                November 2016
                September 28 2016
                : 71
                : 11
                : 1273-1279
                Affiliations
                [1 ]Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
                Article
                10.1111/anae.13567
                27679501
                © 2016

                http://doi.wiley.com/10.1002/tdm_license_1.1

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