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sold's picture
by on Tue, 2015-11-17 10:54

Really enjoyed WAMM
Just going through new DAS guidelines.
Really pleased that they are more simplified and take away the many choices that can only lead to dithering time-wasting in time of stress…
Obvious question:
Plan D:
Option of choice :
Scalpel Cricothyroidotomy.
So, we will now take the bull by the horns and ensure that we get some sheep larynxes in and teach technique, ideally, to all members of the department…
Obvious question:
In York, we have, currently:
in our Plan D drawer on our trollies and in every Anaesthetic Room lots of Quicktrach 2 devices  that we have recently acquired at considerable cost &
a number of VBM needles for attaching to a number of free-standing Manujet devices as an alternative as per previous DAS Guidelines.
I appreciate we all need to be singing off the same hymn sheet and I support the use of the Scalpel technique…but:
Does that mean we should be taking all the Quicktrach 2 devices and Manujet needles off the trollies, out of the anaesthetic rooms, and throwing them all away????
Does this mean that we need no longer teach anyone, especially trainees, how to use Manujet (probably a good idea following NAP4 findings!)?
& does this mean our trainees will not be asked about these techniques in their FRCA exams?
We don’t do much Paediatric elective surgery here in York…but, do we still have to keep and teach the VBM needles and Manujet stuff in case of Paediatric Emergency???
Does this mean VBM will go out of business?
Just wondering??
Simon Old
DAS/RCoA Airway Lead

nrefai's picture
by on Tue, 2015-12-15 00:03

Dear Colleagues
I'm so happy & comfortable with DAS 2015 guidelines . However, I had argument with some colleagues; they claim that FO has no role in unexpected DA !!! As they understood that the algorithm shows that SGD should be used for ventilation in plane B, then we may intubate using FO through SGD only !!!  
My interpretation of the algorithm, is that whenever plane A fails, we go for plane B which means ventilation through any device. Accordingely if we manage to ventilate the patient with oral airway , then we can proceed to intubation using FO , not necessarily through a conduit (SGD) !! As long as the airway is clear & untraumatized.
Am I right, or is it necessary to put SGD to use FO through it ?? Would any body clarify this point ??
Thanks in advance

tcook's picture
by on Tue, 2015-12-15 09:38

My reading of the paper is that a SAD (2nd generation) is the preferred choice of airway to rescue - even when facemask ventilation is possible.
It states that inserting the SAD indicates the end of direct intubation attempts
Intubation should then be via the SAD - and only with a fibrescope
The guidelines state that all should be taught to intubate via a SAD. They merntion but do not specifically recommend the aintree intubation catheter. Of note the only 1st generation SAD that stays in here is the ILMA - though the writing in the paper at that point couldf have been clearer.
So I agree with your colleagues - it's via a SAD.

cfrerk's picture
by on Sat, 2015-12-26 18:13

In the discussion it says "these guidelines are directed at anaestheists with a range of airway skills and are not specifically aimed at airway experts. Some anaesthetists may have particular areas of expertise which can be deployed to supplement the techniques described"
My thoughts on this
So if on first laryngoscopy you saw nothing helpful, no epiglottis no uvula and you thought "ooer" I don't want to do anything lse to this airway ..... and facemask vantilation was easy - , you might decide to place a supraglotic airway (recommended explicitly in the guidelines), you might decide to wake the patient up there and then, or if you had advanced skills and the case merited it you might decide to do an unguided asleep fibreoptic intubation. For many anaesthetists an asleep fibreoptic (unguided) is not a familiar technique and therefore not the sort of thing to attempt (for the first time) in a patient where normal laryngoscopy has failed just to get their gall bladder done this morning rather than this afternoon or next week when wake up and return later is a viable option.
The first option when stopping and thinking is "wake the patient up"
Mind you I think the same applies to the decision making following rescue with a SAD - if you haven't been trained and practised intubate through a SAD with a fibrescope then don't try it on  a day like the one just described

ponkarthik's picture
by on Wed, 2015-12-23 23:27

In our trust we have decided to keep the needle cricothyroidotomy set in the DA trolley atleast for now. We are planning to have training days for all anaesthetists on the scalpel technique, so atleast until all are comfortable to whip out the scalpel we need to have the needle cric equipment.
Also needle cricothyroidotomy can be used electively in some situations involving anticipated DAs.

cfrerk's picture
by on Sat, 2015-12-26 18:00

Hi Simon (thank you for comments) - my thoughts below
In the final paragraph of the guidelines it does say "there are other valid techniques for front of neck access which may continue to be provided in some hospitals where additional equipment and comprehensive training programmes are available". So no you dont eed to throw out your existing kit (yet)...
However you do need to ensure that everyone in your trust is trained to use the kit that is in your plan D drawer, and if there is an emergency cric needed in your trust then you should report what happened and how it went to DAS so that there will be information on how the Quicktrach II  (or whatever is in said drawer) fared in real life.
I have no idea what will happen in the exams but if I was an examiner and a candidate could tell me what they would do in their Trust and what kit they had and that it would be amongst the most stressful situations they would face - I'd give them a pass mark.
Paediatrics - I ask myself the same question (I have a personal answer)
Don't worry about VBM, they are a big company and I'm sure they will be fine

nrefai's picture
by on Sun, 2015-12-27 21:49

Dear Colleagues
Thanks for your kind replies which is great for brain storming & better understanding of new DAS algorithm. 
Can we think together about those points:
1- The algorithms implies 3-4 trials of intubation in plane A before going to plane B!! Isn't that little bit dangerous? Maybe we have to state that the 3-4trials should be optimum nontraumatic while patient maintains his SpO2>90??
2- What about expected DA? Do we have algorithm for it ? or do we need to develope algorithm for expected DA? In my opinion ,yes we have to put algorithm for expected DA. Otherwise,why do we study & teach different methods of assessment of airway? 
3- What do we mean by DA ? what degree of difficulty? I mean when to start by awake FO or asleep FO or try video-assissted before going to plane B?
4- Is it ok to use any asessment score for DA (LEMON, Welson, Ganzoury, PHASE ....ext) , then follow DAS algorithm??
I'm thinking about these points & would like to hear your ideas about it.
Waiting for fruitful replies & have a happy new year

nrefai's picture
by on Mon, 2016-01-25 19:16

Dear all
I gave a lecture about DAS guidelines for DA. It was impressive & audience were pleased to hear the new simple algorithm. However, our junior trainee asked me about the expected DA ?? They said what's DAS algorithm & my opinion about expected DA.!!! Shall we use asleep FO or awake FO? and what if they failed to intubate with awake FO?? what's the role of SAD in this situation ?
I'd like to hear from all of you, meanwhile I'm still thinking & preparing suggestions for expected DA algorithm that follows DAS guidelines.