Your letters - December issue

i-gel® Christmas tree

I would like to showcase the creative talents within our ODP / Anaesthetic Nursing team. Lessley (pictured) is from a family of artists, and her i-gel® ‘cradle’ Christmas decorations have been in high demand in our department.

A brief review of the literature (Googling ‘i-gel Christmas tree’) reveals that she is not the only person who has come up with this idea. However, owing to her avoidance of all things social media, I can vouch that Lessley came up with the concept independently.

We all recognise the need to Reduce, Reuse, Recycle as much as possible. Here is a great example of Repurposing used packaging. We are also faced with the daunting challenge of trying to improve well-being in a system that is under more strain than ever before. There is an unquantifiable additional benefit to the i-gel Christmas tree in the smiles that it induces.

Carl Morris
Consultant Anaesthetist
Buckinghamshire Healthcare NHS Trust

The Green Christmas Initiative

There has been a recent call to arms for anaesthetists to promote environmental sustainability [1, 2]. We are implementing strategies to decrease the carbon footprint in our hospital; however we have found that awareness of, and passion for, the cause were low in some of our staff. To address this, we ran a ‘Green Christmas initiative’ for two weeks in December 2019. Posters were made from recycled materials, such as plastic rings from face masks and cardboard boxes from theatre stores (Figure 1), which were placed in theatre coffee rooms. Staff signed up to sustainability pledges for work and home. Participants were entered into a prize draw, with all prizes being supplied by our generous sponsors – all affiliated with environmentally friendly produce. Over 100 staff made pledges, such as ‘teaching TIVA to junior trainees’, ‘cycling to work’, ‘recycling syringe packaging’, and ‘being vegetarian for January’. Twentyeight prizes were given out by our Green Christmas Santa, including bike shop vouchers, reusable coffee cups, personalised theatre hats, exercise classes and vegetarian meal boxes. The initiative was multidisciplinary, being organised by staff from anaesthesia, recovery and pharmacy, and advertised to all theatre staff. This has helped to emphasise that sustainability is a matter for everyone’s concern. However, we found that few surgeons participated, highlighting that this group should be specifically targeted in future sustainability projects.

This was a fun and celebratory way to think about sustainability, in contrast to the frequent pessimism encountered when approaching the subject. We aim to repeat the Green Christmas initiative in 2020, and to maintain the enthusiasm for sustainability that it has generated in our hospital. We encourage other departments to consider similar initiatives in order to increase awareness of the sustainability challenges that exist in theatres, and to consider enacting small changes to make a big difference.

Figure 1. Green Christmas poster in the coffee room

Emma Claire Phillips
ST3 Anaesthesia

Andrew Grant
Consultant Anaesthetist

Lydia Howell
Recovery Nurse

Alifia Chakera
Lead Pharmacist
Royal Infirmary of Edinburgh

References 

1. Association of Anaesthetists. Long term strategy, 2019. https://anaesthetists. org/Portals/0/PDFs/About%20us/ Policies%20and%20processes/ Association%20of%20Anaesthetists%20 long%20term%20strategy%202019. pdf?ver=2019-05-24-111746-190 (accessed 15/1/2020). 
2. Royal College of Anaesthetists. Sustainability strategy 2019 – 2022, 2019. https://www.rcoa.ac.uk/ about-college/strategy-vision/ environment-sustainability/sustainabilitystrategy- 2019-2022 (accessed 15/1/2020).

The i-gel® protective cradle is now recyclable - manufacturer’s response

Further to Dr Hickman’s letter in the June issue of Anaesthesia News confirming that the protective cradle and cage pack of the Intersurgical i-gel® supraglottic airway can be recycled [1], we would like to thank Dr Winkley for highlighting in the August issue that she had found a company in the North- East who recycle clean plastic waste from industry [2]. We note that a plastic recycling trial for Northumbria NHS Trust is now in progress with this company, recycling clean plastic waste from the hospital including the i-gel protective cradles. This is positive news.

However, recognising that the healthcare sector is a large producer of plastic waste, Dr Winkley also asked whether it is necessary to produce such waste in the first place. In the case of the i-gel, we can confirm that the protective cradle (adult sizes) and cage pack (paediatric sizes) ensure that the product remains in the correct flexion prior to use, and are therefore essential for patient safety and product performance. They also help to optimise gas circulation for effective sterilisation, and act as a base for lubrication.

We can also confirm that Intersurgical are certified to international environmental standard ISO 14001, and are committed to the protection of the environment by minimising the environmental impacts of the company’s products, activities and services, including the prevention of environmental pollution and sustainable resource use. This process includes regular review of existing products and packaging, and we will continue to investigate ways in which we can reduce the packaging for our products, including the i-gel.

David Chapman
Airway Group Product Manager
Intersurgical Ltd Wokingham

Twitter: @daveairways

References 

1. Hickman J. The i-gel® cradle is now recyclable. Anaesthesia News 2020; Issue 395: 42. 
2. Winkley E. The i-gel© cradle is now recyclable - a response. Anaesthesia News 2020; Issue 397: 31.

COVID-19 airway assessment: unmasked

In this COVID-19 era, I would like to reinforce the importance of continuing to undertake a thorough airway assessment before commencing anaesthesia.

Face-to-face interactions with patients are likely to be replaced with virtual consultations where possible, adding a new dimension to airway evaluation. The accuracy of remote assessment is yet to be established, but is likely to benefit greatly from a standardised approach, agreed locally by departments, and undertaken by experienced staff.

Patients presenting on the day of surgery will now routinely be wearing facemasks. After appropriate screening questions and assessments, the patient should be asked to remove their mask briefly to enable a full airway evaluation from an appropriate distance.

Airway assessment in the patient with respiratory failure may be complicated by non-invasive positive pressure ventilation masks or hoods. Ideally, an advance airway assessment should be undertaken (and documented) before commencing noninvasive ventilation, in order to plan a future airway strategy. Should tracheal intubation become necessary, an immediate airway assessment by the designated primary intubator is still recommended, informed by the initial evaluation. In this situation, many of the standard bedside tests are still possible, even with the mask or hood remaining in situ.

Patrick Alexander Ward
Consultant Anaesthetist
Chelsea & Westminster Hospital, London

How many times can one prone a patient with COVID-19 pneumonia?

While tackling COVID-19, many of us are pushing treatment options to the extreme. These patients may develop respiratory failure similar to that seen in ARDS [1]. In severe ARDS, it has been recognised that early prolonged proning is linked with improved 28- and 90-day mortality, although the maximum duration of proning has not been established [2].

Two subtypes have been identified in the critically ill patient with COVID-19, type 1 (non- ARDS) and type 2 (ARDS) [3]. Patients with type 2 have a better response to proning. Lung compliance is low and elastance high, with large portions of non-aerated lung tissue, therefore proning improves recruitment of this lung tissue [3]. Most prone ventilation practices involve 16 h in the prone position with 2- 3 hourly head turns, and 8 h in the supine position [4]. Figure 1 shows the effects of proning on the PaO2/FiO2 ratio of a patient who was proned 16 times over a 14-day period, with good effect despite clear variability in response. This patient survived to discharge.

Proning for a prolonged time often leads to complications, including pressure damage at pressure points and from tube ties. Significant oedema to lips, tongue and eyes have also been recorded. The need for head turns while proned poses a risk of tracheal tube malposition and ventilator disconnection. Two of our patients who were proned for a prolonged period of time developed brachial plexus injuries, which were confirmed on nerve conduction studies [5].

The number of times a patient can be proned is determined by the response to proning and appropriate patient selection. Perseverance may be the key to success.

Prabhjoyt Kler
Specialty Registrar, Intensive Care Medicine/ Anaesthesia 

Matthew Byrne
Speciality Registrar, Anaesthesia 

Timothy Scott
Nageswar Bandla
Consultant Intensivists/ Anaesthetists
University Hospital North Midlands, Stoke-on-Trent

Congratulations to Prabhjoyt Kler for  winning December's letter of the month prize

References 

1. Yuki K, Fujiogi M, Koutsogiannaki S. COVID-19 pathophysiology: a review. Clinical Immunology 2020; 215: 108427. 
2. Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine 2013; 368: 2159-68. 
3. Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Critical Care 2020; 24: 154. 
4. Faculty of Intensive Care Medicine/ Intensive Care Society. Guidance for: prone positioning in adult critical care, 2019. https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf (accessed 11/9/2020). 
5. Malik GR, Wolfe AR, Soriano R, et al. Injury prone: peripheral nerve injures associated with prone positioning for COVID-19-related acute respiratory distress syndrome. British Journal of Anaesthesia 2020 in press.

Tea trolley model of training

We would like to highlight how we have used our anaesthetic rooms, unused for clinical purposes during the COVID-19 pandemic, for training.

We have found that our ability to provide simulation training has decreased because of: difficulty in getting staff together to train due to clinical pressures; requirements for social distancing; and the need for a COVID-secure environment where staff providing care for patients on the ‘green pathway’ remain separate from those on the ‘amber pathway’.

To address this we have adopted the ‘Tea trolley’ model of training [1]. A trolley containing equipment for a 10 min simulation is brought into the anaesthetic room. The anaesthetist and ODP working in theatre are relieved by members of the training team, doff their PPE, and perform the simulation facilitated by other members of the team. They are then given a drink and cake during the debrief.

Utilising our anaesthetic rooms provides us with a private area for training that does not interfere with clinical work in the theatres. Working our way along the corridor, starting in ‘green’ and moving on to ‘amber’, prevents crosscontamination and maintains the COVIDsecure environment.

Our first session on management of the difficult airway and front-of-neck access was well received. We intend to continue this form of training as the pandemic progresses.

Su-Mei Tham
Clinical Fellow 

Victoria Wroe
Hannah Wrigley
Consultant Anaesthetists
Warrington and Halton Hospitals

References 

1. O'Farrell G, McDonald M, Kelly FE. 'Tea trolley' difficult airway training. Anaesthesia 2015; 70: 104.