SummaryAn accurate and reproducible recording of laryngoscopic view at tracheal intubation is an important aspect of anaesthetic practice. Unlike direct laryngoscopy, in which the view achieved by the line of sight directly relates to the ease of intubating the trachea, videolaryngoscopy can create a situation in which the view is good, but intubation difficult or impossible. Communicating this to a subsequent anaesthetist is important. We compared three scoring systems: Cormack and Lehane; POGO (percentage of glottic opening); and the Fremantle score, as used by 74 critical care doctors rating 30 anonymised videos of videolaryngoscopic intubations. Accuracy (degree of agreement of score with an expert panel assessment) was higher for POGO (75.5%) and the Fremantle score (73.9%) than for Cormack and Lehane (65.4%; p < 0.001). Intra-rater reliability (mean free marginal Kappa for ordinal scores and mean Cronbach's Alpha for continuous score) was higher for Fremantle score (0.796) and Cormack and Lehane (0.773) than POGO (0.693). Inter-rater reliability for Fremantle score (0.618) and POGO (0.614) were similar and higher than the interrater reliability of Cormack and Lehane 0.464 (p < 0.001). The higher accuracy and inter-rater reliability of POGO and the Fremantle score suggest they are preferable to Cormack and Lehane for use when documenting videolaryngoscopy. The additional information about ease of intubation conveyed by the Fremantle score may support its routine use in recording videolaryngoscopic intubation.

Background: Procedural sedation (PS) is common in the emergency department (ED) and ideally patients should have no recall of the procedure. Aim: To determine the incidence of recall. Methods: A prospective observational study in an university ED of all patients undergoing PS. Data were collected on a pre-formatted data sheet. Levels of satisfaction with the sedation by the treating physician and nurse were recorded on a 10 cm visual analogue scale. On recovery, the patient was asked a validated questionnaire to determine the rate of immediate recall and at telephone follow-up for delayed recall. Results: 125 patients (88 male, 70%) were enrolled and 110 had completed follow-up. Mean (range) age was 51.6 (13-91) years. Procedures included 84 (67%) orthopaedic reductions and 41 (33%) cardioversions. A wide range of drug combinations were used, including fentanyl/propofol 32 (25.6%), fentanyl/midazolam 30 (24%), fentanyl/midazolam/propofol 16 (12.8%), propofol 13 (10.4%). 87.2% of procedures were successful. A grimace/groan was observed in 61 of 125 (49%). Immediate recall occurred in 9 of 121 (7.4%; 95% CI 3.7 to 14.0) and delayed recall in 5 of 110 (4.5%; 95% CI 1.7 to 10.8). No drug combination was correlated with recall (Spearman's rho = 0.149), nor the presence of a grimace/groan (r = 20.039). Median sedation satisfaction scores were physician 9.0, nurse 10, patient 10. Correlation of delayed recall with patient satisfaction was -0.471 (p,0.001). Conclusions: Recall following PS in ED is uncommon. There is no association of recall with drugs used or the presence of a grimace/groan. There is high patient satisfaction with PS in the ED.

Clear documentation of anaesthetic technique, difficulties and complications is an essential part of good anaesthetic practice, particularly in the area of airway management. The current convention of describing intubation using a videolaryngoscope only in terms of a Cormack and Lehane score is at best unhelpful and at worst dangerous. in an attempt to address the inadequacy of a Cormack and Lehane score to describe videoscopic intubation, we propose a three part scoring system: view, ease and device-the 'Fremantle Score'. Preliminary evaluation of this system in a diverse group of anaesthetists utilising four available videolaryngoscopes in a simulated normal and difficult airway manikin has demonstrated that the system is easy to use, easy to understand and relevant. in three of the eight device and manikin combinations studied, the videolaryngoscopic view correlated with the ease of intubation. This highlights the need for an alternative tool to describe intubation with a videolaryngoscope. We consider this development of a specific videoscopic scoring system a first step in better describing intubation by a videolaryngoscope and improving patient care.