SummaryUse of a bougie is not without risk, and insertion too far may cause airway injury. We designed a new bougie with a 'traffic light' system to indicate depth of insertion. Forty anaesthetists were randomly assigned to insert either a conventional single-coloured bougie or a novel traffic light bougie. Depth of insertion was measured before and after railroading a tracheal tube. Participants were not informed as to the purpose of the colouring system. The median (IQR [range]) insertion depth of the traffic light bougie was 22 (21-24 [19-27]) cm and for the conventional bougie was 28 (21-32 [20-35]) cm (p = 0.011). Median (IQR [range]) insertion depth after railroading for the traffic light bougie was 25 (25-28 [21-34]) cm and for the conventional bougie was 30.5 (27-35 [23-40]) cm (p = 0.003). This simple colouring system appears to allow intuitive use and significantly reduced the depth of bougie insertion. This system could be also used with other airway exchange devices to improve safety.

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Therapeutic hypothermia, an intervention reducing core body temperature below 35 degrees Celsius, has gained popularity in the management of acute brain injury after a series of small clinical trials in patients following cardiac arrest, stroke and traumatic brain injury. This article reviews the evidence relating to therapeutic hypothermia as an intervention in acute injury.

In 2014 and 2017, NHS Improvement released patient safety alerts about the dangers of residual anaesthetic drugs in cannulae and intravenous (i.v.) lines seriously harming patients when subsequent fluids or drugs are administered [1,2]. The 2017 action plan specified that 'all cannulae have been identified and either removed or adequately flushed' [2]. No description of how this flushing should be done was included and many anaesthetists believe that an i.v. infusion running through a cannula will achieve this aim.We were concerned that, although a running infusion will clear an i.v. line and cannula lumen, it may have no effect on residual anaesthetic drugs retained in the injection port of a cannula or a three-way tap. In order to assess this possibility, we tested two makes of cannula (Venflon TM Pro Safety (BD, Oxford, UK) 14G and Vasofix â Safety (B-Braun Melsungen AG, Melsungen, Germany, 16G) and a threeway tap (BD Connecta, BD, Oxford, UK).The cannula was connected to a 500-ml bag of saline via an i.v. line, this was used to flush the cannula and then the flow gate on the line was closed. One millilitre of methylene blue was then injected into the injection port of the cannula.The flow gate was then opened to flush the line and cannula until it ran clear, the flow gate was then closed. Five millilitres of saline was then injected into the injection port of the cannula. On doing this, evidence of dye contamination was clearly observed on a white swab placed at the cannula tip ( Fig. 1). Similar results were observed when the procedure was repeated using a different manufacturer's cannula and a three-way tap (Fig. 2).This demonstration shows that a running i.v. infusion line does not adequately remove residual contamination from cannulae or three-way taps. It is therefore essential that anaesthetists flush all injection ports before discharging patients from their care.

We present a case demonstrating a previously undescribed use for the Cook Staged Extubation Set (Cook SES TM ) via a tracheostomy stoma following decannulation of tracheostomy in a 64year-old male 'at risk' patient. Our experience demonstrates that the Cook SES may be used via a tracheostomy stoma in addition to its described use via the oral route.