'Can't intubate, can't oxygenate' scenarios are rare but are often poorly managed, with potentially disastrous consequences. In our opinion, all doctors should be able to create a surgical airway if necessary. More practically, at least all anaesthetists should have this ability. There should be a change in culture to one that encourages and facilitates the performance of a life-saving emergency surgical airway when required. In this regard, an understanding of the human factors that influence the decision to perform an emergency surgical airway is as important as technical skill. Standardisation of difficult airway equipment in areas where anaesthesia is performed is a step toward ensuring that an emergency surgical airway will be performed appropriately. Information on the incidence and clinical management of 'can't intubate, can't oxygenate' scenarios should be compiled through various sources, including national coronial inquest databases and anaesthetic critical incident reporting systems. A systematic approach to teaching and maintaining human factors in airway crisis management and emergency surgical airway skills to anaesthetic trainees and specialists should be developed: in our opinion participation should be mandatory. Importantly, the view that performing an emergency surgical airway is an admission of anaesthetist failure should be strongly countered.
† Buridan's ass is an illustration of a paradox in philosophy in the conception of free will. It refers to a hypothetical situation wherein an ass that is equally hungry and thirsty is placed midway between a stack of hay and a pail of water. As the paradox assumes the ass will always go to whichever is closer, it will die of both hunger and thirst because it cannot make a rational decision to choose one over the other. See
The role of preoperative fasting is well established in current anaesthetic practice with different guidelines for clear fluids and food. However, chewing gum may not be categorised as either food or drink by some patients, and may not always be specified in instructions given to patients about preoperative fasting. The aim of this paper was to review anaesthesia incidents involving gum chewing reported to webAIRS to obtain information on the risks, if any, of gum chewing during the preoperative fasting period. There were nine incidents involving chewing gum reported between late 2009 and early 2015. There were no adverse outcomes from the nine incidents other than postponement of surgery in three cases and cancellation in one. In particular, there were no reports of aspiration or airway obstruction. Nevertheless, there were five cases in which the gum was not detected preoperatively and was found in the patient's mouth either intraoperatively or postoperatively. These cases of undetected gum occurred despite patient and staff compliance with their current preoperative checklists. While the risk of increased gastric secretions related to chewing gum preoperatively are not known, the potential for airway obstruction if the gum is not detected and removed preoperatively is very real. We recommend that patients should be specifically advised to avoid gum chewing once fasting from clear fluids is commenced, and that a specific question regarding the presence of chewing gum should be added to all preoperative checklists.
Seventy patients undergoing haemorrhoidectomy under general anaesthesia were randomly allocated to one of five treatment groups in order to compare the effectiveness of various caudal agents in the control of postoperative pain. Four groups were given a caudal injection of either 2 % lignocaine, 0.5% bupivacaine, 2% lignocaine + morphine sulphate 4 mg or normal saline + morphine sulphate 4 mg, while the fifth (control) group did not receive an injection. The number of patients requiring postoperative opiates was significantly higher in the lignocaine group than in the morphine (p <0.05) and morphine-lignocaine (p <0.05) groups. No agent significantly reduced the number requiring opiates. In those who received opiates, the mean analgesic period was 228 minutes in the control group, and was significantly longer following bupivacaine (577 min, p <0.01), morphine-lignocaine (637 min, p <0.05) and morphine (665 min, p <0.01). The mean analgesic periodfol/owing lignocaine (349 min) was not significantly differentfrom control. The incidence of catheterisation was lowest in those patients who did not receive caudal analgesia.
I have to thank Dr. Radner for a very stimulating paper. He roamed widely and provocatively across the last five hundred years and I think in his own inimitable style effectively raised some clearly essential issues. I found it a very challenging paper ecumenically. Some of his comments reminded me of an incident I read about before Vatican II, when, as I understand, Patriarch Athenagoras and now-saint Pope John XXIII are reported to have said jokingly that only the hairsplitting and obstinacy of theologians maintains the division between the Churches: the learned will not agree among themselves and project their dispute over the whole of Christianity, though they cannot make any sense of it anymore. In the meantime, of course, some theologians have addressed the same reproach in all seriousness to holders of office. Only the Church authorities, they say, have an interest in division, which is kept in existence by them for the sake of their own survival. Regarding the three questions cited as important for this gathering-Do we celebrate the Reformers' renewal of the Church in light of the Gospel? Do we mourn the division of the one, Catholic Church? Or have events like the globalization of Christianity and the rise of Pentecostalism made the sixteenth-century debates irrelevant?-I am tempted to say both Yes and no to the first two and Somewhat to the third. My comments, however, will focus in three areas. The first of these, not surprisingly, is a reference to the tradition-a very Catholic thing to raise up-alongside Scripture, of course. But here I wish to nuance a
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