These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

SummaryTracheal extubation is a high‐risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri‐operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post‐extubation care.

Metabolic and inflammatory responses and changes in fatigue were studied in groups of patients undergoing either laparoscopic (n = 14) or open (n = 10) elective cholecystectomy. The mean(s.e.m.) cortisol concentration was significantly (P < 0.001) increased from 342(80) and 424(91) nmol l-1 before operation to 895(46) and 966(53) nmol l-1 after surgery in patients undergoing laparoscopic and open cholecystectomy respectively. There was no difference in cortisol response between the groups. Glucose concentration was increased (P < 0.02) at the end of surgery from mean(s.e.m.) preoperative levels of 5.54(0.15) and 6.16(0.15) mmol l-1 to postoperative values of 7.46(0.29) and 8.46(0.86) mmol l-1 for the laparoscopic and open procedures respectively. The mean glucose concentration during the initial 12 h after surgery was significantly greater (P < 0.02) following open than laparoscopic cholecystectomy. The mean(s.e.m.) albumin concentration fell significantly (P < 0.01) during surgery by an equivalent extent from 38.9(0.77) and 38.5(1.10)g l-1 to 35.2(0.79) and 34.6(0.97) g l-1. The mean (95 per cent confidence interval) interleukin (IL)6 concentration peaked 4 h after surgery at 57.2 (44.6-73.4) pg ml-1 following laparoscopic and 99.3 (72.8-135.4) pg ml-1 after open cholecystectomy. Mean (95 per cent confidence interval) C-reactive protein (CRP) levels at 24 h were 17.0 (12.7-21.2) and 49.0 (25.3-93.6) mg l-1 and at 48 h 28.0 (21.4-35.4) and 70.0 (36.4-133.6) mg l-1 following laparoscopic and open operations. The differences in IL-6 and CRP level between the groups were significant (P < 0.01). Mean(s.e.m.) fatigue scores were significantly (P < 0.05) increased from preoperative values of 2.4(0.24) and 2.6(0.44) to 5.5(0.56) and 6.8(0.51) at 24 h after laparoscopic and open operations. At 48 h the mean(s.e.m.) fatigue score (5.6(0.57)) remained significantly (P < 0.05) raised only after open cholecystectomy. Hand grip strength was significantly (P < 0.05) reduced only after the open procedure, to a mean(s.e.m.) of 88(6) per cent of the preoperative value. These results demonstrate that aspects of the metabolic and acute-phase responses are attenuated following laparoscopic cholecystectomy, consistent with a reduction in tissue trauma.

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We read with much interest the special article by Frerk and colleagues 1 about recent updated guidelines on the management of unanticipated difficult intubation in adults. The article appears to be very informative and assists in decision making. The authors described use of the scalpel-finger-bougie technique in case of impalpable cricothyroid membrane and suggested a midline vertical skin incision of 8-10 cm directed caudad to cephalad. We found an 8-10 cm length of incision over the trachea to be quite debatable, as it can lead to higher risk of bleeding/oozing from the local tissues making poor visualization of landmarks and risk of infection postoperatively. However, it can help in better palpation of the cricothyroid membrane. 2 We suggest the authors should acknowledge the use of techniques such as infiltration of local anaesthetic along with epinephrine, or the standby measures such as application of cautery (monopolar/bipolar), to stop bleeding at the local site while performing the procedure in an emergency.

Cuffed tracheal tubes are rarely routinely used in children, particularly in the under 8 yr age group, in specialist paediatric centres in the UK. When used, it is predominantly for a specific indication, and the monitoring of intracuff pressure is not routine. Current expert consensus is that complications are equally as common when using a cuffed as an uncuffed tube.

Experienced anaesthetists required a longer time for intubation in a standard manikin using a McGrath compared with other laryngoscopes, but a shorter time for intubation in a difficult manikin using an APA with DAB, and with fewer glottic advances, compared with other laryngoscopes.

SummaryThe effect of oral premedication was investigated in a double-blind, randomised trial in 85 children undergoing tonsillectomy and/or adenoidectomy. Orally administered midazolam 0.5 mg.kg ¹1 given 30 min pre-operatively was compared with trimeprazine 2 mg.kg ¹1 given 90 min pre-operatively and a placebo preparation. Compliance, sedation and ease of induction were assessed as were the duration and quality of recovery. Following premedication with midazolam none of the patients was anxious, crying or distressed on leaving the ward, compared with 2/28 in the trimeprazine group and 5/28 in the placebo group (p ¼ 0:0007). More patients were calm and quiet on arrival in the anaesthetic room following midazolam than following trimeprazine, with both premedicant agents comparing favourably with placebo. There was no significant difference between the three groups in the time to recovery or the sedation score on discharge to the ward. Midazolam is a safe and effective oral premedicant for children.