Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target-controlled infusions of remifentanil and propofol. Oxygenation was achieved with high-flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.

The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.

SummaryCritical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri‐operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30‐day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. A systematic review of MEDLINE, Embase, CINAHL, Web of Science, the Cochrane database and the grey literature identified 44 studies assessing risk factors for unplanned critical care admission in adult populations undergoing non‐cardiac, non‐thoracic and non‐neurological surgery. Comparative, quantitative analysis of the admission criteria was not feasible due to heterogeneity in study design. Age, anaemia, ASA physical status, body mass index, comorbidity burden, emergency surgery, high‐risk surgery, male sex, obstructive sleep apnoea, increased blood loss and operative duration were all independent risk factors for unplanned critical care admission. Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.

Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low-dose intra-operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra-operative pain, and all would choose this anaesthetic technique again. Surgeon-reported operating conditions were 'indistinguishable from general anaesthesia' in most cases, and surgeons were 'extremely satisfied' or 'satisfied' with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra-operative sedation is a feasible technique for breast surgery.

SummaryWe present the case of unanticipated airway ignition during hard palate biopsy. Transnasal humidified rapid‐insufflation ventilatory exchange (THRIVE) and monopolar diathermy were utilised for the procedure, during which an arc arose from the diathermy tip to a titanium implant, causing a brief ignition on the monopolar diathermy grip. This case highlights the need for maintained awareness of fire risk when using diathermy in the presence of THRIVE during airway surgery.