Stop, Look, Listen, Think

The theme of this month’s blog is Safety (the capital S is deliberate). We teach road safety to our children by telling them to “Stop, look, listen and think” before crossing the road, and maybe as medical providers we need to try this too?

This month, researchers from Manchester publish an analysis of patient safety incidents reported to the National Patients Safety Agency (NPSA), now the National Reporting and Learning Service (NRLS), between 2004 and 2014 from critical care units in England and Wales. Of 1743 incidents, 389 (22%) may have contributed to the patient’s death, and 1555 (89%) may have been avoidable. Over the 10 years, the number of reported incidents per year went up, as did the number of patients cared for in ICU (but not enough to explain the increase in safety incidents). Why are patient safety incidents on the increase, despite our best efforts? Are we just reporting them more frequently? Or are they actually more common, despite the introduction of numerous guidelines, safety procedures and other central and local initiatives? Can we as medical practitioners and the ICU team as a whole do more? The study shows that there was a decrease in the number of incidents related to infection, but an increase in the number of medication incidents. There is certainly much to reflect on in this excellent analysis.

What about cricoid pressure? We were/are all taught to use it for rapid sequence induction, but, although a number of studies have cast doubt on its efficacy and safety, our practice hasn’t really changed. This month, a new study using ultrasound in awake volunteers shows that standard cricoid pressure does not actually narrow the oesophagus at all, let alone occlude it. This would be an interesting study to repeat in anaesthetised patients, but if it held true, does cricoid pressure do what we think it does? The authors also studied a newly described technique which they name paralaryngeal pressure. This was found to be much more effective at occluding the oesophagus, and certainly merits further study. the future of cricoid pressure is eloquently debated in the accompanying editorial, including its safety and when to release the pressure to prevent patient harm, and I urge you to read both the article and the editorial and join in the debate in our correspondence pages or on Twitter.

The final article related to safety describes an investigation modelling oxygen supplementation during tracheal intubation in pregnant women. Because pregnant women desaturate much more quickly during apnoea, rapid sequence induction can be more fraught and dangerous. Recent studies (THRIVE) have shown that high-flow nasal oxygen during intubation can prolong the time to desaturation during apnoea in the non-pregnant population. This most recent study demonstrated that increasing FiO2 at the open glottis increased the time to desaturation, extending the time taken for SaO2 to reach 40% from 4.5 min to 58 min in the average parturient model (not in labour). The greatest increases in time to desaturation were seen at FiO2 1.0, which could be delivered by high-flow nasal cannulae under ideal conditions. Obviously, clinical studies are needed in pregnant women, but my conclusion from this modelling study is – should we now be administering oxygen routinely via nasal specs during rapid sequence intubation, and certainly in pregnant women? Weighing up the risk-benefit model it would certainly seem to, and this may be a very significant change which will increase safety in this and other patient populations. I look forward to more research in this rapidly evolving safety field.

Finally, I am about to decamp to China (for the Chinese Society of Anesthesiology meeting) and Hong Kong (for the World Congress). I will be blogging from there with some special editions of the journal to coincide with these meetings and more updates on breaking research.


Andrew Klein