Correspondence

Anaesthesia 2014, 69, 281290

Reference
1. Association of Anaesthetists of Great
Britain & Ireland. Peri-operative care of
the elderly 2014. Anaesthesia 2014; 69
(Suppl 1): 8198.
doi:10.1111/anae.12616

A reply
Dr Rajamanickam asks a very good
question that is pertinent to our
recent guidelines [1]. The exact
transfusion trigger in surgery, in the
older patient, is still surrounded by
some controversy, despite a recent
Cochrane review [2]. The advice
from this review is to withhold blood
until the haemoglobin concentration
reaches 7080 g.l 1, which is
described as a restrictive transfusion
trigger. The review includes 19 studies, involving over 6000 patients, and
the in-hospital mortality was lower
in those who had a restrictive policy
applied. This review is dominated by
one study, the Focus Study [3],
which was a rehabilitation study in
patients with hip fracture and contributed 2016 patients including
those over 50 years, but with an
average age of around 80 years. All
were randomised after surgery.
Many of the other included studies
involved children and patients
receiving critical care, who are younger than the standard elderly patient.
The recent review does mention that
there are no trials of transfusion triggers in those with acute coronary
syndromes and that studies are also
required in which the trigger is set at
60 g.l 1 [2].
In contrast, there is evidence
from a large observational study
[4] that looked at the effect of

anaemia in older surgical patients

who have had non-cardiac surgery.
It showed a detrimental effect of
anaemia on outcome from surgery.
There are confounding factors at
play, as pre-operative anaemia can
be investigated and corrected and
is often a marker of another disease process, whilst acute blood
loss may just occur in the acute
surgical process.
Transfusion utilises a precious
resource but constant vigilance
around the time of surgery should
be exercised in the older patient,
many of whom have risk factors
for ischaemic heart disease. In
those with risk factors, a higher
trigger, towards 90 g.l 1, may be
advisable.
R. Grifths
Chair
AAGBI Working Party on
peri-operative care of the elderly
Email: workingparties@aagbi.org
Previously posted on the Anaesthesia correspondence website: www.
anaesthesiacorrespondence.com.

References
1. Association of Anaesthetists of Great
Britain & Ireland. Peri-operative care of
the elderly 2014. Anaesthesia 2014; 69
(Suppl 1): 8198.
2. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies
for guiding allogeneic red blood
cell transfusion. Cochrane Database
of Systematic Reviews 2012; 4:
CD002042.
3. Carson JL, Terrin ML, Noveck H, et al.
Libreal or restrictive transfusion in highrisk patients after hip surgery. New England Journal of Medicine 2011; 365:
245362.
4. Wu W-C, Schifftner TI, Henderson WG,
et al. Preoperative haematocrit levels
and postoperative outcomes in older
patients undergoing noncardiac surgery.

2014 The Association of Anaesthetists of Great Britain and Ireland

Journal of the American Medical Association 2007; 297: 24828.

doi:10.1111/anae.12617

Trachway and jaw thrust

We read with great interest the article by Lee et al. [1] and agree with
their conclusion that the modied
jaw thrust is the most effective
manoeuvre to improve the laryngeal
view and shorten tracheal intubation
time with the Clarus Video System
(Trachway) intubating stylet (Biotronic Instrument Enterprise Ltd.,
Tai-Chung, Taiwan). Eight patients
(Cormack and Lehane grade 3-4)
who had a failed double-lumen
endotracheal intubation with conventional direct laryngoscopy (>
three attempts) underwent successful
intubation using the Trachway intubating stylet combined with a modied jaw thrust technique (opening
the mouth, protruding the mandible
forward and elevating both mandibular rami). Intubation was successful
in all cases at the rst attempt without damage to the tube cuff, episodes
of hypoxaemia or obvious airway
trauma.
Although double-lumen endobronchial intubation assisted by the
GlideScope (Verathon Medical
China Sales, Shanghai, China) has
been reported in patients with a
difcult airway [2, 3], the wide
blade of the GlideScope makes
double-lumen intubation a challenge, causing damage to intra-oral
tissue and teeth in patients with
limited mouth opening.
We noticed in Lee et al.s study
that the assistant was facing the

285

Anaesthesia 2014, 69, 281290

patient from the left side. In our

experience, having the assistant
stand to the side and facing the
same way as the operator may ease
the modied jaw thrust manoeuvre
without causing backache.
S. W. Wu
H. T. Hsu
K. I. Cheng
Kaohsiung Medical University
Kaohsiung, Taiwan
Email:
770234kmuhanesthesia@gmail.com
No external funding and no competing interests declared. Previously
posted on the Anaesthesia correspondence website: www.anaesthesia
correspondence.com.

References
1. Lee AR, Yang S, Shin YH, et al. A comparison of the BURP and conventional
and modified jaw thrust manoeuvres for
orotracheal intubation using the Clarus
Video System. Anaesthesia 2013; 68:
9317.
2. Hsu HT, Chou SH, Chen CL, et al. Left
endobronchial intubation with a doublelumen tube using direct laryngoscopy or
the Trachway video stylet. Anaesthesia
2013; 68: 8515.
3. Chen A, Lai HY, Lin PC, Chen TY, Shyr
MH. GlideScope-assisted double-lumen
endobronchial tube placement in a
patient with an unanticipated difficult airway. Journal of Cardiothoracic
and Vascular Anesthesia 2008; 22:
1702.
doi:10.1111/anae.12612

Training and assessment

of mask ventilation
Russo and colleagues found that
airway skills successfully practised
on a manikin were not consistently
effective when transferred to real
patients [1]. Success rates for ventilation through a facemask were also
286

Correspondence

signicantly lower than through a

supraglottic airway device.
Two methods were used to
assess mask ventilation. First, consultant anaesthetists assessed the
difculty of ventilation subjectively.
The grading scale was informal
and operator-dependent, and published scales on grading of mask
ventilation were not used [24].
Second, the success of ventilation
by novices was measured formally
using objective criteria: expired carbon dioxide; chest movement
(none, slight or obvious); and
expired volume.
I do not criticise the use of two
measures: there were sound ethical
and methodological reasons to
assess the ease of mask ventilation
before allowing students to proceed.
However, it is striking that the measurement of ventilation performed
by airway experts was informal and
subjective, but measurement of
ventilation by airway novices was
formal and objective. Surely an
objective, scientic standard should
apply to all?
Perhaps a further implication of
this study is the need for a uniform
and objective method to assess
mask ventilation. The words easy,
difcult and obvious may be
comfortably familiar, but they
remain uncomfortably unscientic.
J. Nielsen
Concord Hospital
Sydney, Australia
Email: jamesrnielsen@gmail.com
No external funding and no competing interests declared. Previously
posted on the Anaesthesia correspondence website: www.anaesthesia
correspondence.com.

References
1. Russo SG, Bollinger M, Strack M, et al.
Transfer of airway skills from manikin
training to patient: success of ventilation with facemask or LMA-Supreme by
medical students. Anaesthesia 2013;
68: 112431.
2. Han R, Tremper K, Kheterpal S, et al.
Grading Scale for Mask Ventilation.
Anesthesiology 2004; 101: 67.
3. Yildiz TS, Solak M, Toker K. The incidence and risk factors of difficult mask
ventilation. Journal of Anesthesia 2005;
19: 711.
4. Warters RD, Szabo TA, Spinale FG, et al.
The effect of neuromuscular blockade
on mask ventilation. Anaesthesia 2011;
66: 1637.
doi:10.1111/anae.12568

Labelling syringe plungers

to reduce medication
errors
I was interested to read the letter by
Webster [1] regarding the colourcoding of prelled syringes and the
inconsistency of manufacturers to
comply with the international standard. It is well known that syringeswap errors are a signicant cause
of complications in the operating
theatre [2]. At the start of an operating list, emergency drugs are routinely drawn up. These are
commonly stored above the anaesthetic machine for easy access,
whilst keeping them separate from
the routine drugs drawn up for each
case. However, placement of the
syringes in this way can mean that
the labels on the barrels of the
syringes are hidden from view,
resulting in a higher chance that the
wrong syringe is selected. I propose
that, in order to reduce this kind of
error, the syringes used for emergency drugs should be clearly
labelled with printed coloured stick-

2014 The Association of Anaesthetists of Great Britain and Ireland