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E-letters: Electronic letters published:
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Airway managment for tonsillectomy.
- tim m cook (11 October 2007)
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Airway management for tonsillectomy: a national survey of UK practice
- AR Lewis, AR Wilkes (5 October 2007)
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Re: Airway management for tonsillectomy: a national survey of UK practice
- Wendy K Laupu (5 October 2007)
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Reusable laryngoscopes and risk of prion transmission
- Rajinikanth R Sundararajan, Kevin D Johnston Specialist Registrar (27 September 2007)
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Re: Airway management for tonsillectomy: a national survey of UK practice
- Francis E Arnstein (27 September 2007)
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Airway management for tonsillectomy: a national survey of UK practice
- tim m cook (25 September 2007)
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Airway management for tonsillectomy: a national survey of UK practice.
- Alexandra J Roper, Shondipon K. Laha (10 September 2007)
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GUIDELINES : THE ROLE OF SPECIALTY SOCIETIES IN PHYSICIANS’ KNOWLEDGE
- Pascal Vignally, Stephanie Gentile (19 July 2007)
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tim m cook
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Dear Editor Drs Lewis and Wilkes suggest that the recently published NICE advice on Patient safety and reduction of risk of transmission of Creuztfeld–Jakob disease (CJD) via interventional procedures, can guide revision of national guidance on appropriate airway management during tonsillectomy. It [1] is perhaps worth reiterating that the guidance document offers no advice for anaesthetists. It does not mention anaesthesia, anaesthetists, anaesthetic airway equipment in general or laryngeal masks specifically. It does mention laryngoscopes (once) but the context suggests this refers to surgical laryngoscopes as opposed to anaesthetic instruments. The fuller ‘final report’ [2] offers useful data regarding laryngoscopes and anaesthesia (but none on laryngeal masks) but again falls short of providing guidance. Further analysis and interpretation of the data presented will be needed to inform this debate. I believe such a process is underway. Yours sincerely Tim Cook References 1. Patient safety and reduction of risk of transmission of Creutzfeldt-Jakob disease (CJD) via interventional procedures – guidance. IPG196. November 2006. London: NICE http://guidance.nice.org.uk/IPG196/guidance/pdf/English ((accessed October 2007)) 2. IPG196 Patient safety and reduction of risk of transmission of Creutzfeldt-Jakob disease (CJD) via interventional procedures: Final report. http://guidance.nice.org.uk/page.aspx?o=387394 (accessed October 2007) Conflict of Interest:None declared |
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AR Lewis , AR Wilkes
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Editor - Dr Clarke and colleagues conducted a national survey to examine current practice in airway management for tonsillectomy.1 This was in response to Creutzfelt-Jakob disease (CJD). They quote the guidelines from the UK Department of Heath (DH),2 the Royal College of Anaesthetists (RCoA)3,4 and the Association of Anaesthetists of Great Britain and Ireland (AAGBI)5 which recommend the use of disposable surgical equipment. Although the guidance from these authorities has not changed, the National Institute for Health and Clinical Excellence (NICE) produced a new guideline in November 2006.6 This guideline relates to patient safety and reduction of risk of transmission of CJD via interventional procedures. The recommendations are that with the exception of those procedures involving neuroendoscopy accessories, the evidence on cost effectiveness related to risk of possible transmission of CJD does not support a change to single use instruments. This includes equipment for tonsillectomy and laryngoscopy. In addition, the guidance suggests that children born since 1 January 1997 who have not had a blood transfusion or a high risk procedure, are unlikely to have been exposed to bovine spongiform encephalopathy (BSE) or CJD and the prevalence of CJD in this population is close to zero. The recommendations from NICE are based on evidence that effective methods for removing CJD infectivity from instruments are likely to be widely available within 5 years. 6 Clarke et al states that “if the risk is insubstantial and the guidelines ‘out of date’ then logically they should be revised or withdrawn”.1 This may be an opportunity for the DH, the RCoA and the AAGBI to revise current guidelines. AR Lewis AR Wilkes Department of Anaesthetics and Intensive Care Medicine, Wales College of Medicine, Cardiff University, Heath Park, Cardiff Cf14 4XN 1 Clarke MB, Forster P, and Cook TM. Airway management for tonsillectomy: a national survey of UK practice. Br. J. Anaesth. 2007 99: 425-8 2 Department of Health. £200 million for NHS equipment to protect patients against possible variant CJD risk (2001) London: Department of Health. 3 Smith G. Variant CJD: What you need to know at present. Bulletin 7. (2001) London: The Royal College of Anaesthetists. 302–4. 4 The Royal College of Anaesthetists. Anaesthesia Equipment and Tonsillectomy. London. (2002) The Royal College of Anaesthetists. 5 Association of Anaesthetists of Great Britain, Ireland. Infection Control in Anaesthesia (2002) London: AAGBI. 6 National Institute for Health and Clinical Excellence. Patient safety and reduction of risk of transmission of Creutzfeldt-Jakob disease (CJD) via interventional procedures. Interventional procedure guidance 196, 2006. London: NICE www.nice.org.uk/IPG196 Conflict of Interest:None declared |
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Wendy K Laupu, EN
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I read with great interest Dr Cook's recent e-letter (British Journal of Anaesthesia published 25 Sept, 2007) in which he refers to both the percieved risk benefit and cost benefit analysis of tonsillectomy management. Dr Cook argues that 'For anaesthesia the risks of both use of, and advoidance of, reusable equipment are different from surgery'(1). Whilst this is true, I suggest that anatomical risk factors are important to any discussion related to risk benefit analysis. Bruce et al(2) found that the brain contained between a hundred and a thousand times more infectivity than that of the spleen [and tonsillar] tissue consistent with previous findings in animal modelling of Transmissible Spongiform Encephalopathies. Two previous studies have investigated lower concerntrations of potassium permanganate on scrapie brain homogenate and rejected the use of potassium permanganate(4)(5). I realise that residual protein deposits on anaesthetic equipment is not the same as misshapen prion proteins. However, our group have demonstrated the elimination of residual protein deposits from metallic and synthetic airway equipment using 8mg/L potassium permanganate solution and flat diet coke to remove any residual manganese oxide deposits (3). The Magill forceps and laryngoscope blades used in the trial were of surgical grade stainless steel not dissimilar to instrumentation used by surgeons in preforming tonsillectomies. I have limited knowledge of UK practice but suggest that the environmental cost of disposable equipment is measurable. Prions are known to adhere to soil minerals, remain infectious and resist burial for three years (6). The contribution of disposables to landfill and risk of variant Creutzfeldt-Jakob disease transmission in the future, if not disposed of by incineration at 1100 degrees centigrade must be acknowledged. With the subject of greenhouse emissions at the forefront of international discussion, as responsible medicos we must surely weigh up the cost of incinerating one reusable LMA versus 40 disposables. We owe this to our children. In December of 2004 we costed the expected savings for our institution's Operating Theatre complex using the available Portex single- use(TM)(Portex Company, UK) versus reusable laryngeal mask airway (LMA)(TM) (Laryngeal Mask Airway Company, Henley-on-Thames, UK). The Intensive Care, Emergency department and clinical area use was not included in the statistics. Our statistical estimates indicated that our institution used laryngeal mask airways 6000 times for the year. Included in the statistics were all forms of LMAs currently available at that time such as; Proseals, Classic LMAs, Reinforced LMAs of all sizes. I have not costed the use of reusable Guedal airways, Magill forceps or laryngoscope blades versus disposable varieties. The formulae used for the laryngeal mask airway cost analysis were; Group A - cost of a Portex single-use LMA (AUS $25 per item) + labour + disposal cost (in specialised yellow infectious bags, incineration at 1100 degrees in Brisbane facility which includes transport costs for the 26 hour drive from Cairns). The Environmental Protection Agency guidelines for Queensland in 2004 allowed for deep burial in certain circumstances. I costed for incineration for a comparision. Group B - cost of a reusable LMA divided by the manufacturer's recommended 40 uses + labour + processing costs (at our institution this involves a six step process including immersion in a mild enzymatic solution, autoclaving for 4 minutes at 134 degrees centigrade, drying for 30 minutes (3)(7) + supplementary cleaning treatment costs (8mg/L potassium permanganate solution and 1 litre of diet coke(TM)(Coke-a-cola Company, USA) per a day (AUS $2.92 cents per a day) + disposal by incineration. We estimated a savings of AUS $100 000 per annum by the continued use of reusable laryngeal mask airways at our institution alone. Acknowledgements: The author would like to thank J. Voogt for her assistance in preparing the initial institute costing and Prof. L. Salamonsen for her assistance. References: 1. Cook T. Airway management for tonsillectomy? A national survey of UK practice. British Journal of Anaesthesia e-letter published. 2007 Sept 25. Retrieved from http://bja.oxfordjournals.org/cgi/eletters?lookup=by_date&days=4 2. Bruce ME, McConnell I, Will RG, Ironside JW. Detection of variant Creutzfeldt-Jakob disease infectivity in extraneural tissues. Lancet 2001;358:208-9. 3. Laupu W, Brimacombe J. The effect of high concerntration potassium permanganate from metallic and synthetic rubber airway equipment. Anaesthesia. 2007 Aug;62(8):824-6. 4. Kimberlin RH, Walker CA, Millson GC, Taylor DM, Robertson PA, Tomlinson AH, Dickinson AG. Disinfection studies with two strains of mouse -passaged scrapie agent. Guidelines for Creutzfeldt-Jakob and related agents. Journal of Neurological Science. 1983 Jun;59(3):355-69. 5. Brown P, Rohwer RG, Green EM, Gadjusek DC. Effect of chemicals, heat, and histopathologic processing on high-infectivity hamster-adapted scrapie virus. Journal of Infectious Diseases. 1982 May;145(5):683-7. 6. Laupu W. Disposing of disposables. British Journal of Anaesthesia [out of the blue e-letters]. 2006 Dec 15. Retrieved from http://bja.oxfordjournals.org/cgi/qa-display/short/brjana_el;1432 7. Laupu W, Brimacombe J, Richards E, Keller C. High concerntration potassium permanganate eliminates protein and particle contamination of the reusable Classic laryngeal mask. Anaesthesia. 2006 Jun;61(6):524-7. Erratum in Anaesthesia. 2006 Jul;61(7):726. Laupau, W [corrected to Laupu, W]. Conflict of Interest:None declared |
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Rajinikanth R Sundararajan, Specialist Registrar Milton Keynes General Hospital, Kevin D Johnston Specialist Registrar
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Editor – the finding that so many of us are non-compliant with national airway guidelines for tonsillectomy cases [1] makes both interesting and worrying reading. Moreover, what makes the timing of these data particularly significant is a very recent multicentre audit of single use surgical instruments for tonsillectomy in which O’Flynn et al argue that the latest single use surgical instruments are now probably as good as the re-usable ones. [2] Despite its disappearance from the media, the issue of variant CJD has not gone away and if otolaryngologists were to set a precedent by again adopting the use of single use instruments, what excuses would there be then for anaesthetists to not follow suit ? Indeed if the risk of prion transmission on laryngoscope blades is real, no matter how small [3] then to play devil’s advocate, should we not be avoiding reusable laryngoscopes for the airway management of all patients, not just tonsillectomies? A radicle suggestion maybe but why should the lymphoid tissue of ENT patients be different to anyone elses? A few years ago, a postal survey of laryngoscope cleaning practices suggested that although laryngoscopes in most units were autoclaved sooner or later, only a quarter of units were autoclaving their laryngoscopes between all patients. Most units did not even have local guidelines on how laryngoscopes were otherwise to be cleaned and practices varied. [4] Furthermore, even routine cleaning and autoclaving doesn’t remove all protein deposits that could harbour prions, [5] so where does this leave us ? In a study by Sudhir et al on different single use Miller blades, there were actually a few single use blades that performed at least as well as or even better than the reusable ones [6]. The latency to obtain the best view at laryngoscopy was only 3 seconds between the best and worst Miller blades. There was greater user satisfaction with metal disposable blades and they required less time and applied force needed to achieve the best view at laryngoscopy when compared to the plastic variants The combined cost of a single use laryngoscope and endotracheal tube may well exceed the cost of even a reinforced single use LMA and even though use of protective sheaths or ‘condoms’ for laryngoscope blades may reduce this cost, they generate other problems such as light quality. Some centres have started using single use laryngeal masks for airway management in tonsillectomies [1] and it may be that more widespread usage of LMAs for tonsillectomies is the way forward. References 1 Clarke MB, Forster P, Cook TM. Airway management for tonsillectomy: a national survey of UK practice. Br. J. Anaesth. 2007; 99:425-8 2 O’Flynn P, Silva S, Kothari R, Persaud R. A multicentre audit of single-use surgical instruments (SUSI) for tonsillectomy and adenoidectomy. Ann R Coll Surg Engl 2007; 89:616-23 3 Hirsch N, Beckett A, Collinge J et al. Lymphocyte contamination of laryngoscope blades – a possible vector for transmission of variant Creutzfeldt-Jakob disease. Anaesthesia 2005; 60:664-7 4 Esler MD, Baines LC, Wilkinson DJ, Langford RM. Decontamination of laryngoscopes: a survey of national practice. Anaesthesia 1999; 54:587-92 5 Clery G, Brimacombe J, Stone T et al.Routine cleaning and autoclaving does not remove protein deposits from reusable laryngeal mask devices. Anesth Analg 2003;97:1189-1191 6 Sudhir G, Wilkes AR, Clyburn P, Aguilera I, Hall JE. User satisfaction and forces generated during laryngoscopy using disposable Miller blades: a manikin study. Anaesthesia 2007; 62:1056-60 Conflict of Interest:None declared |
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Francis E Arnstein
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Editor – Clarke et al’s survey is a useful reminder of the wide variation in advice and practice within the different countries of the United Kingdom.[1] However, when considering tonsillectomy and minimising the potential risk of prion transmission, it is useful to consider that it is not the practice of airway management prior to surgery that is important but how the airway is managed after surgery. I no longer routinely use any device (laryngoscope or suction) in the airway at the end of surgery, checking with the surgeon both verbally and by eye that the airway is clear before the Boyles-Davis gag is removed. This is particularly straightforward with the advent of coblation tonsillectomy when, in experienced surgical hands, blood loss is rarely more than a few millilitres. If more interventional airway management is required then I follow the published recommendations. It should be noted that, in these rare circumstances, although the aim is to minimise potential prion contamination of anaesthetic equipment, the patient is likely to ‘contaminate’ their immediate environment in recovery and continue to do so when they return to the ward and begin to eat and drink using hospital crockery and cutlery. Clarke et al’s comment that the epidemic of variant Creutzfeld-Jakob Disease has fortunately failed to materialise suggests maybe we are approaching the time when the application of the ‘precautionary principle’ in this clinical scenario should be reviewed. 1 Clarke MB, Forster P, Cook TM. Airway management for tonsillectomy: a national survey of UK practice. Br J Anaesth 2007; 99: 425-428 Conflict of Interest:None declared |
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tim m cook Royal United Hospital, Bath, UK
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Response to Dr Roper and Laha I am grateful for Dr Roper and Dr Laha’s interest in our article. They ask for a ‘full assessment of whether the risk of prion transmission is clinically significant’. I understand that the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland (AAGBI) are both in the process of performing such an assessment, before updating the College advice and the AAGBI document ‘Infection and the Anaesthetist’. They refer to the possibility of improved decontamination. This is pertinent to anaesthetic practice: several studies have shown that treatment with potassium permanganate 0.4-0.8% improves decontamination of both reusable silicone laryngeal masks [1,2] and from metal and rubber airway equipment [3]. The stronger concentration appears to eliminate residual protein. This is non-standard treatment but probably merits further exploration for its role in ‘risk reduction’. The authors close their letter with the statement ‘It cannot be consistent to have one rule for surgeons and another rule for anaesthetists’. If, by that they imply that surgeons and anaesthetists should automatically either both use single use equipment or both use reusable equipment, I do not agree. In November 2006 the National Institute for Health and Clinical Excellence (NICE) published their report ‘Patient safety and reduction of risk of transmission of Creutzfeldt–Jakob disease (CJD) via interventional procedures’ [4]. This document makes much of risk-benefit analysis but also cost-benefit analysis. The conclusion that tonsillectomy does not require single-use surgical equipment (and that some neurosurgery does) appears to be based both on the intermediate risk of tonsillectomy and the high cost of single-use surgical equipment: in essence it is mostly a cost-benefit decision. The document makes almost no mention of anaesthesia. Laryngoscopes are mentioned only ‘in passing’ and laryngeal masks are not mentioned at all. The document therefore makes no specific recommendations relevant to anaesthesia. For anaesthesia the risks of both use of, and avoidance of, reusable equipment are different from surgery. However the benefits and costs also differ. For instance the costs of substituting in single-use equipment for anaesthesia are tiny compared to surgery. Therefore the result of a cost-benefit analysis for anaesthesia cannot be inferred from the result of the surgical assessment and indeed the solution may be different. Unfortunately this analysis was not performed for anaesthesia. What is needed, I quite agree, is a clearer statement of what the risk of transmission of vCJD is as a result of anaesthetic practices. If this is available it will allow the College and Association to arrive at clearer advice that is more likely to be accepted and followed. TM Cook References 1. Laupu W, Brimacombe J Potassium permanganate reduces protein contamination of reusable laryngeal mask airways. Anesth & Analg 2004; 99: 614-6, 2. Laupu W, Brimacombe J , Richards E , Keller C. High concentration potassium permanganate eliminates protein and particle contamination of the reusable Classic laryngeal mask airway. Anaesthesia 2006; 61: 524-7 3. Laupu W, Brimacombe J. The effect of high concentration potassium permanganate on protein contamination from metallic and synthetic rubber airway equipment. Anaesthesia 2007; 62: 824-6. 4. Patient safety and reduction of risk of transmission of Creutzfeldt–Jakob disease (CJD) via interventional procedures. Interventional procedure guidance 196. National Institute for Health and Clinical Excellence, London, 2006. www.nice.org.uk/IPG196 Conflict of interest. I have been paid by Intavent Orthofix and the LMA-company for lecturing. They also paid for the postage costs of this survey. They were otherwise uninvolved. Conflict of Interest:I have been paid by Intavent Orthofix and the LMA-company for lecturing. They also paid for the postage costs of this survey. They were otherwise uninvolved. |
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Alexandra J Roper, ST3 Otolaryngology , Shondipon K. Laha
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Editor- We were interested to read the above article. It concludes that there is widespread non-compliance in the use of disposable anaesthetic instruments in tonsillectomies. The authors quite correctly make the point that currently non-disposable surgical instruments are used. Surely, prion transmission is less likely to occur via anaesthetic than surgical instruments which are intrinsically contaminated with tissue. The current RCoA guidelines recommend the use of single-use instruments for anaesthesia in tonsillectomy although reusable instruments are used for the actual operation. We feel that, before enforcing guidelines that have not been complied with nationally, a full assessment of whether the risk of prion transmission is clinically significant is necessary. In 2001, the Department of Health recommended that although there was no evidence of any patient being infected with variant CJD, precautions should be taken to reduce the ‘theoretical risk’. The use of single-use surgical instruments was abandoned after an increased risk of haemorrhage was identified by the National Prospective Tonsillectomy Audit (NPTA)(1). Frosh(2) recommended improved decontamination as well as the use of disposable surgical instruments, prior to the results of the NPTA. Improved decontamination should reduce the risk of CJD transmission and can be applied to both surgical and anaesthetic instruments. This also resolves the problem of substandard single-use instruments, as identified by the authors. It cannot be consistent to have one rule for surgeons and another rule for anaesthetists. 1. National Prospective Tonsillectomy Audit. British Association of Otolaryngologists, Head and Neck Surgeons Comparative Audit Group, Clinical Effectiveness Unit, Royal College of Surgeons of England. May 2005. 2. Frosh A. Iatrogenic vCJD from surgical instruments. BMJ 2001 30;322(7302):1558-1559 Conflict of Interest:None declared |
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Pascal Vignally Department of public health, Faculty of Medicine, Marseille (France), Stephanie Gentile
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Recently, Clarke et al(1) illustrated the main issue of knowledge and adherence in daily practice to national guidelines, demonstrating widespread lack of knowledge and non-compliance. In a study carried out in 2005, we showed how anaesthetists would judge and adhere to guidelines based on who promoted them. Using a multiple- choice questionnaire, we asked a random sample of 100 anaesthetists to evaluate their knowledge of guidelines and promoters. The way they became aware of guidelines was also investigated. The overall response rate was 77%. The level of confidence with guidelines was not related to the scientific evidence (consensus conferences were evaluated more reliable compared to clinical practice guidelines 94,3% vs 76,8% p<0,001). But the level of confidence was significantly linked to the promoter: French society of anaesthesia and reanimation was considered a more reliable promoter than national health agencies and pharmaceutical industries (respectively 67,4% vs 11,6% and 3,8%, p<0,001). Anaesthetists became aware of guidelines mainly through their specialty society (62%). Other channels were congresses (31%), hospital colleagues (23%) and publications (14%). The main resources for finding guidelines were specialty societies internet sites. According to these results, the role of peers and in particular specialty societies appeared preponderant for the knowledge and the appreciation of guidelines. In order to achieve a better appreciation and a higher application of their guidelines, national health agencies have to rely on specialty societies. Nevertheless the role of specialty societies must be limited to promoting guidelines: Grilli et al(2) and more recently Wright (3) showed that the quality of guidelines developed by specialty societies had been often unsatisfactory due to their lack of explicit methodological criteria. 1 Clarke MB, Forster P, Cook TM. Airway management for tonsillectomy: a national survey of UK practice.Br J Anaesth. 2007 Jun 27 2 Grilli R, Magrini N, Penna A et al. Practice guidelines developed by specialty societies: the need for a critical appraisal.Lancet. 2000 Jan 8;355(9198):103-6 3 Wright JM. Practice guidelines by specialist societies are surprisingly deficient. Int J Clin Pract. 2007 Jul;61(7):1076-7 Conflict of Interest:None declared |
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