Australasian Anaesthesia 2019 R. RILEY Australasian Anaesthesia 2019 Invited papers and selected continuing education lectures Editor: Richard Riley Department of Anaesthesia and Pain Medicine Royal Perth Hospital Pharmacology and Anaesthesiology Unit School of Medicine and Pharmacology University of Western Australia Contents AIRWAY 1 The Vortex Approach to airway management 3 Nicholas Chrimes Managing airway trauma: Applying logic and structure to the anaesthetic decision-making process 13 Adam Rehak Unanticipated difficult airway events: A systematic analysis of the current evidence and mapping of the issues involved using a Bowtie diagram 25 Yasmin Endlich, Martin Culwick Flexible bougies, introducers and bronchoscopes – Key adjuvants in the Age of Videolaryngoscopes 35 John Cormack, Wallace Grimmett, David Shan BREATHING/VENTILATION 47 Hyperbaric medicine 49 Bridget Devaney CIRCULATION 59 Perioperative management of heart transplantation 61 Sean Edwards, Sara Jane Allen Preventing vascular damage during central venous catheter insertion via the internal jugular vein 75 Jennifer Bath, Andrew Deacon, Alister Jones Keep calm and know sepsis 89 Linden Martyr, Samuel Cook, Siva Senthuran Midodrine and its potential role in postoperative hypotension 101 Verna M Aykanat, Ian O Fleming, Tomás B Corcoran COAGULATION/BLOOD 113 It’s about bloody time! The massive transfusion protocol in trauma 115 Sinéad O’Keeffe, Ray Paramalingam, Christine Grobler Differentiation of preoperative anaemia 127 Hafiza Misran, Hamish Mace, Shane Gangatharan, Kylie Symons REGIONAL 137 An update on the management of patients with rib fractures 139 Andrew Lumley, Sean Chan, Andrew Deacon Parallel processing pathways for regional anaesthesia: An introduction to block rooms 151 ISBN 978-0-9945075-6-3 Brigid Brown, Tim Donaldson Copyright © 2019 by the Australian and Ultrasound-guided erector spinae plane block 157 New Zealand College of Anaesthetists. Alex Grosso, Gilberto Arenas, Kate Drummond, Sam Whitehouse All rights reserved. None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form, by any means without the prior written permission of the publisher. Please note that any views or opinions expressed in this publication are solely those of the author and do not necessarily represent those of ANZCA. PAIN 167 The “opioid crisis” 169 Stephan A Schug Opioid harm reduction strategies – stemming the tide 175 Michael H Toon The changing face of complex regional pain syndrome treatment 183 Marc Russo, Peter Georgius, Danielle Santarelli BRAIN/NEURO 193 Postoperative delirium 195 Faculty and Regional Editors Kate O’Hare, Silke Brinkmann, Dale Currigan Professor Thomas Bruessel The psychedelic renaissance: Ethnopharmacology, neuroscience and clinical efficacy 203 John Akers Australian Capital Territory High hopes for dope: What role does medicinal cannabis play in current clinical practice? 219 Dr Brenda Cassidy Nilru Vitharana, Jane Standen Faculty of Pain Medicine Anaesthetic implications of restless legs syndrome: A review 227 Nicole Somi, Elizabeth Merenda, Thomas Bruessel Associate Professor Alicia Dennis Victoria LIVER/METABOLIC/IMMUNE SYSTEM 237 Dr Thomas Fernandez Obesity and anaesthesia 239 New Zealand Peter Baumgartner Dr Adrian Langley Euglycaemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitors: Queensland New drugs bring new problems 251 Venkatesan Thiruvenkatarajan, Emily Jane Meyer, Nagesh Nanjappa, John Currie, Dr Priya Nair Roelof M Van Wijk, David Jesudason College of Intensive Care Medicine Anaesthesia and immune modulation 265 Michelle Roets, Melinda Dean, Jaisil EJ Punnasseril, Kerstin Wyssusek, Associate Professor Richard Riley Andre van Zundert, David Sturgess Western Australia OB/GYN 277 Dr Sharon Tivey New South Wales Role of simulation in obstetric anaesthesia training 279 Rebecca A Szabo, Kara Allen, Olivia J Millay Dr Gerald Toh South Australia ASSESSMENT 287 Dr Maurice Vialle Prehabilitation 289 Tasmania Diyana Ishak, Prabir Patel Reifying race in medicine 299 Alan McLintic EDUCATION 311 Human factors in anaesthesia: Beyond non-technical skills 313 Stuart Marshall Feasibility of an open access collaborative anaesthesia knowledge base 319 Ryan Juniper, Agnieszka Ganska MANAGEMENT 325 A resilience engineering approach to out-of-hours healthcare: The SAFE initiative 327 Tim Bowles, Deepan Krishnasivam, Katherine Birkett Preface Welcome to the 2019 edition of Australasian Anaesthesia. This edition has a variety of “hot” topics that I hope you find interesting and relevant to your practice. This is despite several colleagues suggesting to me that the golden age of anaesthesia is over. They argue that the drugs are so good now, the technology is superb and the techniques so well developed that research funding has largely moved away from anaesthesia to other specialties, such as oncology and immunology. The implication is that return on investment in anaesthesia-related pharmaceuticals or equipment is possibly lower than other fields and that we should not expect to witness monumental discoveries in anaesthesia as all the innovation has been largely achieved. Certainly, I feel privileged to have seen the introduction of remifentanil, isoflurane, then followed by sevoflurane and desflurane; the adoption of capnography, oximetry and processed EEG; and the transition from simple mechanical anaesthesia machines to complex, computerised anaesthesia delivery units with integrated monitoring that rival ICU systems. Further, airway management has broadened its armamentarium with the advent of the laryngeal mask airway, videolaryngoscopy and fibreoptic bronchoscopy. Similarly, ultrasound has been adopted by anaesthetists to enhance the practice of regional anaesthesia, vascular access and even airway management and to aid perioperative diagnosis of various crises. And we should not forget the pioneering work of anaesthetists in the hybrid field of simulation in healthcare. Simulation- based learning has contributed to the education of anaesthetists, and all their colleagues in acute-care medicine, and to assist in understanding how we work and, finally, to enhance patient safety. So if I have learned one thing about those who practice anaesthesia it is that they are innovative. Although one age is over, there will be another. There will be better and safer drugs, newer technologies to remove some of the guesswork and enhance decision-making in our practice, and additional strategies to make the perioperative process lower risk. And this will be taking place while facing demands of patients with greater age, body mass index and number of comorbidities; and hospital managers who strive to contain hospital budgets. This is my last edition as editor and I wish to thank the authors, the faculty and regional editors and ANZCA’s Liane Reynolds, Frankie Rowsell and Vanessa Hille for their work and support in producing this edition. Please take the opportunity to thank our authors personally when you can and also consider writing yourself for the next edition. Finally, please continue to give us feedback. This is your publication and we would like to make it better. Associate Professor Richard Riley Editor, Australasian Anaesthesia 2019 [email protected] Airway The Vortex Approach to airway management Nicholas Chrimes Managing airway trauma: Applying logic and structure to the anaesthetic decision-making process Adam Rehak Unanticipated difficult airway events: A systematic analysis of the current evidence and mapping of the issues involved using a Bowtie diagram Yasmin Endlich, Martin Culwick Flexible bougies, introducers and bronchoscopes – Key adjuvants in the Age of Videolaryngoscopes John Cormack, Wallace Grimmett, David Shan The Vortex Approach to airway management 3 The Vortex Approach to airway management Nicholas Chrimes BSc MBBS(Hons) FANZCA Monash Medical Centre, Melbourne, Australia. Dr Nicholas Chrimes is a consultant anaesthesiologist, simulation instructor and the creator of the Vortex Approach. INTRODUCTION While technical competence and adequate planning are crucial to effective airway management, it is well recognised that even well-prepared airway clinicians can sometimes fail to perform basic interventions under stress1. The major airway guidelines are valuable resources that can be referred to prior to the occurrence of an airway crisis, to lay a foundation of knowledge on which subsequent airway management decisions can be based (“foundation tools”). They are not, however, usually presented in a format that makes their content readily accessible in real-time to teams of potentially highly stressed clinicians nor are they intended to be referred to during the process of managing a challenging airway2. In addition, difficult airway guidelines typically provide guidance predominantly directed at anaesthetists and largely restricted to the circumstance where the primary plan for airway management is endotracheal intubation2-4. In contrast, the Vortex Approach5 is based around a “high acuity implementation tool”, designed to be used during the high-stakes, time-critical situation of an evolving airway emergency. It is intended to help clinical teams perform under pressure by providing a simple, consistent template that can be taught to all clinicians involved in advanced airway management, irrespective of critical care discipline and whether they are from a medical, nursing or paramedical background. It is also able to be used in any context