1. DAS Guidelines update April 2015
In this presentation are 3 draft algorithms and highlights of things that are new or considered particularly important emerging as themes in the new guidelines.
Any / all comments would be welcomed by the Guidelines group by to

2. DRAFT Basic Structure of DAS Guidelines flow chart* 2015 *Includes RSI
Plan A:
Mask ventilation and tracheal intubation
Laryngoscopy
succeed
Tracheal intubation
failed intubation
STOP AND THINK
Assess risks and benefits of:
awakening the patient and postponing surgery
tracheal intubation through the supraglottic airway device
proceeding without intubating the trachea
Plan B:
Airway management using SAD, maintenance of oxygenation and review
succeed
Supraglottic Airway Device
failed oxygenation
Plan C:
Attempt
oxygenation, & ventilation
succeed
Revert to face mask ventilation
Postpone surgery
Awaken patient
CICO
Plan D:
Rescue techniques
for "can't intubate,
can't ventilate” situation
Cricothyroidotomy
*Includes RSI

3. DRAFT Any problems call for help 2015 Basic structure
Management of unanticipated difficult tracheal intubation-during induction of anaesthesia in an adult patient (includes RSI)
Any problems call for help
DRAFT
Plan A: Facemask ventilation & tracheal intubation
Optimise head and neck position
Preoxygenate
Adequate neuromuscular blockade
Direct / Video Laryngoscopy (no more than 4 attempts in total)
External laryngeal manipulation (BURP)
Bougie
Remove cricoid pressure
Maintain oxygenation and anaesthesia
2015
Succeed
Verify tracheal intubation with capnography
Failed intubation
Plan B: SAD Insertion
STOP AND THINK
Assess risks and benefits of:
awakening the patient and postponing surgery
tracheal intubation through the supraglottic airway device
proceeding without intubating the trachea
Insert Supraglottic Airway Device
No more than 4 attempts in total
2nd generation device preferred
Oxygenate and ventilate
Succeed
Fail
Plan C: Maintain oyxgenation
Basic structure
Should plan c be revert to face mask ventilation
Would like to see the phrase ENSURE PARALYSis in the dotted line crossing over to D
Management of unanticipated…
Yes I think if in doubt take it out just looks wrong
Failed intubation
And again in this one even tho the title says paralysed…
How many goes at SAD insertion were we going to allow
4 seems like a lot of faffing about time
Do we need a (including RSI) bracket at the end pof the basic algo- I know its stating the obvious but I can be remarkably stupid and it is one of the biggest changes in thinking
Also given that the guidelines are going to be the things on display in the anaesthetic room that people look at in a crisis should it say release cricoid pressure if difficult
And should Laryngoscopy be Primary Laryngoscopy or in bold or something to show that it’s a title otherwise it looks like a list where laryngoscopy comes before optimising head position and pre-oxygenating
Revert to facemask ventilation
Use 2 person technique +/- adjuncts
Review neuromuscular blockade
Succeed
Postpone surgery
Awaken patient
Failed Oxygenation
Plan D: Emergency Front of Neck Access
Surgical Cricothyroidotomy
(alternative techniques only if skilled)
Succeed
Plan for post-operative care

4. Failed intubation, failed oxygenation in the paralysed, anaesthetised patient.
DRAFT
2015
Ensure help is coming
Plan D: Emergency Front of Neck Access
Surgical cricothyroidotomy
Laryngeal handshake
Vertical skin incision
Locate Cricothyroid membrane
Horizontal incision through Cricothyroid membrane
Turn blade through 900
Slide Bougie along blade into trachea
Remove blade
Railroad tube
Inflate cuff
Ventilate
Verify with capnography
Exclude endobronchial intubation
Secure
Equipment:
1. Scalpel (no 10 or 20 blade)
2. Bougie
3. Tube (cuffed 6mm ID)
Cannula cricothyroidotomy
(only if skilled)
Fail

5. Highlights Importance of planning to reduce risk is emphasised
Importance of “anaesthesia team” is recognised
Expanded section around new techniques for preoxygenation and maintenance of oxygenation (including nasal O2)
Videolaryngoscopy is explicitly included
Less distinction between RSI and elective induction with facemask ventilation included in both (maintenance facemask ventilation is supported during RSI)
Cricoid pressure should be removed if laryngoscopy & intubation difficult (and remain off for insertion of SAD in plan B)
Plan B focuses on oxygenation using SAD (with less emphasis on intubation through SAD though this remains an option)

6. Highlights 2nd generation SADs are preferred
ILMA no longer explicitly recommended
Human Factors is considered overtly
The degree of Neuromuscular blockade should be actively reviewed when intubation fails
Emphasis on standardisation and training for plan D
Surgical cric as default (Scalpel bougie tube)
Cannula techniques an alternative if anaesthetist is trained and skilled in the particular technique
Cannula cric with high pressure ventilation reserved for experts only