Reference1. Association of Anaesthetists of Great

Britain & Ireland. Peri-operative care ofthe 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.l1, which isdescribed as a restrictive transfusion

trigger. The review includes 19 stud-

ies, 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 con-

tributed 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 youn-

ger than the standard elderly patient.

The recent review does mention that

there are no trials of transfusion trig-

gers in those with acute coronary

syndromes and that studies are also

required in which the trigger is set at

60 g.l1 [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 dis-

ease 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.l1, may beadvisable.

R. GriffithsChairAAGBI Working Party onperi-operative care of the elderlyEmail: workingparties@aagbi.org

Previously posted on the Anaesthe-

sia correspondence website: www.

anaesthesiacorrespondence.com.

References1. Association of Anaesthetists of Great

Britain & Ireland. Peri-operative care ofthe elderly 2014. Anaesthesia 2014; 69(Suppl 1): 8198.

2. Carson JL, Carless PA, Hebert PC. Trans-fusion thresholds and other strategiesfor guiding allogeneic red bloodcell transfusion. Cochrane Databaseof Systematic Reviews 2012; 4:CD002042.

3. Carson JL, Terrin ML, Noveck H, et al.Libreal or restrictive transfusion in high-risk patients after hip surgery. New Eng-land Journal of Medicine 2011; 365:245362.

4. Wu W-C, Schifftner TI, Henderson WG,et al. Preoperative haematocrit levelsand postoperative outcomes in olderpatients undergoing noncardiac surgery.

Journal of the American Medical Associ-ation 2007; 297: 24828.

doi:10.1111/anae.12617

Trachway and jaw thrust

We read with great interest the arti-

cle by Lee et al. [1] and agree with

their conclusion that the modified

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 (Bio-

tronic Instrument Enterprise Ltd.,

Tai-Chung, Taiwan). Eight patients

(Cormack and Lehane grade 3-4)

who had a failed double-lumen

endotracheal intubation with con-

ventional direct laryngoscopy (>

three attempts) underwent successful

intubation using the Trachway intu-

bating stylet combined with a modi-

fied jaw thrust technique (opening

the mouth, protruding the mandible

forward and elevating both mandib-

ular rami). Intubation was successful

in all cases at the first attempt with-

out damage to the tube cuff, episodes

of hypoxaemia or obvious airway

trauma.

Although double-lumen endo-

bronchial intubation assisted by the

GlideScope (Verathon Medical

China Sales, Shanghai, China) has

been reported in patients with a

difficult airway [2, 3], the wide

blade of the GlideScope makes

double-lumen intubation a chal-

lenge, 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

2014 The Association of Anaesthetists of Great Britain and Ireland 285

Correspondence 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 modified jaw thrust manoeuvre

without causing backache.

S. W. WuH. T. HsuK. I. ChengKaohsiung Medical UniversityKaohsiung, TaiwanEmail:770234kmuhanesthesia@gmail.com

No external funding and no com-

peting interests declared. Previously

posted on the Anaesthesia corre-

spondence website: www.anaesthesia

correspondence.com.

References1. Lee AR, Yang S, Shin YH, et al. A com-

parison of the BURP and conventionaland modified jaw thrust manoeuvres fororotracheal intubation using the ClarusVideo System. Anaesthesia 2013; 68:9317.

2. Hsu HT, Chou SH, Chen CL, et al. Leftendobronchial intubation with a double-lumen tube using direct laryngoscopy orthe Trachway video stylet. Anaesthesia2013; 68: 8515.

3. Chen A, Lai HY, Lin PC, Chen TY, ShyrMH. GlideScope-assisted double-lumenendobronchial tube placement in apatient with an unanticipated diffi-cult airway. Journal of Cardiothoracicand Vascular Anesthesia 2008; 22:1702.

doi:10.1111/anae.12612

Training and assessmentof 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 venti-

lation through a facemask were also

significantly lower than through a

supraglottic airway device.

Two methods were used to

assess mask ventilation. First, con-

sultant anaesthetists assessed the

difficulty of ventilation subjectively.

The grading scale was informal

and operator-dependent, and pub-

lished scales on grading of mask

ventilation were not used [24].

Second, the success of ventilation

by novices was measured formally

using objective criteria: expired car-

bon 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 mea-

surement of ventilation performed

by airway experts was informal and

subjective, but measurement of

ventilation by airway novices was

formal and objective. Surely an

objective, scientific 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,

difficult and obvious may be

comfortably familiar, but they

remain uncomfortably unscientific.J. NielsenConcord HospitalSydney, AustraliaEmail: jamesrnielsen@gmail.com

No external funding and no com-

peting interests declared. Previously

posted on the Anaesthesia corre-

spondence website: www.anaesthesia

correspondence.com.

References1. Russo SG, Bollinger M, Strack M, et al.

Transfer of airway skills from manikintraining to patient: success of ventila-tion with facemask or LMA-Supreme bymedical 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 inci-dence and risk factors of difficult maskventilation. Journal of Anesthesia 2005;19: 711.

4. Warters RD, Szabo TA, Spinale FG, et al.The effect of neuromuscular blockadeon mask ventilation. Anaesthesia 2011;66: 1637.

doi:10.1111/anae.12568

Labelling syringe plungersto reduce medicationerrors

I was interested to read the letter by

Webster [1] regarding the colour-

coding of prefilled syringes and the

inconsistency of manufacturers to

comply with the international stan-

dard. It is well known that syringe-

swap errors are a significant cause

of complications in the operating

theatre [2]. At the start of an oper-

ating list, emergency drugs are rou-

tinely drawn up. These are

commonly stored above the anaes-

thetic 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 emer-

gency drugs should be clearly

labelled with printed coloured stick-

286 2014 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia 2014, 69, 281290 Correspondence