ROYAL COLLEGE OF ANAESTHETISTS
ACCREDITATION STANDARDS 2016
STANDARD 184.108.40.206 There is a policy for the management of morbidly obese patients
EVIDENCE REQUIRED A copy of the policy should be provided PRIORITY 1 CQC KLoEs Safe Responsive
GPAS REFERENCES 9.2.12 The maximum weight that the operating table can support must be known and alternative provision made for women who exceed this. It is recommended that the obstetric operating table should be able to safely support a minimum weight of 160 kilograms in all positions.
9.2.13 Equipment to facilitate the care of the morbidly obese parturient including specialised electrically operated beds, aids to assist patient positioning, for example Oxford head elevating laryngoscopy pillow (HELP), weighing scales, sliding sheets and hoists, should be readily available and staff should receive training on how to use the specialist equipment.
HELPNOTE See Note 2 for an explanation of what is meant by the term ‘policies’.
Oxford Case Histories in Anaesthesia
Edited by Jon McCormack, Keith Kelly
Morbid Obesity in Obstetrics
P.151 Case 5.3
Use a head-up tilt, with a pillow ramp or a proprietary device such as the Oxford HELP pillows, even with regional anaesthesia. This will help the block from spreading to cephalid and also places the patient in an ideal ramped position, should she require a general anaesthesia.
Oxford Textbook of Obstetric Anaesthesia
Core Topics in Basic Anaesthesia
Core Topics in Obstetric Anaesthesia
Textbook of Anaesthesia
ABC of Transfer and Retrieval Medicine
Wiley Blackwell 2015
Sheffield Teaching Hospitals
Royal Berkshire NHS Trust
Obstetric failed intubation (GL774) 2016
Overview: The incidence of failed intubation is 1:3902 in obstetric patients. However, morbidity and mortality is caused not by failure to intubate but by failure to oxygenate. The causes for the increased incidence of failed intubation in the obstetric population cf. non-obstetric population is multifactorial and the new OAA/DAS guidelines address many of these challenges, emphasising the influence of human factors and the value of greater simplicity in decision-making. The focus in the guidelines is on planning and preparation, with the importance of pre-oxygenation and positioning emphasised. Factors to consider when deciding whether to continue general anaesthetic (GA) or wake patient up postfailedintubation are helpfully summarised in table 1 in the OAA/DAS guidelines1 .
5. Ensure optimal positioning of patient. Consider use of the Oxford HELP Pillow, 3- 5 ‘normal’ pillows, ramping using the theatre table and head up.
Revision date March 2019
OBSTETRIC ANAESTHETIC HANDBOOK 22 Caesarean section in morbidly obese ·Senior help · Appropriately sized equipment and staff available for moving · Preoperative ranitidine · Increased risk of bleeding so consider two large-bore cannulae · Difficult intubation ≥ 10% so avoid if possible · Consider CSE if no epidural in situ o In the morbidly obese consider inserting epidural first and securing and then performing spinal at different interspace (To reduce risk of dislodging epidural during positioning) · Ramped intubating position may be useful in morbidly obese (see fig. 1) · Use Oxford HELP pillow which is now available at both sites (see fig. 2) · Consider uncut size 7 ETT · Consider arterial line for BP monitoring Figure 2. The Oxford HELP pillow in the high position
Challenging Concepts in Anaesthesia:
Cases with Expert Commentary
Editors: Dr Phoebe Syme, Dr Robert Jackson, Dr Tim Cook
Chapter 5, P 157
Other relevant adjuncts include the range of head and neck supports to aid ideal positioning of the patients, particularly the obese, prior to intubation, the Oxford HELP (Head Elevating Laryngoscopy Pillow, Alma Medical, UK) being one such device (Figure 5.5).
Implementation of NAP4 in a DGH
Fiona Kelly, Bath, 2013
Aspiration biggest cause of death
Obesity major risk factor for airway complications
Planning and assessment – airway assessment – planning for failure
Issues with…– Multiple repeated attempts at intubation – Awake fibreoptic intubation – Obstructed airway – Capnography trace interpretation – Needle cricothyroidotomy
Emergence or recovery – one third of events • ICU and ED – Continuous capnography – Displaced tracheostomies and tracheal tubes – Rapid sequence induction
2.9 million anaesthetics per year • Risk of airway complication resulting in death or brain death – 1 in 151 000 overall
Risk of death or brain death depending on location: Theatres 14% ED 33% ICU 61%
In Bath Hospital ED and ICU:
Airway complications more common • Airway complications more likely to lead to harm
True emergency – less time for planning and preparation • Full stomach • Equipment • Staff – Junior doctors – Consultants – ICU and ED nurses
Out of hours work.
• Preop assessment – anaesthetic review if BMI > 40 +other comorbidities • Oxford Head Elevation Laryngoscopy Pillow (HELP) • Videolaryngoscopy
• Dedicated CMAC • Dedicated HELP pillow • Manujet plugged in at all times
Mid Essex Hospital Services NHS Trust
Management of Failed Adult Intubation on the Maternity Unit 2013
4.4 Full monitoring should be established and the patient positioned in the optimal intubating position (“sniffing the morning air”, ideally with two pillows). The OXFORD HELP pillow must be used in obese patients to aid optimal positioning.
PROMPT Course Manual
In pregnant women, and in particular those with large breasts or who are obese, it can be useful to adopt the ‘ramped’ position. This has been shown to improve the view of the vocal cords at laryngoscopy, making intubation easier. The ramped position aims to create a horizontal line between the sternal notch and the external auditory meatus, as shown in figure 4.2. The position can be achieved using purpose-made pillows such as the Oxford HELP (Head Elevating Laryngoscopy Pillow)
ACSA standards with full GPAS references 2016 [PDF]
Remove: Royal College of Anaesthetists source – 31 August 2016
…assist patient positioning, for example Oxford head elevating laryngoscopy pillow (HELP), weighing scales, sliding sheets and hoists…undertaken in the main theatre suite. This arrangement may be more flexible for complex work and avoids duplicating theatre skills and…
See below for full citation
Remove: Royal College of Anaesthetists source – 18 June 2014
…suite. This arrangement may be more flexible for complex work and avoids duplicating…positioning, for example Oxford head elevating laryngoscopy pillow