intrafascicular spread, but no evidence of infiltration into thespinal cord. Moreover, in a comparative retrospective analysisof 5436 peripheral nerve blocks steered either by surface land-marks or by ultrasound enhancement, Orebaugh and collea-gues8 found significantly fewer adverse outcomes associatedwith the ultrasound-guided interventions.

Unfortunately, the description of current case reportfails to note patient habitus, use of auxiliary equipment(nerve stimulation or ultrasound), and clinical interpretationof the post-positioning haemodynamic instability (such asBezold–Jarisch reflex). The combination of an increased neckgirth, general anaesthesia, and absent ultrasound-guidanceincreases the likelihood of needle misadventure. Real-timeultrasound identification of the needle tip and pattern ofLA spread should reduce the incidence of this catastrophiccomplication.

Declaration of interestNone declared.

H. D. PalteMiami, USAE-mail: hpalte@med.miami.edu

1 Mostafa RM, Mejad A. Quadriplegia after interscalene block for shoul-der surgery in sitting position. Br J Anaesth 2013; 111: 846–7

2 Benumof JL. Permanent loss of cervical spinal cord function asso-ciated with interscalene block performed under general anesthesia.Anesthesiology 2000; 93: 1541–4

3 Bogdanov A, Loveland R. Is there a place for interscalene block per-formed after induction of general anaesthesia? Eur J Anaesthesiol2005; 22: 107–10

4 Sardesai AM, Patel R, Denny NM, et al. Interscalene brachial plexusblock: can the risk of entering the spinal canal be reduced? Anesthe-siology 2006; 105: 9–13

5 Russon KE, Herrick MJ, Moriggl B, et al. Interscalene brachial plexusblock: assessment of the needle angle needed to enter the spinalcanal. Anaesthesia 2009; 64: 43–5

6 Orebaugh SL, Mukalel JJ, Krediet AC, et al. Brachial plexus root injec-tion in a human cadaver model—injectate distribution and effectson the neuraxis. Reg Anesth Pain Med 2012; 5: 525–9

7 Selander D, Sjostrand J. Longitudinal spread of intraneurally injectedlocal anesthetics. Acta Anaesthesiol Scand 1978; 22: 622–34

8 Orebaugh SL, Williams BA, Vallejo M, et al. Adverse outcomes asso-ciated with stimulator-based peripheral nerve blocks with versuswithout ultrasound visualization. Reg Anesth Pain Med 2009; 34:251–5

doi:10.1093/bja/aeu115

Journal club responseEditor—We read the recent article on the use of propofol byemergency department (ED) physicians, written by Drs Lloyd,Newstead, and colleagues,1 with great interest and alsohad the article presented in our departmental journal clubmeeting. This study, as correctly mentioned by the authors,

adds to the already existing data on procedural sedation inthe ED. We would however like to raise certain points whichwere highlighted in our meeting and we felt that they shouldbe communicated back to the authors. We could not see anyclear sedation endpoints which were set to guide the doctorsusing propofol for sedation and were not sure if differentdoses or endpoints were being used for different proceduresbeing carried out in the ED. We felt that this was importantsince some procedures were potentially more stimulatingthan others and hence the dose required for those would be dif-ferent. The online Supplementary material suggests that theprocedure should be carried out when the patient is ‘uncon-scious, i.e. not responding to command’ which surely constitu-tes an anaesthetic rather than sedation. To add weight to this,the online supplement refers to a propofol anaesthetic, notpropofol sedation. It seems that the vast majority of thepatients were probably being anaesthetized rather thansedated and this may well explain why the incidence ofhypoxia in this study was similar to those reported for non-cardiac anaesthesia. In addition, seven of the patients receivedconcurrent i.v. morphine. Despite this, there was no reductionin the dose of propofol given. In the discussion regarding the11 sentinel cases, it is stated that two elderly patients weregiven above the recommended amounts of propofol. The def-inition of elderly was not described but assuming this was.75 yr, all six elderly patients were given an initial bolusabove 0.5 mg kg21. In addition, all patients who received incre-mental top ups received them above the 0.25 mg kg21 guide-line dose. In total, nine cases received doses above thoserecommended in the guideline. Finally, Cases 3 and 11 clearlydid meet the criteria for a sentinel event before sedation asthey were patients who were very unstable; surely having ananaesthetist present to sedate these patients would havebeen essential in the safe management of these patients.

Declaration of interestNone declared.

C. N. WadeStaffordshire, UKE-mail: charlotte.wade@uhns.nhs.uk

1 Newstead B, Bradburn S, Appelboam A, et al. Propofol for adultprocedural sedation in a UK emergency department: safety profilein 1008 cases. Br J Anaesth 2013; 111: 651–5

doi:10.1093/bja/aeu117

Procedural sedation: it is not what you do, itis how you do itEditor—We read with interest the recent report on the use ofpropofol for procedural sedation in the emergency department(ED) by Newstead and colleagues.1 We applaud the authors fortheir use of a standardized reporting tool and the transparentdiscussion of the encountered adverse events and would like

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to add a few points to the ongoing discussion on the safe use ofpropofol in the ED.

First, while sedation in the ED for painful procedures is un-doubtedly an essential part of front-line medicine, the emer-gency patient population is extremely heterogeneous bydefinition and the use of a standardized propofol dosingscheme is potentially unsafe. The varying combinations of pre-vious analgesia, co-morbidities, trauma, and extremes of agewith a fixed bolus dose of propofol can rapidly convert anepisode of sedation to a general anaesthetic (GA) without aprotected airway.

The difficult to define grey areas of ‘conscious sedation’,‘deep sedation’, and exactly where the transition to GAoccurs depend on the practitioner, their experience, and theexpectations of the support staff. Propofol is an anaestheticdrug when used in all but the smallest of doses and we feelthat patients receiving it should be assessed as for a GA, withparticular attention to aspiration risk and airway assessmentalong with competency in advanced airway management.

With regard to fasting times, it is well known that patientswho have sustained a trauma or have received opiates havegreatly reduced gastric emptying and if being considered fora GA would likely undergo rapid sequence induction. The riskof rendering a patient with uncertain stomach contents uncon-scious must be carefully weighed against the benefits of avoid-ing the operating theatre.

Finally, it is reassuring to see the introduction of end-tidalCO2 monitoring into this group’s protocols. We feel that eventhough it is not required by the UK or Australasian collegesfor ‘sedation’, this commonly available monitor can be thesingle most useful adjunct for early detection of apnoea in asetting outside of the operating theatre. A number of thedescribed sentinel events relating to extended hypoxia mayhave been easily prevented by end-tidal CO2 monitoring anda more tailored dose of anaesthetic agent.

As with most indistinct areas of practice, there is somewhatof an ‘art’ to successful and safe sedation and skill comes onlywith experience. Perhaps ED trainees aiming to practice sed-ation could be encouraged to spend more time with their an-aesthetic colleagues in settings such as elective endoscopylists in order to gain more of a feel for this difficult technique.

Declaration of interestNone declared.

A. R. Lamb*M. HarperFremantle, Western Australia*E-mail: andrewlamb1980@me.com

1 Newstead B, Bradburn S, Appelboam A, et al. Propofol for adultprocedural sedation in a UK emergency department: safety profilein 1008 cases. Br J Anaesth 2013; 111: 651–5

doi:10.1093/bja/aeu118

Tracheostomy care: it is not just about thetrainingEditor—Dr Taylor and colleagues1 correctly highlight that prob-lems continue around the management of tracheostomiesand that increasingly, troubleshooting and emergency man-agement of this vulnerable group is falling on to anaesthetistsand intensivists. There are a number of reasons for this, current-ly being examined by the NCEPOD tracheostomy care study.First, there has been a shift in the patient characteristics whoare receiving a tracheostomy, with the majority of proceduresnow percutaneously performed in our critical care units forweaning rather than the surgical tracheostomies performedas part of head and neck procedures. Secondly, there is a reduc-tion in the quantity and quality of out-of-hours medical cover inmost ward settings, with specialist head and neck traineesoften based off-site or covering multiple geographical loca-tions. Unexpected emergency department attendances orward emergencies are often managed by the resident airwayexperts—anaesthesia and critical trainees. As Dr Taylor pointsout, there is no guarantee among our own trainees that theywill have been taught or be experienced or confident enoughto manage these uncomfortable situations, which mayinvolve time-critical, decisive airway management. Thirdly,our hospital infrastructures often lead to suboptimal manage-ment of tracheostomy patients with care delivered byuntrainednursing staff, unfamiliar with the principles of tracheostomycare, working in clinical locations which lack basic and emer-gency airway-specific resuscitation equipment, managed byclinical teams who often lack tracheostomy expertise.

In the North West of England during 2006, we uncovered thesame issues around training and confidence as Dr Taylor high-lights, with final year anaesthetic and critical care traineesdescribing themselves as inadequately trained and experien-ced to confidently manage tracheostomy emergencies. Wedeveloped multidisciplinary training courses in our region anddelivered these to 379 staff over the following 2 yr (21% anaes-thetists, 30% ICU, 16% ENTand MaxFax, 10% community-based,4% medical, 2% emergency medicine, 17% others). Pre-coursequizzes revealed that the majority of non-ENT clinical staff didnot recognize or appreciate the critical difference between atracheostomy and a laryngectomy. The recognized importanceof multidisciplinary expertise and management led to the initi-ation of the National Tracheostomy Safety Project, with multidis-ciplinary emergency guidelines backed by key stakeholders,published in 2012.2 Our resources are supported by a dedicatedwebsite (www.tracheostomy.org.uk),avideo library, SmartPhoneapplications, e-learning resources developed with the DoH’se-Learning for Healthcare, and a comprehensive, free manual.Our courses have been delivered in the UK and beyond and fulland half-day courses are nowavailable through the internationalAdvanced Life Support Group (www.alsg.org). Local training ofmultidisciplinary clinical staff has been well received with themany courses since 2006 evaluated as ‘excellent’ (65%) or ‘verygood’ (34%). We hope that by improving multidisciplinaryroutine care and standardizing the approach to emergency

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