Adaptation of a difficult airway trolley in a low resource setting

The difficult airway trolley (DAT) is an essential component in an area where a patient’s airway is managed, such as an operation theatre (OT) or an intensive care unit. Although most of the components described in a DAT are easily and readily found in areas mentioned above, the importance of a logically and comprehensively stocked DAT that follows some conformity to a given institution cannot be emphasized enough. It avoids delays, misunderstanding and in an emergency, every anaesthetist will be familiar with the use of its contents and the sequence one must adhere to.

Editor, Complications of a difficult airway although infrequent can be quite detrimental leading to severe morbidity and mortality during intubation. 1 The NAP4 study estimated that 1 in every 22000 airways had a serious complication during general anaesthesia, with 1 in 150000 resulting in brain damage or even death. 1 The difficult airway trolley (DAT) is an essential component in an area where a patient's airway is managed, such as an operation theatre (OT) or an intensive care unit. Although most of the components described in a DAT are easily and readily found in areas mentioned above, the importance of a logically and comprehensively stocked DAT that follows some conformity to a given institution cannot be emphasized enough. It avoids delays, misunderstanding and in an emergency, every anaesthetist will be familiar with the use of its contents and the sequence one must adhere to.

Problems identified
The main operating theatre at Colombo South Teaching Hospital Sri Lanka, is a fully equipped OT complex handling the daily casualty burden of the 1093 bedded hospital -the second largest hospital in Colombo. There are numerous casualty surgeries that take place in this theatre complex which also handles a significant amount of trauma and emergency surgeries sometimes done under the distant supervision of consultants. Here, it is not rare to encounter the occasional anticipated and unanticipated difficult airway during the day. We were able to identify a significant deficiency of not having an organized airway trolley in such a busy unit where help may not always be readily available, especially during the nights.
Here  It needed to be stocked with all necessary airway equipment without over stocking and be readily accessible in an emergency.
Apart from the laminated guidelines hanging from the corner of the trolley we also wanted to use a visual prompt-a sticker depicting the progression of each of the DAS guideline steps from A to D.

Design
This was the finished product with the relevant contents.
We purchased a set of plastic drawers and manufactured the frame and wheels to which it is fixed at the hospital workshop. The stickers were designed in accordance with the current DAS 2015 guidelines and the drawers were stocked accordingly.

Implementation and use
This was successfully introduced to the theatre and its personnel and it was well received. However, it is essential to ensure that they are familiar with its use. As some of the equipment is rarely used, it is vital that there is training in a comprehensive and continual manner so that in an emergency, the anaesthetists will know exactly what and where to look for and more importantly be capable of using that equipment.

Further improvement
The use of the DAT and its training should be serially audited to ensure its efficient use and better outcome. We suggest this cost effective device to be used in theatres nationwide as a means of alleviating the stress of anaesthetists during difficult intubation and as a means of minimizing serious complications due to airway compromise during the management of difficult airways.