Access to videolaryngoscopy: who holds the risk?

The latest Difficulty Airway Society guidance recommends universal, first-line, videolaryngoscopy for all tracheal intubations [1]. The availability of videolaryngoscopy in the UK does not match these recommendations, with an estimated use in 28% of all tracheal intubations and senior residents being the most frequent users [2]. There are many barriers to universal videolaryngoscopy [3] and many departments will find themselves unable to procure enough devices to provide universal access. In the event of an airway catastrophe occurring in a department that does not have appropriate access to videolaryngoscopy, it is unclear where the risk is held. It could be with the individual anaesthetist or with the hospital that has not been able to provide the equipment. We would suggest that lack of access to videolaryngoscopy needs to be on every anaesthetic department risk register. Resident doctors rotate between hospitals regularly, often every 6 months, and this can lead to unfamiliarity with equipment. Resident doctors may have worked in a hospital that has videolaryngoscopy in every operating theatre. It is imperative that as part of induction arrangements, they are made aware of the availability and location of videolaryngoscopy. We are concerned about where resident doctors, who would either use videolaryngoscopy first line or when exposed to a difficult airway, might find themselves in a situation without access to appropriate equipment. In the event of a serious airway incident, we worry they could be criticised, despite 6-month rotational resident doctors having no control over the equipment available to them in their workplace. While guidelines do contain the caveat of ‘where available’ as regards to use of videolaryngoscopy, it is imperative that safety critical equipment is available for all who are delivering peri-operative care. In this transitional period between variable access to videolaryngoscopy and universal videolaryngoscopy, departments must consider how they will mitigate this risk, both medicolegally and to patients. Thought needs to be given to supporting resident doctors who may expect videolaryngoscopy to be the standard of care whilst seeking to document the risks involved when this is not the case.