Timothy M Cook

Royal United Hospital Bath NHS Trust · Anaestheia and Intensive Care Medicine

Background The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest because of existing knowledge gaps in this important topic. This applies in particular to cardiology patients receiving anaesthetic care, because numbers, types and complexity of minimally invasive interventional procedures requirin...

Universal use of Storz C‐MAC® videolaryngoscopes was implemented for adult tracheal intubations in the operating theatres, intensive care unit and emergency department at Royal United Hospitals Bath NHS Foundation Trust in 2017. We report data from 1099 intubations from March 2020 to March 2022, collected contemporaneously and anonymously using a s...

Background Analysing large qualitative datasets can present significant challenges, including the time and resources required for manual analysis and the potential for missing nuanced insights. This paper aims to address these challenges by exploring the application of Big Qualitative (Big Qual) and artificial intelligence (AI) methods to efficient...

Background We analysed the clinical practice of anaesthesia associates in the UK, as reported to the 7th National Audit Project of the Royal College of Anaesthetists, and compared these with medically qualified anaesthetists. Methods We included data from our baseline survey, activity survey and case registry as with other reports from the project...

Background: Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. Methods: We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra...

Frailty increases peri‐operative risk, but details of its burden, clinical features and the risk of, and outcomes following, peri‐operative cardiac arrest are lacking. As a preplanned analysis of the 7th National Audit Project of the Royal College of Anaesthetists, we described the characteristics of older patients living with frailty undergoing an...

The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. An activity survey estimated UK paediatric anaesthesia annual caseload as 390,000 cases, 14% of the UK total. Paediatric peri‐operative cardiac arrests accounted for 104 (12%) reports giving an incidence of 3 in 10,000 anaesthetics (95%CI 2.2...

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. Additional inclusion criteria for obstetric anaesthesia were: cardiac arrest associated with neuraxial block performed by an anaesthetist outside the operating theatre (labour epidural analgesia); and cardiac arrest associated with rem...

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. Among 59 cases reported as possible anaphylaxis, 33 (56%) were judged to be so by the review panel with high or moderate confidence. Causes in excluded cases included: isolated severe hypotension; bronchospasm; and oesophageal intubati...

The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest in the UK. We report the results of the vascular surgery cohort from the 12‐month case registry, from 16 June 2021 to 15 June 2022. Anaesthesia for vascular surgery accounted for 2% of UK anaesthetic caseload and included 69 (8%) reported peri...

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri‐operative cardiac arrest including those that occurred in the independent healthcare sector, which provides around 1 in 6 NHS‐funded care episodes. In total, 174 (39%) of 442 independent hospitals contacted agreed to participate. A survey examining provider pre...

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri‐operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway compli...

Current guidance recommends that, in most circumstances, cardiopulmonary resuscitation should be attempted when cardiac arrest occurs during anaesthesia, and when a patient has a pre‐existing ‘do not attempt cardiopulmonary resuscitation’ recommendation, this should be suspended. How this guidance is translated into everyday clinical practice in th...

The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. Here we report the results of the 12‐month registry, from 16 June 2021 to 15 June 2022, focusing on epidemiology and clinical features. We reviewed 881 cases of peri‐ope...

The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12‐month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri‐operative cardiac a...

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patie...

The Royal College of Anaesthetists' 7th National Audit Project baseline survey assessed knowledge, attitudes, practices and experiences of peri‐operative cardiac arrests among UK anaesthetists and Anaesthesia Associates. We received 10,746 responses, representing a 71% response rate. In‐date training in adult and paediatric advanced life support wa...

It is unclear if cardiopulmonary resuscitation is an aerosol‐generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatmen...

We report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri‐operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paedia...

Purpose of Review This review discusses the incidence of anaphylaxis to neuromuscular blockade drugs (NMBDs), the mechanism and clinical features, as well as theories around sensitisation (including the pholcodine hypothesis), the developing area of anaphylaxis to reversal agents, and testing practices. Recent Findings The incidence and characteri...

Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of u...

Major harm from unrecognised oesophageal intubation continues, despite the 2018 Royal College of Anaesthetists' 'no trace, wrong place' campaign. It is likely that publicly reported cases represent a fraction of real occurrences. This article summarises a 2022 consensus guideline on the prevention of unrecognised oesophageal intubation from the Pro...

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapsho...

Aerosol‐generating procedures are medical interventions considered high risk for transmission of airborne pathogens. Tracheal intubation of anaesthetised patients is not high risk for aerosol generation; however, patients often perform respiratory manoeuvres during awake tracheal intubation which may generate aerosol. To assess the risk, we underto...

Human factors is an evidence‐based scientific discipline used in safety critical industries to improve safety and worker well‐being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high‐quality patient care. To encourage the adopt...

Healthcare relies on high levels of human performance, as described by the ‘human as the hero’ concept. However, human performance varies and is recognised to fall in high‐pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety‐critical industries embed human factors principles into all aspects of their organi...

Recent evidence, highlighted in this editorial, creates a strong argument for universal use of videolaryngoscopy in anaesthesia to improve efficiency and safety of tracheal intubation. In a recent study published in the British Journal of Anaesthesia, the authors implemented widespread (66%) use of videolaryngoscopy as first choice in one hospital...

The perceived risk of transmission of aerosolised viral particles from patients to airway practitioners during the COVID‐19 pandemic led to the widespread use of aerosol precautions, including personal protective equipment and modifications to anaesthetic technique. The risk of these aerosol precautions on peri‐operative airway complications has no...

Cardiac arrest in the peri‐operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri‐operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, an...

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficientl...

Background Tracheal intubation is a commonly performed procedure that can be associated with complications and result in patient harm. Videolaryngoscopy (VL) may decrease this risk as compared with Macintosh direct laryngoscopy (DL). This review evaluates the risk and benefit profile of VL compared with DL in adults. Methods We searched MEDLINE, E...

The evidence base surrounding the transmission risk of ‘aerosol‐generating procedures’ has evolved primarily through quantification of aerosol concentrations during clinical practice. Consequently, infection prevention and control guidelines are undergoing continual reassessment. This mixed‐methods study aimed to explore the perceptions of practici...

Background: Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have...

We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995–2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. Wh...

Background Open respiratory suctioning is defined as an aerosol generating procedure. Laryngopharyngeal suction, used to clear secretions during anaesthesia, is widely managed as being aerosol generating. However, it is uncertain whether upper airway suctioning should be designated an aerosol generating procedure because of a lack of both aerosol a...

The impact of vaccination and new SARS-CoV-2 variants on peri-operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS-CoV-2 infection to assist policymakers, administrative staff, clinicians and patients. The guidance remains that patients should avoid elective surger...

The impact of vaccination and new SARS‐CoV‐2 variants on peri‐operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS‐CoV‐2 infection to assist policymakers, administrative staff, clinicians and patients. The guidance remains that patients should avoid elective surger...

Background: Open respiratory suctioning is considered to be an aerosol generating procedure (AGP) and laryngopharyngeal suction, used to clear secretions during anaesthesia, is widely managed as an AGP. It is uncertain whether such upper airway suctioning should be designated an aerosol generating procedure (AGP) because of a lack of both aerosol a...

Background Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings. Methods We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMP...

Manual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol‐generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS‐CoV‐1 outbreak in 2003. There is no direct evidence to indicate wh...

Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Pr...

Manual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol generating procedure. This designation is based on a single epidemiological study suggesting an association between facemask ventilation and transmission from the SARS 2003 outbreak. There is no direct evidence to indicate whether...

Many guidelines consider supraglottic airway use to be an aerosol‐generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we...

Objective To determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events. Design A prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient’s mouth using...

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed...

This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the...

Respirable aerosols (< 5 µm in diameter) present a high risk of SARS-CoV-2 transmission. Guidelines recommend using aerosol precautions during aerosol-generating procedures, and droplet (> 5 µm) precautions at other times. However, emerging evidence indicates respiratory activities may be a more important source of aerosols than clinical procedures...

The scale of the COVID-19 pandemic means that a significant number of patients who have previously been infected with SARS-CoV-2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and exper...

National (and global) vaccination provides an opportunity to control the COVID-19 pandemic, which disease suppression by societal lockdown and individual behavioural changes will not. We modelled how vaccination through the UK's vaccine priority groups impacts deaths, hospital and ICU admissions from COVID-19. We used the UK COVID-19 vaccines deliv...

Background Exhaled respirable aerosols (<5 μm diameter) present a high risk of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) transmission. Many guidelines recommend using aerosol precautions during "aerosol generating procedures" (AGPs) and droplet (<5 μm) precautions at other times. However, there is emerging evidence that respirato...

The COVID-19 pandemic continues to cause critical illness and deaths internationally. Up to 31 May 2020, mortality in patients admitted to intensive care units (ICU) with COVID-19 was 41.6%. Since then, changes in therapeutics and management may have improved outcomes. Also, data from countries affected later in the pandemic are now available. We s...

A key controversy in the COVID-19 pandemic has been over staff safety in health and social care settings. Anaesthetists and intensivists were anticipated to be at the highest risk of work-related infection due to involvement in airway management and management of critical illness and therefore wear the highest levels of personal protective equipmen...

Background: Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of...

Management of the airway is an important and challenging aspect of many clinicians' work and is a source of complications and litigation. The new edition of this popular book remains a clear, practical and highly-illustrated guide to all necessary aspects of airway management. The book has been updated throughout, to cover all changes to best pract...