A report on participant views of a two-person check confirming tracheal intubation implemented in their institution found that this check was generally considered feasible and useful, but there was some resistance and some concerns that it would not solve the problem. Social, cultural, and cognitive factors play a role in airway management in the operating theatre, partly because of the pre-eminence of airway management as a cornerstone of the profession of anaesthesia. These factors contribute to loss of situation awareness in airway failure. Although situation awareness might be better maintained by the two-person check, there could be advantages if airway management became the responsibility of the whole operating theatre team. Potential strategies to overcoming the ongoing problem of failed airway management are proposed, including multidisciplinary team training in airway management and a new airway point in the surgical safety checklist time out.

中文翻译：

---

插管失败：麻醉的阿喀琉斯之踵


一份关于参与者对在其机构实施的确认气管插管的两人检查的看法的报告发现，这项检查通常被认为是可行和有用的，但也存在一些阻力和一些担忧，即它不会解决问题。社会、文化和认知因素在手术室的气道管理中发挥作用，部分原因是气道管理作为麻醉专业的基石的突出地位。这些因素导致气道衰竭时态势感知丧失。尽管两人检查可能更好地保持态势感知，但如果气道管理成为整个手术室团队的责任，可能会有好处。提出了克服持续存在的气道管理失败问题的潜在策略，包括气道管理方面的多学科团队培训和手术安全检查表超时中的新气道点。