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Download ASM 2012, Belfast - The Neuroanaesthesia Society of Great Britain
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Belfast Health and Social Care Trust Royal Victoria Hospital CPD Points: full mee0ng 10 points www.nasgbi.org 1 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast President’s welcome Dear Delegate, On behalf of council and the organising committee, I would like to welcome you to the 2012 Annual Scientific Meeting at the Waterfront Conference Centre in Belfast. It was always going to be a difficult task to better the last NASGBI meeting held here in 1995, but I am confident the excellent venue, programme and dinner will do just that. In the 15 years since it was completed, The Belfast Waterfront Hall has hosted over 2000 national and international conferences so has a relaxed expertise in staging our event. I am particularly pleased with how lucky we are to have the conference, trade exhibit and catering all on one floor making that interaction with colleagues warm and easy going as befits the society. The challenge every year is to produce a programme that has something for everyone, especially with targeting CPD goals for revalidation. All credit to the organisers for achieving that with topics ranging from preliminary results from the RAIN study on traumatic brain injury, to more anaesthetic topics such as awake craniotomy and anaesthesia for MRI guided neurosurgery. Please remember that reflection is a vital part of the CPD process so feedback on the meeting is required to justify the points awarded. We also have had 36 abstracts submitted so please review the posters for education and inspiration. Of course it is not all work, and the dinner at the recently opened Titanic Centre is likely to be one of the most dramatic and interesting venues we have ever had. I hope you have booked your tickets for a night to remember. Finally I would like to end by thanking our industry sponsors Integra and Codman. Their support allows the organising committee greater freedom in inviting national and international speakers with minimal effect on delegate fees. Cead mile failte – hundred thousand welcomes Dr Plat Razis NASGBI President 2 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Local Organising Committee welcome Dear Delegate We are delighted to host this year’s Annual Scientific meeting. The last time that the NASGBI met in Belfast was 1995. That was the first year that the Society met over two days in a joint meeting with Scandinavian Neuroanaesthetists. It also saw the beginnings of collaboration with the AAGBI in the production of a ‘glossy’ on head injury management. Since then both the Society and Belfast have changed. While the NASGBI has grown in numbers it has retained an emphasis on practical solutions to current problems of Neuroanaesthesia and Critical Care. Belfast has emerged from its chequered history and is now rated as one of the top conference venues in the UK and an excellent city break destination. Discover a city of award winning venues, hotels, culture and legendary hospitality. We are sure that you will enjoy the excellent facilities of the Waterfront Conference Centre that is located in the city centre on the banks of the river Lagan. We are grateful to all the speakers, both local and national, who have agreed to participate in, what we are sure you will agree, is a wide ranging and exciting programme. Topics include head injury management, endocrine disorders, awake craniotomy, sugammadex, post-operative analgesia, assessment and optimisation of auto-regulation, the brain-lung-brain axis, extracorporeal lung support, the RAIN study, interventional MR, neuropharmacology and interventional neuroradiology. There will be a series of workshops on simulation, ethics and analgesic techniques for spinal surgery and chronic back pain. These will allow a small number of delegates to benefit from case based discussions. We received many top quality abstracts and the assessors had great difficulty selecting those for oral presentation. All of the abstracts presented in this programme booklet will be published in the Journal of Neurosurgical Anesthesiology in due course. As you are no doubt aware, this year marks the centenary of the tragic sinking if the Titanic on 15th April 1912. The President’s reception and annual dinner of the Society will take place in the new Titanic Centre which is a "must see" visit in any tour of Belfast and Northern Ireland. It is located in the heart of Belfast, on the slipways where RMS Titanic was built. Inside this iconic building, you will re-live the entire Titanic story from her birth in Belfast to the fateful maiden voyage and her eventual discovery on the seabed. We wish to thank all of our sponsors and acknowledge their generous support. Thanks also to Moya Hennessey who has coped with her administrative duties in a calm and efficient manner and to Dr Peter McGuigan for compiling this programme. We thank you for travelling to Belfast and we hope that you will benefit greatly from attending the Annual Scientific Meeting. We also hope that, in the process of gaining valuable CPD points, you will experience some of Belfast’s legendary ‘craic’. Dr Peter Farling Dr Brian Mullan NASGBI 2012 Belfast Organising Committee 3 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Contents ! ! ! ! ! ! ! ! Pages Programme! ! ! ! ! ! ! ! ! 5-6 ! ! ! ! ! ! 7-13 Speaker abstracts ! Thursday 10th May!! ! Friday 11th May ! ! ! ! ! ! ! ! ! ! ! ! 14-19 20-21 Abstract presentations ! Oral! ! ! ! Poster ! ! ! ! ! ! ! ! ! ! ! ! 22-28 29-45 Local information ! Directions ! ! ! ! Accommodation ! ! ! Pubs and restaurants! ! Things to see and do! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 46 47 48 49 Sponsors! Speaker biographies! ! ! ! ! ! ! ! ! ! ! 50 Forthcoming events!! ! ! ! ! ! ! 51 Glossary of colloquialisms ! ! ! ! ! ! 52 4 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Studio Studio Studio Gallery, Level 1 Studio Green Room & Canberra Green Room & Canberra Gallery, Level 1 Studio BT Studio 5 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Studio Green Room & Canberra Green Room & Canberra Gallery, Level 1 Studio Gallery, Level 1 Studio Studio Studio 6 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Speaker biographies Initial Management and Transfer of the Brain-Injured Child: Dr Mark Terris, Royal Belfast Hospital for Sick Children, Belfast HSC Trust Biography Mark Terris (MBChB MRCPCH FRCA) qualified from the University of Aberdeen in 1998. Following training for three years in Paediatrics and seven years in Anesthesia he was appointed as a Consultant in Paediatric Anaesthesia/Intensive Care in the Royal Belfast Hospital for Sick Children in 2009. He has sessions in Anaesthesia (including regular neuro-anaesthesia), Paediatric Intensive Care and Paediatric Transport. As clinical lead for Paediatric Transport he is involved in the development of the local paediatric retrieval service and contribute to the regional critical care network’s efforts to improve the care to critically ill children in Northern Ireland. Severe TBI: Paediatric Guidelines versus Adult Guidelines Dr Dermot Doherty, Children’s University Hospital Temple St., Dublin Biography Dr. Dermot Doherty (MB BCh, MD, FCARCSI, FJFICMI) received his MB BCh in 1994 from University College Dublin, Ireland. He completed Specialist Registrar training from the College of Anaesthetist’s, RCSI in 2002. He entered fellowship training in the University of Toronto in 2002, receiving a Pediatric Critical Care fellowship, and a combined Research / Pediatric Anesthesia fellowship, both at the Hospital for Sick Children, Toronto. In 2004-05, he moved to the University of Ottawa, where he completed a third fellowship in Pediatric Critical Care and Trauma. During his three fellowship years, he underwent formal research training at the Hospital for Sick Children Research Institute, from which his Doctoral Thesis (MD) on ischaemic brain injury was awarded by University College Dublin. Dr. Doherty was appointed Assistant Professor, University of Ottawa and Staff Pediatric Anesthesiologist and Intensivist in 2005 until 2010. In 2010, he returned to Ireland to take up an appointment as Consultant Paediatric Intensivist in the Children’s University Hospital Temple Street, and Our Lady’s Children’s Hospital in Dublin Dr. Doherty’s primary research interest has been on Ischemic brain injury, where he established a research laboratory in the CHEO Research Institute. He has received several national and international awards for his research including Canadian Anesthesiologists' Society/Abbott Laboratories Career Investigator award. Mannitol or Hypertonic Saline as First-line Osmotherapy: what’s the evidence? Dr Brian Mullan, Regional Intensive Care Unit, Belfast HSC Trust Biography Dr Brian Mullan (MD FCARCSI FJFICMI FRCA FFICM) is a Consultant Anaesthetist/Intensivist for the Belfast Health and Social Care Trust with clinical sessions in Neuroanaesthesia, Head & Neck Surgery and Critical Care Medicine. He is an Educational Supervisor for Intensive Care Medicine (FICM, UK), an Examiner for the College of Anaesthetists in Dublin and an Honorary Lecturer for Queen’s University Belfast. Dr Mullan is also a member of the Northern Ireland Clinical Research Network (NICRN) for Critical Care and he is currently the Clinical Lead for the Northern Ireland Critical Care Transport Service (NICCaTS). He has been an NASGBI Linkman since 2010 and in 2011 he was elected to Council. 7 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Management of Endocrine Disorders for Pituitary Surgery Dr Hamish Courtney, Regional Centre for Endocrinology & Diabetes, Belfast HSC Biography Dr Hamish Courtney is an endocrinologist working in the Royal Victoria Hospital, Belfast. He both qualified in medicine and gained an MD from Queen’s University Belfast. He trained in Endocrinology in Northern Ireland and completed a fellowship at the University of California San Diego. He has an interest in pituitary disease and has a large pituitary clinic, working as part of the regional pituitary team for Northern Ireland. Anaesthesia for Awake Craniotomy Dr Judith Dinsmore, St George’s Hospital, London Biography Judith Dinsmore is a Consultant Anaesthetist at St George's University Hospital Trust, London. Her specialist interests include anaesthesia for neurosurgery and neuroradiology and she has published original articles, chapters and books on various topics in neuroanaesthesia . She has held a number of clinical management positions within her Trust including Lead for Neuroanaesthesia. She enjoys teaching and is an examiner for the Royal College of Anaesthetists. The role of Sugammadex in Neuroanaesthesia Dr Martin Shields, Royal Victoria Hospital (RVH), Belfast Biography: Dr Martin Shields is a consultant anaesthetist at the Royal Victoria Hospital, Belfast. His clinical interests include thoracic, regional and trauma anaesthesia. He has spent time working in the Department of Anaesthesia and Intensive Care Medicine, Queen’s University of Belfast where he worked on phase 2, 3, and 4 clinical trials on muscle relaxants and reversal agents. 8 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Postoperative pain relief in Neurosurgical patients Dr Susan Atkinson and Ms Olga O’Neill, RVH, Belfast Biography Dr Susan Atkinson (MD FFARCSI) is a consultant anaesthetist in Belfast Health and Social Care Trust (BHSCT), with special interest in acute pain medicine, obstetric anaesthesia and blood transfusion. She was a co-founder of the Royal Hospitals Acute Pain Service in 1993 and is currently lead clinician for the BHSCT Acute Pain Service. In this role she works with an experienced team of acute pain nurses to provide staff education and promote safe implementation of new postoperative analgesic techniques. As Honorary Clinical Lecturer at Queens University she has taught and examined in a Master’s Degree in Pain Medicine and coordinated a module on sedation and medical emergencies for dental undergraduates and qualified dentists. Susan has also played an active role in hospital committees as chair of the Trust Resuscitation and Transfusion Committees and she is currently Chairman of the NI Transfusion Committee. Biography Olga O’Neill has been working in the field of Acute Pain Management for 16 years. Olga leads a team of nurse specialists across the four sites of the Belfast Health and Social Care Trust. Olga has a keen interest in developing the knowledge and skills of nursing staff involved in the care of patients with acute pain in an attempt to ensure a positive outcome for patients. This presentation offers some insight into the support of an acute pain service in determining patient satisfaction. Analgesic Techniques for Spinal Surgery Dr Killian McCourt, Royal Victoria Hospital, Belfast Biography Dr McCourt (MD FRCA FCARCSI) is a consultant anaesthetist based at the Royal Victoria Hospital, Belfast Health and Social Care Trust. A graduate of Queen’s University, he trained in the Northern Ireland School of Anaesthesia and then spent a year working in the University of Michigan, Ann Arbor, before taking up his consultant post in which he has a special interest in anaesthesia for thoracic and spinal surgery. He is an examiner in the Final FCAI Examination in Dublin. 9 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Ethical Case-based Discussions Dr Michael McBrien, Royal Victoria Hospital, Belfast Biography Michael McBrien was appointed as a consultant anaesthetist in the Royal Victoria Hospital, Belfast in 1997. Following medical school in Edinburgh, his anaesthetic training posts were in Edinburgh, Oxford, Belfast and Perth, Western Australia. In his initial years as a consultant he campaigned for increased safety for patients and anaesthetists working in the magnetic resonance environment, with eventual publication of guidelines on this issue from the AAGBI in 2002. In 2000, Dr McBrien published a case series reporting the successful use of alpha agonists in adrenaline resistant pulseless electrical activity and has campaigned for incorporation of this treatment earlier in the AAGBI guidelines on the management of anaphylaxis. Over the past 8 years has organised 3 seminars at the AAGBI on ‘Advances in the perioperative management of patients with hip fractures’. In 2006 he wrote an editorial for Anaesthesia on ‘Do not attempt resuscitation (DNAR) orders in the perioperative period’ which prompted the AAGBI to publish guidelines on this subject in 2009. More recently Dr McBrien has published and spoken at the AAGBI Scientific Meeting in Harrogate on the use of echocardiography in the elderly. He continues to work to improve the care of the elderly surgical patient, with a keen interest in ethical issues surrounding their care. Assessment and Optimisation of Cerebrovascular Autoregulation in Neurosurgical Patients Dr Arun Gupta, Addenbrooke’s Hospital, Cambridge Biography Dr Arun K Gupta (MBBS MA PhD FHEA FFICM FRCA) qualified from St Mary’s Hospital, University of London in 1986 and undertook his Higher Specialist Training in Anaesthesia and Intensive Care in Cambridge and the Eastern Region. He spent 2 years on Faculty at the Medical College of Virginia, USA where he pursued his research interest. Dr Gupta was appointed as a Consultant in Anaesthesia and Neuro Critical Care at Addenbrooke’s Hospital, University of Cambridge in 1996. He was Director of the Neurosciences Critical Care Unit for over 3 years before becoming Director of Postgraduate Medical Education for Cambridge University Hospitals NHS Foundation Trust and Director of the Addenbrooke’s Simulation Centre. In June 2011 Dr Gupta was appointed as Director of Multiprofessional Education of the Cambridge University Health Partners Academic Health Sciences Centre. He is an Associate Lecturer at the University of Cambridge and in 2005 was awarded the Macintosh Professorship by the Royal College of Anaesthetists in recognition of his research programme in brain oxygenation and metabolism. Whilst continuing to pursue his research interests in brain injury, Dr Gupta is also supporting a programme of research in Medical Education and Simulation with a particular interest in the Neural Mechanisms of Learning. Dr Gupta has co-edited 3 books the most recent entitled Essentials of Neuroanaesthesia and NeuroIntensive Care (eds Gupta AK, Gelb A; 2008) 10 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast The Brain-Lung-Brain Axis Prof Danny McAuley, Queen’s University, Belfast Biography Prof Danny McAuley is Professor and Consultant in Intensive Care Medicine at the Royal Victoria Hospital and Queen's University of Belfast. He is Co-Director of Research for the Intensive Care Society and Chair of the Irish Critical Care Trials Group. His major research area is acute lung injury. Extracorporeal lung support in the Neuro ITU Dr Simon Finney, Royal Brompton Hospital, London Biography Dr Simon Finney is an Honorary Senior Lecturer at the National Heart and Lung Institute and Consultant in Intensive Care and Cardiothoracic Anaesthesia at the Royal Brompton Hospital, London. Having qualified at Manchester University in 1994, he trained in critical care and anaesthesia in London. Interested in the host's systemic reponse to infection, his PhD ,undertaken in the department of Critical Care at the Royal Brompton, detailed differences in response to components different bacteria and the possible mechanisms underlying these differences. He subsequently undertook an MSc in bioinformatics at the University of Oxford, and has used this to statistical explore large data sets of physiological data gathered from critically ill patients. He is particularly interested in the systemic effects of extracorporeal circulations, and the use of extacorporeal gas exchange to support the failing lung. RAIN Study – preliminary results Dr David Harrison, ICNARC, Tavistock House, London Biography Dr David Harrison is Senior Statistician at the Intensive Care National Audit & Research Centre (ICNARC). David graduated from the University of Cambridge with a BA in mathematics and a PhD in mathematical modelling of disease progression. He has worked for ICNARC since 2002. His main interests are risk prediction modelling, health technology assessment and evaluation of service delivery and organisation in critical care. David is Chief Investigator of the Fungal Infection Risk Evaluation (FIRE) and Risk Adjustment In Neurocritical care (RAIN) research studies. David is a Fellow of the Royal Statistical Society and an Honorary Senior Lecturer in the Medical Statistics Unit of the London School of Hygiene & Tropical Medicine. 11 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Care Pathways in Simulation Dr Jim Murray, Queen’s University, Belfast Biography Dr James Murray (MD, FRCA FCARCSI, M Med Ed) is a clinical Senior Lecturer and joint appointee to the Queen’s University of Belfast (affiliated to the Centre for Medical Education). He is currently an assistant director of Clinical Skills and has completed a mapping exercise for clinical skills that are delivered in the curriculum in QUB, against the GMC’s document ‘Tomorrow’s Doctors 09. He has completed his dissertation for the Masters in Medical Education graduating in 2010, with a thesis entitled ‘A review of high fidelity immersive simulation with specific reference to debriefing techniques’. He is the overall co-ordinator for the Perioperative and Emergency Module and has significant experience in curriculum re-design and delivery of this module. He is the Director for Medical Simulation in QUB and organises and runs high fidelity courses for both medical and nursing undergraduates. He has held a career long interest in medical education, initially as Regional Adviser for postgraduate anaesthetists and now in his roles as outlined above for undergraduates. Chronic Back Pain – Case-based Discussions Mr Gavin Quigley, Neurosurgeon, Belfast Dr Terry Muldoon, Chronic Pain Specialist, Belfast Biography Gavin Quigley (MBChB FRCS(Neurosurgery)) is a consultant neurosurgeon in The Royal Victoria Hospital, Belfast. He graduated from the University of Dundee 1996, completed neurosurgical training at the Walton Centre Liverpool and Alder Hey Hospital. He has an interest in surgery for pain, including spinal cord stimulation, intra-thecal drug delivery systems, trigeminal neuralgia and deep brain stimulation. Anaesthesia for MRI-Guided Neurosurgery Dr Sally Wilson, Queen Square, London! ! Biography Sally Wilson is a consultant in neuroanaesthesia and neurocritical care at the National Hospital for Neurology and Neurosurgery, Queen Square. Her current areas of interest in theatres are anaesthesia for skull base surgery and neurooncology. Since her appointment Sally has developed up and managed the anaesthetic services for MRI, developing a safe responsive service for elective and emergency patients. She has been involved with teaching and setting national standards for the provision of anaesthesia and sedation within the MRI unit. Since 2004 she has been Deputy Clinical Director at Queen Square, with responsibility for all aspects of quality and clinical governance. 12 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Anaesthesia & Neuropharmacology: what’s new? Dr Stephen Luney, Royal Victoria Hospital, Belfast Biography: Dr Stephen Luney is a whole-time Consultant Neuroanaesthetist at the Royal Victoria Hospital, Belfast, and an Honorary Senior Clinical Lecturer in the School of Clinical and Experimental Medicine at the University of Birmingham. A member of the NASGBI for twenty years, he has a longstanding interest in neuroanaesthesia. Following completion of his Specialist Training in Anaesthesia in the UK he worked in Canada as a Neuroanesthesia Fellow at the University of Western Ontario. There he performed clinical research conducting phase III trials, wrote a variety of review articles and published peer-reviewed articles under the guidance of Professor Adrian Gelb. After a decade as a consultant he subsequently undertook a sabbatical in the United States at Mount Sinai Hospital, New York, NY. There he continued writing in the field of neuroanaesthesia, authoring and coauthoring book chapters on Seizures and the Difficult Airway in Neuroanesthesia. Currently, he most recently has been acting as a case reviewer for NCEPOD, and regularly lectures in the United States. Future plans include establishing further clinical neuroanaesthesia research in Belfast, involvement in the development of difficult airway devices and forthcoming lecture tours of the far East. Emerging Therapies in Interventional Neuroradiology Dr Peter Flynn, Regional Neuroradiology Service, Belfast HSC Trust Biography Dr Peter Flynn (MB BCH MRCP FRCR) is a consultant neuroradiologist in the Royal Victoria Hospital Belfast. In 1989 he graduated for Queen’s university Belfast. He undertook training in diagnostic and interventional neuroradiology in Newcastle Upon Tyne in the late 90s, and was appointed a consultant neuroradiologist in RVH in 1999. He was appointed primarily to lead and develop the interventional neuroradiology service in Belfast. To date academic endeavours include over 50 publications including 3 book chapters along with guest lectures on various neuroradiology topics at national and international meetings. 13 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Speaker abstracts ! Thursday 11th May Initial Management and Transfer of the Brain-Injured Child: Dr Mark Terris, Royal Belfast Hospital for Sick Children, Belfast HSC Trust Worldwide, trauma remains one of the leading causes of death in children. Traumatic Brain Injury (TBI) is present in the majority of cases and is commonly given as the primary cause of death. Mechanisms of brain injury vary widely across age groups. In infants TBI most often results from non-accidental injuries, while in toddlers falls are the most common cause, whereas older children are more likely to be involved in road traffic accidents or experience sports injuries. This spectrum of causes may also result in specific pathological patterns. In infants and young children a more diffuse cerebral injury pattern is seen, with fewer focal lesions than are observed in older paediatric patients. The developing child, particularly during the pre-school age, also presents challenges with regards to the effect of varying physiology and anatomy. This, coupled with a lack of evidence, has resulted in difficulties in producing guidelines for the management of paediatric TBI. However such a guideline was produced in 2003, and recently updated in 2012, and provides a useful resource to assist clinicians(1). Initial management of the brain-injured child requires a team approach with early input from senior paediatric, anaesthetic and emergency department staff. A structured assessment as covered in APLS or ATLS courses allows rapid identification and management of problems identified(2). During this time particular attention to avoidance of hypoxia and hypotension are important. Hypotension is defined as a systolic blood pressure <5th percentile for age or by clinical signs of shock. Charts are available with specific values or for children >1 year of age this may be estimated using the formula 70+(Age in years X2). Indications for intubation are similar to those in adults and include respiratory insufficiency, GCS <8 or evidence of raised ICP. During airway manipulation, consideration should be given to the possibility of associated spinal injuries. Care should be taken to place an appropriately sized cervical collar as soon as possible. Due to the disproportionate size of the head to torso ratio, infants and children placed on a flat surface, including spinal boards, may be forced into excessive flexion, potentially worsening any cervical spinal injury. This may be remedied by placing a pad under the torso to maintain alignment(3). Brain injured children commonly require intra- and inter-hospital transfers to allow imaging, intensive care and/or surgery. Achieving this in a timely and safe fashion requires clear communication and careful planning. Factors that should be included within local arrangements are described in the 2010 Paediatric Intensive Care Society standards document(4). These include contact details, indemnity cover and arrangements with a local ambulance service. Due to the time critical nature it may be inappropriate for the local retrieval team to undertake these transfers. However they should be available to provide advice and support. During transfer, continuous monitoring should be maintained to those levels described by the AAGBI(5). References 1. Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-Second Edition. Pediatric Critical Care Medicine. 2012 Jan;13:S1–S2. 2. Samuels M, Wieteska S, Advanced Life Support Group (Manchester E. Advanced paediatric life support : the practical approach. Chichester, West Sussex, UK: BMJ Books; 2011. 3. Easter JS, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part II: management and special considerations. The Journal of emergency medicine. 2011;41(3):252–6. 4. The Paediatric Intensive Care Society. Standards for the care of critically ill children [Internet]. [cited 2012 Apr 19]. Available from: http://www.ukpics.org.uk/documents/PICS_standards.pdf 5. AAGBI. Recommendations for the Safe Transfer of Patients with Brain Injury 2006 [Internet]. [cited 2012 Apr 19]. Available from: http://www.aagbi.org/sites/default/files/braininjury.pdf 14 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Severe TBI: Paediatric Guidelines versus Adult Guidelines Dr Dermot Doherty, Children’s University Hospital Temple St., Dublin This year, the Second Edition of the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents-was published [1]. This edition reports on several clinical trials in paediatric TBI, and also reviews (and ranks) the evidence since the last iteration of the guidelines in 2003. In general, there have been some advances in paediatric-specific evidence to support recommendations, based on the reports of randomized controlled clinical trials from large research consortia. Yet, there remain gaps in knowledge in key areas of pediatric TBI. The challenge to the development of pediatric TBI guidelines pertains to the relative paucity of available evidence on which to base robust recommendations. While many brain-injured children are cared for in academic institutions, the infrequency of their presentation (relative to adults) poses a difficulty in recruitment of sufficient numbers of patients to adequately power clinical trials. Additionally, given that traumatic brain injury is not a homogenous injury, the spectrum of developmental physiology (from infants to adolescents) poses an added challenge to trial design and recruitment. Occasionally, the results of pediatric studies have been different to those reported in similar adult studies. This makes the ‘trickle-down’ application of adult research to paediatric TBI a potential source of error or even harm to children, and underscores the need for continued research in pediatric TBI. In this presentation, we will review those areas of brain physiology that make children different to adults. We will also review the recommendations of the new guidelines for children. We will also describe some of specific practicalities of managing pediatric TBI, which differ from adult TBI. References 1. Kochanek, P.M., et al., Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2012. 13 Suppl 1: p. S1-82. Mannitol or Hypertonic Saline as First-line Osmotherapy: what’s the evidence? Dr Brian Mullan, Regional Intensive Care Unit, Belfast HSC Trust Osmotherapy can be used to control intracranial hypertension in brain-injured patients. Mannitol, a naturally occurring sugar alcohol, has been considered the gold-standard agent for many years [1]. It exerts its ICPlowering effects via two possible mechanisms – an immediate effect due of plasma expansion and a slightly delayed effect due to an osmotic action. Mannitol therapy can however result in a number of clinically important adverse effects such as hypovolaemia, renal failure and rebound intracranial hypertension. The use of hypertonic saline (HTS) has gained a renewed interest in neurocritical care [2]. In addition to an osmotic action, HTS has haemodynamic, vasoregulatory, immunological and neurochemical effects. It reduces ICP without causing volume contraction and with less risk of nephrotoxicity. It may be particularly useful for refractory intracranial hypertension. A recent meta-analysis has suggested that HTS is superior to mannitol for the management of ICP [3]. However, the argument for HTS is complicated by the fact that too many different regimens (in terms of concentration, dose, bolus versus continuous infusions, plus or minus colloid supplementation) have been utilised. Currently there are no widely accepted optimal dosing regimens for either mannitol or HTS. This presentation will cover the basic science and physiological principles behind osmotherapy. The beneficial effects and potential complications of both mannitol and HTS will be examined and discussed. A case will then be made that the current scientific evidence supports HTS, and not mannitol, as the first-line osmotherapeutic agent in neurocritical care. References 1. Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2007; 24 (Suppl 1): S1S106 2. Hypertonic saline, not mannitol, should be considered gold-standard medical therapy for intracranial hypertension. Marko NF. Critical Care 2012; 16: 113 [Epub ahead of print] 3. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: A meta-analysis of randomised clinical trials. Kamel H et al. Crit Care Med 2011; 39: 554-59 15 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Management of Endocrine Disorders for Pituitary Surgery Dr Hamish Courtney, Regional Centre for Endocrinology & Diabetes, Belfast HSC Despite advances in medical therapy, pituitary surgery is a frequently required procedure for pituitary tumours. The associated co-morbidity of several pituitary conditions, in particular Cushing’s disease and acromegaly, may present the anaesthetist with challenges peri-operatively. Additionally, any type of pituitary lesion may be associated pre-operatively with hypopituitarism, which can also have implications in the perioperative period. Disorders may also occur that are the direct result of the pituitary surgery, including sodium and water imbalance, causing diabetes insipidus or SIADH and hypopituitarism, in particular hypocortisolism. Furthermore, pituitary surgery may also be required relatively urgently in the patient presenting with pituitary apoplexy, and in such cases endocrine considerations are also pertinent. For successful peri-operative patient care during pituitary surgery therefore, an understanding of a patient’s pre-operative endocrine status is necessary along with an awareness of potential endocrine complications and their management. Anaesthesia for Awake Craniotomy Dr Judith Dinsmore, St George’s Hospital, London There have been many recent advances in neurosurgery with the introduction of endovascular interventions, image guided, minimally invasive and functional neurosurgery. However awake craniotomy has been around in one form or other throughout the years. Ancient civilisations performed trephination to cure a multitude of ailments but the modern era of awake craniotomy was heralded by Wilder Penfield and André Pasquet’s 1954 landmark paper. 1 Penfield and Pasquet’s early experiences laid the groundwork for the awake craniotomy today. Although anaesthetic drugs and adjuncts have radically changed there are many similarities in practice. Routine for epilepsy surgery for many years, awake craniotomy is now standard practice for the implantation of deep brain stimulators and also for tumour surgery in, or adjacent to, eloquent brain. Intraoperative cortical mapping allows planning of safe resection margins and awake resection, with continuous neurological assessment allows maximal tumour resection with minimal neurological dysfunction. 2 The anaesthetist plays a key role in these challenging cases. They must provide adequate analgesia and sedation, haemodynamic stability and a safe airway but also, an alert and cooperative patient for intraoperative testing. A huge variety of techniques have been described which fall into three main categories: local anaesthesia, sedation or asleep-awake-asleep (AAA) with or without airway instrumentation. The range of reported complications is dependent upon the technique chosen but includes pain, nausea and vomiting, local anaesthetic toxicity, respiratory, cardiovascular, neurological and technique failure.3 The most appropriate technique will be the one considered best for the particular procedure, patient’s age and co morbidity. With no consensus as to the best technique most institutes have developed their own regimes to suit the needs of their surgeons and their individual preferences. The success of awake craniotomy is self-evident. Once practiced by only a few, with increased patient safety and survival, better functional outcome and the opportunity for day case activity, it now verges on becoming standard procedure for supratentorial tumour surgery.4 5 References 1. Penfield W, Pasquet A. Combined regional and general anaesthesia for craniotomy and cortical exploration. Anesthesia & Analgesia 1954; 33: 145–6. 2. Meyer FB, Bates LM, Goerss SJ, et al. Awake craniotomy for aggressive resection of primary gliomas located in eloquent cortex. Mayo Clin Proc 2001; 76: 677 – 87. 3. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy—evolution of a technique that facilitates awake neurological testing. Br. J. Anaesth. 2003; 90: 161-165. 4. McGirt MJ, Chaichana KL, Attenello FJ, et al. Extent of surgical resection is independently associated with survival in patients with hemispheric low-grade glioma. Neurosurgery 2008; 63: 700 – 8. 5. Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumor: a prospective trial of 200 cases. J Neurosurg 1999; 90:35 – 41. 16 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast The role of Sugammadex in Neuroanaesthesia Dr Martin Shields, Royal Victoria Hospital (RVH), Belfast Many conditions exist that have altered interactions between neuromuscular blocking agents (NMBAs) and muscle function; these include myasthenia gravis and Duchenne’s muscular dystrophy. This talk will include details of several case series in which patients with myo/neural diseases have successfully received NMBAs where they would previously have been avoided. In patients with myasthenia gravis the continuation of cholinesterase inhibitors throughout the peri-operative period and the use of aminosteroidal NMBAs with sugammadex for reversal can potentially add to the safety of the anaesthetic delivered. Reasons for this includes less pre-operative bulbar palsy, better intubating conditions, earlier return to baseline medications and avoidance of the need for critical care admissions, planned or unscheduled. Such techniques had also been used to deliver rapid sequence induction of anaesthesia (RSI) to patients with myasthenia gravis. The variable response of individual patients with myasthenia gravis to NMBAs is such that choosing an effective dose for RSI can be difficult. We present two cases in which a RSI was used for patients undergoing emergency laparotomy. They received rocuronium 0.6 to 1.0 mg/kg. Sugammadex was used to reverse the neuromuscular block at the end of surgery and neither required post-operative ventilation nor critical care admission. A final use of sugammdex in neurosurgery can be to facilitate the monitoring of motor evoked potentials in patients that have required an NBMA for intubation. Indications for this type of anaesthesia may include surgery for cervical spine or cervico-occipital pathology and foramen magnum decompression where it may be preferred that no movement or coughing occurs with intubation. The practical aspects of this technique will be presented. Postoperative pain relief in Neurosurgical patients Dr Susan Atkinson and Ms Olga O’Neill, RVH, Belfast Although the 1990 Working Party Report on Pain after Surgery produced by the Royal College of Surgeons in England and College of Anaesthetists highlighted the requirement for acute pain services and regular pain assessment, a recent survey of British neurosurgical centres found that only 65% of units routinely assessed postoperative pain1. Nurses working in these Units reported that 20% of post craniotomy patients experienced severe pain. Acute pain services have a vital role to play in pain management, staff education and in monitoring the safety and efficacy of analgesic regimes for different surgical procedures. Surveys of patient satisfaction and patient focus groups can be valuable in triggering improvement in the delivery of postoperative analgesia. The introduction of standardized regimens for regular postoperative multi modal analgesia may reduce the incidence of severe pain following neurosurgical procedures, but safe and effective analgesia must be tailored to individual patient requirements, since the response to too many opioids, including codeine, is dependent on genetic2 and demographic interpatient variation and co-morbidity. Postoperative pain severity also varies with neurosurgical procedure3. The opioid sparing effects of intravenous paracetamol, NSAIDs and anticonvulsant drugs have been widely exploited following surgery but potent opioids are not uncommonly required on emergence from remifentanil based anaesthesia. Reduction in 24-hour opioid requirement does not equate with a decrease in opioid induced side effects4. Scalp nerve blocks have been shown to reduce pain severity for up to 48 hours following supratentorial craniotomy5, 6 and may reduce the incidence of chronic postsurgical pain7. References 1. Kotak D, Cheserem B, Solith A. A survey of post-craniotomy analgesia in British neurosurgical centres: time for perceptions and prescribing to change? Br. J. Neurosurg. 2009; 23: 538-42. 17 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast 2. Crews KR, Gaedigk A, Dunnenberger HM et al. Clinical Pharmacogenetics Consortium (CPIC) Guidelines for codeine Therapy in the Context of Cytochrome P450 2D6 (CYP2D6) Genotype. Clin. Pharmacol. Ther. 2012; 91: 321-6. 3. Thibault M, Girard F, Moumdjian R et al. Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can. J. Anesth. 2007; 54: 544-8. 4. Gottschalk A. Craniotomy pain: trying to do better. Anesth. Anal. 2009; 109: 1379-81. 5. Nguyen A, Girard F, Boudreault D et al. Scalp nerve blocks decrease the severity of pain after craniotomy. Anesth. Analg. 2001; 93: 1272-6. 6. Bala I, Guota B, Bhardwaj N et al. Effect of scalp block on postoperative pain relief in craniotomy patients. Anesth. Int. Care 2006; 34: 224-7. 7. Batoz H, Verdonck O, Pellerin C et al. The analgesic properties of scalp infiltrations with Ropivacaine after intracranial tumoral resection. Anesth. Analg. 2009; 109: 240-4. Assessment and Optimisation of Cerebrovascular Autoregulation in Neurosurgical Patients Dr Arun Gupta, Addenbrooke’s Hospital, Cambridge Cerebral autoregulation is defined as the intrinsic ability of the cerebral vasculature to constrict or dilate in response to a changing perfusion pressure in order to maintain a relatively constant blood flow. Autoregulation of cerebral blood flow is a complex process composed of at least two mechanisms operating at different rates; a rapid response sensitive to pressure pulsations (dynamic autoregulation) followed by a slow response to changes in mean pressure (static autoregulation). Autoregulation has limits (upper limit around 150 mmHg and lower limit around 50 mmHg), above and below which, Cerebral Blood Flow (CBF) is directly related to perfusion pressure. However, in clinical practice there is significant interindividual and regional variation within the brain and more current studies indicate that these limits can change. The lower autoregulatory limit is the Mean Arterial Pressure (MAP) at which CBF begins to decrease. Above the upper limit, the high perfusion pressure causes forced dilatation of cerebral arterioles, disruption of the blood-brain barrier, reversal of hydrostatic gradients and cerebral oedema with resultant increases in CBV and ICP. Autoregulatory changes in vessel diameter alters Cerebral Vascular Resistance(CVR) probably arise as a result of myogenic reflexes in the resistance vessels, but neurogenic mechanisms (sympathetic nervous system activity) and even metabolic factors are likely contributors. A number of factors including intracranial pathology, chronic hypertension, sympathetic activation and anaesthetic agents may alter autoregulation. Assessment of Autoregulation Transcranial Doppler (TCD) Both static and dynamic autoregulation can be tested using TCD. The static rate of autoregulation or the index of autoregulation (IOR) is the ratio of percentage change in estimated cerebral vascular resistance (CVRe) to percentage change in mean blood pressure (MAP). An IOR of one implies perfect autoregulation and an IOR of zero implies complete disruption of autoregulation. Dynamic autoregulation (dRoR) is tested by measuring the recovery in FV after a rapid transient decrease in perfusion pressure induced, for example by deflation of large inflated thigh cuffs or carotid compression. The dRoR describes the rate of restoration of FV (%.sec-1) with respect to the drop in perfusion pressure, in other words the rate of change in cerebral vascular resistance. The normal dRoR is 20%.sec-1 (i.e. dynamic autoregulation is complete within approximately 5 seconds). Near Infrared Spectroscopy(NIRS): Preliminary work comparing NIRS derived parameters with TCD blood flow velocity have shown significant association. As the technology advances, contamination of NIRS readings from extracranial blood flow detection will be minimised, allowing an alternative continuous monitor of autoregulation which can be used in the operating room or ICU. Pressure Reactivity: The correlation between spontaneous waves in arterial blood pressure (ABP) and ICP is dependent on the ability of the cerebral vessels to autoregulate. With disturbed autoregulation, changes in ABP are transmitted to the intracranial compartment and result in a passive pressure effect. The correlation coefficient between slow changes in mean ABP and ICP is called the pressure reactivity index (PRx). When PRx is negative, cerebral vessels are pressure reactive, whereas a positive correlation indicates disturbed reactivity. 18 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Optimisation of Autoregulation 1. The limits of autoregulation may be affected by disease processes and are modulated by sympathetic nervous system activity. Alpha and Beta-blockade shift the autoregulation curve to the left whereas chronic hypertension increases the limits of autoregulation (shift the curve to the right.) Identification of the ‘optimal CPP’ along the autoregulation curve for an individual can be helped using PRx. 2. Various drugs can affect autoregulation. A number of inhalation anaesthetic agents for example impair autoregulation, whereas most intravenous agents maintain autoregulation. Statins have been shown to increase autoregulation in patients with subarachnoid haemorrhage. 3. Hyperventilation increases cerebrovascular tone and may improve autoregulatory function when impaired. Hypercapnia however significantly obtunds autoregulation and may render the cerebral circulation pressure passive Clinical applications. Autoregulation testing has been shown to be useful in patients both in the ICU and in the operating room. In the ICU, there is evidence to suggest that autoregulation testing can help optimise CPP and contribute to the management of patients with traumatic brain injury. In patients with subarachnoid haemorrhage, assessment of autoregulation may help with predicting vasospasm. Preliminary studies have shown that TCD derived autoregulation assessments have helped to predict outcome in patients with acute ischaemic stroke. In the operating room, potential clinical applications for autoregulation assessment include patients undergoing neurosurgical or non neurosurgical surgery after traumatic brain injury, and the intraoperative management of patients undergoing carotid endarterectomy. References 1. Czosnyka , Brady KM, Reinhard M, Smielewski P, Steiner LA Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care. 2009;10(3):373-86. 2. Dagal A, Lam AM. Cerebral autoregulation and anesthesia. Curr Opin Anaesthesiol. 2009 Oct;22(5): 547-52. 19 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Speaker abstracts ! Friday 12th May The Brain-Lung-Brain Axis Prof Danny McAuley, Queen’s University, Belfast In this presentation the mechanisms of interaction of the injured brain on the lung will be reviewed and the implications for clinical care and novel therapies will be reviewed. In addition the epidemiology of respiratory failure and considerations regarding the use of mechanical ventilation in patients with brain injury and/or increased intracranial pressure will be discussed, and an evidence-based approach to ventilatory management in these patients will be presented. Extracorporeal lung support in the Neuro ITU Dr Simon Finney, Royal Brompton Hospital, London Abstract unavailable at time of publication. RAIN Study – preliminary results Dr David Harrison, ICNARC, Tavistock House, London Abstract unavailable at time of publication. Anaesthesia for MRI-Guided Neurosurgery Dr Sally Wilson, Queen Square, London! ! Intra-operative magnetic resonance imaging (iMRI) has been in use in some parts of the world since the mid 1990s. It allows imaging of the patient during surgery and is a useful tool for intermittent assessment of the progress of the operation and maximal safe resection. The technique brings with it all the challenges of anaesthesia in the MRI environment associated with the magnetic field and safe access to the patient. The National Hospital for Neurology and Neurosurgery opened the first iMRI unit in the UK dedicated to neurosurgery in 2009. The process has brought us both expected and unexpected challenges for anaesthesia, neurosurgery, neuroradiology and medical physics. To date we have performed several hundred cases for neuro-oncology and pituitary surgery,, temporal lobe resections for epilepsy and insertion of deep brain stimulators for movement disorder. This talk will discuss the establishment of the iMRI unit, the vision and the reality. It will also focus on the evidence for its use and current research applications. Anaesthesia & Neuropharmacology: what’s new? Dr Stephen Luney, Royal Victoria Hospital, Belfast Neuroanaesthetists and neurointensivists are currently expected to manage a wide range of patients for whom novel therapies are currently undergoing development. Subarachnoid haemorrhage, stroke, seizures, traumatic brain injury etc. all attract multicentre international studies, a growing number of which are being undertaken in the far East. This lecture will review some of the recent developments and ongoing studies linking anaesthesia and neuropharmacology, and will examine why some of the newer ideas have or have not worked, and what opportunities there are to contribute to further development. 20 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Emerging Therapies in Interventional Neuroradiology Dr Peter Flynn, Regional Neuroradiology Service, Belfast HSC Trust Interventional neuroradiology (INR) has been in existence in some form since the early 1970s. It has though rapidly expanded since the early 1990s mainly due to the development of the Guglielmi detachable coil (GDC) and the subsequent landmark publication of the international subarachnoid aneurysm trial (ISAT) in 2002. I will demonstrate some of the continuing technological advances that are improving our ability to treat even the most complex of intracranial aneurysms. There will also be illustrations of INR embolisation techniques that are now an integral component of the treatment paradigm for arteriovenous malformations, both cranial and spinal, and are invaluable for preoperative devascularisation of hypervascular tumours. Much of the above is relatively mature in its evolution however the next “big thing” will be acute stroke treatment. This has major implications for both INR and neuroanaesthesia services but in my opinion will ultimately be proven to be the best way to treat acute thrombotic stroke. I will illustrate this belief with cases and discuss some of the barriers we have faced and lessons learned from our own acute stroke service. 21 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Abstracts for Oral Presentations A National Survey On The Use Of Bispectral Index For Sedation Management In Adult Patients With Traumatic Brain Injury P. Battu*, J. Andrzejowski*, I. Tweedie§. *Sheffield Teaching Hospitals NHS Trust, Sheffield, UK. §Walton Centre NHS Trust, Liverpool, UK. Introduction: Despite wide variations in practice, there are no validated objective tools used to assess sedation in neuro-critical care (NCC) patients. Bispectral index (BIS) monitoring is used in a limited way, although it has not been validated. We aimed to assess the indications and variability in of BIS use in NCC in the UK. Methods: An online survey was forwarded to linkmen of the UK NCC Network. It included questions on the demographics of the unit, BIS availability, usage, indications, and target scores. Free text comments were also collected. Results: We received responses from 21 of the 32 units (65%). Only 10/21(47%) use BIS monitoring on NCC. 62% of 13 units admitting only NCC patients used BIS monitoring vs only 25% of the 8 mixed units. Table 1 summarises the responses. Comments indicated that a frequent reason for BIS monitoring was its ease of application with no requirement for neurophysiology personnel input. No untoward critical incidents from BIS use were reported. TABLE 1. Summary of responses (percentages relate to the 10 units that use Bispectral index monitoring). Ques%on Op%ons Which side of the head do you monitor with BIS? Normal side (no pathology) Side with pathology Unsure % response 60% 10% 30% What are the indica%ons for using Monitoring seda%on with paralysis BIS moniitoring? (more than 1 Monitoring seda%on with labile ICP choice allowed) Monitoring/%tra%ng barbiturate coma Seda%on in unparalysed pa%ents S%mula%ng procedures 60% 60% 70% 40% 10% What are your target BIS values < 20 for %ta%on in pa%ents with labile < 40 ICP? < 50 < N/A(2) What are your target BIS values < 40 for %ta%on in pa%ents with < 50 normal ICP? < 60 N/A 30% 30% 20% 20% 30% 10% 20% 40% What are your target BIS values < 40 for %ta%on in pa%ents during < 50 s%mula%ng procedure? < 60 N/A 40%, 10%, 10%, 40% Which personnel adjust the sseda%on according to BIS values? 30% 10% 40% 20% Doctor Nurse Nurse or doctor Dont Adjust acc to BIS 22 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: A small number of studies have demonstrated the reliability and validity of BIS with subjective sedation scales1,2, yet BIS monitoring is used in less than 50% of UK units. Optimal sedation and analgesia are important in brain injured patients and a continuous objective monitor such as BIS might be beneficial. However, the results of our survey suggest that until strong evidence for an effect on outcome is available, the use of BIS monitoring in NCC patients is likely to be sporadic. References: 1. Deogaonkar A, et al. Bispectral Index monitoring correlates with sedation scales in brain-injured patients.Crit Care Med 2004; 32(12): 2403-2406. 2. Ogilvie MP, et al. Bispectral index to monitor propofol sedation in trauma patients. J Trauma 2011; 71(5): 1415-1421. Spinal Clearance in Unconscious Children with Traumatic Brain Injury: a Survey of Current Practice in Paediatric Intensive Care Units of Great Britain and Ireland A. Cullen*, M. Terris*, B. Mullan§. *Paediatric Intensive Care Unit, Royal Belfast Hospital for Sick Children, Grosvenor Road, Belfast, UK. §Regional Intensive Care Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, UK. Introduction: No national guideline exists for spinal clearance in unconscious paediatric trauma patients. Spinal injuries in children are difficult to detect. Prolonged spinal immobilisation is associated with significant morbidity. Methods: We surveyed all the PICUs in Great Britain and Ireland. Information was collected on use of a protocol to manage spinal clearance, minimum imaging to clear the spine, time frame in which spinal clearance should occur, specialties involved in the process and minimum grade of clinician permitted to clear the spine. Results: 21 of the 27 PICUs replied. One unit did not accept paediatric trauma. 13 units use a local protocol to guide spinal clearance. Table 1 reveals the minimum imaging required for spinal clearance. Neurosurgery are responsible for clearing the spine in 6 units, orthopaedics in five, critical care in two and in seven units a combination of specialties are involved. In 13 units a consultant is needed to clear the spine, four units permit grade ST3 or above to do this and one unit allows grade CT1 or above. Seven units aim to clear the spine within 48hrs of admission to PICU, four units within 72 hours and six units beyond 72 hours. TABLE 1: Minimum imaging required to clear cervical and thoracolumbar spine in children following trauma%c brain injury in PICUs of Great Britain and Ireland C-Spine Imaging No. of Units T-L Spine Imaging No. of Units Plain films only 3 Plain films only 5 Plain films + undirected CT 2 Plain films + Directed CT 5 Plain films + directed CT 6 Undirected CT only 3 Plain films + directed CT + MRI 5 MRI only 1 Undirected CT only 3 Plain films + directed CT + MRI 3 MRI only 1 No standard described 3 Conclusions: Huge variation exists regarding minimum imaging required, speciality involved, seniority of clinician permitted to make the judgement and time frame within which clearance should occur. National evidence-based spinal clearance guidelines are urgently required. 23 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast A Full Audit Cycle of Pre-Operative Fluid Fasting at The Wessex Neurological Centre H. Edgar, T. Madamombe, J. Stubbing. Department of Anaesthesia, Southampton General Hospital, Southampton, Hampshire. UK. Introduction: Enhanced Recovery after Surgery (ERAS)1 programmes rely on factors including good hydration at the start of surgery. Excessive preoperative fasting from fluids is deleterious to patients and their recovery2. Our aim at the Wessex Neurological Centre (WNC) was to improve the preoperative fluid management in patients having elective surgery. Methods: We undertook a prospective audit on elective adult neurosurgical patients, over a two-month period. The gold standard was – 100% of patients to drink still water between 2 and 6 hours before arrival in the anaesthetic room. Data was collected in the form of a questionnaire. Multidisciplinary changes were implemented. A re-audit was carried out four months later. Results: In the first audit there were 86 valid responses, median age 59 (23-88). 20 patients (23%) had drunk water between 2-6 hrs. 62 patients (72%) had fasted for > 6 hours. Mean time of fasting 10.1 hrs. The 2nd audit had 80 valid responses, median age 50 (18 to 84). 57 patients (71%) had drunk water between 2-6 hrs, and 22 patients (28%) had prolonged fasting of over 6 hrs. Mean time of fasting 5.7 hrs. (figure 1) Conclusions: Following changes at WNC (staff education, patient information leaflets and operating list organization) re-audit demonstrated a reduction of preoperative fasting time. Our primary audit measure was improved from 23% to 72% and mean fasting time reduced from 10.1 to 5.7 hours. Further work in enhanced recovery will be useful to reduce patient morbidity and hospital length of stay. References: 1. Kehlet H, Dahl J. Anaesthesia, surgery and challenges in postoperative recovery. Lancet 2003; 362 (9399): 1921-1928. 2. Brady MC, Kinn S, Stuart P, et al. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Sys Rev 2003; (4) CD004423. Tracheostomies in Patients with Neurological Disease - The first 10 Years K. Hunt, S. McGowan, L. Platt, E. Bayely. The National Hospital for Neurology and Neurosurgery (University College London Hospitals), Queen Square, London, UK. Introduction: Since 2001 a multidisciplinary tracheostomy team has delivered ward based care and weaning to patients with tracheostomies at our institution. Each year we have conducted an audit to benchmark our results and standards of care. We have collected a database of results of tracheostomy management in the neuroscience population and after extensive literature searches, are assured that this is the first and largest of its kind. Methods: Following institutional approval, we have collated 10 years of audit data, analysing the following population characteristics and standards of tracheostomy weaning; disease presentation, rate of and time taken to decannulation, rate of recannulation, complication rate and patient outcome. Results: 453 patients have been treated over the last 10 years. Of these two thirds presented with a neurosurgical condition, and a third with a medical condition. The largest disease subset was subarachnoid 24 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast haemorrhage, which made up 15% of the total tracheostomy population. Our average rate of decannulation (53%) is similar to that quoted in the literature; however our recannulation rate of 1.6% is lower than that stated in other reviews (2-5%)1, and late complication rate of 2.2% significantly lower than most reported (up to 65%) 2. In addition our continued review of practise and individualised patient weaning programmes has led to a fall in weaning times over the last 10 years (Table 1). TABLE 1. Average tracheostomy weaning %mes in days (start of weaning to decannula%on) over 10 years by admission type. Year 01-‐02 02-‐03 03-‐04 04-‐05 05-‐06 06-‐07 07-‐08 08-‐09 09-‐10 10-‐11 Medical 19 16 37 21 11 18 17 24 13 9 Surgical 27 23 23 17 12 14 14 22 23 21 Conclusion: We present a unique database of tracheostomy characteristics and weaning results in the neuroscience population, which can be used as a benchmark by other institutions. Our standardised approach and our methods of weaning and management have led to reduced weaning times, low recannulation and low complication rates. References: 1. Stelfox HT, Crimi C, Berra L. Determinants of tracheostomy decannulation: an international survey. Critical Care 2008; 12(1): R26. 2. Epstein SK. Late Complications of tracheostomy. Respiratory Care 2005; 50 (4): 542-549. Estimating Weight In Neurosurgical Patients With A Raised BMI: A Recipe For Drug Delivery Errors D. Miller, M. Wiles, K. Parsons. Royal Hallamshire Hospital, Sheffield, UK. Introduction: Target-controlled infusions (TCI) are commonly used in neuroanaesthesia. TCI algorithms depend upon accurate patient’s weights being programmed. With acute admissions it is often not possible to measure weight, so estimates are used. Previous work has shown that anaesthetists can estimate weight accurately in non-obese patients1, but the accuracy in overweight and obese individuals has not been determined. Method: After gaining local hospital ethical approval, 32 elective neurosurgical patients with a BMI > 25 were randomly selected2. Their weights were then estimated by a randomly selected and blinded anaesthetist (A), ward nurse (N) and operating department assistant (ODA). These estimates were then compared to the patients’ actual weight. Data were analysed by linear regression, Bland-Altman plots and ANOVA. Results: Of the 32 patients (17 male) 12 had a BMI 25-29 and 20 BMI >30. The mean weight was 89 (15) kg. Weight was underestimated by -8% (11) overall with a wide variance (see figure 1). All groups (A, N & ODA) underestimated weights to a similar degree (-6% (11), -10% (11) and -8% (11) respectively (p=0.287). There was no relationship between increasing weight and accuracy (R2 0.54 (A), 0.57 (N), 0.54 (ODA)). All values are mean (SD). FIGURE 1. Scatter diagram showing percentage error in weight estimate against actual patient weight. The solid line shows mean, the dotted line 1.96 SD. 25 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: In overweight/obese patients, medical staff tend to underestimate the patient’s true weight. This may result in the under dosing of drugs delivered by TCI algorithms, which has important clinical implications. References: 1. Coe TR, Halkes M, Houghton K, Jefferson D. The accuracy of visual estimation of weight and height in pre-operative supine patients. Anaesthesia 1999; 6: 582-586. 2. World Health Organisation. Global Database on Body Mass Index. Available at: http://apps.who.int/bmi/ index.jsp?introPage=intro_3.html. Accessed 30th January, 2012. Interhemispheric EEG Variability Measured Using A Bilateral Bispectral Index (BIS) Sensor. M. Smith, M. Wiles, J. Andrzejowski, G. Eapen. Sheffield Teaching Hospitals NHS Foundation Trust., Sheffield, UK. Introduction: BIS monitors are commonly used to measure anaesthetic depth. A new sensor has been developed that measures EEG data bilaterally, allowing a BIS value to be calculated for both cerebral hemispheres. Large interhemispheric variability has previously been shown using two BIS sensors and machines in tandem1. We aimed to assess this variability using an electrode specifically designed to detect left to right EEG variability. Methods: Approval was obtained from the hospital clinical effectiveness board. Bilateral BIS recordings were obtained from patients having neurosurgery under general anaesthesia. Data were analysed using BlandAltman plot, regression coefficients and Pearson Correlation. Results: Twenty patients were studied (12 male; 10 volatile/remifentanil vs 10 propofol/remifentanil ). Mean anaesthetic time was 161 minutes. In total 3194 paired BIS readings were analysed, each representing 60 s of mean BIS values. 95% limits of agreement between sides ranged from -8.3 to 7.1 (see figure 1). Correlation (R) was 0.95 and regression (R2) was 0.90. Left – right separation of > 10 BIS units occurred in 2.8%, and a separation of > 10% in left – right readings occurred in 8.6% of measurements. This compares to 6% and 16.7% respectively for the two electrode/monitor technique. See figure 1. Difference BIS EFT - BIS RIGHT 20.0 7.5 -5.0 -17.5 -30.0 0 25 50 75 100 Mean BIS Value (BIS LEFT + BIS RIGHT/2) FIGURE 1. Difference between BIS readings from right and left electrodes plotted against mean BIS value. The solid line shows mean; the broken lines +/- 1.96 SD. Conclusion: Intrapatient variability between left - right BIS measurements using a bilateral sensor is low, and seems a preferable technique for observation of interhemispheric EEG changes. References: 1. Niedhart DJ, Heiko AK, Jacobsohn E et al. Intrapatient Reproducibility of the BISxp monitor®. Anesthesiology 2006; 104:242-248. 26 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Family Satisfaction in a Neurosciences Intensive Care Unit D. Snell, H. McConnell. Department of Anaesthesia & Intensive Care, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK. Introduction: Patients’ experience of their treatment and care is a core domain of the new NHS Outcomes Framework1.Many patients in intensive care (ICU) either lack capacity, are unable to express their opinions or have little recollection of events. The opinions of relatives are a useful alternative and the internationally validated Family Satisfaction in the ICU (FS-ICU) questionnaire can capture this information2. Method: Over 3 months all patients admitted to the Neurosciences ICU for more than 48 hours were identified. Next of kin were informed of the FS-ICU survey during the admission and were invited to complete a questionnaire four weeks after discharge of the patient. The option of completing either a paper or an online version was offered. Results: 132 questionnaires were sent out and 55% returned. Overall satisfaction with the care and compassion delivered was excellent (Figure 1). There were lower scores for the frequency of communication; the atmosphere in the waiting room and religious support. Only five questionnaires were completed online. Most responders welcomed the questionnaire and the opportunity to feedback on their experiences from home. FIGURE 1. Results illustrating the support shown to the relatives of patients. Conclusion: Although families have a very positive view of the clinical care that we provide we have identified key areas for improvement including addressing religious needs and improving communication between medical staff and families. The waiting room atmosphere was a frequently cited area for improvement. In response we have incorporated communication into daily checklists and introduced specific communication documentation. We have highlighted the importance of offering religious support and are looking at ways to address the waiting room experience. References: 1. Equity & excellence: Liberating the NHS. [Department of Health website]. July 2010. Available at: http:// www.dh.gov.uk (accessed 29 Aug 2010). 2. Wall RJ, Engelberg RA, Downey L et al. Refinement, scoring, & validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med 2007; 35: 271- 279. Targeting of Pre-operative Clotting Studies for Elective and Emergency Intracranial Surgery R. Thompson, C. Luong, P. Razis. Department of Anaesthesia, St Georges Hospital, London, UK. Introduction: The British Committee for Standards in Haematology does not provide clear guidelines for coagulation screening in neurosurgery due to a lack of data1. Although not originally intended as screening 27 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast tests, many neurosurgical units perform INR and APTT ratio (APTTR) routinely prior to intracranial surgery. Our aim was to question the necessity of these tests as a screening tool, unless indicated by the patient’s history. Methods: A retrospective audit of intracranial cases was carried out between 01/08/2010 – 31/07/2011 at St Georges Hospital, London. The procedure, whether the patient was taking anticoagulants or anti-platelet therapy, and the first clotting study for the 2 weeks prior to surgery were recorded. Abnormal tests were grouped as APTTR > 1.2 or INR ≥ 1.4. Where the results were abnormal, the hospital notes and electronic records were reviewed. Ethics committee approval was not required. It was registered with the trust’s audit department (No. 2637). Results: Of the 729 intracranial cases, 427 (58.6%) were elective and 302 (41.4%) were emergencies. See table 1: Clotting Results Prior To Intracranial Surgery TABLE 1. Clotting study results prior to intracranial surgery INR ELECTIVE (n=427) HISTORY No Test 21 (4.9%) 27 (8.9%) INR < 1.4 404 (94.6%) 254 (84.1%) INR > 1.4 2 (0.5%) 2 predicted EMERGENCY (n=302) 21 (7.0%) HISTORY 19 predicted APTT Ratio No Test 22 (5.2%) 27 (9.0%) APTTR < 1.2 399 (93.4%) 269 (89.0%) APTTR >1.2 6 (1.4%) 4 predicted 6 (2.0%) 4 predicted Conclusions: History was almost totally predictable for the INR abnormalities with the possibility of omission in 2 out of 21 emergency cases. Reasons included warfarin therapy and alcoholic liver disease. The benefit of correction of small INR abnormalities remains unclear2. For APTTR, the results were the same for both elective and emergency procedures, with 2/3rd being predictable. No evidence base currently exists for the APTTR cut off. We therefore conclude that clotting studies in elective intracranial surgery should only be performed as predicted by the history, but that they may be more useful in emergencies. References: 1. Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the Assessment of Bleeding risk Prior to Surgery or Invasive procedures. British Committee for Standards in Haematology. Br J Haematology 2008; 140: 496-504. 2. West KL, Adamson C. Prophylactic Correction of International Ratio in Neurosurgery: a brief review of a brief Literature. J. Neurosurgery 2011; 114: 9-18. 28 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Abstracts for Poster Presentation Antibiotic prophylaxis for neurosurgery: a survey of current practice across the UK and Ireland S. Bahlool, C. Fumagalli. Brighton and Sussex University Hospitals, Brighton, UK. Introduction: Postoperative surgical site infection (SSI) is one of the commonest health care associated infections and carries a high rate of morbidity to patients1. The advantages of antibiotic prophylaxis are well established and in this survey, we aimed to investigate the awareness of available guidelines and to examine different aspects of the current practice across the UK and Ireland. Methods: Thirty eight UK and Ireland neurosurgical centres were invited to participate in this survey. An online questionnaire was sent via email to all these centres through the Neuroanaesthesia Society of Great Britain and Ireland (NASGBI). Results: Response rate was 82% and 86% of centres acknowledged the existence of local polices and/or guidelines. Cefuroxime remains the agent of choice for most procedures with Co-Amoxiclav being next. Prophylaxis was not recommended for clean craniotomy and spinal surgery without instrumentation by 3% while not recommended for interventional neuroradiology by 72%. Regarding CSF shunt procedures, the current practice seems to be widely variable. For all kinds of prophylaxis, a second dose was considered in 83% centres with the main trigger (65%) being an operation lasting more than six hours. Concerning proven penicillin allergy, Cefuroxime was given by 27%. FIGURE 1: Antibiotic prophylaxis for all types of cranial surgeries ( ▓ clean, contaminated) ▒ clean-contaminated, ░ Conclusions: Prophylaxis is widely used for most but not for all clean procedures despite the widely available recommendation2, and prophylaxis for interventional neuroradiology procedures remains controversial. Despite the concerns of possible links with C. difficile infection3, Cefuroxime and Co-Amoxiclav remain popular choices. A second antibiotic dose seems to be delayed and Cefuroxime is still given to patients with true allergy to Penicillin. References: 1. Hospital Infection Society. Third prevalence survey of healthcare associated infections in acute hospitals in England 2006. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_078388 (published September 12, 2007). 29 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast 2. National Institute for Health and Clinical Excellence. Clinical guidelines, CG74: Prevention and treatment of surgical site infection. Available from http://www.nice.org.uk/nicemedia/pdf/CG74NICEGuideline.pdf (accessed October 2008). 3. Dancer SJ. The problem with cephalosporins. J Antimicrob Chemother 2001; 48: 463-78. An Audit On Current Practice Of Obtaining An Anaesthetic Consent. S. Bashir*, S. Williamson§. *Northern General Hospital, Sheffield, UK. §Anaesthetic Department, James Cook University Hospital, Middlesbrough, UK. Introduction: Anaesthetists are legally and ethically obliged to seek consent from patients before medical intervention wherever possible. This obligations concerning consent for anaesthesia have been established by the Association of Great Britain and Ireland (AAGBI). In our Trust adequacy of the anaesthetic consent has not previously been audited. Methods: The anaesthetic charts for all the patients who have been admitted to Neurosurgical Department were assessed against two standards driven from AAGBI guideline. The first one is that all patients should give either a verbal or written consent to anaesthesia or record of inability to consent. The criterion is met if the checkbox on the anaesthetic record is ticked. The second one is that every anaesthetic record should contain an element of discussion referring to risks involved or a record of incapacity to discuss. Results: One hundred and eight procedures were undertaken during the audit period. Ninety two cases (85.2%) were elective and 16 (14.8%) were emergency procedures. Sixty eight cases (63%) were consented by the consultant anaesthetists and 40 cases (37%) by anaesthetist trainees In term of the standards application (see Table 1). There was no statistical difference in compliance with the audited standards between consultants and anaesthetic trainees. TABLE 1. Result of the audit on current practice of obtaining an anaesthetic consent. Standards application Number of cases Percentage Standard 1 not applied 22 20.4% Standard 2 not applied 23 21.3% Both standards not applied 13 12% Both standard applied 50 46.3% Total 108 100% Conclusions: Documentation of anaesthetic consent is inadequate. The audited forms were completed by permanent and rotational staff and may therefore reflect widespread practice. This raises the need of a tick box to be added to the anaesthetic record, which was not recommended by the AAGBI. We suggested introduction of a detailed local guidance, increase awareness among anaesthetists and the use of formatted pre- printed standardized records1. References: 1. Ausset S, Bouaziz H, Brosseau M, Kinirons B, Benhamou D. Improvement of information gained from the pre-anesthetic visit through a quality-assurance programme. Br. J. Anaesth 2002; 88: 280-283. Improving the Transfer of Traumatic Brain Injured patients. B. Batuwitage, K. Brennan, S. Jankowski. Department of Anaesthetics, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK. Introductions: High quality transfer of patients with brain injury improves outcome1. A prospective audit of the transfer of severe traumatic brain injured (TBI) patients to our neurosurgical centre using a data collection form designed to provide guidance and improve transfer quality was undertaken. The aim was to identify delays in transfer and their causes and assess quality of transfer. Methods: Intubated TBI patients urgently transferred to the neurosurgical intensive care unit (NICU) or to neurosurgical theatres over a 10-month period were included. Forms were placed in critical care and emergency departments (ED) of referring hospitals and were completed during or after transfer. Data on the quality of the transfer was collected at the neurosurgical centre; any missing data was collected retrospectively. 30 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Results: 31 TBI patients were transferred over the study period. Complete data on transfer time was available for 27. Average time from admission to ED of referring hospital to admission to the neurosurgical centre was 7 hrs and 3 mins, this varied widely among referring hospitals. 20/27 (74%) of transfers were delayed. 2/20 (10%) of delays were unavoidable. 18/20 (90%) were deemed avoidable. Table 1. illustrates causes for avoidable delays. TABLE 1. Causes for avoidable delay Cause No of patients Delay in accepting patient by neurosurgeons 5 Delay in performing CT 5 Delay in referral to critical care 3 Lack of necessary equipment 1 Delayed referral to neurosurgeons 1 Delay in reporting CT 1 Cause unclear 2 11/31 (35%) of transfers were undertaken by junior trainees. Pre-transfer arterial blood gas results were documented in 18/31 (58%). A contemporaneous record was kept in 22/31 (71%). In 11 patients data was collected on admission to the neurosurgical centre. In 2/11 this fell below the targets set for a high quality transfer. Conclusion: There were many areas where transfer of TBI patients could be improved. We plan to discuss our findings with neurosurgeons, medical staff in referring hospitals and continue to use our transfer forms with an aim to improve the standards of transfer in our region. References: 1. Recommendations for the safe transfer of patients with brain injury. AAGBI guidelines 2006. Audit of the use of Central Venous Catheters and Critical care beds for patients undergoing interventional Neuroradiology J. Bilmen, M. Knowles, D. Cope, N. Huggins. Queen Elizabeth Hospital Birmingham, University Hospital Birmingham Foundation Trust, Birmingham, UK. Introduction: The insertion of central lines and use of neurocritical care beds for interventional neuroradiological procedures is varied. An internal audit performed in 2007 suggested that central line insertions should be considered in WFNS Grade 1-2 Subarachnoid haemorrhage (SAH) patients and should be mandatory in Grade 3-5 SAH patients. It was also policy in our trust that all patients undergoing interventional neuroradiology should have a neurocritical care bed post-procedure. We therefore decided to audit the use of central lines and determine the appropriateness of patients being placed on critical care post-procedure. Methods: A retrospective casenote study was undertaken to collect data over a 7 month period for endovascular coilings and a 12 month period for elective AVM embolisations (due to smaller numbers, a longer time period was required). Results: 76 patients underwent coiling procedures between January and July 2010. 24 of these were elective, 52 were emergency. The results of the data collection are displayed in Table 1. Of 22 patients undergoing elective embolisation for AVMs in 2010, 21 cases were reviewed. The mean length of stay was 1.1 days ± 0.7 (SD). None of these patients required any level 2 or level 3 critical care input (as defined by the CCMDS). 31 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast TABLE 1. Data illustra0ng use of central lines and length of stay for pa0ents undergoing interven0onal radiology. No. of pa%ents reviewed No. of central lines inserted No. Requiring use of central line Median length of stay (IQ range) Elec%ve AVM embolisa%ons 21 0 0 1 (1-‐1) days Elec%ve aneurysm coilings 24 3 0 1 (1-‐1.25) days Grade 1-‐2 SAH coilings 38 23 13 3 (1.25-‐8.75) days* Grade 3-‐5 SAH coilings 5 4 3 4 (1-‐16) days Ungraded emergency coilings 9 7 5 9 (3-‐13) days** Group Conclusions: These data suggest that elective interventional neuroradiology procedures do not require central lines routinely and do not require critical care beds post-procedure. A review is currently underway to establish whether all Grade 1 SAH need a central venous catheter and subsequently whether a neurocritical care bed is required. In the small sample size of both studies we did not detect any patient complications in these elective cases. National Survey of Anaesthesia Practices for Endovascular Ischaemic Stroke Treatment M. Bishop*, I. Wilkins§, S. Shinde§, C. Oliver§. *Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Australia. §Department of Anaesthesia, Frenchay Hospital, Bristol, UK. Introduction: Endovascular interventions for acute ischaemic stroke (AIS) are becoming increasingly common. Although there is a growing body of evidence to support improved outcomes in selected patients, data relating to anaesthesia practice is limited. The aims of this survey were to identify the UK centres performing these procedures, elucidate the related anaesthesia practices, and ascertain any challenges to service provision. Methods: We distributed a peer-reviewed electronic survey to NASGBI linkmen in all adult neuroscience centres in the UK in July 2011. Results: Data was received from 27 of the 31 centres. Twenty-five of the responding centres perform interventional neuroradiology (INR). Most (16/25) of these INR centres provide endovascular treatment for AIS, although half (8/16) currently undertake less than one case per month with the anaesthesia service. The choice of anaesthetic technique is influenced by a wide range of factors, with general anaesthesia (GA) the first preference in a majority (9/15) of centres (Figure 1). Respondents most commonly identified insufficient resources as a challenge to service provision. Figure 1. Preferred anaesthetic technique for endovascular ischaemic stroke procedures 32 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: This is the first report of anaesthesia practices for endovascular ischaemic stroke treatment in the UK. Anaesthesia services in most adult UK neuroscience centres are now involved with these procedures. The preference reported here for GA is broadly consistent with recent data from North America,1 but contrasts with a number of retrospective – and controversial2 – reviews favouring non-GA techniques.3 There is a need for prospective studies to guide anaesthesia management and service provision in this developing area of emergency neurological care. References: 1. McDonagh DL, Olson DM, Kalia JS, et al. Anesthesia and sedation practices among neurointerventionalists during acute ischemic stroke endovascular therapy. Front Neurol 2010;1:118. 2. Molina CA, Selim MH. General or local anesthesia during endovascular procedures: sailing quiet in the darkness or fast under a daylight storm. Stroke 2010;41:2720 -2721. 3. Gupta R. Local is better than general anesthesia during endovascular acute stroke interventions. Stroke 2010;41:2718 - 2719. Survey of Anaesthesia for Awake Craniotomy C. Burnand, J. Sebastian. Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK. Introduction: Awake Craniotomy is increasingly used as a method to facilitate surgical success and is considered to be safe and a well-tolerated experience1,2. There is no current data concerning the number of UK neurosurgical centres offering awake craniotomy or the anaesthetic techniques involved. This survey will provide information that could allow individual anaesthetists and centres to compare themselves to others in the UK. Methods: A questionnaire was validated by the NASGBI (Neuroanaesthesia Society of Great Britain & Ireland). It was sent via email in October 2011 to all consultant members of the NASGBI. All replies were voluntary and anonymised. Results: There were 113 completed replies and 30 out of 33 adult UK Neurosurgical Centres were represented. 27 of the 30 Neurosurgical centres performed awake craniotomies (90%). 45% of neuroanaesthetists do not practise the technique. 42% of neuroanaesthetists perform 1-5 cases per year. 70% of neuroanaesthetists state that their preferred anaesthetic technique is asleep-awake-asleep (35%) or asleep-awake (35%). 71% of neuroanaesthetists always insert an arterial line. 23% of respondents who use ‘asleep-awake+/-asleep’ use a volatile anaesthetic and a remifentanil infusion. When an ‘asleep-awake+/asleep’ technique is used 76% of respondents use controlled ventilation. 11% of respondents use an endotracheal tube. For the most common reported complications see figure 1. 50% of respondents reported that the patient returned to a normal surgical bed post-operatively. Conclusions: The majority of neurosurgical centres now provide anaesthesia for awake craniotomies. The survey has provided a valuable insight and there appears to be a variety of techniques, and a trend for common practice in individual centres. References: 1. Wahab SS, Grundy PL, Weidmann C. Patient experience and satisfaction with awake craniotomy for brain tumours. Br J Neurosurg 2011; 25(5): 606- 613. 2. Whittle IR, Midgley S, Georges H et al. Patient perceptions of “awake” brain tumour surgery. Acta Neurochir (Wien) 2005; 147(3): 275- 277. 33 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Decompressive Craniectomy: Early or not at all? B. Clevenger, P. Pemberton. Department of Anaesthesia, Royal Free Hospital, London, UK. Introduction: 60 percent of patients with severe traumatic brain injury either die or survive with severe disability1. Decompressive craniectomy is performed to minimise intracerebral pressure and maintain cerebral perfusion pressure to prevent secondary brain injury2. Its timing remains controversial. We evaluated the outcome of patients with traumatic brain injury who underwent decompressive craniectomy. Methods: All patients who underwent decompressive craniectomy for traumatic brain injury between December 2008 and December 2010 were retrospectively audited. The clinical course was examined from time of presentation to time of surgery, and their outcome based upon the Glasgow Outcome Score (GOS) assessed. Results: 12 patients underwent decompressive craniectomy for traumatic brain injury. 5 died, 5 made a good recovery (GOS 5), 2 had a GOS of 3 or 4. 58% of patients had their operation within 24 hours of presentation; 71% survived with a good recovery. Only 1 (20%) of the patients operated upon after 24 hours had a good outcome; 60% died. [Table 1] Only 2 patients (40%) with a severe head injury (initial GCS of ≤ 8) survived. Three patients had evidence of uncal herniation on CT scan – all died. TABLE 1. Outcome by number of patients against interval to decision to operate Interval Immediate (4 hours) 5 (Good Recovery) 1 24-48 hours 1 2 1 (RIP) 1 1 12-24 hours >7 days 3 3 4-12 hours 48 hours - 7days 4 1 2 1 1 Conclusions: Early decompressive craniectomy correlated with a better outcome. If the decision to perform the craniectomy is made after 24 hours, the likelihood of improving the patient’s prognosis is much reduced. The outcome of patients was also associated with the severity of injury. Patients with a severe head injury and CT evidence of uncal herniation had a higher mortality. References: 1. Cooper DJ, Rosenfeld JV, Murray L. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. New Engl J Med 2011;364:1493-1502. 2. Olivecrona M, Rodling-Walhström M, Naredi S, et al. Effective ICP Reduction by Decompressive Craniectomy in patients with Severe Traumatic Brain Injury Treated by an ICP-Targeted Therapy. J Neurotrauma 2007;24(6):927-935. Social Deprivation And Traumatic Acute Spinal Cord Injury: A National Survey A. Gupta*, S. Young*, N. Crutchley*, A. McLean§. *Department of Neuroanaesthesia, Institute of Neurological Sciences, Glasgow, UK. §Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow, UK. Introduction: It has been previously established that traumatic brain injury is more common in patients from deprived areas1. The aim of this study was to examine the association between socio-economic factors and traumatic acute spinal cord injury (SCI) in Scotland. Methods: The database of the National Spinal Injuries Unit for Scotland was used to collect the domicile postcode of patients admitted after sustaining an acute SCI from April 2010 to March 2011. This postcode was then used to obtain a Scottish Index of Multiple Deprivation (SIMD) 2009 v2 rank and quintile from the Scottish Government website2. SIMD quintile categorizes social deprivation from 1 (most deprived) to 5 (least deprived). Results: Of the 148 patients admitted, a total of 121 patients were included in the survey – exclusions: 2 postcodes unrecorded, 5 outside Scotland, 20 non-traumatic injuries. Median patient age was 48 (range 12 – 88) years. The major cause of traumatic acute SCI was fall (57%); other causes included road traffic incident 34 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast (27%), gymnastics or other sports (4%) assault (4%), and other (8%). Figure 1 shows that the numbers of patients from each SIMD quintile were evenly spread (p=0.48; chi-square). Conclusions: Residing in a more deprived area is not associated with increased risk of traumatic acute spinal cord injury, even though there is more risk of traumatic brain injury. This may be a reflection of the cause of injury, although further demographical study is required. References: 1. Tennant A. Admission to hospital following head injury in England: Incidence and socio-economic associations. BMC Public Health 2005; 5: 21 2. The Scottish Government SIMD Postcode Lookup. Available at http://www.scotland.gov.uk/Topics/ Statistics/SIMD/SIMDPostcodeLookup. Accessed February 6, 2012. Teaching Neuroanaesthesia using simulation, a pilot study K. Kamalanathan, H. Cain, A. Goswami, S. Shinde. Frenchay Hospital, North Bristol NHS Trust, UK. Introduction: A simulation-based Neuroanaesthesia and Critical Care course hasn’t been run in Bristol before. This day was designed to provide Pre-Fellowship anaesthetic trainees with exposure to clinical scenarios in order to teach the principles of management of such patients. Our aim was to improve both candidates’ knowledge and confidence prior to undertaking clinical placements within these specialties and before sitting the Final FRCA. Methods: Twelve candidates attended the study day. They participated in a number of simulated clinical scenarios including “Raised ICP in the Intensive Care Patient”, “The Blocked EVD” and “Vasospasm postsubarachnoid haemorrhage”. A final extended scenario, “The Patient Journey”, involved multiple candidates managing a polytrauma patient with an extradural haematoma. Candidates were responsible for the initial assessment, resuscitation and stabilisation1 of the patient in ED, preparing for and undertaking an inter-hospital transfer and finally intra-operative care during emergency neurosurgery. Questionnaires featuring a numerical rating scale were used to assess confidence in the management of the scenarios. These were distributed before and after the course, the results were later analysed using an unpaired t-test. Results: Table 1 shows that there was a mean increase in confidence scores in all scenarios. In all but one scenario this increase achieved statistical significance. Qualititative feedback from the candidates was extremely positive. TABLE 1. Pre and post course confidence scoring Question Pre course Post course Confidence anaesthetising in the MRI scanner 3.08 5.9 Confidence managing a patient with raised ICP 5.25 7.18 Confidence managing a patient with vasospasm 2.58 6.36 Confidence performing inter hospital transfers 5.33 7.27 Confidence managing a patient with major trauma and a head injury Average scores out of a maximum of 10 4.67 6.72 35 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: Our results show this study day, which heavily utilises simulation can be used effectively to improve confidence in Pre-Fellowship trainees in managing a number of common scenarios within Neuroanaesthesia and Critical Care. References: 1. Recommendations for the safe transfer of patients with Brain injury. AAGBI Guidelines, May 2006. Neurocritical care after titanium cranioplasty – is it necessary? A. Luoma*, C. Hill§, G. Kumar*, N. Kitchen§, S. Wilson*. *Dept. of Neuroanaesthesia & Neurocritical Care, §Dept. of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK. Introduction: Cranioplasty is a neurosurgical procedure to repair a skull defect & prevent associated morbidity. It is often considered to be simple, but is associated with a significant complication rate of 16-34%. 1,2,3 Our aim was to determine the incidence of early complications following titanium cranioplasty (TC) & use of neurocritical care (NCC) in their management of these patients. Methods: A retrospective review of all patients who underwent a TC over 42 months. A database was created for analysis of: patient demographics, primary surgery, complications, unplanned neurocritical care admissions & skull defect size. Early complication defined as within 1 week. Skull defect size measured from CT reconstructions. Results: 92 patients included: incidence of complications 31.5%, incidence of early complications 13.0% (table 1). There were 13 elective post-operative NCC admissions, of these 2 had a complication (pneumonia n=1, extradural haematoma n=1). 5 patients had an unplanned NCC admission (seizures (n=2) & extradural haematoma (n=3)). There were no factors to predict complications or need for NCC; skull defect size was not predictive. TC removal rate 9.8%. TABLE 1. Complications following titanium cranioplasty by Accordion classification of surgical complications. Classification (% of complications) Early complications (patients = 9) Late complications (patients = 20) Mild (8.1%) • • Moderate (24.3 %) • Severe (10.8%) • Severe requiring surgical intervention under GA or single organ failure (56.8%) • Nausea and vomiting (n=1) Small extradural haematoma (n=2) Pneumonia (n=1) • • • • • CSF leak requiring intervention (n=1) Seizures requiring HDU admission (n=3) Extradural haematoma requiring surgery (n=4) Seizures requiring ITU admission (n=1) Intracerebral haemorrhage (n=1) • • • • • • Subgaleal collection, conservative management (n=4) Wound infection (n=4) Infection; TC removed (n=7) Wound infection, debrided (n=1) Moving TC, removed (n=1) Pain, requiring TC repositioning (n=1) Subgaleal collection requiring shunt (n=4) Subgaleal collection requiring TC removal (n=1) 23 Death 0 0 Mean skull defect area (SD) cm² 71.30 (31.21) 75.63 (37.5) Conclusions: Our incidence of complications is similar to other published data.3 We found no factors to predict need for elective post-operative NCC, in particular skull defect size. 36 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast References: 1. Stephens FL, Mossop CM, Bell RS et al. Cranioplasty complications following wartime decompressive craniectomy. Neurosurg Focus 2010; 28 (5):E3. 2. Chang V. Hartzfeld P, Langlois M et al. Outcomes of cranial repair after craniectomy. J Neurosurg 2010; 112:1120-1124. 3. Gooch MR, Gin GE, Kanning TJ et al. Complications of cranioplasty following craniectomy: analysis of 62 cases. Neurosurg Focus 2009; 26(6): E9 Audit Of Effectiveness Of Epidural Blood Patches In Spontaneous Intracranial Hypotension (SIH) T. Madamombe, J. Hell. University Hospital Southampton NHS Foundation Trust, Southampton, UK. Introduction: Spontaneous intracranial hypotension (SIH) is a syndrome characterized by postural headache without any history of dural puncture or penetrating trauma. SIH is thought to result from occult cerebrospinal fluid (CSF) leak, resulting in low CSF volume and, consequently, in low CSF pressure. In our centre, these patients are initially managed conservatively. They receive lumbar epidural blood patches if this fails. Methods: We conducted a 2 year retrospective audit of patients with SIH who were treated with epidural blood patch. Our gold standard was that all patients would have complete resolution of their symptoms with no procedural complications, having been appropriately consented. Data was collected from case notes. We looked at their age, symptoms at presentation, initial management and preparation for blood patch, including investigations. The effect of the epidural blood patch was then evaluated as reported by the patient at 24 hours and at the follow up clinic. Results: 15 patients were treated with epidural blood patches over 2 years. All patients complained of postural headache, 4 had hearing changes, 4 had diplopia and dizziness, and 2 patients presented with a reduced level of consciousness from subdural haematoma requiring intubation and ventilation. 12 patients had full resolution of their symptoms with the first blood patch. 2 patients required repeat blood patches. 1 patient suffered back pain post procedure, which resolved spontaneously but there were no other complications. Conclusions: We have demonstrated that epidural blood patch is a safe effective treatment for spontaneous intracranial hypotension provided that our guidelines for its performance are followed precisely. External ventricular drain related infection: working towards a pragmatic surveillance tool. H. McConnell, J. Collins, J. Crossman. Departments of Anaesthesia and Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK. Introduction: External ventricular drains (EVDs) are associated with a risk both of colonisation and infection. The definitions used and the reported incidence of these potentially devastating complications vary significantly in the literature.1 Duration of EVD placement is associated with increased risk of infection but the incidence of infection is rarely reported in terms of duration of exposure.2 As part of a quality improvement exercise we sought to quantify our baseline incidence of EVD related infection (EVD-RI). Method: Local definitions for EVD colonisation (EVD-Col) and infection were adapted from those described by Lozier et al.3 Samples of cerebrospinal fluid (CSF) were taken for analysis routinely on alternate days and urgently if infection was clinically suspected. Denominator data quantifying the number of “EVD-days” was also collected at a set time each day. An initial ten month retrospective audit was undertaken followed by a continuous prospective audit to monitor the impact of change. Results: The initial retrospective audit of 86 patients demonstrated an overall infection rate (colonisation and/or infection) of 12% or 13.5 per 1000 EVD days. Prospective audit revealed a mean overall infection rate of 10.2 per 1000 EVD days (Figure 1.) Two thirds of infections were caused by common Gram stain positive skin commensal organisms. 37 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: Our rates of infection are similar to those quoted in the literature but we believe that there is significant room for improvement. This surveillance tool will also be of benefit in monitoring the impact of changes on out recently amended EVD guidelines and may be of value to benchmarking between institutions. References: 1. Beer R, Lackner P, Pfausler B, Schmutzhard E. Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008;255:1617–1624 2. Scheithauer S, Burgel U, Ryang Y-M et al. Prospective surveillance of drain associated meningitis/ ventriculitis in a neurosurgery and neurological intensive care unit. J Neurol Neurosurg Psychiatry 2009;80:1381–1385. 3. Lozier AP, Sciacca RR, Romagnoli MF et al. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2008; 62(2):688-700. Audit reviewing the depth and position of ICP and EVD device insertion in patients admitted to the Neurointensive Care Unit J. McKinlay, T. Halsey, G. Woodward. Leeds General Infirmary, Leeds, UK. Introduction: Intracranial pressure monitors (ICP) and external ventricular drains (EVD) are medical devices routinely utilised on neurointensive care. The insertion of these are not without complications. A prospective audit was undertaken to assess documentation, positioning and complications. Method: Data was collected over 4 months for 25 patients, 12 had 18 EVDs placed and 13 patients had 15 ICPs sited. Measurements of device depth from insertion point to tip were taken from CT scans. ICP devices were described as being well positioned if placed in superficial white matter of the non dominant hemisphere (<30mm into the brain), moderately malpositioned if placed in deep white matter (>30mm) and significantly malpositioned if located in the ventricle, crossing the midline or within an identifiable deep brain structure. EVD position was assessed as well positioned if within the frontal horn of the lateral ventricle, moderately malpositioned if intra-ventricular but crossing the midline and significantly malpositioned if crossing the midline and entering brain tissue. Results: For ICPs we defined significant complications as device failure, infection or haematoma formation. For EVDs significant complications were defined as infection, tract or tip haematoma, failure to drain secondary to poor position. (see table 1) 38 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast TABLE 1 Number Mean inserted Depth (mm) Depth range Depth > Malposi0oned Significant (mm) recommended from (%) complica0on inside of skull (%) rate (%) ICP > 30mm EVD > 70mm ICP 15 37.85 6.9 – 83.2 53.85 61.53 6.67 EVD 18 70.94 56.0–105.8 56.25 75 16.6 Conclusions: Devices were frequently poorly placed, often to a depth exceeding manufacturer’s guidelines and neurosurgical consensus1,2,3. Poorly positioned devices had the highest associated complications. Documentation of placement e.g. rationale for insertion, person(s) inserting devices or record of actual device placement was poor. Gradations on devices would resolve the majority of problems. References: 1. Greenberg M. Handbook of Neurosurgery. New York: Thieme Publisher, 2010. 2. Connolly E, Huang J, Choudhri T, Komotar R. Fundamentals of Operative Techniques in Neurosurgery. New York: Thieme Publisher, 2010. 3. Ross MJ, McLellan SA, Andrews PJD. Depth of intraparenchymal brain monitoring devices in neurosurgical intensive care. Journal of the Intensive Care Society 2010;11: 250 - 252. A National Survey of various support devices used for Prone Position Surgery in Obese, Adult Patients R. Mittal*, R. Venkatasamy§, M. Varma*.*Dept. of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK. § Dept. of Anaesthesia, James Cook University Hospital, Middlesbrough,UK. Introduction: Prone positioning is associated with functional and physiological harm1. Obese patients are more prone to complications and the prone position is expected to increase their likelyhood2. This survey was intended to find out which devices are most commonly used for obese patients and what, if any, problems have been encountered in this patient group. Methods: All NASGBI members were sent out an electronic survey to identify their practice for prone surgery and complications encountered. Further questions were asked to identify the factors leading to variation in practice in the obese. Results: We received an overall response rate of 43%. Wilson frame (77responses) and the Montreal mattress (65responses) were the commonly used support devices for lumbar spine surgery. Montreal mattress was favoured for intracranial (55%), skull base (42%) and cervical spine (54%) procedures. 38% of the responders changed their practice for obese patients. For 36% BMI >40 triggered change, while 16% and 13% changed their practice for weight >120Kg and 150Kg respectively. 13% changed when the weight limit for the table was exceeded (Table 1). Knee chest position, pillows, bolsters, Jackson’s table and blocks were preferred for obese patients. Hypotension, increased airway pressure & bleeding, were regularly seen complications. 40% associated Wilson frame with pressure ulcers. Ventilation problems were more frequent with Montreal mattress or pillows (31% each). Lower limb compartment syndrome was more commonly seen in Knee chest position. 39 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast TABLE 1. What changes practice in prone positioning obese patients. Reason for change Number (%) of responses BMI >30 1(2) BMI >35 4(7) BMI >40 20(36) Body wt >100Kg 4(7) Body wt >120Kg 9(160 Body wt >150Kg 7(13) Body wt more than operating table allows 7(13) Other reason 5(9) Conclusions: This survey reignites the challenges faced while anaesthetising obese patients for prone surgery. Montreal mattress was least favoured. Our survey only highlights the practice of NASGBI members; a survey involving a wider population is indicated. References: 1. Palmon SC, Kirsch JR, Depper JA, et al. The effect of the prone position on pulmonary mechanics is frame-dependent. Anesth Analg 1998; 87:1175-80. 2. Paul DR, Hoyt JL, Boutros AR. Cardiovascular and respiratory changes in response to change in posture in the very obese. Anesthesiology 1976; 45: 73 – 7. Paracetamol And Cerebrovascular Dynamics T. Monro-Somerville*, S. Young*, N. Roy*, I. Piper§. *Departments of Neuroanaesthesia & §Clinical Physics , Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK. Introduction: It is recognized that paracetamol administration can reduce arterial blood pressure1,2 as well as fever. Our aim was to investigate whether this phenomenon had an additional effect on cerebral perfusion pressure (CPP), intracranial pressure (ICP) and cerebrovascular pressure reactivity index (PRx) in patients with severe traumatic brain injury (TBI). Methods: The electronic records of minute-by-minute physiological data3 from 5 patients with TBI, ICP monitoring and receiving 1g/100ml IV paracetamol (Perfalgan®) were retrospectively examined. Three hour long epochs - 1 before paracetamol, and 2 after - are reported. The earliest paracetamol dose timing is described for each patient. Data are presented as mean (range). PRx is reported as the Pearson correlation coefficient of paired ICP and MAP over 60 mins; repeated measures ANOVA is utilized for comparing the differences over the 3 epochs. Results: CPP and ICP did not change significantly over the 3 epochs – means of 67, 69, 69 mmHg and 16, 16, 16 mmHg respectively. The PRx (fig 1) trended up from –0.05 (-0.45 to +0.64) before paracetamol, to +0.24 (-0.30 to +0.68) [p=0.26] after drug administration (the 60-120 min epoch). 40 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: This pilot study suggests that paracetamol may alter PRx (making it more positive) in severe TBI, possibly worsening cerebrovascular reactivity, and potentially making patients more susceptible to secondary ischaemic injury. More study of this phenomenon is warranted. References: 1. Mackenzie I, Forrest K, Thompson F et al. Effects of acetaminophen administration to patients in intensive care. Intensive Care Med 2000; 26: 1408. 2. de Maat MM, Tijssen TA, Bruggemann RJ, et al. Paracetamol for intravenous use in medium- and intensive care patients: pharmacokinetics and tolerance. Eur J Clin Pharmacol 2010; 66: 713-9. 3. Piper I, Citerio G, Chambers I et al. The Brain-IT Group: Concept and core dataset definition. Acta Neurochir (Wien) 2003; 145: 615-28. An Audit of Postoperative Critical Care Utilisation Following Elective and Expedited Supratentorial Craniotomy for Tumour. S. Mungroo#, P. Panaretos*, N. Ross*, H. McConnell#. #Department of Anaesthesia & Intensive Care and *Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK. Introduction: Our centre performs about 300 craniotomies for tumour per year. Postoperative haematoma (POH) is devastating if not treated promptly and all patients are observed in critical care for 24 hours. This may not be cost-effective 1 and ideally “high risk” patients should be targeted. POH has an incidence of 2.2%, higher in emergency and posterior fossa surgery and presents either within 6 hours or beyond 24 hours. Discharge to a ward has been deemed safe if a patient is neurologically stable at 6 hours.2 We undertook an audit to ascertain the potential impact of the adoption of this policy in our centre. Methods: Data was prospectively collected for all patients undergoing supratentorial craniotomy for tumour over a 3 month period. This included the location and suspected type of tumour, anaesthetic factors, intraoperative surgical factors and recovery factors that may be relevant to the need for critical care. Patients were followed up on critical care. Results: 42 patients were identified. The median length of stay was 0.9 days. 19 patients required admission due to perioperative concerns arising up to 6 hours postoperatively. 5 patients stayed beyond the first postoperative day (Table 1.) One patient needed to go back to theatre after 14 hours for evacuation of a POH. 41 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Conclusions: 23 patients were identified as being at low risk of complications and received “monitoring only” in critical care. They could have gone to a lower dependency environment saving 20 critical care bed days without any increase in complications. A pre-existing hemiparesis in the patient that developed a POH may have confounded earlier detection and early post-operative CT may improve the safety of this practice in addition to documenting tumour resection.3 References: 1. Bui JQ, Mendis RL, van Gelder JM, Sheridan MP, Wright KM, and Jaeger M. Is postoperative intensive care admission a prerequisite for elective craniotomy? J Neurosurg 2011; 115: 1236-41. 2. Taylor WA, Thomas NW, Wellings JA, Bell BA. Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg 1995; 82: 48–50. 3. Khaldi A, Prabhu VC, Anderson DE, Origitano TC. The clinical significance and optimal timing of postoperative computed tomography following cranial surgery. J Neurosurg 2010; 113: 1021-1025. Airway Management in Adult Cervical Spine Injury or Disease: A Prospective Audit of Our Current Practice in the Walton Centre E. Pabs-Garnon., T.Mahalingam, S. Lakhani, A. Sule, G. Kakkar. The Walton Centre Foundation Trust, Liverpool, UK. Introduction: Following blunt trauma, there is a 2% incidence of cervical spine injury, which is significantly higher with severe head injury. There is subsequent secondary neurological injury in 2-10%.1 There are also a large number of unstable c-spines resulting from non-traumatic causes. There is no consensus on the best method of definitive airway control, and practice varies with the existence of a wide range of equipment, although fibreoptic intubation still remains the gold standard.2 This has influenced the perceived medico-legal implications. Methods: This was a prospective audit carried out over 6 months. Consultants and senior trainees were asked to fill out a questionnaire for all eligible cases. All cardiovascularly stable, co-operative adults with isolated c-spine injury or disease presenting for non-urgent surgery were included. The questionnaire consisted of 15 questions about choice of airway control. Results: There were 46 patients of which 78% were non traumatic, 12 % traumatic cord compression and 11% non-traumatic instability of the c-spine. Airway management comprised Awake fibreoptic 13%, LMA with an Aintree catheter 17%, Airtrak 6%, and Direct laryngoscopy 63% (including 22% with the McCoy blade +/a bougie). No post-op neurological deficits were recorded. Familiarity and medico-legal issues were the most common influencing factors for choice of technique (see Table 1). A secondary finding was that only 24% of anaesthetists (mostly trainees -22/24 – 92%) had undergone a recent structured airway training block. TABLE 1. Primary Outcome – Factors influencing choice of Airway Management Technique Factors influencing Technique Weighting§ 0 1 2 3 4 5 Medico-legal 25 5 6 4 2 4 Personal preference 9 25 6 4 2 4 Ease of use 11 19 7 1 7 1 Availability of Equipment 27 6 0 10 0 3 Low risk of compromising cord 27 10 4 2 3 0 §Weighting: 0 = No Influence to 5 = Maximum Influence Conclusions: Techniques for airway control in compromised cervical spines remain widely varied, with no consensus as to the most appropriate. There is also no outcome data favouring any one method in terms of neurological safety. 42 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast References: 1. Crosby ET. Airway Management in Adults after Cervical Spine Trauma. Anaesthesiology 2006;104:1293-318. 2. Behringer EC, Kristensen MS. Evidence for benefit versus novelty in new intubation airway equipment. Anaesthesia 2011; 66 ( Supp2 ): 57-64. Bilateral Bispectral Index (BiBIS): recordings from a patient with vasospasm following clipping of a cerebral aneurysm. S. Pothuneedi, M. Wiles, J. Andrzejowski, U. Patel. Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK. Introduction: BiBIS is used in patients with subarachnoid haemorrhage (SAH) on our unit as part of a NASGBI funded study. This case report illustrates the potential role of BiBIS in SAH. Case History: Day 1: A 45-year-old lady with hypertension presented with Grade 1 SAH. Transcranial doppler (TCD) showed normal velocities. Day 3: Open clipping of left middle cerebral aneurysm. Intra-operative BiBIS showed separation between the hemispheres from the time of clip application. GCS 14 for 24 h after extubation. Day 6: Onset of dysphasia. CT showed a small extradural under the craniotomy site requiring no intervention. Vasospasm was confirmed by TCD (R 100, L 50 ml sec-1), noradrenaline commenced. BiBIS persistently lower values over the left hemisphere. Patient’s dysphasia resolved if SBP was greater than 180mmHg. With HHH therapy BiBIS values slowly equalised over 7 days. (Figure 1) Day 11: CT showed mild hydrocephalus treated with single LP. Dysphasia resolved by day 13. She was discharge on day 21 with an Addenbrooke’s cognitive score of 96%. Discussion: BiBIS showed left-right variation from the time of clip application. The immediate perioperative changes could have been due to distortion of blood flow to the frontal lobes and/or to the small extradural collection. Vasospasm may have contributed to the persistent separation which appeared to resolve following HHH therapy. As BiBIS is non-invasive and can be used continuously it may have a place in the management of patients following SAH. 43 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Delays In Transfer Times For Patients With Acute Brain Injury From Referring Hospitals To Essex Regional Neurosciences Unit K. Subhas, S. Wijayatilake, G. De La Cerda, A. Bellini, R. Shetty, R. Jain. Department of Anaesthesia & Critical Care, Queen's Hospital, Romford, Essex, UK. Introduction: Patients with severe head injury or focal signs should be transferred to a neuroscience unit regardless of whether they need surgical intervention.1 Surgical evacuation of a clinically significant extradural haematoma should be achieved within four hours of the onset of symptoms.1 Previous studies have shown that this time target is rarely met.2, 3 We investigated all patients with acute brain injury requiring neurointensive care and/or neurosurgical intervention that were referred to our unit from regional Hospitals during a four month period to establish any causes of delay in transfer times. Methods: Data of transfer times were collected prospectively for all patients with acute brain injury referred to our unit over a four month period (February - May 2011). Results: The results are summarized in table 1. TABLE 1. Time periods during transfer of acute brain injury patients from referring Hospital’s Accident and Emergency department (A&E) to Neuro Intensive Care Unit (NITU) or Operating Theatre at Essex Regional Neurosciences Unit, Queen's Hospital. Referring Hospital Arrival in A&E CT scan to N/S N/S referral to to CT scan referral acceptance N/S acceptance to arrival in NITU or Operating Theatre Total time from arrival in A&E to start of surgery Basildon University Hospital (n=1) 00:46 hrs 01:15 hrs 00:30 hrs 03:05 hrs 05:36 hrs (n=1) Broomfield Hospital (n=5) 00:40 hrs 02:09 hrs 00:36 hrs 02:43 hrs 04:18 hrs (n=2) Colchester General Hospital (n=2) 00:57 hrs 00:22 hrs 00:15 hrs 02:40 hrs 04:35 hrs (n=2) Princess Alexandra Hospital (n=2) Southend University Hospital (n=3) Total (n=13) 00:26 hrs 00:59 hrs 00:15 hrs 02:11 hrs 05:00 hrs (n=1) 01:47 hrs 00:21 hrs 00:20 hrs 03:31 hrs 06:40 hrs (n=1) 00:55 hrs 01:01 hrs 00:23 hrs 02:50 hrs 05:13 hrs (n=7) Times entered are the average (arithmetic mean) of the time taken for all patients from each Hospital. hrs = hours; n= number of patients; N/S= Neurosurgeon; CT= computed tomography scan of head Conclusions: Transfer times for acute brain injury patients are currently longer than recommended for optimal neurological outcome. During the study period, 13 patients were referred and 7 underwent urgent neurosurgical intervention. The average time from admission to Accident & Emergency in referring Hospital to start of surgery at our centre was 313 minutes (range 258-400). The main barriers to expediting transfer are the time taken to make a referral to the Neurosurgeon after obtaining the CT scan and the time taken to depart on transfer once accepted by the Neurosurgical Unit. 44 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Once a diagnosis of acute brain injury requiring neurosurgical intervention is established by CT scan, the referral to the Neurosurgeon should be made immediately, preferably by a second clinician. The transferring clinician can then proceed with preparations for transfer immediately without awaiting acceptance of referral. References: 1. The Royal College of Surgeons of England: a position paper on the acute management of patients with head injury. Ann R Coll Surg Engl 2005;87:323-5. 2. Leach P, Childs C, Evans J, Johnston N, Protheroe R, King A. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester. Br J Neurosurg 2007;21:11-15. 3. Bulters D, Belli AA. Prospective study of the time to evacuate acute subdural and extradural haematomas. Anaesthesia 2009;64:277-81. Transfusion Threshold For Acute Aneurysmal Subarachnoid Haemorrhage C. Taylor, K. Gough, J. Gross, M. Smith. The National Hospital for Neurology and Neurosurgery (University College London Hospitals), Queen Square, London, UK. Introduction: Optimal haemoglobin (Hb) concentration after aneurysmal subarachnoid haemorrhage (SAH) is uncertain, but recent recommendations (2011)1 suggest a target Hb of 8-10 g/dl. We reviewed our pre-2011 practice when our target Hb was >8g/dl. Methods: We undertook a retrospective case note review of patients with SAH admitted to a neurocritical care unit between November 2009 and May 2011. Patient demographics, grade of SAH, transfusion threshold & dichotomised Glasgow outcome score at 3 months post ICU discharge were recorded. Results: 90 SAH patients were identified; 10 were non-aneurysmal & outcome data were unavailable for 4. Data are presented on the remaining 76. 16 (21%) patients were transfused and the median (IQR) threshold for transfusion was 7.8g/dl (7.3- 8.2). 31 (41%) patients were good grade (WFNS grade 1-3) of which one (3%) was transfused. 45 patients were poor grade (WFNS 4-5) & 15 (33%) of these were transfused. 77% of good grade and 29% of poor grade patients had a good outcome at 3 months. Good outcome was seen in 27% of transfused compared to 30% of non-transfused poor grade patients. Conclusions: Compared to good grade, poor grade SAH increases the likelihood of receiving a blood transfusion. This might be related to higher rates of intracranial & systemic complications in these patients. Our median transfusion threshold was close to our target. Our policy has now changed to reflect recent consensus guidance1 and re-audit will determine whether this will result in improved outcome. References: 1. Diringer MN, et al. Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211-240. 45 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Local information Directions to the Belfast Waterfront Hall By car Belfast Waterfront is located in Lanyon Place, just off Oxford Street in the city centre. On major roads into the city, follow signs for the city centre and Belfast Waterfront via East Bridge Street or Oxford Street. There are two 24-hour car parks located near Belfast Waterfront. The multi-storey Lanyon Place car park is located 100 metres from the venue. The car park at the Belfast Hilton Hotel is also next door to the building. Public Transport The nearest bus station is the Laganside Bus Centre, which is around two minutes’ walk from Belfast Waterfront. There is a bus stop on Oxford Street, directly outside the building. The nearest train station is Central Station, which is in East Bridge Street, around five minutes’ walk from the venue. The main bus and train provider in Belfast is Translink. For timetables, visit www.translink.co.uk By taxi Fon-A-Cab tel. 028 9023 3333 Value Cabs tel. 028 9080 9080 On foot Belfast Waterfront is located in Lanyon Place beside the River Lagan, around five minutes’ walk from the city centre – just follow the directions from Belfast City Hall towards Chichester Street. Cross the traffic lights at Victoria Street and pass through the law courts. Then cross the traffic lights on Oxford Street – we are located next to the Belfast Hilton Hotel. 46 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Accommodation Hilton Belfast Hotel 4 Lanyon Place, Belfast, BT1 3LP Tel 0289 027 7000; www.hilton.co.uk/belfast The Hilton is located next to the Waterfront Hall and it will be the designated hotel for ASM Speakers and Guests. A reduced rate has been negotiated for all NASGBI delegates ‐ £89pn B&B single occupancy and £99pn B&B double occupancy. To avail of these conference rates please use the following promotional code when booking ‐ “GNEUA”. Europa Hotel Great Victoria Street, Belfast, BT2 7AP Tel +44 (0) 28 9027 1066; www.hastingshotels.com/europa‐belfast The Europa is located in the heart of Belfast’s city centre, next to Great Victoria Street bus station and the Grand Opera House. The historic Crown Bar, the National Trust’s only public house property, is across the street, 0.7 miles from the Waterfront Hall. Prices start at £70pn (room only) single and £85pn (room only) double. Holiday Inn 22 Ormeau Avenue, Belfast, BT2 8HS Tel 0871 9429005; www.holidayinn.com/hotels/gb/en/belfast/bfsoa/hoteldetail This convenient hotel is opposite the BBC’s Broadcasting House and the Ulster Hall, 0.5 miles from the Waterfront Hall. £104pn (room only) single/double – advance purchase required. Premier Inn – Belfast City Centre Alfred Street, Belfast, BT2 8ED Tel 0871 527 8068;www.premierinn.com/en/hotel/BELFAS/belfast‐city‐centre‐alfred‐street This is located about 0.3 miles from the Waterfront Hall. Prices are £34pn (room only) for all rooms and guests, pre‐pay, no amends or refunds. £61pn (room only) for all rooms and guests – flexible, amend up to 1pm on arrival day. Jurys Inn Belfast Hotel Great Victoria Street, Belfast, BT2 7AP Tel 028 9053 3500;http://belfasthotels.jurysinns.com/ This is located about 0.6 miles from the Waterfront Hall. Prices are £58pn (room only) single/double – advance purchase – non‐refundable. Premier Inn – Belfast Titanic Quarter 2A Queens Road, Belfast, BT3 9DT Tel 0871 527 9210; www.premierinn.com/en/hotel/BELTIT/belfast‐titanic‐quarter 1.4 miles from the Waterfront Hall but right beside the new Titanic Centre where the President’s Reception and Dinner will be held. Prices are £34pn (room only) for all rooms and guests – pre‐pay, no amends or refunds. £50pn (room only) for all rooms and guests – flexible, amend up to 1pm on arrival day. 47 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Pubs and Restaurants The Potted Hen Edward St, (Beside Ramada Encore), Belfast BT1 2LR tel. 028 90 234 554 awarded ‘The Best Restaurant in N. Ireland’ by the National Restaurant Awards London Mains £10.50 - £18.95 Deanes 36-40 Howard Street, Belfast, BT1 6PF tel. 028 9033 1134 1 Michelin Star 1997 - 2010 3 course fixed price menu £19.95 Deanes at Queens 1 College Gardens, Belfast BT9 6BQ tel. 028 9038 2111 "A quality venue which serves up carefully cooked, well considered dishes and creates one of the most relaxed environments of any restaurant in the capital."Joris Minne, Food Writer Belfast Telegraph 3 course fixed price menu £15 Mourne Seafood Bar 34- 36 Bank Street, Belfast, BT1 1HL tel. 028 9024 8544 Mains £8.25 - £19.00 The Apartment 2 Donegall Square West, Belfast, BT1 6JA tel: 028 9050 9777 Overlooking the City Hall. Winner of 'Bar Of The Decade' at the 2010 FATE Awards and recognised by the Sauce Guide as one of the 50 best cocktail bars in the UK. Crown Bar Liquor Saloon 46 Great Victoria Street, Belfast, BT2 7BA tel. 028 9024 3187 This gin palace is one of Belfast’s best-known landmarks and one of the few bars owned by the National Trust. The Spaniard 3 Skipper Street, Belfast, BT1 2DZ, tel: 028 9023 2448 Winner of the Belfast Telegraph pub of the year. It’s over 25s only with 50 different types of rum. 48 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Things to see and do In addition to its fine selection of restaurants and pubs, Belfast has a wide selection of tourist attractions, cultural experiences and activities that visitors may wish to avail of. The Titanic Belfast www.titanicbelfast.com The Titanic Building is a landmark development commemorating the 100 year anniversary of the Titanic’s fateful maiden voyage. The exhibition takes you through nine galleries with a mix of interactive media experiences, full scale replicas and original artifacts. Tickets, £13.50, can be bought online (www.titanicbelfast.com), by phone (02890 766 399) or in person from the Belfast Welcome Centre, 47 Donegall Place, Belfast, BT1 5AD. Cathedral Quarter Arts Festival 3-13 May 2012 Unit 8, Northern Whig House, BT1 1LU tel: 02890232403 www.gotobelfast.com/whats-on/event/cathedral-quarter-arts-festival A eclectic festival of music, theatre and comedy. Including the hit Edinburgh Fringe Festival play “John Peel’s Shed”, Alexei Sayle, Mark Thomas and many more. The MAC 10 Exchange Street West, Belfast, BT1 2NJ, tel: 02890 235053 www.themaclive.com Belfast’s new arts venue, The MAC (Metropolitan Arts Centre), opens in April 2012. Situated in Belfast’s Cathedral Quarter it promises to bring a rich mix of music, theatre and art from the best of local and international talent. Tours and sightseeing A number of bus tours around Belfast are available including: www.belfastcitysightseeing.com 02890 321321 www.allensbelfastbustours.com 02890 915613 The Giant's Causeway 40 Causeway Road, Bushmills, BT578SU, tel: 02820 731855 www.nationaltrust.org.uk/giants-causeway/ For any visitor to Northern Ireland the Giant’s Causeway, just 90 minutes from Belfast, is a must see. Situated on the North East Coast of Co Antrim this UNESCO World Heritage site is made up of spectacular 12m high basalt columns that jut out into the sea set against a background of rugged cliffs. The Carrick-aRede Rope Bridge provides spectacular views for those brave enough to look down. 49 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast 50 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Forthcoming NASGBI Events Neuroanaesthesia - Level 3 CPD Workshop Held in association with: Wednesday 07 November 2012 Organisers: Dr Plat Razis, London Dr Elfyn Thomas, Plymouth Dr Jane Sturgess, Cambridge Programme 09:45 Registration and coffee 10:00 Welcome and Preparation for Workshops 10:15 Four rotating workshops of 40 minutes each: Sedation for Awake Craniotomy Antiplatelet and Anticoagulation Drugs and Neuroanaesthesia Spinal Surgery in the Elderly Managing Cerebral Vasospasm complicating Subarachnoid Haemorrhage 13:15 Lunch 14:00 Preparation for afternoon workshops 14:15 Three rotating workshops of 40 minutes each BIS/Entropy monitors – which and how do you use them in theatre and NITU? Neuroscience Critical Incident Simulation What do you use for Cooling Patients in Neuro-ITU? 16:30 Feedback on Level 3 CPD Goals 16:45 Depart 51 Neuroanaesthesia Society of Great Britain and Ireland ASM 2012, Belfast Glossary of Colloquialisms ‘bout ye: derivation of “what about you?”, meaning “How are you?”. This is a rhetorical question and should not be construed as meaning that we actually want to hear how you are. It should be met with a reciprocal “‘bout ye” or “dead on” (see below). Dead on: meaning OK. This is the standard reply to the above question. It should be noted that no mater how good, bad or indifferent your day has been you should always tell people that you are “dead on”, the inflection in your voice should be the only clue as to how you actually feel. This phrase should be seen as analogous to the “physiological averaging” the CT1s perform when filling in blood pressure observations. Alright Missus: friendly greeting between females. Sometimes used when one person cannot remember the name of the female they are greeting. Come ‘ere, here: meaning come over here, often used when about to divulge gossip. Wee: meaning small. Confusingly this can be applied to any noun but does not always denote size of object. For example, ‘wee man’ may relate to a small boy (friendly) or a fully grown male (not so friendly, only use if trying to start a fight). A common use of this term would be “wee scratch”, when siting a 14G cannula. Our: meaning ownership. Most often used in reference to family members. For example “our Sharon” means “my sister / aunt / second cousins mother’s daughter’s niece Sharon”. Ya wha’: derivation and apocopation of “you what?”. Meaning “pardon”, used with inflection to indicate incredulity. and here’s me: “and I said”. Scundered: meaning cross, embarrassed, bored of or all of the above. Often used interchangeably with “had a sickener for...” Using the above straight forward glossary the following example conversation should be easy to follow. Alright Missus? ‘bout Ye? Dead on. Any craic? Come ‘ere, here. Did you hear our Sharon fell outside the pub and broke her ankle? Ya wha’? Aye, I know, she says she’s scundered. And here’s me; “are you gonna claim?” And here’s her... “yeah.” But that wee solicitor she seen says the fact she had 14 Pineapple Bacardi Breezers means the pub may not be cupla... cupla... cupla-bubble. Ya wha’? What’s calpa-bubble Means it was her fault. 52
