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Anaesthesia
News
ISSN 0959-2962
No. 297 April 2012
Guest
Editorial
Contents
03 Editorial
05 President’s Report
06 Afghanaesthesia: Warfare has always 06
SEE MORE.
ACHIEVE MORE.
EDGE
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15 Anaesthesia Digested
12 16
Too little, too late?
19 GAT: Anaesthesia Conference Benin, Dr Bythell is away at the moment, so I am stepping into the
breach. Deciding whether and when to intervene is an integral
part of our everyday practice. This month’s article on Anaesthesia
in Afghanistan demonstrates what can be done when good teams
take joint responsibility for patient management. Meticulous attention
to detail, in which every aspect of care is reviewed and perfected,
has improved survival and quality of life for people with the most
extreme injuries. Much of this success depends on the culture of
the organisation; amongst defence medical teams the culture is one
of constant practice, improving speed, sharpening skills and getting
the right equipment to deliver what is needed. Not all of us work in
organisations with such a ‘can do’ approach. Attention to detail in the
NHS is more often centred on the purchase of cheaper disposables.
Leadership, in this situation – getting from an idea to an outcome
involves encouraging people to understand the wider picture, to
take what they see as ‘risks’, with the potential to incur the wrath of
‘management’.
At last month’s AAGBI Council meeting I had the privilege of listening
to Dr Stuart White explain how he had introduced recycling of plastic
and paper theatre waste into his organisation. Hospitals can earn
good money by recycling. Despite this, he still had to work hard to
explain to hospital managers that the material was not ‘an infection
risk’, and a doctor had to sign a form stating that bags did not
contain contaminated waste. He struck a chord with me; my list this
morning produced a large bag of plastic packaging. A recent survey
showed that 94% of UK anaesthetists wanted to recycle at work. So
why don’t we?
SonoSite Ltd
European Headquarters, Alexander House, 40A Wilbury Way, Hitchin, Herts SG4 0AP, United Kingdom
Tel: +44 1462-444800 Fax: +44 1462-444801 E-mail: [email protected]
Members of Defence Anaesthesia
who served in Afghanistan
15 The Queen’s Honorary Surgeon
.
Contact SonoSite today on 01462 444800 or email us
at [email protected]
12 Pask Certificate of Honour:
™
Learn how this innovative new system can bring you
and your patients invaluable benefits.
stimulated advances in medical care
Rather than encouraging innovation, the NHS culture seems to put
barriers in the way. Change comes from the top, often in the form
of service reconfigurations, and major health service reorganisation
costs millions. I’m left wondering what would happen if, instead of
pressing on with the latest set of changes, the money was spent
on developing ideas from ordinary jobbing doctors. Anaesthetists
are innovative and thoughtful people with lots of good ideas. The
article by the trainee (pages 16-17) about her granny’s hip fracture
shows just one. Perhaps growth this spring could be led by working
clinicians developing the good ideas we all have in our daily practice.
Nancy Redfern
West Africa
21 The Misuse of Anaesthetic
16
Agents through time
23 Letter from America:
A most fascinating book!
24 Out of Programme Experience:
Life as a fellow down under
26 Particles
21
29 Your Letters
24
The Association of Anaesthetists of Great Britain and Ireland
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Anaesthesia News
Editor: Val Bythell
Assistant Editors: Kate O’Connor (GAT), Nancy Redfern and Felicity Plaat
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Anaesthesia News April 2012 Issue 297
3
The AAGBI is
now connecting
with members
through online
social networks
Facebook and
Twitter.
According to the recent membership survey,
over 70% of you use a Smartphone and over
40% of you use Facebook - so this is another
opportunity for you to keep up-to-date with
news from the industry and the AAGBI
@AAGBI
AAGBI1
©Photographer Hamish Burke/UK MOD Crown Copyright 2012
THIS MONTH’S FRONT COVER IMAGE
Soldiers board a Royal Air Force Merlin helicopter during
Operation Omid Haft in Afghanistan. Hundreds of Afghan
soldiers, supported by British and coalition forces have
taken part in a major operation in Central Helmand to clear
out insurgents from one of their last remaining strongholds.
Operation Omid Haft was planned and executed by the
Afghan National Army (ANA) partnered by International
Security Assistance Force (ISAF) troops. For several
days, Afghan Warriors battled alongside Royal Marines
and soldiers in harsh and hostile terrain where the enemy
have intimidated and threatened the Afghan population for
many years. ©Crown Copyright
President's
Report
An exciting opportunity:
Editor of
Anaesthesia News
Anaesthesia News is the paper
newsletter of the AAGBI, and
is circulated to over 10,000
members, at home and overseas.
A recent membership survey (2011) suggests that
98% of members read the newsletter at least several
times a year. The Editor’s post is therefore a key role
within the Association of Anaesthetists.
Key highlights and benefits for the editor include:
•
The opportunity for a national leadership role for
the specialty
•
Join the AAGBI Board of Directors (co-opted
member)
•
Join an excellent production team
•
Interact with a large number of colleagues
•
Free registration for all AAGBI educational events
•
Computer allowance
For a job description, person specification
and details of the recruitment process please visit:
www.aagbi.org/publications/anaesthesia-news
If you would like to chat about the post
informally please contact the current editor at:
[email protected]
Closing date for applications: Monday 23 April 2012
At the Winter Scientific Meeting in London this year I was delighted to present Pask
Certificates of Honour to Defence Anaesthetists who have served in Afghanistan. Details of
the work performed by our uniformed colleagues, and details of the citation, can be found in
different sections of this edition of Anaesthesia News, which celebrates their achievements.
The Pask Certificate is a prestigious award named after an RAF
anaesthetist, Professor Edgar Pask, who literally put his own life at
risk during the Second World War to reduce the danger faced by
aircrew baling out of aircraft at high altitude or into the sea. His
high altitude parachute descent simulations involved breathing a
hypoxic mixture of gases whilst suspended in a parachute harness,
becoming unconscious for several minutes. The other better-known
experiments were on the design of life jackets to prevent unconscious
aircrew floating face down in the water. To simulate these conditions,
Pask was anaesthetised, intubated and whilst breathing ether through
a long circuit allowed to float or sink in a swimming pool. All without
monitoring – a risky anaesthetic! Almost certainly aspiration must
have occurred as well as cooling and other unpleasant side effects.
The experiments were filmed in order to demonstrate to aircrew
the work being done on their behalf. An excellent review about the
remarkable work of Professor Pask has been published recently.1
The Council of the AAGBI decided to award a Pask Certificate to
each anaesthetist who has served in Afghanistan in recognition of
the bravery and dedication of all those involved, from the front line
battlefield rescue, the hospital at Bastion to the return journey to UK.
The work is clearly exhausting both physically and mentally. The
trauma that we face in UK is of a much lesser degree and seldom
inflicted deliberately with such catastrophic results. The medical
expertise received by our soldiers is of the highest quality with many
of the lessons from the battlefield being translated to civilian practice.
Many of the local casualties are children who are in the wrong place
at the wrong time, or have been targeted deliberately. Tough stuff.
Many of our young soldiers who return to UK, often only a few hours
after being injured on the battlefield, face long term rehabilitation
to cope with their injuries, both physical and mental. Many of these
injuries are truly life-changing and support from our nation will need
to go on for many years.
So, when you meet a colleague coming back from Afghanistan,
remember to welcome them home, shake their hands and let them
know we appreciate them – that is the spirit and the message behind
the award. Also let’s not forget the loneliness faced by families in our
departments left at home during lengthy detachments.
Anaesthesia News April 2012 Issue 297
The NHS and the politics of Healthcare continue unabated. At the
time of writing the Health and Social Care Bill is receiving a lot of
opposition. Of particular risk to the NHS in my view, is convenient
outsourcing to the independent sector for short term gain followed by
fragmentation of services and future increased costs to resolve the
resulting difficulties.
The BMA is due to ballot their members on industrial action on
pensions. The AAGBI responded to the pension review (see website)
and made a number of points including the fact that anaesthetists are
more likely to work part-time or to take career breaks than doctors
in many other specialties, are less likely to get Clinical Excellence
Awards and if they do, they tend to receive them later in their career.
An additional important factor when you consider your response to
the BMA ballot is whether you believe you will feel safe working in
anaesthesia until the age of 67 years? Most of my colleagues seem
to prefer to retire at 60 – 62 years of age. This is a complex debate,
especially given the pension problems in the private sector and our
increasing longevity.
By the time you receive Anaesthesia News this month, the NPSA
deadline to change to new neuraxial connectors will have passed.
Many hospitals will use the risk register while waiting for independent
testing of the new products. The new connectors will reduce risks to
patients in anaesthesia but mostly by preventing epidural infusions
or regional injections / infusions being administered intravenously.
Check the Safety section of the AAGBI website for details and up to
date information.
Trainees – check the remarkable GAT conference offer this year – 3
days of education for only £195 – see you there!
Dr Iain Wilson,
AAGBI President
1. Enever G. Edgar Pask and his physiological research – an unsung hero of World
War two. J R Army Med Corps 2011;157:8-11 http://www.ramcjournal.com/2011/
mar11/enever.pdf
5
The purpose of this article is to record the scope and current practice
of DMS anaesthesia in some detail. This is both a personal view, with
the limitations inherent in such, and a more general compilation of
information from a variety of sources. Any opinions expressed are my
own, and do not necessarily reflect those of any official body. Serving
members of the DMS will note that some details have been omitted
or simplified in the following descriptions. I apologise for any residual
inaccuracies.
Warfare has always
stimulated advances
in medical care.
General Casualty Care
The UK armed forces have been
involved in conflict in the Middle East
and Afghanistan for over a decade
and, during this time, medical care
has seen huge changes, some of
which are applicable to civilian
trauma practice. Despite this, many
anaesthetists will be unaware of
the work of their colleagues in the
Defence Medical Service (DMS).
The concept of a “golden hour” is of limited validity in military trauma,
where traumatic injuries may lead to exsanguination within minutes. The
current paradigm of “the platinum ten minutes” reflects this, and has
driven first responder care and equipment design. A wounded soldier
may self-aid, or receive ‘buddy aid’ from an immediate colleague using
tourniquets and elasticated field dressings within a few moments of
being wounded. Soon after, a more highly trained Team Medic may use
additional equipment such as Celox® haemostatic dressings or chest
seals to address the C-ABC of trauma- catastrophic haemorrhage,
airway, breathing, circulation. Increasingly, the aspiration for field units
is to have 50% of front line soldiers trained to a Team Medic level.
6
1
The involvement of anaesthetists occurs from the point of wounding
onwards. Pre-hospital care is provided by the Medical Emergency
Response Team (MERT). Although MERT is a concept (forward
delivery of care) rather than a place, the current MERT configuration
is a team of four- a nurse, two paramedics and an anaesthetist or
emergency physician, flown to the point of wounding in a Chinook
helicopter. Less severely injured casualties may be retrieved in smaller
aircraft e.g. Sikorsky Pave Hawk helicopter staffed by American
paramedics, but the configuration of the Chinook, with large floor
space and equipment stores allows many casualties to be collected,
and for early aggressive treatment of the more complex casualties. It
is not unknown to have six stretcher cases and a similar number of
less injured patients in a single trip.
Chinook at Camp Bastion
Historically, patients are then evacuated through echelons of care,
each having greater capability to stabilise and treat patients (see
Table1). Typically, Roles 1 & 2 are relatively basic facilities, Role 3 is
the most capable in-country asset, and Role 4 is the NHS in the UK.
The exact structure varies between different strategic situations, but in
Afghanistan currently, the ability to use helicopter transport allows direct
retrieval from point of wounding to Role 3 for many casualties.
Figure 1: Echelons of Care
Role
Pre-Hospital Care
2
3
4
Surgery, CT scan,
transfusion, larger holding
capacity (up to 200beds).
Integral transfer capacity
Typical Capability
Primary Care. First Aid,
triage, immediate life
saving measures.
No holding or transport
capacity
Treatment, limited holding
capacity (<25 beds),
limited transport capacity.
Perhaps limited surgery
Medical Resources
1 doctor
2-5 doctors Perhaps 1
surgical team
3-6 surgical teams
NHS tertiary level care
Example
Regimental Aid Post
Dressing Station/Medical
Regiment
Camp Bastion
University Hospital
Birmingham
Definitive treatment &
rehabilitation
Anaesthesia News April 2012 Issue 297
Table 2: Typical MERT Interventions
•
•
•
•
•
•
Rapid Sequence Intubation
Application of cervical collar & pelvic splint,
Elasticated field dressings, tourniquets & Celox gauze.
Intraosseous access, transfusion of blood and plasma.
Administration of analgesia, muscle relaxant & sedative.
Thoracostomies /intercostal drainage
At all times, a dedicated Chinook is available in Camp Bastion,
equipped with MERT stores – such as stretchers, fluids (including
blood and FFP), monitors (MRL PIC), oxygen cylinders, pneuPAC
ventilator etc. Emergency and controlled drugs are carried separately
by the MERT doctor.
The role of the MERT doctor is a challenging one - delivering
simultaneous, time critical decision making for multiple seriously ill
casualties requires mature judgement, a strong team ethos, and
good practical skills, especially since the helicopter is frequently flying
tactically to avoid potential or actual hostile ground fire. Despite this,
first time successful intubation rates are over 95%, and it is possible
to carry out multiple, high quality interventions in a much shorter
timescale than is usually possible in civilian environments.
Emergency Department (ED) & Operating Room (OR) Management
Once the helicopter lands on HLS Nightingale at Camp Bastion,
patients are transferred briefly to a land ambulance for the two
hundred metre journey to the Role 3 hospital. Generally, the MERT
medical officer will accompany this transfer, and continue appropriate
resuscitation as required.
The initial management of a typical severely injured casualty (e.g.
triple limb amputee) is described in table 2. This can be accomplished
during a flight time as short as ten minutes, due largely to the high
degree of teamwork and co-ordinated care provided by Medical
Emergency Resuscitation Team (MERT). MERT is considered by many
to represent the cutting edge of pre-hospital medicine worldwide.
Medical Emergency
Response Team layout
Patients are assessed in ED by a trauma team consisting predominantly
of senior, experienced decision makers. Digital radiology provides
images within seconds, while a consultant radiologist concurrently
carries out a FAST scan (Focused Assessment with Sonography
for Trauma) and limited echocardiography. Surgical specialists are
immediately to hand, with their approach to the patient controlled by
the ED consultant. Dedicated runners carry blood samples and blood
products to and from the lab, which is only a few metres from the ED.
Often, the MERT give advance warning of the need for a massive
transfusion before the patient arrives, so blood is already primed and
warmed as the patient is brought into the Emergency Department.
Haemodynamically stable patients ideally undergo whole body CT
(“Afghanogram”) prior to surgery. The definition of haemodynamically
stable is much more flexible than in civilian practice due to the ability
to scan patients rapidly which materially affects decision making
during surgery. Not uncommonly, clinically unrevealed tension
pneumothoraces are visible on trauma CT scans, as are fragment
and projectile wounds far removed from wounds at the point of entry .
Typical times from admission to CT scan to the Operating Theatre are
within 10-15minutes for this patient group.
Anaesthesia News April 2012 Issue 297
7
Critically unstable patients may undergo. Local slang refers to this as
“right turn resus”. This Damage Control Resuscitation (DCR) named
from the historical configuration of the operating theatre in Bastion –
a right turn from the Emergency Department. In essence, this group
of patients undergo immediate resuscitative surgery in the operating
theatre, bypassing ED. Embarking on Damage Control Resuscitation
requires confident decision making, but can be triggered the MERT, the
Emergency Department or initial surgical examination. Admission to
surgical incision times may be measured in seconds to minutes, rather
than minutes to hours as so often in civilian practice.
typically started with a ratio of red cells to FFP of 1:1. Early use of
platelets, calcium and tranexamic acid is standard, and later blood
product replacement is guided both by clinical response (resolution
of acidaemia, base deficit, tachycardia etc) and thromboelastography
using the ROTEM machine. Single limb amputations typically require
7-10 units of blood, bilateral leg amputations 12-15, and triple limb
amputations often in excess of 20 units of blood.
Given the relative difficulties with apheresis & platelet storage, military
resuscitation resorts to the emergency donor panel at times. The
emergency donor panel is a pre-selected group of donors who are
used as a source of fresh whole blood during massive transfusion.
Generally, one would consider activating the Emergency Donor Panel
at around 25-30 units transfused if non-surgical haemorrhage was an
ongoing problem.
There is active research into fibrinogen concentrates, cryopreserved
red cells, activated platelet fragments, oxygen carrying substitutes etc.
All these are driven by the logistic challenges of surgical teams working
in battle zones. As an indicator, the monthly blood use in Bastion (four
operating tables) is up to five times greater than the 800 bed tertiary
hospital I work in (20 operating theatres).
Operating Theatre
Camp Bastion - echelon 3
Resuscitation is thus heavily dependent on good team working
between surgeons and anaesthetists- often, two anaesthetists are
required: one to manage the anaesthetic itself, and one to achieve
vascular access, usually with one or more wide bore (Swan Sheath)
subclavian catheters and to supervise transfusion and management of
Acute Coagulopathy of Trauma using one or two Level One or Belmont
infusor systems.
Initial surgery is typically intended to control haemorrhage, with
surgical access determined by injuries. Clamshell thoracotomy,
median sternotomy and midline laparotomy are common techniques
for major vessel control. Anaesthesia for all these, including for nonanatomical lung resection (using stapling devices) is usually feasible
with a single lumen endotracheal tube. Once haemorrhage control is
satisfactory, many patients undergo CT scanning during a surgical
pause prior to returning immediately to theatre for ongoing surgery.
Again, the proximity of CT scan to the operating room makes this a
logistically easier intervention than in most civilian hospitals.
Historically, Damage Control Surgery was abbreviated surgery, often
interpreted as shorter than one hour to prevent the onset of the bloody
vicious triad of hypothermia, coagulopathy and acidosis. Conceptually,
this may be regarded as “operating on physiology, not anatomy”
Advances in anaesthesia and the management of massive transfusion
have led to a marked reduction in the requirement for Damage
Control Resuscitation. The ability to warm fluids adequately and treat
coagulopathy aggressively allows prolonged, almost definitive, surgery
for some injuries. Examples would include triple limb amputees with
significant vascular injuries to the remaining limb. Prolonged (up to six
hours) surgery to salvage the remaining limb is now possible at initial
presentation, even if following immediately on from Damage Control
Resuscitation. This reduces residual physical deficits and improves the
potential for rehabilitation.
Massive transfusion management
Many fit young soldiers will tolerate extreme hypovolaemia, even to the
point of pulseless electrical activity states, but may recover fully once
resuscitated. Volume replacement before starting cardiac compressions
may be required. Aggressive blood and product replacement is
8
Planned surgery
Typically, soft tissue wounds are debrided at the initial resuscitative
surgery, and packed loosely with gauze dressings. After several days,
re-look surgery with additional debridement or delayed primary closure
(DPC) if appropriate is carried out. Anaesthesia for delayed primary
closure is generally straightforward- large blood loss is not common,
and spontaneous breathing, laryngeal mask anaesthesia is suitable for
many cases. If not, a typical “Afghanaesthetic” would include ketamine,
vecuronium, and morphine. Midazolam is usually given with ketamine,
although emergence phenomena are well recognised.
lung or significant contusions or other pulmonary injuries are difficult
to ventilate and oxygenate, and separate lung ventilation via a double
lumen tube is occasionally used, or (rarely) total pneumonectomy.
Continuous renal replacement therapy is technically available,
but very rarely used. Cardiac output measurement is currently not
used, although debate about the utility of this, and of intracranial
pressure monitoring, continues. Bronchoscopes are available,
but percutaneous tracheostomy equipment is not, so surgical
tracheostomy is the intervention of choice if required.
For Afghan nationals, the medical support available locally is limited,
so many remain in Camp Bastion pending sufficient improvement
in their clinical condition to allow discharge. Thus, many of the ICU
beds are occupied by Afghans- perhaps 60% of all casualties seen
in Camp Bastion are Afghan, and around 10% of the ICU caseload
is paediatric. Burns, complex head and facial injuries, and the gamut
of penetrating traumatic wounds account for much of the caseload.
Many of the Afghan patients are poorly nourished prior to
wounding, and the catabolic stresses of severe injury often lead
to a high mortality rate, or a prolonged recovery for the survivors.
This generates a steady flow of ethical dilemmas and practical
management issues requiring senior group discussions and mature
judgement.
The current staffing of the 10 bed (14 if surge capacity required)
ICU is provided by two consultants working a 24 hour, 1:2 rota,
and around 40 nursing staff. At busy times, other anaesthetists or
medical staff can help but generally, if the intensivist is busy, so is
everyone else. In my last summer tour, the ICU in Camp Bastion
accepted as many patients each month as my 17 bed NHS Intensive
Care Unit (which has 18 medical staff and over 100 nurses).
Camp Bastion memorial
Currently, RAF anaesthetists lead, and form the backbone of, the
Critical Care Aeromedical Support Team (CCAST). A detailed article
on CCAST was published recently in Anaesthesia News [1].
Patient Flow
The number of patients admitted to Camp Bastion varies widely
day by day. In the winter the intensity of fighting is typically less
than in the summer months. Frequently, incidents result in multiple
rather than single casualties, and often, simultaneous incidents
generate surges in activity. Clearly, this impacts on the Emergency
Department in the initial phase, but is generally ameliorated by
calling in off duty staff (who live only a few hundred meters away).
Since almost all Camp Bastion ED admissions require surgery, a
significant amount of operating time is required following mass
casualty incidents, both for the hours afterwards, and for any
planned surgical interventions several days later. Likewise, ICU and
the wards become busy for hours to days following an incident,
aand the aeromedical support team are in great demand to move
casualties to available beds. Usually, by the time the casualties from
one incident have been treated , another incident has occurred.
It is a tribute to the exceptional organisational abilities of those in
command that the hospital always seems to simply step up a gear
to cope with whatever response is required. Even so, a three month
tour to Camp Bastion allows clinicians to experience more major
incidents than most would see in a life time of civilian practice, and
longer tours become progressively more physically and mentally
demanding.
Injury Patterns
Historically in 20th Century warfare three soldiers were wounded for
every soldier killed. Advances in protective equipment and medical
treatment have altered this ratio to around 1:9. These advances
include more heavily armoured vehicles, along with improved
helmets and body armour (including blast resistant underwear).
Not only do these save lives, but they reduce the effects of injuries
sustained.
The number of anaesthetic staff in Camp Bastion has varied over time,
especially with increasing numbers of other nations providing medical
staff (particularly American and Danish). Generally, a 1st call, 2nd call,
3rd call, day off type of rota operates, allowing a measured response to
variable casualty numbers. Many patients require multiple operations
(see patient flow below), so even those days with few acute admissions
are often long. It is not uncommon to have in excess of 500 hours of
operating time a month, split between perhaps five anaesthetists.
Different conflicts produce different wounds: for example, armoured
combat results in a high number of burns (and during Afghan winters
many children are burned in domestic incidents). Well equipped
soldiers suffer proportionately fewer torso injuries than Afghan
troops, who don’t have body armour. As with previous conflicts, the
majority of the injuries seen are to the limbs.
Intensive Care Management
There are several distinct groups of Intensive Care patients in Camp
Bastion: UK and other ISAF (International Security Assistance Force)
military patients, typically awaiting rapid evacuation; Afghan soldiers
and adult civilians, with a longer expected length of stay; and Afghan
children with traumatic injuries.
The signature injury for the Afghan conflict over the last few years
has become the triple amputation. Generally, a casualty sustains
bilateral lower limb amputations (mostly above knee) and severe
injuries to one arm (due to carrying a rifle when triggering the
device). Usually there are less severe additional injuries to the
remaining limb. Perineal, abdominal and facial/ophthalmic injuries
are common in this patient group, and around 25% of bilateral
amputees suffer pelvic fractures. Lumbar spinal injuries are relatively
common, although cervical or high thoracic spinal fractures with
cord injuries are rare amongst survivors.
Most UK or allied military casualties undergo evacuation and retrieval
from Afghanistan within a few hours (often casualties arrive in the UK
less than 36 hours after being wounded). The period between ICU
admission and discharge is spent correcting residual coagulopathy,
inserting epidural and nerve catheters if appropriate, identifying
missed injuries, and ensuring ongoing general care. Rapid evacuation
is preferred both for patient care and for logistical reasons (to avoid
“bed blocking”) Most of these patients, despite massive injuries, do
not develop a SIRS response or multiple organ dysfunction during their
brief ICU Stay in Camp Bastion, although this evolves more commonly
by their return to the UK.
Clinical Outcomes
One scoring system in military use is the Injury Severity Score (ISS).
This score (validated in civilian practice) ranges from 0-75, where
75 is considered non survivable, and 15 is considered the threshold
There are some differences between therapies which are used in Camp
Bastion and those familiar to UK intensivists. Some patients with blast
Anaesthesia News April 2012 Issue 297
Repatriation & Rehabilitation
Anaesthesia News April 2012 Issue 297
9
for major trauma (since the mortality rate for ISS16 and above is 10%).
The average ISS for UK military casualties in Afghanistan is 53. The
military are currently revising ISS in part to account for a large number
of unexpected survivors, both statistically and clinically, over the last
decade.
RCoA EVENTS 2012
RETURNING TO WORK
Extreme injuries which many in civilian practice would regard as nonsurvivable are not only survived by this military population, but the long
term functional outcomes, even if significantly physically disabled, have
been sufficiently good to justify the large amount of resource devoted to
managing them. This fit, young, and highly motivated population may
not be reflective of the general population, but are repeatedly defining
the limits of survival. This constantly raises ethical questions about the
appropriateness of some truly epic treatments such as hemipelvectomy
for triple limb amputations. In many ways, this is similar to civilian
debate around the practical limits of neonatal resuscitation.
HOW TO SUCCEED
Date and venue:
21 June 2012 (code: D08)
Royal College of Anaesthetists, London
Registration fee:
£150 (£125 for registered trainees and affiliates)
Approved for 5 CPD credits
Event organiser:
Dr C Evans
Hospital - echelon 3
The meeting will focus on how to manage a successful
return to work, with an exploration of responsibilities
and best practice from the employer and employee’s
prospective, and is aimed at trainees, SAS and Specialty
Doctors, Consultants, Programme Directors, Clinical
Directors and Human Resource Directorates at Deanery
and Trust level.
Please scan the code to go to the College
website for further information:
Apply: www.rcoa.ac.uk/events
Contact: 020 7092 1673
[email protected]
Conclusion
24-25 May 2012
Ankara, Turkey
The Philosophical Transactions of the Royal Society (B) published in
January 2011; issue 366, also provides more details of much of the
above.
*ACoT- Acute Coagulopathy of Trauma
**ISAF International Stabilisation Afghanistan Force
***FAST- focussed Abdominal Sonography in Trauma
The AAGBI and MPS would like to offer a new Patient Safety
Prize to showcase examples of improved safety in anaesthesia.
The prize is open to members of the AAGBI. The project could involve an individual, department, medical students
or allied health care professionals, provided the project lead is a member of the AAGBI.
You will need to demonstrate:
Clear aims and objectives
An innovative idea(s)
How the project was introduced and implemented
How performance was measured and benchmarked
How information about the project was disseminated
The sustainability of the project
Transferability of the project to other departments
The deadline
for submissions
is midnight on
Monday 28th
May 2012
Amount: Up to £1000 (at the discretion of the awarding Committee).
There may be more than one prize.
Awarded: At the AAGBI Annual Congress
Format of submissions: Poster presentation
In addition, the shortlisted entries will be expected to:
Make a brief oral presentation to the judges at Annual Congress
The winner will be expected to:
Make a five minute oral presentation at Annual Congress
Submit an article for Anaesthesia News
We are very grateful to the AAGBI Foundation
and the Medical Protection Society for supporting this prize
Please visit www.aagbi.org/research/awards for further details.
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 8812 or [email protected]
28/02/2012 08:50
Abstracts for presentation
at the AAGBI Annual Congress,
Bournemouth 2012
You are invited to submit an abstract for oral (free paper)
or poster presentation at the Annual Congress.
References:
1. GAT - The Royal Air Force Critical Care Air Support Team. Roberts
DE, Davey CMT Anaesthesia News. June 2011: 8-11.
The website for the Journal of the Royal Army Medical Corps http://
www.ramcjournal.com/index.html allows open access to the journal,
which contains numerous articles of interest.
for 2012
AAGBI
Dr Ian Nesbitt
Consultant in Anaesthesia & Critical Care,
Freeman Hospital, Newcastle upon Tyne
Military medicine is a rapidly evolving field, especially in the area of
trauma resuscitation. The information in this article is freely available
from various sources.
Dr Samantha Shinde, Education Committee Chair • Dr Isabeau Walker, Safety Committee Chair
SafetyPrize.indd 1
Whatever one may think of the reasons for, and conduct of the wars of
the last decade, it is undeniable that the Defence Medical Service has
risen to the challenge and performed at a very high level. Lessons have
been learned about the management of victims of major trauma which
should help save lives in future.
Further reading
AAGBI & MPS PATIENT SAFETY PRIZE NEW
In association with the
British Ophthalmic Anaesthesia Society
•
•
International speakers from 14 countries worldwide
Session themes include: World Ophthalmic Anaesthesia,
Refresher lectures (both basic science and clinical practice),
Specialist Ophthalmic Anaesthesia, Risk Management,
Free Papers, Regional Anaesthesia Workshops, Challenges
and Hot Topics in Ophthalmic Anaesthesia
Congress Venue: Dedeman Ankara Hotel
For further information and registration, visit: www.wcoa2012.org
or email [email protected] or [email protected]
Submission of abstracts for both verbal and poster
presentations is now open. For instructions, please visit the
Congress website. Closing date for submission of abstracts:
15th March 2012.
An exciting programme of sight-seeing tours and activities for
accompanying persons is also available.
www.wcoa2012.org
The deadline for submission is midnight on Monday 28th May 2012 and full instructions, including a template
abstract and submission form, can be found on our Annual Congress microsite: www.annualcongress.org and
on the AAGBI website www.aagbi.org/research/awards
After the deadline, a preliminary review of the abstracts received will determine which ones are accepted for
presentation at the Annual Congress in Bournemouth. Some authors will be invited to present their work orally,
under the following three categories: audits and surveys, case reports, and original research. The remaining
successful authors will be invited to present a poster.
All accepted abstracts will be published in Anaesthesia in the form of a fully referenceable online supplement.
In addition, the best ones, selected by a judging panel at the meeting, will be printed in the hard copy version of
the journal. (NB Editor-in-Chief reserves the right to refuse publication, e.g. where there are major concerns over
ethics and/or content).
Authors of the best free papers and poster(s)
will be awarded ‘Editors’ Prizes’.
If you have any queries, please contact the AAGBI Secretariat
on 020 7631 8812 or [email protected]
Anaesthesia News April 2012 Issue 297
11 is a potential lure to an ambush, but for the sake of the injured they
have not flinched from their duty. Likewise, particular consideration
is due for Royal Air Force Anaesthetists who have been deployed in
Tactical Critical Care Air Support teams. A number have undertaken
particularly hazardous missions where they have experienced constant
exposure to danger above that normally experienced when flying over
and landing in hostile territory. Tactical flying at night through mountain
passes in helicopters or fixed wing aircraft, while striving to save the
lives of critically injured service personnel, is not for the fainthearted.
Tactical and Strategic Critical Care Air Support teams have transferred
and evacuated hundreds of patients over thousands of miles. These
patients have been saved from death by the skill and resolve of their
Triservice anaesthesia and intensive care colleagues, working tirelessly
with the rest of the multidisciplinary team. Many patients have been so
critically ill, that even moving them by air or ambulance in the UK would
have been a severe challenge and perhaps not even attempted. During
these missions not a single patient has been lost and quoting Professor
Sir Keith Porter (University Hospitals Birmingham Foundation Trust)
these multiply injured patients have been delivered to critical care, in
his Trust, in better condition than patients transferred in from a few miles
away and who have had much less trauma. This speaks volumes about
the ability and dedication of Defence Anaesthetists.
Regular and
Reserve Defence
Anaesthetists from
the Royal Navy,
the Royal Army
Medical Corps and
the Royal Air Force
have been serving
in Afghanistan since
the beginning of
the conflict there in
October 2001.
© Photographer Sgt Laura Bibby, RAF UK MOD Crown Copyright 2012
Pask Certificate of Honour
Members of Defence Anaesthesia
who served in Afghanistan
Operations in Afghanistan were commenced as a
direct result of the 11th of September 2001 attacks on
the United States. Initially a small number of Defence
Anaesthetists worked to support Special Forces during
the commencement of Operation Enduring Freedom
with forward on the spot resuscitation and critical care
evacuation. Since early 2002 they have been part of the
coalition of up to 42 Nations who have contributed to
the International Stabilisation Assistance Force (ISAF).
Consultants and later in the mission, trainees, have been
deployed to provide medical support to combat and
security operations.
Defence Anaesthetists have been outstanding members
of the medical team, leading advances in care, which
have seen a great many unexpected survivors from
trauma. This has heralded the lowest mortality amongst
casualties in any conflict to date. Key to that has been
the involvement of the anaesthetist at every stage of the
evacuation chain from pre-hospital care, resuscitation,
anaesthesia, intensive care, pain management and
aeromedical evacuation, through to command roles as
Deployed Medical Directors.
Conditions at the commencement of the conflict during
entry operations were extremely harsh and fraught with
personal danger and though the threat to personal safety
has declined over the 11 years of the conflict to this date,
it will be ever-present. Personal risk has been a constant
accompaniment over many tours of duty for some and
they deserve particular mention. Before specific groups
are identified it is important to recognise the dedication
12 and personal resolve demonstrated by those volunteers
who repeatedly return for these extremely taxing duties
on operational deployments. The stress of working daily
with critically injured young UK and Coalition Service
personnel and local civilians, including many children,
cannot be overstated. This outstanding commitment has
never faltered and has been carried out with unflagging
professionalism which should be an example to all.
Many Defence Anaesthetists have seen more severe
trauma in a single day than many civilian anaesthetists will
see in an entire career, with as many as 3 major incidents
in a 24 hour period being experienced on occasions.
The level of trauma and the ensuing resuscitation
continuing long into surgery, subsequent intensive care
and even into tactical and strategic evacuation has been
demanding in the extreme. It has often required two or
more anaesthetists to manage up to six surgical teams
operating on a single patient. Transfusions of blood and
blood products of as much as 1 unit every 50 seconds
and 50 units of blood per hour have not been unusual.
When considering courage and commitment a special
mention must be made of those individuals, from all
three services, undertaking duties with the Medical
Emergency Response Teams (Enhanced) (MERT (E)).
These individuals have carried out remarkable feats
of resuscitation taking advanced airway techniques,
rapid sequence induction, therapeutic thoracotomy,
interosseous vascular access, blood and blood products
onto the battlefield, more often in pitching helicopters
and regularly under enemy fire. They have undertaken
mission after mission in the knowledge that everyone
Anaesthesia News April 2012 Issue 297
This conflict has seen an unprecedented improvement in care of the war
wounded. This has been backed by continuing world class research
and development, which in many cases has been undertaken by
Defence Anaesthetists while deployed. This level of exceptional care
has led to the description of the UK led hospital in Camp Bastion, as
being the “best trauma hospital in the world”. Both the National Audit
Office and the Healthcare Commission have praised the DMS trauma
care most highly, but Defence Anaesthetists who have been part of
this trauma system deserve their own recognition for the exemplary job
they have done. This and other acknowledgments are a huge tribute
to the skill and dedication of the entire evacuation chain from point
of wounding to repatriation to the NHS. The integrity of this chain is
entirely dependent for the provision and maintenance of its links on
Defence Anaesthesia. Advances in analgesia provision throughout
the chain of care are also worthy of mention. Dedicated members of
Defence Anaesthesia have forged a comprehensive and effective
system for providing analgesia to the highest standard possible and
this work continues. Royal Air Force Defence Anaesthetist trainees
have also been the backbone of advanced analgesia support to the
many thousands of war wounded who have been transferred by the
Royal Air Force Aeromedical Evacuation Service. In the UK Defence
Anaesthesia provides support to those war wounded in rehabilitation
with outreach clinics and multidisciplinary teams. Recognition must
also be extended to the families of Defence Anaesthetists, who are,
for the most part, unrecognised. Without their encouragement, support,
sacrifice and backing, many of those deploying would not have, so
readily, undertaken the missions that they have, nor would they have
felt as secure as they undertook the great challenges which faced them.
When the Association of Anaesthetists of Great Britain and Ireland
awarded the Pask Certificate for service in Iraq, the citation stated that
“It is a great tribute to Service Anaesthetists’ dedication, courage and
professionalism that they were able to produce a consistent, high quality
and enduring clinical effect in the most difficult of circumstances, in order
to treat their patients and support the overall medical effort during the
campaign”. This sentiment applies just as truly to service in Afghanistan.
It remains true that these individuals have served and continue to serve
their patients, Defence Anaesthesia, the Defence Medical Services and
their Country with loyalty, dedication and honour. It is, likewise, right that
they are recognised for that. Council of the Association of Anaesthetists
of Great Britain and Ireland takes great pride in awarding the Pask
Certificate of Honour to Defence Anaesthetists that have served in
Afghanistan.
Group Captain Neil McGuire
Pask Certificate of Honour
The Pask Award was instituted in 1977 after the Moorgate Underground
disaster of 1975 and the desire of Council to honour the gallantry of a
Registrar Anaesthestist. The award is made by Council of the AAGBI
to honour those who have rendered distinguished service, either
with gallantry in the performance of their clinical duties, in a single
meritorious act or consistently and faithfully over a long period. The
award was named after Professor E A Pask. Pask had a distinguished
career in the Royal Air Force Medical Branch as an experimental
physiologist in the Second World War. This included dangerous self
experimentation requiring considerable personal courage.
Pask Certificate of Honour Recipients 2012
Surg Cdr Allister Dow
Lt Col Sue Ackerman
Sqn Ldr Deborah Easby
Maj Richard Allan
Surg Lt Cdr Amanda Edward
Surg Lt Cdr Ed Allcock
Surg Cdr Charlie Edwards
Wg Cdr Jon Ball
Sqn Ldr David Evans
Maj Oliver Bartels
Col Glynn Evans
Surg Lt Cdr Dave Beard
Flt Lt George Evetts
Wg Cdr Robin Berry
Sqn Ldr Ian Ewington
Wg Cdr Kristina Birch
Capt Jonathan Farmery
Surg Cdr Dave Birt
Maj Adam Fendius
Gp Capt David Blake
Col Jeremy Field
Sqn Ldr Jim Bradley
Lt Col Mark Fox
Surg Capt Steve Bree
Lt Col Scott Frazer
Surg Capt Andy Burgess
Maj Claire Gaunt
Col Richard Cantelo
Wg Cdr Phil Gillen
Maj Mary Cardwell
Lt Col Andy Griffiths
Capt John Chambers
Lt Col Sanjay Gupta
Maj James Chinery
Flt Lt Elise Hindle
Lt Col David Clough
Maj Andrew Haldane
Surg Cdr Dan Connor
Lt Col Jim Hammond
Sqn Ldr Iain Cummings
Capt Rachel Hawes
Wg Cdr Phil Dalrymple
Lt Col Hamish Hay
Lt Col Mark Davies
Maj Clare Hayes-Bradley
Sqn Ldr Matt Davies
Lt Col Jeremy Henning
Capt William Davies
Surg Capt David Hett
Maj Rob Dawes
Lt Col Ian Hicks
Col Winston De Mello
Maj Tim Hooper
Surg Cdr Barrie Dekker
Wg Cdr Simon Hughes
Maj Phil Docherty
Anaesthesia News April 2012 Issue 297
Maj David Hunt
Surg Cdr Sam Hutchings
Lt Col Mike Ingram
Maj David Inwald
Col Soundararajan Jagdish
Lt Col Nick Jefferies
Capt Ami Jones
Lt Col David Kelly
Lt Col Iain Levack
Lt Col Jason Lewis
Maj Stephen Lewis
Maj Catherine Livingstone
Lt Col David Lockey
Flt Lt Jemma Looker
Lt Col Tim Lowes
Surg Capt David Lunn
Col Peter Mahoney
Maj Malcolm Mathew
Maj Ben Maxwell
Surg Cdr Shane McCabe
Wg Cdr Gavin McCallum
Lt Col William McFadzean
Gp Capt Neil McGuire
Lt Col James McNicholas
Surg Cdr Adrian Mellor
Lt Col Ian Mellor
Surg Cdr Simon Mercer
Maj Linzi Millar
Lt Col Paul Moor
Maj Paul Morrison
Lt Col Ian Nesbitt
Maj Tim Nicholson-Roberts
Lt Col Giles Nordmann
Lt Col Julian Olver
Maj Claire Park
Lt Col Duncan Parkhouse
Maj Kevin Patrick
Surg Cdr Mark Patten
Wg Cdr Michael Peterson
Maj Craig Pope
Maj Victoria Pribul
Surg Cdr Kate Prior
Maj Henry Pugh
Lt Col James Ralph
Maj Bryce Randalls
Surg Cdr Jon Read
Maj Mark Reaveley
Maj Richard Reed
Flt Lt Daniel Roberts
Lt Col Matt Roberts
Surg Lt Cdr Julie Robin
Maj Jonny Round
Wg Cdr Martin Ruth
Surg Cdr Mark Sair
Sqn Ldr Claire Sandberg
Maj Guy Sanders
Surg Lt Cdr Tim Scott
Lt Col Mark Sheridan
Wg Cdr Peter Shirley
Surg Cdr Ben Siggers
Sqn Ldr Charlotte Small
Gp Capt Denis Smyth
Maj Nick Tarmey
Surg Cdr Mike Tennant
Lt Col Rhys Thomas
Lt Col Rob Thornhill
Sqn Ldr Bob Tipping
Lt Col Jeff Tong
Wg Cdr Simon Turner
Maj Caroline Walker
Maj Christopher Walker
Maj Brett Webster
Surg Cdr Jon Wedgwood
Sqn Ldr Joanna Wheble
Wg Cdr Curtis Whittle
Maj Daniel Willdridge
Surg Cdr Douglas Wilkinson
Sqn Ldr Stephen Wilson
Maj Kate Woods
Lt Col Tom Woolley
Maj Mark Wyldbore
Lt Col Adrian Hendrickse
13 KEYNOTE SPEAKERS INCLUDE:
College of Anaesthetists
o f I re l a n d
Professor Steve Shafer, US
The Queen’s
Honorary Surgeon
ANNUAL MEETING 2012
Professor Karen Domino, US
Professor Robert Dyer, South Africa
Professor Hugh Hemmings, UK
Professor Monty Mythen, UK
Professor Alex Sia, Singapore
Dr Steve Yentis, UK
THE CONVENTION CENTRE DUBLIN
CPD points = 12
Group Captain Neil McGuire
CALL FOR ABSTRACTS
Defence Consultant Adviser Anaesthesia,
Pain & Critical Care
Irish Congress of Anaesthesia
• “Free” means – case reports, series of cases or
clinical investigations
This two day meeting is the most prestigious and important
in the College’s academic calendar. It will feature:
•
•
•
•
•
Keynote addresses from international experts
Current issues / update sessions
Workshops / debates
Free papers and posters
Excellent social programme
Further details on WWW.ANAESTHESIAIRELAND.COM
• The absolute time limit for receipt of applications
is Friday 27 April 2012 at 17:00 hrs.
• Abstract forms available from www.anaesthesia.ie
or email Orla Doran on [email protected]
SPECIAL DEAL:
1 day rate available
Congress Chair:
[email protected]
Scan with your smartphone to connect to
www.anaesthesiaireland.com
21 PORTLAND PLACE
Room Hire & Private Dining
Digested
Anaesthesia April 2012
Perioperative transoesophageal echocardiography: past, present & future
D.L. Greenhalgh, M.R. Patrick
An investigation into the causes of unexpected intraoperative transoesophageal echocardiography findings
• Eligibility – Trainees, Consultants and Non-Consultants.
25–26 MAY 2012
Anaesthesia
H. J. Skinner, A. Mahmoud, A. Uddin and T. Mathew
Congratulations are in order for Group
Captain Neil McGuire, who has represented
anaesthesia, critical care and pain doctors in
the defence medical services at the AAGBI
since 2007 on his appointment as Queen’s
Honorary Surgeon.
The appointment takes effect on the 1st April 2012 and was
approved by Her Majesty the Queen in late 2011. It is for a
period “at Her Majesties pleasure”, but it is normally continued
while serving in HM Forces. This is one of a small number of
Honorary Medical appointments made from the Armed Forces,
which includes Queen’s Honorary Dental Surgeons, Queen’s
Honorary Physicians and Queen’s Honorary Nursing Sisters.
The role includes duties at Royal occasions such as Investitures,
Garden Parties and State Banquets where the incumbent is a
part of the extensive medical cover which is accorded such
events. The QHS etc are always accompanied by a “registrar”,
who is either a consultant or senior trainee anaesthetist.
The holders of this appointment are distinguishable by the
fact that the uniform has Royal Cyphers (EIIR) accompanying
their shoulder rank insignias and the wearing of aiguillettes
with some uniforms (ornamental braided gold wire cord with
metal tips).
Buckingham Palace, London
This month’s Anaesthesia contains an editorial and accompanying article
discussing trans-oesophageal echocardiography (TOE) practiced by anaesthetists.
Greenhalgh and Patrick’s excellent editorial considers how far TOE operated by
cardiac anaesthetists has developed in cardiac surgical practice and on cardiac
intensive care units.
In the space of a few years, cardiac anaesthetists have become an invaluable part
of the intra-operative care of cardiac surgical patients. The editorial discusses how
surgical or medical management is now frequently altered by the TOE findings at
operation. It goes on to consider how useful TOE has become in the management
of patients on cardiac intensive care units.
The following article by Skinner et al. is a further illustration of the significance
of TOE practiced by cardiac anaesthetists. They demonstrated a number of new
findings at time of surgery that were not recognised pre-operatively and which
changed the surgical plan in 4% of operations. This article also raises issues around
proper pre-operative informed consent for patients who may actually require an
extra or a different procedure depending on the intra-operative TOE findings.
It is a credit to our speciality to see how cardiac anaesthesia has embraced this new
technology and subsequently organised the training and competency requirements
required to perform these responsible roles for the undoubted benefit of patients.
Anaesthetists’ risk assessment of placebo nerve
block studies using the SHAM (Serious Harm and
Morbidity) scale
J. Jarman, N. Marks, C.J. Fahy, D. Costi and A. M. Cyna
The role that placebos play in clinical research involving local anaesthetic blocks
has created some controversy. This study follows a previous publication by this
group in which they described a SHAM (Serious Harm and Morbidity) scale to
assess the risk that patients are subjected to by the performance of a placebo block.
The authors reviewed a number of studies using their scale and concluded that
some studies were in contravention of the Declaration of Helsinki, which states
that ‘the patients who receive placebo or no treatment will not be subject to any
risk of serious or irreversible harm’. Some criticism and useful debate followed the
publication of this article in our correspondence section.
In this article, the authors examined the validity of their scale. They compared the
SHAM scale scores awarded by 43 anaesthetists who were given ten randomised,
controlled trials involving local anaesthetic blocks. They concluded that the
agreement was sufficient to suggest that the scale can successfully grade the
potential for complications caused by placebo blocks, and that this represented a
first step towards validation of their scoring system. I am sure this article will lead
to further debate in this area and raise the profile of this important topic.
For availability or to make a booking, please contact our Facilities Manager
on 020 7631 8809 or email [email protected]
www.aagbi.org/about-us/venue-hire
N. Bedforth
Editor, Anaesthesia
Anaesthesia News April 2012 Issue 297
15 leaflets were more readily available in the pre-assessment clinics.
A re-audit, again of 88 patients, took place during March and April
of 2011. This demonstrated that 83% had received some written
information about their anaesthetic and 62.5% had been given the
anaesthesia information leaflet. These results fell short of the target
of 100%, but did show a significant improvement. Of the 82% of
patients seen in a pre-assessment clinic, 52 of 72 patients (72%)
felt that they had received adequate verbal information about their
imminent anaesthetic – less than previously. However, 85 out of the
total 88 patients (97%) were satisfied with the information that they
had been given. Again, all patients who had been seen in a preassessment clinic or who had received written information about
their anaesthetic were satisfied.
Too little, too late?
A study of the pre-operative information we impart to our patients
In early 2009, my grandmother underwent an elective total knee replacement at her local district general hospital.
At her pre-assessment visit she was given lots of written information about the procedure to take home and read.
A surgeon discussed the procedure with her and she was given the details of an interactive American website,
which allowed her to learn about the different stages of the procedure should she wish.... and she did.
However, she was not given any information about her anaesthetic
choices at these appointments and had concerns about what this
could entail. She therefore looked to me for this information. I
explained that practices vary between hospitals and anaesthetists,
but she found the information I was able to give reassuring. This led
me to think about the information that my patients were receiving prior
to their preoperative visit on the day of surgery. Were they too being
placed under unnecessary stress because of our communication, or
lack thereof?
16 In 1992, the Patient’s Charter informed British patients that they have
the right “to be given a clear explanation of any treatment proposed,
including any alternatives, before you decide whether you will agree
to the treatment”.1 A systematic review of the literature on patients’
priorities conducted in 1998 by the European Task Force on Patient
Evaluations of Practice (EUROPEP) found “patients’ involvement in
decisions” and “time for care” were values patients sought in their
doctors that were second only to “humaneness” and “competence”.2
Indeed, provision of information and the opportunity for patient
participation feature prominently in most studies of satisfaction or
dissatisfaction.3,4 In 2001 the Department of Health (DoH) published
a reference guide to consent, stating that “in elective treatment, it
is not acceptable for the patient to receive no information about
anaesthesia until their preoperative visit from the anaesthetist; at
such a late stage the patient will not be in a position genuinely to
make a decision about whether to proceed.”5 These sentiments are
echoed in literature investigating the consent process related to
patient autonomy.6
The Royal College of Anaesthetists’ book Raising the Standard:
Information for patients7 describes how best to enable information
transfer from medical professional to patient. We used this
information, along with standards suggested in the RCoA Raising the
Standard: A compendium of audit recipes – Patient information about
anaesthesia8 to design and undertake an audit investigating what
information patients undergoing anaesthesia for elective procedures
at the Royal Devon and Exeter Hospital (RD&E) were receiving. This
initial audit, of 88 patients across a range of specialities, took place
during May and June 2009. As well as looking at the types of media
used to transfer information (information sheet, procedure booklet,
anaesthesia booklet, verbal advice), it also investigated whether the
patients were satisfied with the information that they had received. It
demonstrated that although all but one received fasting information,
only 11% of patients had been given the RD&E’s anaesthesia
information booklet. 65% had received a procedure specific
information leaflet – most of which contained some information about
the anaesthetic. 52 of 66 (79%) of patients seen in a pre-assessment
clinic felt that they had received adequate verbal information at this
time. At this time, 13 of the 88 patients (15%) surveyed were unhappy
with the quantity or quality of information that they had received. All
patients who had been seen in an anaesthetic pre-assessment clinic
or had received the anaesthetic information leaflet were satisfied.
The only dissatisfied patients were those who had not received either
of these interventions. In response to this audit, the importance of
verbal and written information transfer was explained at a succession
of pre-assessment practitioner courses. The funding for the
leaflets was also changed to another budget and as a result the
Anaesthesia News April 2012 Issue 297
Graph comparing the pre-admission anaesthetic information provided to patients
undergoing elective surgery at the RD&E in 2009, compared to 2011.
The re-audit correlates with previous studies, demonstrating that
whatever format the information transfer takes, informed patients
are generally more satisfied patients.3 It also showed that although
our department had improved its communication of information to
patients prior to their admission, it was still falling short of the RCoA
and DoH guidelines. Although the vast majority of patients were
happy with the service that we offer, some were still dissatisfied.
Most of these patients were those who felt they had access to too
little information, but a few also wanted to receive less information.
In the reference guide to consent, first published by the DoH in
2001, it is acknowledged that some patients may not wish to be
given information prior to a procedure. Both audits demonstrated
a small proportion of patients who thought that providing
anaesthetic information prior to their admission, or even prior to
their procedure was unnecessary. The guidelines recognise that
it is possible that these individuals’ wishes may change over time
and that respecting a person’s wish not to know, at the same time
as providing opportunities for access to further information is even
more important in this subset of patients.5
Our hospital is working towards streamlining its pre-assessment
processes, which will ultimately result in fewer of the ASA I and II
patients attending a pre-admission clinic. Although these patients
are the most medically fit for surgery, the audits demonstrated that
it is this patient group that are most likely to receive inadequate
access to information about their anaesthetic prior to their admission
to. This led us to consider: In this age of advanced technology,
should we really be relying on just verbal and written information
to inform our patients? My Grandma was very impressed with
the service offered by the orthopaedic surgical team at her local
hospital. The interactive computer programme led her to feel
empowered. Although not all octogenarians are as internet savvy
as she, an increasing proportion of our patients are, especially the
younger ASA I and II patients. Some studies have demonstrated
that patient satisfaction is improved if information is given in an
interactive format, including a study by Gautschi et al in Switzerland
Anaesthesia News April 2012 Issue 297
in 2010. This demonstrated that through the use of an audiovisual
computer programme, patient satisfaction with the informed consent
process prior to neurosurgery improved substantially.9 However, the
aim of improving information transfer to our patients is not solely
to improve their satisfaction. The aim is to improve information
transfer and thus create a group of well informed patients, who are
able to make autonomous decisions about their care. As well as
Gauchi’s study, others have demonstrated that the use of interactive
media improves patient knowledge and retention of information.
For example, Huang et al in Taiwan in 2009 demonstrated that the
use of an interactive multimedia device to intervene in diabetes
self-care was effective in raising the subjects’ knowledge about the
disease.10 As well as being a point of access for more information
for all patients undergoing elective surgery, this type of medium
could also be beneficial for the minority of patients who do not wish
to receive information at that time, but whose wishes change prior
to their admission to hospital.
Although interactive multimedia information transfer undoubtedly
confers many benefits, its disadvantages must also be recognised,
as demonstrated in a recent US based study by Zigmund-Fischer
et al. Through assessing the effect of the introduction of interactive
graphs to a computer-based information programme about the
risks of different thyroid cancer interventions, they demonstrated
that the interactivity, however visually appealing, distracted people
from understanding relevant statistical information. The intervention
group were also less likely to complete the survey.11 In order to
encourage patient autonomy, one of the main purposes of providing
pre-operative information for our patients is to obtain informed
consent. This requires patients to understand and retain information
relating to risk. Developers of this medium would therefore need to
be aware that interactive risk presentations may create worse more
disquiet than presentations of static risk graphic formats.
In summary, we have a wide variety of patients, with a wide variety of
requirements, undergoing a wide variety of procedures, which can
be performed using an increasingly wide variety of anaesthetics.
Although it would be very difficult to encompass all of the information
required in one computer programme, providing only written and
verbal information for patients may not be enough. With the trend
towards reducing the number of face-to-face pre-assessment
meetings, conveying this information will become more problematic.
It is our duty as anaesthetists to provide the best possible service
to our patients and find ways to ensure those that want detailed
information are able to obtain this, and hence are satisfied with the
service we provide.
Dr Clare Attwood
CT2, Royal Devon and Exeter hospital
Clare is currently volunteering as an anaesthetist at Juba Teaching Hospital in
South Sudan. The AAGBI generously awarded her a travel grant to work there.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
`Patient’s Charter’, Patients Standard Care Committee Mar 1992-Sept 1993.
Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on
patient priorities for general practice care. Part 1: Description of the research domain.
Social Science and Medicine 1998;47:1573-88.
Coulter A, Fitzpatrick R. The patient’s perspective regarding appropriate healthcare. In:
The handbook of social studies in health and medicine. London: Sage, 2000:454-464
Coulter A. Patients’ views of the good doctor. British Medical Journal 2002;325:669-70
Department of Health. Reference guide to consent for examination and treatment, second
edition. DH, London 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_103643 (accessed 22/12/2011)
Coulter A. Choosing appropriate treatment: patient as decision-maker. In: The
Autonomous Patient. The Nuffield Trust, 2002:37
Royal College of Anaesthetists. Raising the Standard: Information for patients. RCoA,
London 2003 www.rcoa.ac.uk/docs/prelimscontents.pdf (accessed 22/12/2011)
Royal College of Anaesthetists: Raising the Standard: a compendium of audit recipes.
1.1 – Patient information about anaesthesia. RCoA, London 2006 www.rcoa.ac.uk/docs/
ARB-section1.pdf (accessed 22/12/2011)
Gautschi OP, Stienen MN, Hermann C, Cadosch D, Fournier JY, Hildebrandt G. Web-based
audiovisual patient information system - a study of preoperative patient information in a
neurosurgical department. Acta Neurochirurgia 2010;152(8):1337-41
Huang JP, Chen HH, Yeh ML. A comparison of diabetes learning with and without
interactive multimedia to improve knowledge, control, and self-care among people with
diabetes in Taiwan. Public Health Nursing 2009;26(4):317-28
Zikmund-Fisher BJ, Dickson M, Witteman HO. Cool but counterproductive: interactive,
web-based risk communications can backfire. Journal of Medical Internet Research
2011;13(3):e60
17 Anaesthesia Conference
Benin, West Africa
My journey to Benin began shortly after I commenced working at the North Hampshire Hospital in Basingstoke.
Within the first week Dr Keith Thomson had, in his own words, ‘taken the liberty of booking my leave’ to enable
me to attend (as faculty) an Anaesthesia conference he was organising in Benin, West Africa.
was co-ordinated by Dr Thomas Lokossou, the lead anaesthetist
and a formidable local driving force in the efficient running of the
hospital. Financial restraints unsurprisingly present the greatest
barrier for him. Though there was new equipment, many pieces
were not being utilized; charitable gifts for which the hospital did
not have the necessary disposables to facilitate their use. Sadly,
this is not an uncommon problem in Africa. At CNHU, the larger
University hospital in the city, each patient in the 18-bed intensive
care unit had a monitor but no ECG because of a lack of adhesive
electrodes. The medical and nursing staff were knowledgeable,
polite and informative, however, the lack of equipment resulted in
their being left rudderless with limited parameters to guide therapy.
On the evening before the conference began we visited the venue
to survey the facilities and found thankfully an air-conditioned
lecture hall. Our last minute changes proved over burdensome for
our interpreters; as the most junior members, Stuart and I e-mailed
our final drafts to students at the school of anaesthesia, crossed our
fingers and hoped nothing got lost in translation.
Heading out for the first day of the conference we loaded up the
Mercy Ship’s Land Rover with Resusci-Annie and her pals. On
arrival at the venue it was a daunting prospect to watch the lecture
theatre fill up with more than 200 people; 50 medical anaesthetists
and 150 nurse anaesthetists, mostly from Benin, though some from
further afield; Nigeria, Mali and The Republic of South Africa. The
conference opened with a lecture from Dr Thomson, detailing his
work in Africa and with Mercy ships over the years. I was surprised,
though Keith took the comment with good grace, that the first
question from the floor was a doctor questioning the longevity of
Western intervention in Africa. This is a commonly debated issue
and in some ways not a surprise at all, but made me consider it
anew in light of this man’s question.
The conference had been planned in partnership with Professor
Martin Chobli who runs the School of Anaesthesia in Benin, the
only school for medically trained anaesthetists in West Africa.
I have to confess I’m not sure I’d heard of Benin before; it is a
small country by African standards, covering 110 000km2, with
a population of 8.5 million and a national religion of Voodoo. I
had never been to Sub-Saharan Africa and the little I knew of the
travel within West Africa involved guarded enclaves and armoured
vehicles. But Keith said it would be fine, and so it was.
Aside from Dr Thomson there were three consultant and three
trainee faculty members. In addition, we had two interpreters: a
Canadian computer engineer and a French national anaesthetic
nurse working in Cotonou, who would prove invaluable to us
monolingual “plebs”.
We arrived late at night in Cotonou’s hot and humid airport and
were delighted upon our arrival at the Africa Mercy of Mercy
Ships Foundation to be provided with a lovely meal and pristine
accommodation. Our first wander off the ship was swelteringly
hot with the port entrenched in a shantytown smelling strongly
of the nearby fish market. An initial reaction to escape back to
the ship with its air conditioning, clean water and Western food
was thankfully short lived. I have travelled in many developing
countries over the years and this reaction surprised me; I can only
assume it was a symptom of my getting older.
We visited the stilt village of Ganvie situated within an expanse of
marshland, the likes of which I have only seen in heavy National
Geographic coffee table books. The village is serviced by a water
bus and floating markets, which we sailed past whilst enjoying the
breeze afforded by our “speed boat”.
On board the ship we took a tour of The Oak Hospital. Though
operating had ceased for the year, a few recovering maxillofacial
18 most invaluably his working knowledge of anaesthesia in Benin
and an appreciation of the resources available. We concluded he
must be the star pupil of the Benin School of Anaesthesia, and
I’m sure my presentations benefited from it! Our teaching format
was morning lectures with practical sessions in the afternoon. We
ran workshops on resuscitation (adults, children, and neonates),
airway management, and P.R.I.M.E, a teaching and discussion
forum on professionalism. Anaesthesia in Africa does not bear
a terribly high profile or status amongst the surgical community
(even less so than in the South of England), and it was obvious
that the subject matter was an unfamiliar topic for interactive
study. It was however well received with enthusiastic discussion
of topics such as the qualities of a good doctor or nurse and what
makes an effective team.
Due to a communication error we were not told until Thursday that
Friday was a national holiday, and there was no question that the
conference would continue despite this. We went on an inland
tour of Benin taking in a Portuguese Fort to hear the desperate
story of the slaves deported to Brazil in the late 1700’s and visited
the Gate of No Return, the port from which the ships departed.
The experience was interesting and very humbling. Later in the
day we enjoyed lunch on the beach and a dip in the Gulf of Guinea
to stave off the blistering heat. The final day of the conference was
attended by the minister for health, Professor Issifou Takpara who
had very recently made a significant positive change of policy
by introducing government funded Caesarean sections. At $100
(US) per procedure this was a cost previously met, or not, by the
patient and their family. The final fun took the form of an end of
conference quiz, an intense competition necessitating Stuart and
Paul being placed amongst the crowd to police the delegates. At
the end of the conference we distributed memory sticks complete
with presentations and ensured one person from each hospital
received a stick.
I think we learnt a great deal about the practice of medicine in
another part of the world with a very different system and many
different stresses to our own. We also learnt a host of new skills
regarding teaching and interacting in a learning environment with
people of a different culture and language.
A river taxi
patients remained- having undergone repairs of cleft lip and palate
or removal of massive facial tumours. Not only debilitating, these
deformities may be considered a curse, resulting in ostracisation
from the community of the individual as well as their family.
Indeed, one very young patient’s strongest indication to operate
had been acceptance into the community. Despite his neurological
manifestations from which he would almost certainly die before his
1st birthday, his cleft lip and palate had been repaired with excellent
cosmetic result and he was recovering well. It was a touching sight
to witness the obvious joy of his mother now able to return and be
accepted in her community. We also met with Tony Giles and his
wife. Tony is a Maxillofacial surgeon who has worked on the ship
and in Africa for some time, performing amazing surgery on some
truly awful facial and oral tumours. They had many tales, both
devastating and inspiring from their time on the continent, and
an astonishing personal story of how this work had become their
lives. Prior to the conference we toured two local hospitals. HOMEL
(the women and children’s) Hospital was clean, well run, and
according to team members with first-hand experience, compared
favourably to hospitals in neighbouring African countries. Our visit
Anaesthesia News April 2012 Issue 297
The conference faculty
There is no doubt some truth in the idea that ‘you can’t solve a
problem like Africa’, and this may be worth preaching in the face,
for example, of the misguided donation of thousands of pounds
worth of anaesthetic machines for which no vapourisers are locally
available. However in the context of this forum, where there is an
obvious legacy of education I felt it unfair. After all we don’t often
‘change the world’ when we go to work at home in the UK; fixing one
individual’s hernia or even a coronary artery bypass truly only helps
one individual, much the same as any intervention in a developing
country. One difference with patients in the developing world is
they often have lived with their disfigurement or disability for much
longer. I suspect that this man had planned in advance to ask this
question and it was not a reflection of Keith’s opening presentation.
During my first presentation on Major Obstetric Haemorrhage, my
interpreter Vladimir surpassed all expectations with his excellent
grasp of English combined with sound anaesthetic knowledge, but
Anaesthesia News April 2012 Issue 297
There are many Medical
Schools
and
other
establishments in Africa for
the undergraduate teaching
of health care professionals.
There are Schools of
Anaesthesia, though less
of these. As a culture many
graduates work in rural areas
and as such postgraduate
teaching and continuing
professional development
for these individuals can
be hard to come by. The
feedback obtained told
us that our teaching had
been well received and on
appropriate subjects for
the delegates attending.
Conference cand
idates
using a bougie
to intubate
In summary we would wholly
recommend the experience of
teaching on a conference in
Sub-Saharan Africa.
Dr Emma Taylor
ST6, Wessex Deanery
19 AAGBI History SEMINAR
West of Scotland Subcommittee in Anaesthesia
ANAESTHETIC STUDY DAY:
IMPROVING PRACTICE
BSOA
and
Royal National Orthopaedic
Hospital Stanmore
Thursday 17 May 2012
Venue: Kelvin Conference Centre,
West of Scotland Science Park, Glasgow
TOPICS WILL INCLUDE: -
Perioperative Diabetes – implementing the 2011 NHS Diabetes Guidelines
Indications for a pacemaker and other serious arrhythmias
The role of Anaesthesia in recovery after orthopaedic surgery
Enhanced recovery after abdominal surgery and abdominal wall blocks
Critical Incidents and Simulation
Airway management
Perioperative renal protection
REGISTRATION FEE: £75
THIS STUDY DAY CARRIES 5 CME POINTS
Application forms and further information from:
Miss Lillian Cumming
Administrative Assistant (Courses)
NHS Education for Scotland
3rd Floor, 2 Central Quay
89 Hydepark Street
Glasgow G3 8BW
Telephone: 0141 223 1504
Fax: 0141 223 1480
Email: [email protected]
Orthopaedic Anaesthesia Update
Thursday 10th May 2012, RNOH Stanmore
5 External CPD points applied for
Career grade; BSOA Members £50.
Non members £75. Trainees £25
BSOA Membership £15, visit www.BSOA.org.uk
The Misuse of Anaesthetic
Agents through time
All anaesthetic agents have the potential for abuse as well as use. The abuse can be both criminal
and recreational and this seminar, timed to link-in with the current, temporary exhibition in the
Portland Place museum, explored all these aspects over the years.
An update on treatment for Sarcoma patients
DVT prophylaxis, new questions about treatment
Trauma – who cares?
New challenges of Spinal Procedures– pushing the boundaries
Legal implications of anaesthetic management for scoliosis surgery
An Update on TEG: are we using it to our best advantage?
Antifibrinolytics in modern orthopaedic anaesthetic practice
Management of spinal cord injury- what we need to know
Ultrasound guided blocks – challenges of modern practice
A paper that may change our practice
Further information please contact: RNOH Education Centre
Tel 020 8909 5326, email [email protected]
or register via our website www.rnoh.nhs.uk/courses
Royal National Orthopaedic Hospital, Stanmore, HA7 4LP
The RNOH has good transportation connections & free car parking
The Pain Relief Foundation
A registered charity funding research and education in chronic pain
CLINICAL MANAGEMENT OF CHRONIC PAIN COURSE
5-9 NOVEMBER 2012
An advanced practical course in clinical pain management for pain specialists and trainees with
some experience of treating chronic pain. Limited to 30 participants at The Pain Relief
Foundation, Liverpool, UK
Demonstration Clinics • Practical Pain Imaging • Case presentations • Practical Pharmacology
PMPs—How to assess and treat patients • Managing common pain problems
The Pain Clinicians Role in Palliative Care • Implants for Chronic Pain • CRPS Clinic
Demonstration Theatres • Setting up and running a pain clinic & PMP • Course dinner
FEE £850
Contact:
Mrs Brenda Hall, Pain Relief Foundation, Clinical Sciences Centre, University Hospital Aintree,
Lower Lane, Liverpool L9 7AL UK. Tel +151 529 5822 or
[email protected]
www.painrelieffoundation.org.uk
The first speaker was Alistair McKenzie
who took us back to the beginning…and
into the future. He traced the use and
abuse of drugs – from alcohol and opium
in antiquity to nitrous oxide and ether in the
19th century. Then he covered accidental
addiction in scientists and doctors, deaths
of patients under anaesthesia before the
introduction of measures to improve
safety, equipment hazards and human
error. Three aspects of the ‘dark side’ of
anaesthetic drugs were considered:
- legal (execution by lethal injection)
- illegal (suicide, murder and chemical warfare )
- questionable (euthanasia).
In the future, anaesthesia for cloning may
present an ethical minefield.
Anaesthesia News April 2012 Issue 297
Mark Harper then looked at the abuse
of chloroform over the years. In fact its
potential for use as an anaesthetic was
first recognised by a medical student,
Michael Cudmore Furnell, who tried it
recreationally, having been banned from
using and abusing ether. He explored
the origins and then dispelled the myth,
so popular in drama, that it could be
used to instantaneously render victims
unconscious. He then went on to describe
its role in murder, rape, auto-eroticism
and even Tintin taking in some interesting
tangents along the way.
Ann Ferguson described “Some Curare
Murders”. Of note, the Wheeldon case
was a misguided prosecution for alleged
attempted murder of the British prime
minister by curare in 1917. The Jascalevich
case involved multiple deaths of patients
at Oradell, New Jersey in 1965-66, curare
being found in exhumed bodies.
Roger
Maltby
investigated
some
“Mysterious Deaths at Ann Arbor VA
Hospital”. These consisted of a number
of related but unexpected crash calls
to patients who had suddenly stopped
breathing. It was the courageous effort of
Dr Anne Hill in the summer of 1975 that
led to identification of pancuronium in
the urine of patients who unexpectedly
arrested in ICU. However, it was never
established who deliberately injected the
pancuronium!
The afternoon started with another talk
21 Letter from America:
AAGBI History SEMINAR
The Misuse of Anaesthetic
Agents through time
A most fascinating book!
I just read a most fascinating book, “Laughing and Crying about Anesthesia: A Memoir
of Risk and Safety”, by Gerald Zeitlin, MD (2011) (LACAA). In the spirit of full disclosure,
Dr. Zeitlin and I worked as colleagues at my hospital starting in the 1980’s, and we have
remained good friends ever since. This book describes his journey through the world of
anesthesia over a career spanning almost five decades, but it is much more than the
details of a medical career; it is a book of powerful, and sometimes difficult, emotions.
from Professor Maltby entitled ‘Things are not always what they
seem” which had the subtext of how to fake a fall from a horse.
This described a case from the US where a husband murdered
his wife when they were out riding by injecting her with Sucostrin
(succinylcholine). When she was dead, he inflicted a head injury
on her and initially managed to convince the authorities that this
was the cause of death. However, this injury was not consistent
with a fatal outcome and a drug scan revealed a chromatographic
peak overlapped by the peak of succinylcholine. Then a second
autopsy revealed an injection site.
Professor Alan Dronsfield, a retired chemist (and president of the
historical section of the Royal Society of Chemistry) then gave us an
intriguing account of a propofol murder. Michelle Herndon was, by
all accounts, an extremely friendly and personable sports scientist.
Unfortunately she attracted the interest of a male ITU nurse who,
when she didn’t reciprocate his affections, administered a fatal dose
of propofol to her under the guise of helping her migraines. This
would never have been discovered were it not for the persistence
of the pathologist, Martha Burt. She noticed a tiny puncture
wound on the victim which led her to investigate more closely. The
murderer was eventually convicted on the basis of DNA from his
saliva on the needle sheath (from when he brought out the needle)
and the records from the electronic drug dispensing system
from the hospital where he worked. Next, Professor Aitkenhead
discussed the legal history of anaesthetic misuse. This led us from
the first inquest into death under anaesthesia (1847) through the
use of ether and chloroform for nefarious purposes in the 19th
century. Moving into the 20th and then 21st century he described
many Court cases of negligence, manslaughter, sexual assault and
murder involving various anaesthetic agents.
Ann Ferguson is both a retired anaesthetist and one of the judges
of the premier crime fiction prize, the Golden Dagger Awards.
She gave us a talk that encompassed the worlds of books and
medicine. She described the classes of murder seen in literature
(ranging from the usual, the unusual, the unbelievable and the
unacceptable) and the problems really good story-telling has
encountered since the advent of DNA testing in the last 20 years.
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Mark Harper then brought us right up to
date on the misuse of anaesthesia with an
account of the circumstances of Michael
Jackson’s death and the subsequent trial of
his personal physician, Conrad Murray. He
showed toxicology evidence that he must
have been given much more than the 25mg
of propofol that Murray claimed as well as the
extraordinary set-up he employed (see below
for a way not to administer propofol). In the
three months before Jackson’s death, Murray
had ordered over 11litres of propofol! As a
Propofol
side-show there was the battle between the
two expert witnesses Steven Shaffer (prosecution) and his former
mentor, Paul White (defence) which was as much a personal as a
legal and scientific battle in which the latter was always likely to
lose especially when confronted with the contradiction between
his previously published writings and his defence of Murray. In all,
it was a fascinating and enlightening day, that was greatly enjoyed
by everyone present.
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
Mark Harper, Consultant Anaesthetist, Brighton
Alistair McKenzie, Consultant Anaesthetist, Edinburgh
22 Dr. Zeitlin began his career in the UK, having attended medical
school at Oxford, training with Dr. Robert Macintosh and other British
anesthetic luminaries. He worked at the North Middlesex Hospital in
London, Whittington Hospital, Brompton Hospital, and other assorted
NHS venues. Very early in his career, after a brief (and most unpleasant)
exposure to ophthalmology, Dr. Zeitlin encountered much of what today
would be considered archaic anaesthetic practice, and unacceptable
behaviour. Iron lungs for respiratory care, spinal anesthesia without
IV access, and obstetrical hemorrhage without adequate blood bank
resources or uterotonic drugs were all common practices. Interpersonal
interactions that today would be considered unacceptable were
commonplace, and patient safety was a foreign concept. After several
years of various frustrations in the UK anaesthetic world, and urged by
colleagues and personal circumstances, Dr. Zeitlin travelled to the USA
in 1965 to work in anaesthesia in Boston, for what was ostensibly to be
a year-long stay, with every expectation of returning to the UK. However,
as we sit here today in 2012, Dr. Zeitlin has remained a Bostonian for
all these years! Did the NHS scare him away? Did the lure of American
practice keep him in USA? Or both? I think both.
Anaesthesia News April 2012 Issue 297
In Boston, Dr. Zeitlin practiced in every imaginable setting, including
large teaching hospitals, small ambulatory surgical centers, mid-sized
private practice groups, and operating rooms as well as ICUs. He
continued his tradition of working with the best of the best in the world
of anaesthesia, including American luminaries such as Leroy Vandam
and J. Ellison Pierce, founder of the patient safety movement. LACAA
describes all of these practice settings, but what permeates the book
and connects to the reader are the emotional aspects of this remarkable
career. Reading some of the cases described in the book, both during
the UK portion as well as the American, one can literally feel the tension
and emotional angst - we’ve all been there! As in a case of bleeding
oesophageal varices, and not knowing if the bleeding will ever stop. Or
dealing with a case of massive postpartum hemorrhage, with minimal
resources, an inexperienced obstetrician, and watching a new mother
almost die in front of you. Or the feeling of utter dread as you watch a
patient turn blue and then black from oxygen deprivation during a difficult
intubation, today of course replaced by the horrible gut-wrenching
sound of the change of the pulse oximeter tone as the oxygen saturation
declines to levels incompatible with life. All of these situations are
only made more difficult when dealing with totally uncooperative and
antagonistic surgeons. Much of the book compares UK and American
anaesthetic practice, and in particular UK and American personalities
- this I would call the laughing part of the title. Where are the quirkiest
people? Answer – it depends on your perspective, we both have our
Anaesthesia News April 2012 Issue 297
quirks. But the
message is clear – UK
anesthetists are probably a bit quirkier than
those in the USA. Or is this just the biased perception
of a Brit-turned-American? Let the reader decide! And who has the
most unusual operating rooms? A comparison is made between the
windows, or lack thereof, the temperatures (usually freezing), the
induction areas, the wall colours, and more, between UK and USA
operating rooms. I will not divulge the details, but the most unusual,
peculiar operating theatre the author has ever encountered is the
neurosurgery room at the Whittington Hospital in London. Read the
book for details! Of course any American (with our traditional 7:30am
surgery start times) will be jealous of Dr. Zeitlin’s fond recollections of
a leisurely 9:00am start in the UK.
As the book draws to a close, we learn of the real emotional turmoil
resulting from this author’s career in anaesthesia – this I would call
the crying part of the book. Dr. Zeitlin is quite open about the various
medical problems that have plagued him for the last several decades,
including heart issues (a bypass, multiple stents, pacemakers, but
still going strong), and major depression (including the medical and
electrical treatment thereof) that eventually resulted in his leaving
clinical practice. Was the depression caused by his anaesthetic career
and the trauma he witnessed? Or was it an “incidental” finding? The
reader is challenged to ponder some questions: Are anaesthetists
particularly prone to psychiatric problems? Or are physicians with a
tendency toward psychiatric issues drawn to a career in anaesthesia?
Perhaps a little of all is true, but this book will make the reader think –
think about your practice, think about your choices in life, think about
patient safety, even think about what you think about during a boring
case when there is nothing to think about. You will also be forced to
confront the signs that maybe your career should draw to a close. How
do we know when it is time to retire? Are we all as observant as Dr.
Zeitlin to know when either medical or emotional issues are affecting
our ability to deliver proper patient care? I think many of us live in too
much of a state of denial to ponder such matters. Perhaps the author
of this book thinks too much. Perhaps we all think too much. Or maybe
we don’t think enough. Maybe we’d be better off if we all, as the kids
say today, chillax. In any case, this book is a fascinating exploration of
a remarkable anaesthetic career, and provides an insightful view into
the inner workings of our specialty. Read it!
William Camann, MD
Brigham & Women’s Hospital, Boston, USA
23 THE Out of Programme Experience:
Life as a fellow
down under
My interest in undertaking a fellowship abroad started early on in my anaesthetic training.
As a senior house officer in the West Midlands, I would listen with considerable interest
to senior registrars discussing their various plans to travel and work abroad. One such
registrar had organised a fellowship in the US. Although she turned her work and family
life upside down, I thought that doing this would be an interesting experience!
There were numerous reasons for choosing a fellowship in Melbourne,
Australia. Namely, I have a strong interest in anaesthesia for trauma,
head and neck surgery and major general surgery. The Alfred Hospital
is a tertiary referral centre, and all surgical specialties are performed
with the exception of paediatrics and obstetrics. The hospital is also
the state burns and trauma unit, as well as the state cardio-thoracic
transplantation centre. The above reasons, along with our interest to
travel to an unseen country, cemented our decision.
Although this is considerably shorter than the UK system, it offers
many advantages. Principally, having a shorter more intense training
programme focuses the trainees. With the advent of the EWTD and
a considerable reduction in working hours, the case numbers of UK
anaesthetists have decreased significantly. Australian trainees on the
other hand, are still working longer hours, with less mandatory ‘off’
days. The result being that anaesthetic case numbers would be roughly
on a par in the two groups.
The General Anaesthetic Fellowship at the Alfred Hospital commenced
in February. I started work within a couple of days of flying out to
Melbourne. The first striking observation was how incredibly friendly
and down-to-earth everyone seemed to be. From the Professor of the
department to the anaesthetic secretaries, they were all warm and
inviting. I was instantly made to feel at home - which is so important
when you are thousands of miles away from your true home.
One advantage with the structured modular training programme in the
UK is having a sense of completeness with a particular anaesthetic
sub-speciality. The requirement of maintaining a logbook is also useful,
both in the short and long term. The disadvantage of such a rigid
system means that a trainee can get particularly experienced with a
sub-speciality, and then may have no exposure to that field for another
three years.
The Australian training system in not too dissimilar from ours in the UK.
Trainees were mostly from Monash University, and had undergone 5
years of medical school training, after which they did their compulsory
intern year. The subsequent one to three years could be spent in
rotations or out of training positions, after which time they apply to
commence a registrar training programme.
Compulsory anaesthetic training in Australia
is a total of 5 years; two years shorter than
the UK. Australian trainees are made
to sit both the primary and final exams
during their five year training period.
The main difference in Australia is that whilst it lacks such structure,
trainees are expected to anaesthetise for a variety of different subspecialties on a day to day basis. For instance vascular day one,
cardiac day two. This keeps trainees on their toes, and channels them
to giving a more academic anaesthetic whilst also allowing them to
tailor their anaesthetic. I feel that they may be at a disadvantage with
such a constant change as younger more inexperienced trainees may
not get a ‘good handle’ on each sub-speciality until later in their training.
They may also not be exposed to as wide variety of cases in each subspeciality as the UK.
Supervision of all trainees ranging from the first year registrar to the
most senior trainees was commendable. All trainees and fellows were
doubled up with a consultant colleague for the vast majority of the
week. This was especially apparent in the first few weeks of the year.
As familiarity with the hospital environment grew, trainees were placed
on independent lists. At all times, a consultant-in-charge ‘CIC’ was
available, to discuss any challenging cases, administrative issues
or any other problems. One could argue that senior trainees were
‘over supervised’, however in most instances we were still given the
autonomy to manage our own anaesthetic.
If a trainee or fellow were placed on their own theatre lists, provision
was almost always made to have tea breaks and lunch. There were
only a handful of occasions where trainees and fellows were made to
stay late if they were not on-call.
Obviously having flexibility in the system does positively affect work-life
balance. If trainees or fellows know that they will be relieved of duties
when not on-call, they are more likely to have a better work ethic. As do
UK trainees, Australian trainees work very hard. There is a work-hard
play-hard atmosphere. Whilst it is expected they put in long hours –
and they do, 24 hour on-calls for fellows with the next day off- they
are also expected to relax and pursue extra-curricular activities during
their time off. I haven’t met such a large group of anaesthetists who
regularly participate in tri-athlons, marathons and cycling events since!
Trainees at the Alfred are also strongly encouraged to pre-operatively
assess their patients the day before. This reduces the incidence of any
surprises on the day of surgery, whilst also encouraging the trainee to
read any relevant current literature. Patients in the UK commonly arrive
the morning of an elective case thereby limiting trainees somewhat.
However, better provision could be made here in raising awareness of
theatre lists and cases in advance.
The case-mix at the Alfred Hospital was varied, ranging from highly
complex patients with multiple co-morbidities to the straightforward
patient needing an appendicectomy.
As a general fellow, I gained experience in most fields of anaesthesia
including trauma anaesthesia, anaesthesia for major general surgery
(including liver resection), vascular anaesthesia, neurosurgical
anaesthesia and anaesthesia for major ENT surgery. I also had the
opportunity of rotating to the Royal Victorian Eye and Ear Hospital for
8 weeks, where I became extremely proficient with various eye blocks.
During this time, there were also many opportunities to visit local cafes
and enjoy sitting in the numerous public gardens that Melbourne has
to offer!
early on and potential complications can be rectified prior to them
coming to theatres. Theoretically this could mean fewer cancellations
and more holistic care. For instance, chronic pain patients could be
identified as potentially difficult to manage peri-operatively, and could
be seen by pain anaesthetists pre-op as a result of being seen in the
pre-assessment clinic.
Anaesthetic teaching is another matter taken seriously at the Alfred
Hospital. A weekly Friday afternoon teaching session is held and
all are expected to attend. Anaesthetic Registrars and Fellows have
the opportunity of presenting clinically relevant and topical subjects.
Teaching is facilitated by a consultant anaesthetist and importance is
placed on evidence based medicine.
A mandatory tea break ensues, whereby a junior registrar is rostered
to bring in cakes for the rest of the department. This lightens the
atmosphere and facilitates camaraderie amongst trainees and
Consultants. A weekly ‘blue sheets’ follows on from the registrar
teaching. This is a less formal weekly morbidity/ mortality meeting
where relevant cases are presented by a consultant or trainee to
the rest of the department in a non-threatening manner. This weekly
‘blue-sheets’ allows for many junior trainees to listen and learn from
others without feeling judged or blamed. I think modelling this in the
UK would have many advantages and promote less of the ‘blame
culture’ which tends to occur.
Friday afternoon sessions end with a visit to the local ‘Belgian beer
garden’ where you can sit back, relax and wait for the weekend to start!
Despite only having five weeks of annual leave compared to 33 days
in the UK, there was more than enough time to travel and sightsee. We
spent many weekends visiting local attractions in Melbourne as well as
day trips around Victoria, including sampling the wineries in the Yarra
Valley. We travelled to Sydney, the Blue Mountains, Cairns, and Port
Douglas. We drove through the Great Ocean Road and visited the
Twelve Apostles. We had the chance to dive in the Great Barrier Reef
too– all with a small baby in tow! We had the opportunity of making
many new life-long friends who we will keep in touch with.
Overall, it was a tremendously enjoyable
experience – one which I would recommend
any trainee to apply for in the future.
Dr Anjalee Brahmbhatt,
ST7 Anaesthetics,
Norfolk and Norwich Hospital
In addition, I was exposed to obstetric anaesthesia at Sandringham
Hospital, a District General Hospital, where we functioned as a junior
consultant on-call. The Sandringham Hospital provides care to the
local community. However, one major contrast from the UK was our
ability to provide obstetric anaesthetic care from home! I was surprised
that despite there being multiple major teaching
hospitals in the near vicinity, some patients still opted
to deliver their babies in an environment with no
PICU or ICU facilities. The anaesthetic department
at the Alfred has a very dynamic research unit. I
had the opportunity to successfully complete a
16-week course in Peri-operative medicine there,
run in conjunction with Monash University. The
recognition that surgical patients are becoming
older with the ever increasing aged population,
more unwell and increasingly complex, has led
to more thorough pre-operative anaesthetic
management plans. Various clinical specialities
can be involved pre-operatively leading to better
patient care and outcomes. The advantage
of having pre-anaesthetic clinics means that
trouble shooting problematic patients can occur
Twelve Apostles, Great Ocean Road
, Victo
Great Barrier Reef
with a small baby in tow
!
ria, Australia
24 Anaesthesia News April 2012 Issue 297
Anaesthesia News April 2012 Issue 297
25 Particles
C Challand, R Struthers, J R Sneyd, PD Erasmus, N Mellor, K B Hosie, G Minto
Randomised controlled trial of intraoperative
goal-directed fluid therapy in aerobically fit and
unfit patients having major colorectal surgery
British Journal of Anaesthesia 108 (1) 53-62 (2012)
Perioperative fluid management for elective major colorectal surgery
continues to be controversial.1 National Institute for Health and Clinical
Excellence (NICE) guidelines recommend individualised Goal-Directed
Therapy (GDT) through the optimisation of stroke volume(SV) to optimise
cardiac output and oxygen delivery, using e.g. the Oesophageal Doppler
Monitor.2 The authors of this study set out to validate a simplified intraoperative GDT algorithm which places emphasis on SV maximisation3, and
investigated whether this could reduce the surgical readiness to discharge
(RtD) time and complications, in patients with both poor and good aerobic
fitness as assessed by cardiopulmonary exercise testing (CPET).
Methods
179 patients were recruited for this double-blind randomised controlled
trial. All patients had open or laparoscopic major colorectal surgery.
Pre-operatively they were characterised as aerobically ‘fit’ based on the
results of CPET (Anaerobic Threshold AT >11.0 ml O2/kg/min) (n=123),
or ‘unfit’ (AT 8.0-10.9 ml O2/kg/min)(n=52). Patients with AT <8 ml O2/
kg/min were excluded from the study. Patients were then randomised
to receive a standard fluid regimen (n=90) with or without oesophageal
Doppler-guided intraoperative GDT (n=89). Perioperative care followed
the principles of enhanced recovery.
Results
The patients in both groups received similar volumes of crystalloid (17ml/
kg/hr), however the GDT group had an average of 1360 mls of additional
colloid, as per the protocol. The mean cardiac index and SV at skin
closure were significantly greater in the GDT group compared to the
control group. Median times for RtD and length of stay (LOS) were 2 days
longer in the GDT group compared to control but this was not statistically
significant (6.8 vs. 4.9 days; p=0.09, 8.8 vs. 6.7 days;p=0.09). However
fit patients in the GDT group had an increased RtD and LOS compared to
controls (median 7.0 vs. 4.7 days;p=0.01, median 8.8 vs. 6.0 days p=0.01
respectively).
Conclusions
In contrast to previous studies, and contrary to expectations, GDT and
intraoperative optimisation of SV did not improve RtD or LOS compared
to standard fluid regimes in this cohort of patients. In the subgroup of
aerobically fit patients the GDT had a disadvantageous effect on RtD
and LOS. However the trial was not powered to compare outcomes of
medically fit and unfit patients and there was no blinding to the results of
the CPEX. Although the principles of enhanced recovery were followed4,
there was no definitive protocol for intra-operative fluid management, and
17mls/kg/hr crystalloid given by anaesthetists is greater than in previous
studies. More research is needed to define ‘high-risk’ surgical patients and
the surgical procedure needs to be clearly defined (open vs. laparoscopic,
rectal vs. colonic) in order to fully assess the benefits of GDT in these
cohorts.
3.
4.
Bellamy MC. Wet, dry or something else? Br J Anaesth 2006; 97: 755-7
Available
from
http://www.nice.org.uk/nicemedia/live/13312/52624/52624.pdf
(accessed April 1, 2011)
Available from http://deltexmedical.com/downloads/clinicaleducationguides/CQ_
OR_QRG9051_5309_3.pdf (accessed March 17, 2011)
Kehlet H. Fast-track colorectal surgery. Lancet 2008;371:791-3
Sarah Barnett
SpR Anaesthesia,
North Central London Rotation
26 Evidence-based management of postoperative pain
in adults undergoing open inguinal hernia surgery
British Journal of Surgery Volume 99, Issue 2, pages 168–185, Feb 2012
Pain after open hernia surgery can be moderate to severe and may be associated with prolonged
hospital stay, unanticipated hospital admission and delayed return to normal daily activities1,
2
. There is some suggestion that inadequately treated postoperative pain may be a risk factor
for persistent pain after hernia surgery3. Multiple approaches have been used to manage pain
after hernia surgery, but optimal evidence-based pain therapy remains unknown. Recently,
the European Hernia Society published guidelines on treatment of inguinal hernia in adult
patients and local anaesthetic (LA) postoperative pain management techniques were preferable,
however, multimodal analgesia techniques were not evaluated4. The authors of this article
evaluated the available literature on the management of pain after hernia surgery. Postoperative
pain outcomes (pain scores and supplementary analgesic requirements) were the primary focus
of this review.
Methods
The authors conducted a systematic review of literature in Embase and MEDLINE between
January 1966 and March 2009, concerning analgesia after inguinal hernia. Randomized
controlled trials assessing analgesic and anaesthetic interventions in adult inguinal hernia
surgery, and reporting pain on a linear analogue, verbal or numerical rating scale, were
included. Laparoscopic inguinal hernia repair was excluded.
The criteria used to assess the quality of eligible studies included: 1. Statistical analyses and patient follow-up assessment. 2. Allocation concealment assessment indicated whether there was adequate prevention of
foreknowledge of treatment assignment by recruiters.
3. Numerical scores for study quality were assigned to indicate whether a study reported
appropriate randomization, double-blinding and statements of possible withdrawals.5 4. Assessment of how closely the study report met the requirements of the Consolidated
Standards of Reporting Trials (CONSORT) statement6.
Summary information for each included study was extracted and recorded in data tables. This
information included pain scores, supplementary analgesic use, the time to first analgesic
request, functional outcomes and adverse effects. The effectiveness of each intervention for each
outcome was evaluated qualitatively, by assessing the number of studies showing a significant
difference between treatment arms (P<0·050 as reported in the study publication). Current
clinical practice information was also taken into account, in addition to procedure-specific and
transferable evidence, to ensure that the recommendations had clinical validity.
Results
A total of 334 studies of analgesic interventions in adult hernia surgery were identified, of which
79 were included in the systematic review. Pharmacological interventions showed that NSAIDs
reduced postoperative pain scores as well as reducing the need for supplementary analgesia.
Local anaesthetic (LA) use via field block and wound infiltration reduced post op pain and the
use of supplementary analgesics, as well as for extending the time to first analgesic request.
LA instillation in the surgical wound at the end of surgery reduced pain scores and showed
little difference if infiltrated preoperatively. However, preoperative field block and instillation
at wound closure showed similar pain scores and supplementary analgesia use. Continuous
LA infusion showed benefit in providing a longer duration of analgesia. Quantitative analysis
suggested that regional anaesthesia (RA) was superior to general anaesthesia (GA) for reducing
postoperative pain. Spinal anaesthesia (SA) was associated with a higher incidence of urinary
retention, reduced PONV and increased time to home-readiness compared with RA.
Discussion Field block (ilioinguinal, iliohypogastric and genitofemoral nerve blocks) with, or without
wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to GA, is
recommended to reduce postoperative pain following hernia repair. Continuous LA infusion of a
surgical wound provides a longer duration of analgesia and should be considered. Conventional
NSAIDs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol are optimal
with opiods available on request. However, subfascial LA infiltration and subcutaneous
infiltration cannot be recommended because of limited data. Also, the analgesic efficacy of
preoperative LA administration was comparable to that of postoperative administration. Wound
instillation with LA and postoperative repeat wound injections did not provide any significant
benefit and are not recommended. Addition of clonidine, dextran, steroids, NSAIDs, opioids
or adrenaline to LA solution for wound infiltration is not recommended because of limited
analgesic benefit. RA techniques are recommended because they provide superior pain
relief and additional recovery benefits. If RA is not possible/appropriate, GA is preferred over
neuraxial anaesthesia (SA or epidural). Although SA provides excellent surgical anaesthesia and
early postoperative analgesia, potential limitations (delayed ambulation and urinary retention)
could impact on discharge after ambulatory surgery4. Paravertebral block is not recommended.
References
References
1.
2.
G. P. Joshi, N. Rawal, H. Kehlet
1.
2.
3.
4.
5.
6.
Natasha Campbell
ST4 Anaesthetics,
South London Rotation
Callesen T, Bech K, Nielsen R, Andersen J, Hesselfeldt P, Roikjaer O et al. Pain after groin hernia
repair. Br J Surg 1998; 85: 1412–1414.
Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin
North Am 2005; 23: 185–202.
Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J et al. Predictive risk
factors for persistent postherniotomy pain. Anesthesiology 2010; 112: 957–969.
Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G,Conze J et al. European
Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009;
13: 343–403.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ et al. Assessing the
quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;
17: 1–12.
Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I et al. Improving the quality of
reporting of randomized controlled trials. The CONSORT statement. JAMA 1996; 276: 637–639.
Anaesthesia News April 2012 Issue 297
Dubost C, Le Gouez A, Zetlaoi PJ, Benhamou D, Mercier FJ
and Geeraerts T.
Increase in optic nerve sheath diameter induced
by epidural blood patch: a preliminary report
British Journal of Anaesthesia 2011; 107(4):627-30
Background
The incidence of post-dural puncture headache (PDPH) is estimated
at 0.5% in obstetric anaesthesia1. The most effective treatment remains
lumbar epidural blood patch (EBP). One of the proposed mechanisms
of action is that injection of blood around the dura mater leads to
symptom relief by an increase in intracranial pressure (ICP). MRI
studies also suggest CSF hypovolaemia is involved in PDPH pathology.
Changes in CSF pressure can be transmitted along the optic nerve
sheath2. Several studies have shown that optic nerve sheath diameter
(ONSD) measured non-invasively using ultrasound correlates well with
invasive ICP measures in a variety of clinical situations3.
Aims
This study is the first human study investigating the changes induced by
EBP on ICP, using ONSD as a surrogate marker of ICP.
Methods
Ten subjects were enrolled in the study. Subjects were all referred to
an anaesthetist following failure of symptomatic PDPH to respond to
medical treatment. Pain scores and ONSD were recorded pre- and postEBP at a total of four time points. With the patient supine, a 7.5Mhz
ultrasound probe was applied over closed eyelids. ONSD was measured
3mm behind the globe in two planes. EBP was considered successful if
pain was relieved with a pain score <4/10.
Results
EBP was clinically successful in nine subjects. A mean volume of 24.1ml
was injected. Median pain scores decreased from 6.5/10 at baseline to
0/10 at two and 20 hours. In subjects in whom EBP was successful,
ONSD significantly increased from baseline at 10 minutes and two
hours post-EBP, and remained increased after 20 hours. In the subject
in whom EBP failed, there was only a small non-sustained increase in
ONSD post-EBP. There was no difference in baseline ONSD values in
subjects with successful versus failed EBP.
Conclusions
This study supports an increase in ICP as the therapeutic mechanism
behind successful EBP. Success of EBP was accompanied by a substantial
increase in ONSD (as a surrogate marker of ICP), whereas in a single
case, failure was not. The authors suggest EBP effectiveness is due to
an immediate transient “tamponade” effect followed by a longer term
“sealing” effect on the dura by injected blood, preventing CSF leak.
They propose that the immediate increase in ONSD in this study was
due to tamponade, and the sustained ONSD increase over 20 hours,
due to progressive correction of ICP with CSF production.
Dr Zoë A Smith
CT2 Anaesthetics,
Queen Alexandra Hospital, Portsmouth
References
1. Van de Velde M, Schepers R, Berends N, Vandermeersch E, De
Buck F. Ten years of experience with accidental dural puncture and
post-dural puncture headache in a tertiary obstetric anaesthesia
department. Int J Obstet Anesth 2008; 17: 329-35
2. Hansen HC and Helmke K. The subarachnoid space surrounding
the optic nerves. An ultrasound study of the optic nerve sheath.
Surg Radiol Anat 1996; 18: 323-8
3. Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial
pressure detected by bedside emergency ultrasonography of the
optic nerve sheath. Acad Emerg Med 2003; 10: 376-81
Guidelines for Performing Ultrasound Guided
Vascular Cannulation: Recommendations of the
American Society of Echocardiography
Anesthesia & Analgesia Volume 114(1), January 2012, p46-72
Over the past ten years the use of ultrasound guided techniques for
vascular access has become widespread. This review article uses PubMed
and Medline to review the current literature on the use of ultrasound and
whether it reduced complications. In the United Kingdom evidence that
the use of ultrasound imaging before or during vascular cannulation greatly
improves the first-pass success and reduces complications means it has been
incorporated into recommendations from the National Institute for Health
and Clinical Excellence.1
Ultrasound is available in different modalities and the addition of Doppler
colour flow to two-dimensional images can help confirm presence and
direction of blood flow. Higher frequency probes are preferred for viewing
vascular structures even though they will have poorer penetrance for deeper
structures.
Appreciating how probe orientation relates to image display is fundamental
– for example when cannulating the internal jugular vein it is usual to stand
behind the patient whereas when accessing the femoral route it is usual to
stand facing the patient. Therefore it is essential to check that the probe is
held the correct way around to orientate the user to the image on the screen.
Ideally ultrasound guidance is best used in real time with a sterile cover
rather than to simply check the anatomy.
Vessel identification can be done using anatomical and morphological
characteristics to distinguish a vein from an artery with 2-D ultrasound.
A Trendelenberg position should be used and a Valsalva manoeuvre will
augment the venous diameter, which is especially useful in hypovolaemic
patients. Misidentification of the vessel is a common cause of arterial
puncture and therefore use of ultrasound is no replacement for anatomical
knowledge of the relative positions of the vein and artery to each other at
each anatomical site.
This review suggests a clear advantage of ultrasound guidance over landmark
technique for internal jugular central venous cannulation. Troianos et al
describes the first attempt success rate being improved from 54% to 73%
with the use of ultrasound.2 However review of the current literature does
not necessarily support the use of ultrasound in uncomplicated subclavian
vein cannulation, but more high risk patients (especially those with BMI
>30 or coagulopathy) may benefit from screening of the vessel to identify
the vessel location and patency. Similarly the evidence for using real time
ultrasound for femoral vein cannulation is not as strong as for the internal
jugular site. It is noted though that scanning pre-procedure to identify the
relative anatomy of the femoral artery and vein is useful.
The use of ultrasound for arterial cannulation is also reviewed and although
first-attempt success rates are improved compared to using palpation
technique alone, routine use is not currently recommended. Similar advice
is given for peripheral cannulation although the use of ultrasound may help
identify the presence, location and patency of peripheral veins for cannulae
or PICC lines.
From the evidence available it is generally accepted that to gain sufficient
knowledge and the required dexterity a trainee needs to perform ten
ultrasound guided vascular access procedures under supervision to
demonstrate competence to practice independently.
Jennifer Price
SpR Anaesthesia,
North Central London Rotation
References
1.
2.
Anaesthesia News April 2012 Issue 297
National Institute for Health and Clinical Excellence. NICE Technology
Appraisal No 49: guidance on the use of ultrasound locating devices for
placing central venous catheters. Available 2011.
Troianos CA, Jobes DR, Ellison N. Ultrasound guided cannulation of the
internal jugular vein. A prospective, randomised study. Anesth Analg
1991; 72:823-6
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Anaesthesia News April 2012 Issue 297
The Editor, Anaesthesia News at
[email protected]
Please see instructions for authors
on the AAGBI website
Dear Editor
Anaesthesia Training: It’s a piece of cake
Frenchay Anaesthetic Department in Bristol is a popular attachment for trainees
within the South West region, with consistently high performance in national
training surveys1,2.The Severn Deanery expects high standards of trainees and their
CVs at completion of training often reflect this. It is therefore difficult for trainees
to stand out amongst their peers. We have hit upon a novel way of improving this
and preparing trainees for life as consultants. As part of the national drive towards
a consultant based service we introduced a departmental ‘Bake-Off” designed to
meet Departmental Daily Cake Targets and to introduce an Enhanced Recovery
Scheme for tired anaesthetists on their allocated coffee breaks. We have applied
for recognition of this activity for Cake Proficiency Development (CPD) and it will
form a significant part of Succulent Pastry Acquisition (SPA) time in the consultant
job plan.
Following the success of the consultant programme trainees are encouraged
to join a separate competition designed to be compliant with Royal College
Guidelines on Workplace Based Assessments. Initial competence is assessed
using the standard DOPS (Direct Observation of Pastry Skills) form. Progression
is confirmed with completion of mini-CAKES and final assessment is through a
Cake Based Discussion (CBD).
Following a recent sitting of the European Diploma in Intensive Care the Frenchay
Anaesthetic Departmental Bake Off received international acclaim and accolades
for its rigorous quality control. The scheme is in line with current government
policy to increase competition within the NHS, and we have been able to achieve
this without resorting to commissioning (spouse-baked) or outsourcing (shopbought) cakes. We would strongly advise any department wishing to adopt a
similar system to also actively encourage a ‘Cycle to Work’ scheme to offset the
increased calories consumed.
Dr Abigail Lind
Specialist Trainee in ICU and Anaesthesia, Severn Deanery
Dr Jules Brown
Consultant in ICU and Anaesthesia, Frenchay Hospital, Bristol
Dr Ben Walton
Consultant in ICU and Anaesthesia, Frenchay Hospital, Bristol
Dear Editor
Warning! Concerns of a first year core trainee
I would like to express a few concerns of my own regarding the article
“Warning!” Concerns of a first year core trainee” in February’s edition of
Anaesthesia News. The aim of the article appears to be to highlight when
to consult with a senior colleague if a clinical scenario exceeds one’s skills
or knowledge. Whilst I agree that the article may indeed illustrate this point,
I have concerns with the subsequent handling of the scenario, particularly
that the manner in which it is portrayed might suggest that this is standard
anaesthetic technique or even that it is within the remit of CT1 trainee. To
summarise the case as presented, a young elective patient with a raised BMI,
significant history of reflux and severely restricted mouth opening appears to
have been assessed by an extremely junior trainee.
An anaesthetic was then constructed using two opioids concurrently, an
induction agent which is known to increase mortality and muscle relaxant of
variable efficacy. With no mention of how the airway was maintained, a nasal
intubation was achieved despite “significant” epistaxis.
I do not believe that this in any way reflects an appropriate description of the
anaesthetic options (including awake fibreoptic intubation) which should
have been discussed by the consultant in charge of the case with the patient
preoperatively. It does not examine the possible hazards of the chosen
technique, particularly the risk of encountering a “Can’t intubate, Can’t
ventilate” scenario and the plan for managing it. I also am surprised at the
need to add further agents to an already complicated induction regimen in
order to achieve “neuroprotection”. Whilst there are many ways to provide
an anaesthetic, I do not feel that this article, which is aimed at very junior
trainees, provides a model by which they should base their practice and may
actually encourage them to undertake what would (in their hands) likely be
a hazardous non-standard technique 1.
Your sincerely
Alastair Rose
Consultant in Anaesthesia & Intensive Care,
Pinderfields Hospital, Wakefield
(1) Difficult Airway Management. Chapter 5 “Management of the anticipated
difficult airway: without clinical upper airway obstruction”. M Popat. OUP 2009
Editor’s note: We did not intend to endorse the technique described nor
suggest that this would be a suitable case for a junior trainee except under
direct supervision of a consultant. We would encourage trainees to ask their
seniors to explain the rationale behind the techniques used especially if they
are non-standard.
Dear Editor
Vit D deficiency
It started off a year ago, when even simple procedures like intubation or
inserting central lines would cause severe back ache, and regular intensive
care ward rounds caused excessively tiredness. I initially attributed this to
general tiredness, stress, lack of rest or my erratic vegetarian diet.
But when things went from bad to worse, I consulted my GP who discovered
my vitamin D levels were 4nm/L [normal levels 50-120nm/L]. Vitamin D
deficiency may be a particular hazard and a growing problem, albeit not
discussed much. As trainees we spend time most of the time in theatres, and
with our odd shifts, we may be particularly prone to this defficiency. It is
also more common among dark skinned people, vegetarians, and pregnant
women. Vitamin D deficiency has been associated with osteoporosis,
depression, heart disease, stroke, cancer, diabetes and depressed immune
function With the incidence increasing this is a potential hazard we should
be very much aware of.
1.GMC Trainee Survey 2011 Severn Deanery North Bristol NHS Trust
http://www.severndeanery.nhs.uk/deanery/quality-management/surveys/gmc-trainee-andtrainer-surveys/2011-gmc-trainee-survey/
Dr R Kulkarni
ST6 Anaesthetics and ICM, RCSH
2. Severn Deanery End of Placement Survey Results 2010. http://www.severndeanery.nhs.
uk/deanery/quality-management/surveys/deanery-end-of-placement-surveys/2010-deaneryend-of-placement-survey/
Dr Chinmayi D N
ST1 Paediatrics, East Midlands Deanery
Anaesthesia News April 2012 Issue 297
29 Day 1: Cadaveric Course Thursday 19th July 2012
th July2012
Day• 1: Cadaveric CourseCOURSE
Thursday 19July
2012
Cadaveric Anatomy of Upper and Lower Limbs, Trunk & Neuraxis
• Cadaveric Anatomy of Upper and Lower Limbs, Trunk & Neuraxis
• Volunteer Ultrasonography
Day
Cadaveric Course Thursday 19th July 2012
• 1:
Volunteer Ultrasonography
• Cadaveric Anatomy of Upper and Lower Limbs, Trunk & Neuraxis
Day •2: Peripheral Nerve Block Course Friday 20th June 2012.
Volunteer Ultrasonography
Day• 2: Peripheral Nerve Block Course Friday 20th June 2012.
Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
• Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
• Needling Techniques on Phantoms
Day
Peripheral Nerve Block Course Friday 20th June 2012.
• 2:
Needling Techniques on Phantoms
• Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
Department of Anatomy and ASSET Centre, University College
• Ireland.
Needling
Techniques
Phantoms
Department
of Anatomy
andonASSET
Centre, University College
Cork,
Cork, Ireland.
Course
fee: € 250
per day;and €ASSET
450 forCentre,
2 days University College
Department
of Anatomy
Course
fee:
€ 250
per day;
€ 450
for 2 days
(10%
to ESRA
and ESA
members)
Cork,discount
Ireland.
(10% discount to ESRA and ESA members)
7Course
CME points
College
Anaesthetists of Ireland
fee: €per
250day
perawarded
day; by
€ 450
for 2ofdays
7(10%
CME discount
points pertoday
awarded
College
of Anaesthetists of Ireland
ESRA
and by
ESA
members)
Approval pending for ESRA Diploma on Regional Anaesthesia
Approval
pending
Diploma
on Participants
Regional
Anaesthesia
Strictly
Limited
to 30
7 CME points
perfor
dayESRA
awarded
by College
of Anaesthetists
of Ireland
Strictly Limited to 30 Participants
Approval pending for ESRA Diploma on Regional Anaesthesia
For further information and application form, please contact:
Strictly Limited to 30 Participants
Dr. Brian
O’Donnell
For further information
and application
form, please contact:
Dr. Brian O’Donnell
Anaesthesia News
13th CORK CADAVERIC &
13th CORK CADAVERIC &
PERIPHERAL NERVE BLOCK
PERIPHERAL
NERVE BLOCK
13th CORK
CADAVERIC
COURSE
July 2012 &
COURSE
July 2012BLOCK
PERIPHERAL NERVE
Department of Anaesthesia, Cork University Hospital, Cork, Ireland
For further information and application form, please contact:
E-mail:
[email protected]
Department
of Anaesthesia, Cork University Hospital, Cork, Ireland
Dr. Brian O’Donnell
E-mail:
Tel: [email protected]
21 4922135 Fax: +353 21 4546434
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Lecture topics include:
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| Multiple streams of lectures | Debates | Hands-on workshops | Industry exhibition
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GLASGOW
Wed 27th Fri 29th June
2012
the best trainee scientific meeting of 2012!
VENUE: GRAND CENTRAL HOTEL, GLASGOW
The programme has been completely redesigned and
updated with parallel scientific sessions to fulfill your
educational needs for all stages of your training.
Sessions to include:
Advanced ventilation • Depth of anaesthesia monitoring
• Airway and ultrasound • Clinical updates on core topics for exams
Workshops to include:
Interview preparation • Getting research published
• Organising a year abroad
Plus the annual keynote lectures, local and nationally renowned
speakers, competitions and a world famous social programme...
AND MUCH MUCH MORE!
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Closing date for Oral and Poster Abstracts: 23 April 2012
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aes
thetists
Book your
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Members flat fee of
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Non members rate £300
* There will be a nominal fee for the bigger workshops