Here - aagbi

Transcription

Here - aagbi

The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
INSIDE
THIS ISSUE:
The WISE
Anaesthetic Cup
Arterial line safety
– can we do better?
Brugada syndrome:
resources for the
anaesthetist
Teaching primary
trauma care in
Mozambique
ISSN 0959-2962
No. 337
AUGUST 2015
Editorial
Contents
03Editorial
05 President's Report
Once again the honour of writing an
editorial falls upon this still-new Council
Member. Producing good material is
always a challenge, and I hope you will
enjoy the articles selected for this issue.
07 The WISE Anaesthetic Cup
07
09
First I would draw your attention to two events for which your generous
donations are sought. At this year’s AAGBI Annual Congress in Edinburgh,
there will be a football tournament contested between AAGBI members
from Wales, Ireland, Scotland and England. This event demands an
acronym, like every other medicine-related term, and so the victors will
receive the WISE Anaesthetic Cup. Proceeds will go towards Lifeboxes
for Rio and help to provide pulse oximeters to hospitals in need in Africa.
In addition, from 17th to 21st September, volunteers will be cycling from
the AAGBI headquarters, 21 Portland Place, London, to the Edinburgh
International Conference Centre. Your donations can be offered via the
Lifeboxes for Rio section of the AAGBI website. Alternatively, you can set
up your own ‘My Donate’ facility, with reference to aagbi.org, then donate
the proceeds to Lifeboxes for Rio. Further details can be found here –
http://www.aagbi.org/about-us/fundraising/cycle/routes-and-information
Meanwhile, the SAFE Programme goes from strength to strength, and
teaching is now offered in many Francophone countries. Support for the
delivery of this is given by the AAGBI – via the International Relations
Committee (IRC) – which is important and valuable. Grants are available to
those willing to give up their time, pending approval by the IRC. It behoves
us to help improve the standard of worldwide anaesthesia if we are to be
considered ‘worth our salt’.
Visionary.
Bringing advanced ultrasound to the bedside.
Improve quality of care, efficiency, patient safety, patient satisfaction, and reduce complications and costs.
To learn more about SonoSite Point-of-Care Ultrasound Solutions or request a product demonstration email
us at ukresponse@sonosite.com or visit www.sonosite.co.uk
The Value of Visualisation
©2015 FUJIFILM SonoSite, Inc. All rights reserved.
The articles on safe arterial lines and Brugada syndrome are most
interesting and may induce a few ‘There-but-for-the-grace-of-God-go-I’
feelings. Brugada syndrome seems to be uncommon yet each of us may
encounter a few cases per career. I wonder how many have passed through
my care unnoticed? Think of young patients without an ECG to hand.
Finally, as Seminars Lead, I would like to make a call for new material. This
request challenges all to produce new ideas and extends across the entire
AAGBI membership. All ideas for seminars will be considered. Please do
not be reticent. The format is not fixed but is theme-based. There are usually
5 or 6 talks in the morning and fewer in the afternoon, lasting 25 minutes
each, with 5 minutes of questions. However, you could design something
innovative, interactive, electronic, cinematic or whatever you think might be
of educational value. Contact Rachael Arnold (rachaelarnold@aagbi.org)
with submissions.
Please come to Congress next month in Edinburgh. The Castle dungeons
await those who don’t take part in ceilidh dancing…
www.sonosite.co.uk
www.sonosite.co.uk/education
FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of
FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners.
The Northern Irish SAS Group appears to be developing well, and such
gatherings can only enhance knowledge and the fellowship colleagues
might gain through education and dialogue. The social benefits cannot be
undervalued and it would be excellent to hear about more of these events
throughout the UK and Ireland. SAS doctors are important to our Association,
and we hope that in future years more will come forward to represent this
group at the AAGBI. It is quite difficult to find willing representatives, so if
you feel inclined to come forward when the need arises, please do so.
Gerry Keenan
09 The Needle-Free
Non-Injectable Arterial
Connector (NIC)
11Safety Matters: Standards Committee work
13 Northern Ireland SAS Group Meeting
13
14 Brugada syndrome: resources for the anaesthetist
16 Art exhibition at Annual Congress 2015
17 ‘Anesthésie a moindre risque’
20 Teaching primary trauma
care in Mozambique
17
25 Arterial line safety
29 Anaesthesia Digested
30 Particles
32 Your letters
32
16
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: anaenews@aagbi.org
Website: www.aagbi.org
Anaesthesia News
Managing Editor: Nancy Redfern
Editors: Phil Bewley and Sarah Gibb (GAT), Nancy Redfern,
Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis,
Upma Misra, Felicity Platt and Gerry Keenan
Address for all correspondence, advertising or submissions:
Website: www.aagbi.org/publications/anaesthesia-news
Editorial Assistant: Rona Gloag
Design: Chris Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Email: chris@aagbi.org
Printing: Portland Print
Copyright 2015 The Association of Anaesthetists of Great Britain and Ireland
The Association cannot be responsible for the statements or views of the contributors.
No part of this newsletter may be reproduced without prior permission.
2170 04/14
Anaesthesia News August 2015 • Issue 337
Advertisements are accepted in good faith. Readers are reminded that
Anaesthesia News cannot be held responsible in any way for the quality
or correctness of products or services offered in advertisements.
3
The
Preoperative
10 West of England
Anaesthesia Update
th
10th West of England Anaesthesia Update
Based in Chalet Hotel St Christoph
Talks cover a wide range of topics 15 CPD points RCOA
Flights available from Bristol, Gatwick and other airports nationwide
All grades of Anaesthetist from everywhere welcome.
18th – 22rd January 2016
St Christoph am Arlberg (nr St Anton), Austria
EAST MIDLANDS CONFERENCE CENTRE
Association
NATIONAL CONFERENCE
5TH NOVEMBER 2015
NOTTINGHAM
Pre-op
ACCREDITED WITH 5 CEPD POINTS
TOPICS TO INCLUDE:
Role of Preoperative Assessment in Perioperative Medicine /
Dynamic Cardiac Testing / Diabetic Guidelines Update / Obstructive Sleep Apnoea
& ECG workshops / Brief Interventions in Preoperative Assessment / Debate:
‘Who is best placed to be the Perioperative Physician - Anaesthetist vs Physician’
ABSTRACT FOR PRESENTATIONS OR POSTERS TO BE SUBMITTED BY 25TH SEPTEMBER 2015
Open to all healthcare professionals involved in the preoperative assessment of
the surgical patient. For full details and to book your place, please contact us:
www.weauconf.com
W: WWW.PRE-OP.ORG / T: 020 7631 8896
RESEARCH GRANTS
THE ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN
& IRELAND AND ANAESTHESIA WILL BE AWARDING
RESEARCH GRANTS IN SEPTEMBER 2015.
The Associations’
research aims are:
•
Patient safety
•
Innovation
•
Clinical outcomes
•
Education and training
•
Related professional
issues (e.g. standards
and guidelines, working
conditions, medico-legal
issues)
•
The environment
Applications must describe how the proposed project meets the
Association’s research aims. Suitable projects may be large research
studies, small clinical/benchtop projects, idea (innovation) development,
observational studies/data collection, quality improvements or clinical
audits (although the latter are unlikely to receive AAGBI funding if they
are small, ‘routine’ local audits). Funding up to £20,000 may be sought,
but applications will be judged on ‘value-for money’ as well as scientific
credibility. Awards will be made via the NIAA and, if appropriate, will be
eligible for NIHR portfolio status.
For further information and to apply please visit the AAGBI website
http://www.aagbi.org/research/aagbi-research-grants
Completed application forms and supporting docs should be returned
to the NIAA secretariat info@niaa.org.uk
The deadline for applications is
5pm Friday 07 August 2015
PRESIDENT's
REPORT
All change!
The last few months have seen changes at the top of
many national anaesthetic organisations either take
place or be announced. Dr Ben Fox took over as Chair
of GAT from Dr Sarah Gibb at a hugely successful
Annual Scientific Meeting in Manchester. It was an
enormous privilege to be able to present Sarah with
the AAGBI’s Anniversary medal, the first time a trainee
has received one of the AAGBI’s high honours. Ben’s
previous role as Honorary Secretary was taken by
Dr Emma Plunkett, and Dr Rowena Clark succeeded
Dr Caroline Wilson as Vice Chair.
In Dublin, Dr Ellen O’Sullivan hands over the
Presidency of the College of Anaesthetists of Ireland
to Dr Kevin Carson. Ellen has been a permanent
feature on the medico-political landscape for so many
years, it will seem strange not to see her at AAGBI
Council meetings. As Convenor of the Irish Standing
Committee, an elected Council Member, Honorary
Membership Secretary, AAGBI Vice President and
finally as CAI President, I can think of no-one who has
served longer or in as many roles at the AAGBI. Add to
this her contributions as President of the Difficult Airway
Society and to NAP5, Ellen was a very worthy recipient
of the AAGBI’s John Snow Silver Medal presented on
home turf at Annual Congress in Dublin in 2013.
Closer to home, Tom Grinyer has recently taken over
from Kevin Storey at the Royal College of Anaesthetists.
Dr Liam Brennan will succeed Dr J-P Van Besouw as
President in September and there will be new Vice
Presidents in Drs Richard Marks and Jeremy Langton.
On behalf of the AAGBI I congratulate all these new
appointments and look forward to working closely
with them, and thank all those demitting office for their
massive contribution to our specialty.
Here at 21 Portland Place we now know that Dr Paul
Clyburn will succeed me as President and Dr Mike
Nathanson will take over from Samantha Shinde as
Honorary Secretary in 2016. I’ve worked with Paul for
almost eight years on Council and know the AAGBI will
be in safe hands.
Despite ‘all change’ I doubt many Members or Fellows
will notice any major changes in what our respective
Councils, Boards or Committees actually do. However
the change (or non-change) in UK Government is likely
to have a much greater impact on our working lives.
I’ve yet to meet anyone who admits they saw a majority
Conservative government as the likely outcome of
the 7 May election. The slim, but working majority
certainly gives the Government an opportunity to force
legislation through the House of Commons, although
with the House of Lords reforms it no longer benefits
from the automatic majority in the Lords enjoyed by
the last majority Conservative government led by John
Major in the 1990s.
Prime Minister David Cameron has made NHS reform
one of his personal priorities with Jeremy Hunt
remaining as Health Secretary. In England at least, we
can expect rapid movement on Consultant Contracts
to incorporate the commitment to seven day working,
not only for emergency work, but for the whole range
of NHS services. I suspect the impact on anaesthetists
and intensive care doctors will be less than for many
colleagues, and I personally fear for the impact on an
already stretched and demoralised primary care sector.
As colleagues get used to the change in pension
arrangements, from final salary to the Career Average
scheme only implemented recently, we should not
assume there will be no further, probably unwelcome,
changes such as the recent reduction in the pensions
Lifetime Allowance, which is likely to affect most
consultants, not just those in receipt of higher Clinical
Excellence Awards. The AAGBI’s ability to influence
contract, pay and pension negotiations is limited,
although we will continue to support the BMA as far as
we are able. In all such discussions we will maintain our
priorities of Patient Safety and Membership Wellbeing,
stressing that the two are closely linked.
The other truth highlighted by the result of the General
Election campaign is the starkly different political map
of the four countries of the UK. Employment conditions
and service priorities for the National Health Services
55 are likely to diverge even further during the current Parliament.
Each NHS faces its own challenges and I’m not sure the grass
is greener in any one of them. The challenge for the AAGBI
and the Royal College will be to work together to maintain
standards of practice, education and employment. The need for
consultant anaesthetists is predicted to increase significantly
over the next 20 years, but where these additional anaesthetists
will come from is unclear. With the lag between medical student
entry, specialist training recruitment and award of CCT currently
almost three parliamentary sessions, governments can avoid
getting bogged down in detail too.
Free movement of workers (subject to recently imposed
language requirements for medical specialists) is one of the
key principles of the European Union, and the one perhaps
most responsible for current government proposals for EU
reform and a referendum before the end of 2017. During
the recent Euroanaesthesia meeting in Berlin, I attended the
UEMS EBA (European Union of Medical Specialists European
Board of Anaesthesiology). The Board works mainly through
three standing committees: Education and Professional
Development, Patient Safety and Quality of Care, and
Workforce, Welfare and Working Conditions. I was impressed
by the energy of the EBA to drive forward standards in all
three areas, and it was gratifying that the UK and Ireland are
acknowledged to be leaders, with many countries aspiring to
our levels of achievement. Regardless of the outcome of any
referendum, the AAGBI and the UK can and should play a
major part to improve standards across the EU, and can only
hope to benefit from such change.
The thorny issue of non-physician providers of anaesthesia is
never far from discussions at the AAGBI or the Royal College.
The UK is in the minority of countries where physician providers
are the overwhelming majority of anaesthetists, but PA(A)s exist
in the UK and are unlikely to disappear. This is an area of where
opinions remain sharply divided and there a few shades of grey.
The debate continues, and is lively and (for the most part) good
tempered. The AAGBI recognises the divergence of opinion
exists not just at Board level but also within its membership and
strives to strike the balance between quality of care, economic
reality and professional reputation. This is one area where we
will never be able to keep everyone happy, but we will keep
trying. Whatever your view of this, it’s not going to go away.
August is one of the quieter months at Portland Place, with
few committees meeting and many Board members and staff
taking holidays and the opportunity to spend time with family
and friends. I’m certainly looking forward to one or two Fridays
off before we meet again in September and prepare for Annual
Congress in Edinburgh, welcoming new Board Members,
saying farewell to those departing and starting all over on
another annual cycle of the AAGBI (unintentional pun - but
better than most I write!). Enjoy the summer.
Andrew Hartle
President, AAGBI
The WISE Anaesthetic Cup
It was on a drab Tuesday morning, as an operation dragged on like a Hibernian
football game that minds in Glasgow’s Western Infirmary began to wander. As the
surgeon asked, yet again, what the blood pressure was, it seemed extra time was
inevitable. Then the surprise arrival of the country’s one trainee facilitated a prompt
departure to the coffee room and perhaps a pie. Here, other minds escaping the
monotony of the list united, and the idea of challenging the great Glasgow Royal
Infirmary to a game of football started to take shape.
It turned out it had all been done before. The secretaries had found a dusty cup
called the Chadwick Trophy, which was now in two pieces at the bottom of a
cupboard. The Chadwick Trophy was last engraved in 1992, and it was now time
to glue it back together, dust it off, and sharpen the engraver’s pen. Soon all talk of
the impending hospital merger was replaced by in depth discussion of the merits
of a 4-4-2 formation. An inclusive approach allowed anaesthetists aged from their
20s to their 50s to take part and an open sub policy meant the varied fitness levels
did not prevent the less fit taking part – they did, but only for as long as an average
SPA rotation. Despite the all-encompassing approach, the competition was fierce,
and unity across the city was only re-established when, during the post-match
analysis (a pint in the West Brewery), a plan was hatched to team up and challenge
Edinburgh. And so the annual fixture became two annual fixtures with great rivalry,
but colleagues across all grades walked off the park knowing each other a little
bit better. With the AAGBI coming to Edinburgh in 2015 we reached the inevitable
conclusion that we should team up with Edinburgh and indeed all hospitals across
Scotland and host a home nation’s cup. Who knows – perhaps at the end we can
unite in British and Irish Lions tops and attend a world congress!
The Wales, Ireland (as one team, like the rugby), Scotland and England (WISE)
Anaesthetic cup will now be competed for on Wednesday the 23rd September
2015, after the first day of the AAGBI Annual Congress. It will be hosted at
Hibernian Football Club’s training venue, which is a state-of-the-art facility just
outside Edinburgh.
All anaesthetists (male and female) are welcome and they should ensure they are
members of the AAGBI to qualify to play. There are to be no ‘ringers’ (a ‘ringer’ is
generally a theatre orderly with a past as a professional footballer…). An open sub
policy will allow those who may have concerns regarding their fitness to dust off
the boots and participate until their wisdom should return. You should feel free to
play for the nation of your birth or nation where you now work. If you work in the UK
but are not of a home nation’s heritage then please join in and approach the nation
where you currently work. If you are outwith the UK, approach any of us (unless
your surname is Messi in which case you should use the Scotland contact). The
tournament will start at 1820 hrs and consist of a cup format with a winners and
losers final. Each team would therefore play two matches – a qualifying match (2 x
25min halves) and either a 3rd or 4th place play-off (2 x 30 min halves). Penalties
will be used in case of a draw at full-time. A large squad of players making use of
an open sub policy will allow more of us to take part and stamina to become less
of an issue.
The target: The AAGBI wants to raise £96,000 which will buy 600 Lifebox Pulse Oximeters over the
next 2 years - the same as the number of Team GB athletes attending the Olympic and Paralympic
Games in Rio de Janeiro in 2016.
Help us to reach the target! Join the campaign and become a Lifeboxes for Rio fundraiser
So, if you are keen to contribute to this good cause and get involved please do
not hesitate to use the relevant contact from the list on the right and declare your
interest. Finally, if there are any referees who would like to contribute, could they
make themselves known by using the Scotland contact?
Bake, bike ride, run or walk – or devise your own fundraising concept.
www.aagbi.org/lifeboxesforrio
Fame may beckon if the match report meets the exacting publication standards of
Anaesthesia News.
AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697
Lifebox: Registered as a charity in England & Wales (1143018)
Rio_Poster.indd 1
Contacts
Wales:
Pl
refe ayers
William Harrop-Griffiths
dec rees and
awhg@mac.com
la
p
rele re int lease
e
van
Ireland:
r
t co est to
Colm Keane
nta
ct
colmpkeane@hotmail.com
Scotland:
Graeme Hilditch
graeme.hilditch@gmail.com
England:
Fraser Dunsire
fraserdunsire@nhs.net
General Enquiries:
Michael Macmillan
mhmacmillan@aol.com
AAGBI contact
Mathew Checketts
mathew_checketts@mac.com
It is hoped that this event will carry on the good work of the AAGBI in raising funds
for the AAGBI fundraising campaign Lifeboxes for Rio. Each player would be
expected to pay an entrance fee to cover expenses and obtain sponsorship. In
addition we are looking at other fundraising initiatives including a sweepstake on
the result, opportunity to be a spectator and strips available for sale.
The aim: To save thousands of lives around the world where patients are at risk of death from hypoxia.
66 Team from the Western Infirmary, Glasgow
19/01/2015 10:31
Anaesthesia
AnaesthesiaNews
NewsAugust
August2015
2015••Issue
Issue337
337
7
WSM_A5_Flyer.pdf
1
08/06/2015
15:35
The Needle-Free Non-Injectable
Arterial Connector (NIC)
European
Accreditation Council
for Continuing
Medical Education
(EACCME) has been
applied for
C
13 -15 JANUARY 2016
M
Y
CM
MY
CY
CMY
K
Taking place over three days and offering:
• Keynote lectures • core topics • poster competition
• extensive industry exhibition • networking opportunities
Paradoxically never events are fortunately rare, yet all too common.
When they do occur the effects can be devastating for patients,
distressing for healthcare workers and institutions may suffer
considerable reputational damage. In a national survey, 28.5% of
ICU directors reported having experienced mis-administration
of medication into the arterial line at their trust.1 While education,
labelling, training, audit and reporting structures are important, it
is essential that, where possible, devices are developed to provide
engineered solutions to eliminate otherwise inevitable human errors.
Historically, as a specialty, anaesthesia can be congratulated above
all others in this regard.
AAGBI
AAGBI
INNOVATION
INNOVATION
Annual
AAGBI
Prize
forInnovation
Innovation
TheThe
Annual
AAGBI
Prize
for
in Anaesthesia,
Critical
Careand
andPain
Pain
in Anaesthesia,
Critical
Care
The Association of Anaesthetists of Great Britain and Ireland invites applications for
the 2016 AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain. This prize
is open to all anaesthetists, intensivists and pain specialists based in Great Britain
and Ireland. The emphasis is on new ideas contributing to patient safety, high quality
clinical care and improvements in the working environment. The entries will be judged
by a panel of experts in respective fields.
Applicants should complete the application form that can be found on the AAGBI website
www.aagbi.org/research/innovation.
The closing date for applications is Wednesday 30 September 2015.
Three prizes will be awarded and the winners will be invited to present their work and
collect theirwww.aagbi.org/research/innovation
prizes at the Winter Scientific Meeting in London on 15 January 2016.
www.aagbi.org/research/innovation
Kindly sponsored by:
The Needle-Free Non-Injectable Arterial Connector (NIC; Amdel
Medical, Liverpool, UK) eliminates the accidental administration of
medication into the arterial line. Developed by a team of clinicians at
the Queen Elizabeth Hospital, Kings Lynn, this simple device utilises
the combination of a stop-valve and a unidirectional valve within the
inner chamber. This combination physically prevents the injection of
fluid, but permits sampling from the arterial line. The physical barrier
also prevents bacterial ingress into the arterial line hub, reduces
accidental blood spillage and supports the EU needle free directive.
It is compatible with all arterial luer sampling sets.
National policy detailed in the NHS document Innovation for Health
and Wealth,2 seeks to harness grass roots NHS innovation and
support UK businesses. Supporting this policy, the Eastern Academic
Health Science Network has been instrumental in facilitating the
implementation of the NIC into ICUs and theatres in 11 Trusts in
the East of England. The study showed a 79% implementation
rate over 6 months. Overall the NIC was extremely well received. A
survey of healthcare staff showed that 96% said the NIC improved
identification of the arterial hub and 81% wanted to continue using
the connector after the trial period because of ease of use and in
recognition of improved safety for their patients. An independently
commissioned health economic evaluation demonstrated that while
providing benefits, the NIC was also cost-effective, leading to a
saving of £25,691 over 11 Trusts during this 6 month period.
Despite proven benefits and cost-effectiveness, new devices are
notoriously difficult to introduce into the NHS due to complex
and inconsistent local procurement decision making processes.
Alongside our publication in Anaesthesia,3 winning 1st prize in the
AAGBI Innovation Award (2015) has provided invaluable support and
a seal of approval from peers for the NIC connector. The prize money
has helped fund further research into arterial line safety, including
the glucose problem,4 which has only been partially addressed and
is also open to an engineered solution. Personally this award has
supported my doctorate at the University of Cambridge examining
Engineered Solutions to Never Events and has gained me a
highly coveted place as a fellow on the NHS Innovator Accelerator
Programme, allowing the opportunity to implement the patient safety
benefits of the NIC both nationally and internationally.
Maryanne Mariyaselvam
Clinical Research Fellow
Addenbrooke’s NHS Foundation Trust, Cambridge University Hospitals
The Queen Elizabeth NHS Foundation Trust, Kings Lynn
Conflict of interest
The Queen Elizabeth Hospital, King’s Lynn NHS Trust holds the patent and
has been supported by NHS Innovations East and by a grant from the Eastern
Academic Health Science Network.
References
1. Mariyaselvam M, Wijewardena G, Hutton A, Young P. Complications of
accidental intra-arterial injections. Anaesthesia 2014; 69 (Suppl): 78.
2. Department of Health. Innovation Health and Wealth. http://www.institute.
nhs.uk/images/documents/Innovation/Innovation%20Health%20and%20
Wealth%20-%20accelerating%20adoption%20and%20diffusion%20in%20
the%20NHS.pdf (accessed 10/6/15).
3. Mariyaselvam M, Heij R, Laba D, et al. Description of a new non-injectable
connector to reduce the complications of arterial blood sampling. Anaesthesia
2015; 70: 51–5.
4. Problems with infusions and sampling from arterial lines. Supporting
information for the Rapid Response Report. National Patient Safety
Agency. July 2008. NPSA/2008/RRR006. http://www.nrls.npsa.nhs.uk/
resources/?entryid45=59891 (accessed 10/6/2015).
9
Anaesthesia & Cri-cal Care Update SAFETY MATTERS
9th & 10th October 2015 Hilton Warwick/Stra:ord-‐Upon-‐Avon Standards
Committee work
the leading centre in the delivery of awake upper
limb regional anaesthesia in the uK presents:
12th royal Derby Hospital
upper Limb regional anaesthesia Course
thursday 26 November 2015
Workshops: Friday, 9th October, 2015 (6 CPD Credits) •  Airway: Awake intuba9on Airway Ultrasound, ORSIM simulator •  Focused Intensive Care Echo •  Total Intravenous Anaesthesia •  Ultrasound Guided Regional Anaesthesia royal Derby Hospital
We work on the premise
“the right block in the right place works every time!”
the programme is dedicated to upper limb regional
anaesthesia with an emphasis on practical, hands-on
ultrasound training experience.
Scien-ﬁc Programme: Saturday 10th October, 2015 (6 CPD Credits) Course features:
Live theatre link demonstrating techniques
of upper limb blocks
Small group workshops on scanning
techniques on human models
Practical hands-on training in probe
handling and needling techniques on
animal models and gel-phantoms
Course Organisers: Dr Adrian Searle and Dr Zahid Sheikh
CME approved 5 points
Application forms and more information from:
Course fee: £150
Course secretary Mrs. Shirley Goddard
shirley.goddard@nhs.net tel. 01332 787195
Royal Derby Hospital, Anaesthetic Office, Uttoxeter Road, Derby DE22 3NE
Sponsored by:G16418/0415
• 
• 
• 
• 
• 
• 
• 
Shape of Training Prepara9on for Consultant Post Advances in Cri9cal Care Updates in Bariatric Anaesthesia What’s new in Airway Management Anaesthesia Conundrums Free Paper presenta9ons For further details and registra9on please visit www.baoia.co.uk Organised by: Bri9sh Associa9on of Indian Anaesthe9sts (BAOIA) It has been my pleasure to work with many experts on the AAGBI Standards Committee during
my time on Council. I write this in the hope that I can ignite a flame of interest among some of our
younger members to help continue the vital, yet little-publicised work that is done by a dedicated
band of heroes, some of whom are in part supported by AAGBI grants. Standards work hit the national
headlines with neuraxial connector development several years ago, but they are just a small part of
‘small bore connector’ work, which in turn is just a fraction of the ever-evolving Standards that shape
our work environment.
A browse through the International Organization for
Standardization’s (ISO) catalogue1 reveals the wide spectrum
of items subject to standards, and you can find anaesthetic
and respiratory equipment at 121. Therein lies ISO 26825:2008
‘Anaesthetic and respiratory equipment - User-applied labels for
syringes containing drugs used during anaesthesia - Colours,
design and performance’, which may be vital for the reduction of
wrong drug errors and has been discussed in several forums. ISO
4135:2001 ‘Anaesthetic and respiratory equipment - Vocabulary’
is settled and published, but ISO/CD 19223 ‘Lung ventilators
and related equipment - Vocabulary and semantics’ remains in
development. This standard introduces a number of new terms
to the description of ventilation modes and ventilator/patient
interaction, with commendable intention to reduce the scope for
confusion, particularly as different manufacturers use many of the
current terms with a different meaning. The AAGBI approves of
standardisation and feedback from members would be invaluable.
ISO/TC 210 is ‘Quality management and corresponding general
aspects for medical devices’ within which we find ISO/DIS 803696 ‘Small bore connectors for liquids and gases in healthcare
applications - Part 6: Connectors for neuraxial applications’.
At the time of writing, I can see that voting has closed on this
Standard, and the anticipated date of publication is December
2015. California is going to mandate that all neuraxial connectors
meet the ISO standard within 6 months of publication, and so
manufacturers will be racing to supply that market. In the UK, I
would expect we will start to see ISO Standard connectors later
in 2016.
TC121/SC1 – ‘Breathing attachments and Anaesthetic machines’.
Terry Longman chairs the UK delegation to ISO and keeps the
AAGBI updated with developments. Terry is also a vital messenger
of our views and concerns to various organisations who work on
Standards.
Reports to the Standards Committee can be found on our
website.3 Why not make them part of your regular reading?
Perhaps you’ll be both entertained and inspired.
Dr David Scott chairs several BSI committees. Ever a practical
man, David has recently drawn our attention to the importance
of standards concerning the relative humidity in an operating
theatre: ‘at every opportunity I point out that condensing
atmospheres are common in my [Scottish] practice, especially in
the home healthcare area. Equipment should, in my opinion, be
capable of withstanding condensation without failing’.
Dr Bill Boaden attended the June 2014 meeting of the ISO TC/121
in Incheon, South Korea. Bill is a member of British Standards
Institute’s CH 121/SC1, the equivalent of ISO committee ISO/
Anaesthesia News
News August
August 2015
2015 •• Issue
Issue 337
337
Anaesthesia
Dr Harvey Livingstone was also in South Korea. He spent most
of his time in the SC2 ‘Airways and related equipment’ meeting
and was appointed to the drafting committee to prepare the
resolutions to be submitted.
Dr Philip Bickford-Smith, a co-designer of the Neurax connector
system, is involved in practical testing of equipment. The
British Anaesthetic and Respiratory Equipment Manufacturers
Association (BAREMA) are represented on the AAGBI Standards
Committee and Mr Paul Dixon currently provides reports from an
industry perspective.
For my part, I have enjoyed working with NHS England’s Small
Bore Connector Clinical Advisory Group chaired by Dr Paul
Sharp.2 As we approach a critical time of change, risks to patients
are increased as incompatible connectors may find themselves in
the same place at the same time. I’d strongly advise members to
visit this website regularly over the next year or two. We are in no
doubt that Standards work is vital to the safety of patients in Great
Britain and Ireland, yet funding for NHS clinician participation
is now the responsibility of commissioners. Unsurprisingly,
obtaining that money is difficult or impossible. Earlier this year
the President wrote to the Chief Medical Officer for the UK
Government who replied that standards work is included in the
national work for the benefit of UK healthcare systems that should
be funded by local commissioners out of their allocations.
Tom Woodcock
Chair, Standards Committee
References
1.
2.
3.
International Organization for Standardization Standards catalogue. http://
www.iso.org/iso/home/store/catalogue_tc.htm
NHS England. The safe introduction of medical devices with new small
bore connectors into use in the NHS. http://www.england.nhs.uk/ourwork/
patientsafety/medical-device-incidents/small-bore-connectors/ (accessed
10/6/15).
AAGBI Standards Committee. http://www.aagbi.org/safety/safety-andstandards-committee/committees/standards-committee
11 11
Lectures from GAT 2015
are now available to view
The template is easy to use allowing you to reflect on the conference as a whole or on individual lectures.
Step-by-step guide on how to reflect using the site:
Step 1. Go to www.aagbi.org/education
Step 2. Click on the ‘Learn@AAGBI’ box
Step 3. Log in
note: you will need your AAGBI membership number and password
Step 4. From the search page select your required option
Step 5. From the list select the video that you wish to reflect on
Northern Ireland
SAS Group Meeting
Step 6. After watching the whole video, open the reflective learning form and
complete it
Step 7. If you are happy with what you have written, click on ‘Submit form’,
or if you would like to add more later on, click ‘save draft’.
This will upload into the ‘My CPD Area’ as either ‘draft’ or a
completed ‘Submitted Reflective Note’.
Go to www.aagbi.org/education and use Learn@AAGBI for your reflections
at our meetings, and for your ongoing CPD and exam preparation.
Learn_Anews_Aug.indd 1
Photograph ©spumador - Sunset over Peace Bridge of Derry, Northern Ireland
Learn@AAGBI
Northern Ireland may be small geographically but it has a lively and proactive SAS group. Formed in
2008 to try and add to the specific educational needs of SAS doctors who, for various reasons, were
finding difficulty in meeting their CPD targets, it has gone from strength to strength over the years.
22/06/2015 14:43
It is a great way of getting together with others of the same grade
to discuss work, opportunities, and changes in the delivery
of healthcare as it pertains to us. We are lucky that our group
comprises an AAGBI rep (yours truly), a Royal College rep and
a BMA rep so that when we get together we can discuss any
revisions that have occurred plus the opportunity to consider any
matters which concern us as a group. These can then be brought
up at the relevant committees which allow us a voice at local and
national level.
At present Northern Ireland has five large teaching hospitals and
five DGHs with SAS doctors employed in all of them. Some jobs
are pure ICU, some pure anaesthetics but most jobs are a mix of
the two, many with an out-of-hours commitment. We can be the
most senior doctors immediately available so we are keen to keep
our skills up.
Our meeting this year was held at Altnagelvin Hospital in
Londonderry and 16 delegates attended. We try to have at
least one person per hospital so that they can disseminate any
information to as wide an audience as possible. The meeting was
approved for 5 CPD points by the RCoA and was divided into two
sessions.
present case histories of difficult patients. There was a prize, this
year won for the presentation on ‘Partial Subarachnoid Block at
Caesarean Section’. Finally there was an appraisal workshop with
the opportunity to see what is relevant and useful to include for
Revalidation.
At the close of the meeting there was a group dinner at a local
restaurant and further informal discussion of life as an SAS doctor.
It was also suggested that next year’s overall theme could be all
things paediatric.
In conclusion I would say that a local meeting has many benefits
including tailored CPD, close proximity to home and an opportunity
to meet with the people you have most in common with. It is also
a way of finding out the good working practices available in other
hospitals that could improve your own!
Cathy Callaghan
The morning session had a CPR simulation scenario to allow all the
delegates to practice their ALS skills and a difficult airway station
where candidates could practice low skill fibreoptic intubation and
emergency tracheostomy skills with a manikin.
The afternoon session consisted of a talk on management of the
obese parturient and the opportunity for attendees to submit and
13 Brugada syndrome: resources for the anaesthetist
It is tempting to dismiss rare
eponymous syndromes as small
print; interesting problems, but
of little practical relevance given
the small probability of seeing a
patient with one on your theatre
list. That is until the surgeons list a
patient with a rare and potentially
life-threatening cardiac abnormality
during your weekend emergency
theatres shift.
an anaesthetic plan for the patient was formulated. Anaesthesia
was induced with external defibrillator paddles present, using
a combination of 1 mcg.kg-1 fentanyl and 5 mg.kg-1 thiopentone.
Rocuronium 1 mg.kg-1 and 4mg.kg-1 sugammadex were used for
muscle paralysis and reversal, respectively, thereby avoiding the
theoretical arrhythmia risk with neostigmine. The peri-operative
period was uneventful with no ECG changes detected. The patient
was then extubated, recovered and received continuous ECG
monitoring for the first 24 hours following surgery.
that will be practical and valuable for anaesthetists caring for BrS
patients on an international scale. I would like to commend the
diligent and prompt response of Dr Postema, who has managed
to make an already excellent resource even better. Clear, concise
and careful recommendations are an important part of preparing
for the anaesthetic management of patients with unfamiliar
conditions in emergency situations. The care of BrS patients is
clearly benefiting from the ongoing work and I would urge readers
to take an overview of the information provided on the website.
The website (http://www.brugadadrugs.org) and associated letter
were vital resources in helping to plan the anaesthetic management
of a patient with BrS, particularly in the context of providing simple
recommendations in a time-dependent scenario. However it
occurred to me that even greater value for anaesthetists, in similar
positions to my own, could be gained with further clarification and
additions to this resource.
The Advisory Board at BrugadaDrugs.org would love to hear
about your case experience with BrS. Feel free to contact them
via: http://www.brugadadrugs.org/about
The patient I saw had no ICD, but did show me the letter from his
wallet, given to him by his cardiologist and produced by http://www.
brugadadrugs.org, of medications that should be avoided in BrS.
The list includes a number of anaesthetic and analgesic drugs,
such as propofol, ketamine, tramadol and local anaesthetic agents.
After a more detailed reading of the website, alongside case reports
and several review articles (including Kloesel and Ackermann5),
14 Typical CG from a patient with Brugada syndrome Peter M. E
Odor
ST5, Department of Anaesthesia, East Surrey Hospital, UK
Pieter1G.
Type BPostema
rugada ECG pattern with coved type ST segments (arrows) in the right precordial
Department of Cardiology, University of Amsterdam, the
Netherlands
and V2 and in leads placed one intercostal space above V1 and V2 (V1ic3 and V2ic3). Oth
specific) features of the Brugada ECG that are shown are the prolonged PR interval and w
ECG from a patient with Brugada syndrome
the Typical
QRS w
ith rECG
ight ventricular delay. Type
1 Brugada
pattern
with coved type
ST segments (arrows) in the right precordial leads V1 and V2 and in leads placed
I saw a 35-year-old male with Brugada syndrome (BrS), who was
listed for a laparoscopic emergency appendectomy. Although I
had heard the term ‘Brugada’ back in medical school, I had little
memory of exactly how the syndrome should influence anaesthetic
management. Luckily I had some time to prepare and the patient
came complete with a list, produced from his wallet, of drugs that
should be avoided in his condition.
Brugada syndrome is genetic cardiac conduction disease, which
can lead to the development of ventricular arrhythmias and sudden
death in otherwise fit, young individuals.1 Brugada syndrome
is uncommon, with an estimated prevalence of approximately
1:2000,1,2 but not so rare that some awareness of the condition isn’t
important for the general anaesthetist. The ECG of a BrS patient
typically has a characteristic ST elevation in the right precordial
leads (V1-V2 in the standard 4th intercostal space and in V1-V2 in
higher intercostal spaces) with or without a right bundle branch
block.1 However this pattern may not always be present or is only
detected when pharmacologically provoked. Importantly, drugs
with sodium channel blocking properties should be avoided in BrS
as they can trigger ventricular arrhythmias.3 Fever, a notable risk in
the septic patient on my theatre list, is another potential precipitant
of arrhythmias.4 There are not many drugs available to prevent
arrhythmic events in BrS except for quinidine, therefore implantable
cardioverter defibrillators are recommended in those at high risk of
arrhythmias.
Written consent was gained from the patient for publication of
details regarding this case.
References
1. Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS
Expert Consensus Statement on the Diagnosis and
Management of Patients with Inherited Primary Arrhythmia
Syndromes. Heart Rhythm 2013; 10: e85-e108.
2. Postema PG. About Brugada syndrome and its prevalence.
Europace 2012; 14: 925–8.
3. Postema PG, Wolpert C, Amin AS, et al. Drugs and
Brugada syndrome patients: review of the literature,
recommendations, and an up-to-date website. Heart
Rhythm 2009; 6: 1335–41.
4. Amin AS, Meregalli PG, Bardai A, Wilde AA, Tan HL.
Fever increases the risk for cardiac arrest in the Brugada
syndrome. Annals of Internal Medicine 2008; 149: 216–8.
5. Kloesel B, Ackerman MJ, Sprung J, Narr BJ, Weingarten
TN. Anesthetic management of patients with Brugada
syndrome: a case series and literature review. Canadian
Journal of Anaesthesia 2011; 58: 824–36.
one intercostal space above V1 and V2 (V1ic3 and V2ic3). Other (but less specific) features of the Brugada ECG that are shown
are the prolonged PR interval and widening of the QRS with right ventricular delay.
I
II
Sternal angle
V1
V2
I contacted Dr Pieter Postema, University of Amsterdam and lead
author of the website, with my thoughts. Following the course of
several email correspondences, sharing references and ideas,
there is now a new page on the website, presented alongside an
updated patient letter (available in a range of language translations).
This new page provides a set of easy-to-follow recommendations
for emergency anaesthetic management of BrS and is universally
accessible at http://www.brugadadrugs.org/emergencies
Only a limited number of case reports and experimental studies
have been conducted with anaesthetic drugs in BrS. Furthermore
there may be large variability in terms of the response to certain
drugs and conditions, such as fever. These recommendations are
pragmatic, but not a substitute for clinical judgment in individual
patient care.
V1ic3
V1
ic3
V2
V1
V2
ic3
V3
V4 V5 V6
V4
Alternative lead
placement to enhance
Brugada pattern
recognition
V2ic3
V6
10 mm/mV
25 mm/s
10 mm
It is satisfying to reflect that my management of a single patient with
BrS has prompted the further development of a clinical resource
15 ABSTRACTS FOR
PRESENTATION AT AAGBI
WSM LONDON 2016
You are invited to submit an abstract for
poster presentation at WSM London in
January 2016. The deadline for submission
is 23:59 on Monday 31 August 2015 and
further instructions and information can be
found on our WSM microsite:
www.wsmlondon.org
C
M
Y
CM
AT ANNUAL CONGRESS,
EDINBURGH 23-25 SEPT 2015
After the deadline, a preliminary review of
the abstracts received will determine which
ones are accepted for poster presentation.
MY
CY
CMY
All accepted abstracts will be published
in Anaesthesia in the form of a fully
referenceable online supplement (NB
Editor-in-Chief reserves the right to refuse
publication, e.g. where there are major
concerns over ethics and/or content).
K
Authors of the best poster(s) will be
awarded ‘Editors’ Prizes’.
If you have any queries, please contact the
AAGBI Secretariat on 020 7631 1650 (option 3)
or secretariat@aagbi.org
DIFFICULT AIRWAY SOCIETY
AIRWAY
REVALIDATION
COURSE
13 Oct 2015
Venue: Medical Education Training
Centre, Kirklands Hospital, Fallside Rd,
Bothwell, Glasgow, G71 8BB
Local coordinator - Dr Raj Padmanabhan, Consultant Anaesthetist, NHS Lanarkshire
CPD approved meeting
5 CPD points
What you need to know
about safe Airway Management
Following on from the very successful National Audit Project 4 (NAP4),
Airway Leads Day, and several new ‘Airway’ guidelines, Difficult Airway
Society is pleased to announce the second of a series of Airway
Revalidation Courses to be held on 13 Oct 2015. The Course launched in
collaboration with The RCoA is specifically designed to meet the airway
CEPD requirements of UK Anaesthetists.
It benefits from DAS standardisation, peer review and quality control. It is
based on latest evidence and draws upon the experience and consensus of
experts in airway management. DAS experts and high profile airway trainers
have developed the full day course consisting of up-to-date lectures on
various aspects of airway management which include
•
•
•
•
•
•
•
Airway Assessment
Decision making in Airway management
Choosing The Right Equipment
Managing The Correct Technique
Extubation
Human Factors and Non Technical Skills
Airway management outside theatre environment
The Course is specifically designed to meet the Airway CPD requirements of
UK anaesthetists.
For more information
and booking details visit
www.das.uk.com
Artistic anaesthetists are
encouraged to submit their work
to this year’s Art Exhibition.
The aim of the exhibition is to showcase the talents of all
anaesthetists and their families and help raise funds for the
Lifeboxes for Rio campaign.
Your work will need to be brought along yourself at the
beginning of Congress. It would greatly assist us if you
register your work in advance regardless as it will enable us
to plan the exhibition and provide a catalogue of contributors
for visitors’ use during the exhibition.
In recent years the exhibition has been opened out to
include all manner of art and craft other than the mainstay
painting and photography. We have had jewellery,
needlework, beading, sculpture, pots - there seems to be
no end to the creativity of anaesthetists and their families!
Please come along and support the Art Exhibition in
Edinburgh in September. You can do this in so many ways.
You can:
•
•
•
•
•
Contribute by exhibiting some of your art or craft
Donate for sale any you can bear to part with
Buy a stunning work of art created by a colleague for
a fraction of the market cost
Buy beautiful greetings cards
Just simply visit and enjoy the talents of your
colleagues
For further information and a submission form,
please visit www.annualcongress.org or contact
members@aagbi.org.
a
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‘An
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es introdu
Our experienc
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obstetric cou
The Safer Anaesthesia From Education (SAFE) obstetric
course, an initiative of the AAGBI, was designed in
2010. It is a 3-day intensive training course of lectures,
small group discussions and simulation sessions
aimed specifically to teach the safe conduct of obstetric
anaesthesia for practitioners in developing countries.
It has been taught throughout the world, particularly in
English-speaking African countries including Uganda,
Rwanda, Liberia and Ghana. In 2014, in association
with Mercy Ships, we introduced the first SAFE obstetric
courses in parts of French-speaking Africa; CongoBrazzaville in March and Madagascar in December.
Worldwide, more than 800 women die every day due to complications
in pregnancy and childbirth; that’s equivalent to 33 women per hour.
Of these deaths, 99% are in developing countries and more than
half are preventable.1 Although huge improvements in maternal
mortality have been made in the last 20–30 years, it is a sobering
fact that we remain woefully short of achieving the Millennium
Development Goal 5’s aim ‘to reduce maternal mortality by threequarters by 2015’. The causes of these deaths are multifactorial
and often deeply entrenched but include poverty, lack of adequate
antenatal care, education, insufficient numbers and training of
staff, as well as distance or other barriers to reaching care. Training
healthcare workers to conduct safe obstetric anaesthesia is one key
component to improving outcomes.
The SAFE obstetric course covers a range of topics including airway
management, safe conduct of general and regional anaesthesia,
resuscitation of the newborn and mother, and management of
common obstetric emergencies including eclampsia, sepsis and
haemorrhage. The course is evaluated by pre- and post-course
MCQs and hands-on skills-testing. The aims are to improve
knowledge and competence and empower anaesthetists to be a
force for change in their hospitals, region and country.
Both week-long trips involved a team of around ten teaching faculty
members; a mix of both consultant and trainee anaesthetists and an
obstetrician. In addition to the SAFE team, a group of at least four
interpreters attended per day, from the UK, France, Australia and
Canada, working alongside local interpreters.
The trips began with a visit to local hospitals, with opportunities to
speak to anaesthetic providers about their equipment, drugs and
common experiences, before finalisation of last-minute course
details.
Pointe Noire, Congo-Brazzaville, 25th–27th March 2014
Congo-Brazzaville in Central Africa has just ten anaesthetic doctors
for a population of 4.4 million, seven of whom work in the capital,
Brazzaville. The majority of anaesthetics are therefore given by
trained anaesthetic nurses or practitioners with little support.
Maternal mortality currently stands at 410 per 100,000 live births,2
slightly below the average for Africa as a whole. In the UK this figure
is 8 per 100,000.2
Running the first French-speaking SAFE obstetrics course involved
significant prior translation of course material and lecture notes.
17 The course was also adapted, removing aspects which had been
taught in-country in recent programmes to make allowances for
the extra time required for translation, and because knowledge and
experience of 'local timekeeping' meant it would not be realistic to
cover all the information without prioritising key aspects! This was
highlighted on day one when, after a heavy rainstorm overnight,
early buses could not run due to flooding on the roads leading to a
delayed start.
Many of our teaching techniques – for example, using simulation
with manikins – were very unfamiliar to the participants, but after only
a short time we had all relaxed enough to learn, teach and have a
good time. Particular highlights were discussing safe conduct of a
rapid-sequence induction using intubating manikins, watching the
participants manage faculty members having an eclamptic seizure
and the infamous ’guess the blood loss quiz‘ when discussing
massive obstetric haemorrhage. In all, 35 participants (25 anaesthetic
nurses, three doctors and seven midwives and obstetricians) were
trained on the course in Pointe Noire, the second largest city in
Congo-Brazzaville.
The MCQs showed a small improvement (66% pre-course vs 68%
post-course) and a significant improvement in the skills assessments
(4 to 6 out of 10). Feedback from the course was overwhelmingly
positive; ‘In summary I can say that in 3 days I grew a year’ and ‘Our
wish would be that simulation training seminars be performed every
year’ were just two of the comments received. All candidates were
given copies of the lectures, as well as a French textbook aimed
specifically for anaesthetists working in resource poor locations.
Antananarivo, Madagascar, 16th–18th December 2014
Madagascar is the fourth largest island in the world and situated 250
miles off the east coast of Africa. The population is estimated to be
just over 22 million, with a physician to population ratio of just 2 per
10,000.3 The maternal mortality ratio is currently 440 per 100,000 live
births3 and, although this is a significant improvement since 1990, it
is almost double the 2009 figures before political instability.4
The course took place in the capital Antananarivo, located in the
very centre of the island, in order to reach as many anaesthetic
practitioners as possible. Fifty-five healthcare professionals attended
the course, comprising 24 anaesthetic doctors, 15 anaesthetic
nurses, as well as 16 obstetricians and midwives. There was a
much higher ratio of doctors to nurses than had been the case in
Congo-Brazzaville but often the variation in management was more
notable between hospitals than between these groups. We found the
addition of the midwives and obstetricians on the second and third
days to be of particular benefit to the group when discussing issues
surrounding communication and teamwork in the management of
obstetric emergencies.
There was a significant increase in both the MCQ results (average
of 68.9% improved to 77.4%), and the skills test (4.8 out of 10, to 8),
most notably demonstrated in the neonatal resuscitation scenario
which improved from average 2.9 to 7.8 by the end of the course.
Feedback for the course was again very positive; when asked if the
course had helped to improve practice, and how likely they were
to share the information learned they rated 9.4 and 9.7 out of 10,
respectively.
A further SAFE obstetrics course will run in Madagascar in 2015, and
the hope is that a ‘Training of Trainers’ course will also run alongside
this to teach some of the more impressive candidates to become
faculty and lead to a sustainable teaching programme for the country.
SEMINARS
Summary
Teaching on these courses has been a real privilege; the healthcare
practitioners were engaged and keen to learn and improve standards,
and we were humbled by their experiences and learnt many lessons
from them.
Small group work helped us to understand what it might be like
to work in a hospital where perhaps 4–5 patients on a ward were
suffering the complications of severe pre-eclampsia and eclampsia
at any one time, or the regular devastation of seeing women
presenting critically unwell due to unnecessary delay or being left to
die because of being unable to afford simple, lifesaving treatments.
It also allowed us to see novel methods of dealing with common
healthcare problems; in Madagascar, for example, they had
reduced delay and improved access to potentially lifesaving blood
transfusions because patients are no longer required to pay, but
instead must arrange for two people to donate blood for every unit
used thus replenishing the supply.
Working in a different language was probably the most significant
challenge we faced, including the use of lay-interpreters. We stayed
alert to ensure the correct message was passed on – one subtle
example was explaining to a local interpreter that a ‘seizure in a
pregnant patient’ could not be translated as ‘epilepsy’. But with the
incredibly hard work of the interpreters and the nature of the course
to use repetition of important points in different stations as a teaching
tool, we were able to demonstrate improvements in knowledge and
skills, showing this course can be run successfully in French.
To see the courses in the Congo and Madagascar in action, please
view the videos at http://vimeo.com/91066502 and https://vimeo.
com/119803729
Acknowledgements
Our special thanks to Mercy Ships who helped organise the course
and supported us financially and logistically, particularly Dr Michelle
White and Ms Krissy Close, and to the AAGBI and Mrs Thomson for
additional sponsorship. Finally thanks to Dr Keith Thomson, Dr James
Leedham, Dr Emma Halliwell and all the faculty and interpreters who
helped make these first French-speaking SAFE obstetric courses
such a success.
Nikki Cox
ST3, University Hospital Southampton
Helen Howes
ST5, Great Western Hospital, Swindon
Savini Wijesingha
ST4, Royal Infirmary of Edinburgh
Further information about the SAFE Obstetric Anaesthesia
Course can be found on the AAGBI website: www.aagbi.org/
international/safe-safer-anaesthesia-education
References
1.
WHO. Maternal mortality statistics. Updated May 2014. http://www.who.int/
mediacentre/factsheets/fs348/en/ (accessed 8/2/2015).
2.
The World Bank. Maternal mortality ratio, 2014. http://data.worldbank.org/indicator/
SH.STA.MMRT (accessed 8/2/2015).
3.
WHO. Madagascar: Factsheets of Health Statistics, 2010. http://www.aho.afro.
who.int/profiles_information/images/c/cb/Madagascar-Statistical_Factsheet.pdf
(accessed 8/2/2015).
4.
WHO. Madagascar: Maternal and Perinatal Health Profile. http://www.who.int/
maternal_child_adolescent/epidemiology/profiles/maternal/mdg.pdf (accessed
8/2/2015).
DATES FOR YOUR DIARY
SEPTEMBER 2015
An introduction to obstetric regional
analgesia and anaesthesia for trainees
Quality improvement in emergency
laparotomy
Monday 07 September 2015
Wednesday 11 November 2015
Organisers: Dr Sunil Halder, Oxford
& Prof Steve Yentis, London
Trainees
Discounted
fees apply
OCTOBER 2015
Organiser: Dr Dave Saunders, Newcastle
World Anaesthesia Society (WAS) seminar
Thursday 12 November 2015
Organiser: Dr Bruce McCormick, Exeter
One lung anaesthesia: Challenges
and practical solutions
Thursday 01 October 2015
Perioperative complications in anaesthesia –
Prevention & cure
Organiser: Dr Kate O’Connor, Bristol
Organisers: Drs Jane Sturgess & Kamen Valchanov, Cambridge
Difficult airways
AAGBI Management & leadership course
Monday 12 October 2015
Monday 23 & Tuesday 24 November 2015
Organiser: Dr Mark Sandby-Thomas, Cardiff
Organiser: Dr Jonathan Price, London
GAT: Consultant interview
Tuesday 13 October 2015
Organiser: Dr Lyndsey Forbes, Dundee
Trainees
Wednesday 14 & Thursday 15 October 2015
Organisers: Dr Atul Gaur, Leicester
& Dr Vijay Kumar, Scunthorpe
Delegates can
register for one
or both days
NOVEMBER 2015
Anaesthesia for trauma and orthopaedic
surgery
Monday 02 November 2015
Organisers: Dr Santhosh Babu, Manchester
History - Anaesthesia & resuscitation in
unusual environments: Past, present and
future
Tuesday 03 November 2015
Organiser: Dr Alistair McKenzie, Edinburgh
Infectious outbreaks
Wednesday 04 November 2015
Organisers: Dr Jonathan Handy & Prof Steve Yentis, London
Perioperative management of the surgical
patient with diabetes mellitus
Organisers: Dr Nicholas Levy, Bury St Edmunds
& Dr Bev Watson, Kings Lynn
Special fees
apply
Ultrasound in anaesthesia
2 day spinal sonography
Monday 09 November 2015
18 NOVEMBER 2015
Organiser: Dr Andrew McEwen, Torquay
DECEMBER 2015
SAFE - Safer Anaesthesia From Education:
Training of the trainers
Monday 07 December 2015
Organiser: Dr Kate Grady, Manchester
Anaesthesia for non-cardiac surgery in
congenital heart disease - Paediatric
anaesthesia
Tuesday 08 December 2015
Organiser: Dr Raju Reddy, Birmingham
Bleeding, clotting & haemorrhage
Thursday 10 December 2015
Organiser: Dr Ravi Rao Baikady, London
Venue: 9-10 Portland Place, W1B 1PR
All AAGBI seminars are priced as
listed below unless otherwise stated
£133 - AAGBI members
£88 - AAGBI trainee members
£66.50 - Retired members
£260 - Non-members
All meetings & seminars are held at 21 Portland Place,
London unless otherwise stated.
Check availability and book online today
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Teaching primary trauma
care in Mozambique
Despite its many problems, the NHS is
still highly regarded by many patients
and healthcare professionals in Europe
and further afield. The UK Department for
International Development (DFID), and the
Tropical Health Education Trust (THET) have
established the Health Partnership Scheme
(HPS) as a four-year programme to support
developing health services in some of the
world’s poorest countries. NHS staff who
volunteer overseas are contributing to the
advancement of global health. By gaining
teaching experience, they return with skills
and experiences that benefit the UK.
The Primary Trauma Care Foundation (PTCF) is a non-profit nongovernment organisation set up in 1997 and currently supported
by the HPS to go to ten countries in Africa. It trains doctors and
other frontline healthcare professionals in the management of
severely injured patients in resource poor settings. The PTCF aims
to work alongside each country’s healthcare system, assessing
healthcare needs and providing trauma procedure and teaching
methodologies to facilitate the creation of locally sustainable
training schemes for the care of trauma patients. So far the PTCF
has run courses in over 60 countries worldwide. The PTC Manual,
which is used to support the course, has been translated into 14
languages and can be downloaded from the web.
20 Each PTCF visit comprises a two day PTC course for those
experienced in trauma management, a one day instructor course
and then supervision and guidance for these newly trained local
instructors to run their own two day locally delivered course with
a new batch of trainees. The latest African operation of the PTCF
is a collaboration between the PTCF and the College of Surgeons
of East, Central and Southern Africa (COSECSA), facilitated by
the COSECSA-Oxford Orthopaedic Link. The initial courses in
each of the ten COSECSA countries have been delivered by NHS
clinicians. Over the last two years nearly 45 courses have been
conducted in these countries and that number is increasing.
Mozambique is a Portuguese speaking country, rich in natural
resources. It lies on the southeast coast of Africa bordering
Tanzania, Malawi, Zambia, Zimbabwe, Swaziland and South
Africa, with extensive tropical coastline along the Indian Ocean.
As a result, its cuisine is famed, with sumptuous seafood, chicken
and nuts, often spiced with piri-piri and garlic.
After a turbulent period of civil war, multi-party elections were first
held in 1994. Despite starting to capitalise on foreign investment,
Mozambique’s gross domestic product per capita still ranks
among the lowest in the world.
The population is over 25 million with 1.2 million living in the
capital Maputo.1 Only a proportion of the population has access
to safe water and improved sanitation, 43% and 19% respectively,
with these resources being more accessible to those who live in
urban rather than rural areas.2 There are only three physicians
per 100,000 people, one of the lowest doctor to patient ratios
worldwide,3 and the country’s spending on healthcare per capita
is a fraction of that spent in the developed world.4,5 It is therefore
unsurprising that the average life expectancy remains one of the
lowest in the world at just 53 years.6 The region also has the
highest fatality rate from road trauma in the world. The World
Health Organization Global Status Report on Road Safety in 2013
estimated that the annual number of road deaths in Mozambique
to be 18.5 per 100,000 people, which is five times that seen in the
UK.7 In addition there are also a significant number of patients
that will sustain non-fatal injuries from road trauma.
In February 2013, we travelled to Maputo to conduct the first PTC
course and have all subsequently returned as part of smaller
groups to aid and facilitate the running of some of the local
courses in Mozambique’s provinces, between us going to Beira,
Pemba and Tete. In total UK instructors have attended five courses
in Mozambique over the past two years.
The Mozambiquan government is currently trying to reduce the
impact of trauma nationally, implementing primary prevention
strategies, such as traffic regulations, and improving the care
received by trauma victims. Our presence coincided with these
initiatives and was publicised heavily, helping to advertise and
reinforce the importance of the above.
on the responsibility themselves and our role became more
supportive. There have been three courses so far that have been
held using exclusively Mozambiquan faculty, which is encouraging
progress. We hope that the Mozambiquan government will support
the introduction of this course into the teaching curriculums for
both doctors and clinical officers/technicians. Positive engagement
from enthusiastic and dynamic local faculty provides hope that
local health professionals can continue to sustain this project,
disseminating it across Mozambique to improve the care of trauma
patients throughout the country.
The first trauma and instructor courses in Maputo were run in
English but by using the newly qualified local instructors meant
subsequent courses were taught predominantly in Portuguese
(with translation when required for the UK instructors). Initially, while
local faculty would teach the course content, all the administration,
timing and co-ordination of the courses was left almost entirely
to the UK faculty. Throughout the programme these tasks were
increasingly delegated to the local faculty who ultimately took
21 Teaching primary trauma
care in Mozambique
Emma King
Juan Graterol
Being involved in PTC has been an incredibly rewarding
experience. Participating in the scheme provided the perfect
opportunity to combine my interests of teaching and medicine in
a resource poor environment. It was with feelings of excitement
and trepidation that I boarded the plane to Mozambique for the
first time. When teaching in the UK I have been familiar with the
local set up, the resources available and taken for granted that
both faculty and candidates speak English. None of this could
be guaranteed for the course in Mozambique. I would also be
teaching experienced clinicians and technicians with a wealth of
trauma experience that would greatly exceed my own.
As an overseas-trained doctor I feel very passionate about this
project. I would have been a willing recipient of this course had
I stayed in Venezuela when I graduated from medical school.
I need not have worried. Candidates had an attitude of mutual
respect and a willingness to learn from each other's experiences.
There was great interaction and the concept of ABCDE was
readily acknowledged, appreciated and easily taught. The
original candidates were then able to teach these concepts
effectively in their own courses later in our stay. Seeing them
take ownership of the course and the enthusiasm they had for
running it was a real highlight for me.
Experienced clinicians may be sceptical at first, which is why
mutual respect is important. By recognising their expertise
and encouraging them to contribute positively to the learning
experience, they may incorporate it into their own teaching with
a multiplying effect. Respect also includes adapting the course
material to local circumstances; there is very little benefit in
pretending to get a CT scan or FAST scan during the simulations
or scenarios if those facilities are not currently available. The
learning tools are usually those available at the host country.
This makes it more realistic and relevant for participants but
demands a degree of flexibility from the UK-based instructors.
My Portuguese is somewhat limited but we were assured
the whole course would be run in English. On our arrival it
became clear that this was not the case. Throughout medical
training we are frequently taught the importance of non-verbal
communication. This experience has helped me truly appreciate
its importance. It is amazing what can be conveyed by an
individual’s body language and tone of voice.
There were many additional challenges that arose in attempting
to run a course abroad. There was a great deal of local
excitement about the course, but the helpful attitude and desire
to please did sometimes mean questions would be answered
with what we wanted to hear, rather than the truth. Adapting and
working to the relaxed 'African Time' ethos, although not always
conducive to efficiency, was quite a refreshing change from the
occasionally restrictive British expectations on time keeping.
Working collaboratively with each other, adapting to local needs
and finding solutions to problems as they arose, we were able to
run excellent trauma courses that were enjoyed by all.
It was rewarding to be involved in a project that gives local people
the resources and skills to continue their own development. In
doing so we hope it may have a lasting impact on trauma care
throughout Mozambique. I learnt an incredible amount from
this experience. I further developed my skills as a teacher and
clinician but also renewed my appreciation for the NHS, the
service it provides, the resources we all have available to us, and
the quality of training we receive. I would thoroughly recommend
getting involved.
For further information regarding PTC visit
www.primarytraumacare.org
22
22 There are two aspects of this model that I find particularly
attractive: sustainability and respect. The main emphasis on
the first course was to train local trainers who will continue
cascading the ABCDE approach to trauma care. It is essential
to involve local leaders for this type of project to get a firm hold
on the ground and be able to stand on its own two feet once our
brief visit ended.
Local idiosyncrasies and cultural differences must be
acknowledged and embraced; time keeping in tropical countries
is not always as rigid as Brits would expect! A good deal of
diplomacy, interpersonal skills and socialising in a less formal
environment usually helps to ensure that positive links are
formed – links that will be key to keep momentum and drive the
project forwards.
I am very pleased I had the opportunity to be part of the first
PTC visit to Mozambique and would encourage everyone to get
involved. It is an enriching experience on many levels.
MSc in Anaesthesia (Perioperative)
1 year full-time or 2 years part-time
Starting October 2015 in Medway (London in 42 mins by rail)
A high quality programme which focuses on perioperative care and quality improvement.
Our MSc in Anaesthesia (Perioperative) has been designed in collaboration with leading anaesthetists to ensure it
meets the personal and professional development of anaesthetists working in the NHS and private sector.
Practical sessions, lectures and research methodologies are used to cover:
 Quality improvement in anaesthesia
 Pre-assessment and risk stratification
 Intraoperative and postoperative care
Find out more
e: allison.allen@canterbury.ac.uk
www.canterbury.ac.uk/pg/anaesthesia
A AGBI
TOPICS INCLUDE:
Anaesthetists in training
Clinical anaesthesia
Clinical measurement/equipment
GUIDELINES APP
Contractual/job planning
Elderly anaesthesia
Ethics and law
Haematology
Human factors
Independent practice
6 new guidelines
recently added
Irish anaesthetists
Emma King
ST7 in Anaesthesia, University Hospitals Bristol NHS
Foundation Trust
Thomas Hampton
CT2 in Plastic Surgery, Queen Victoria Hospital, East Grinstead
Juan Graterol
Consultant in Anaesthesia and Pain Medicine, Royal Cornwall
Hospital NHS Trust
References
1.
http://www.citypopulation.de/Mocambique.html (accessed 7/11/14).
2.
http://www.unicef.org/mozambique/child_survival_2948.html (accessed 7/11/14).
3.
http://www.usaid.gov/mozambique/global-health (accessed 6/11/14).
4.
http://www.who.int/countries/moz/en/ (accessed 6/11/14).
5.
http://data.worldbank.org/indicator/SH.XPD.PCAP (accessed 6/11/14).
6.
http://www.who.int/gho/countries/moz.pdf?ua=1 (accessed 6/11/14).
7.
World Health Organization. Global Status Report on Road Safety 2013.
http://www.who.int/violence_injury_prevention/road_safety_status/2013/en/
(accessed 7/11/14).
Anaesthesia
Anaesthesia News
News August
August 2015
2015 •• Issue
Issue 337
337
Obstetric anaesthesia
Resuscitation and trauma
ntent
Updates to existing co
SAS anaesthesia
Wellbeing
FREEGBI
FOR A A RS
MEMBE
Checklist for
t
anaesthetic equipmen
ol
Reflective learning to
DOWNLOAD THE APP TODAY
FOR APPLE AND ANDROID DEVICES
www.aagbi.org/guidelines-app
25th
National
Acute Pain Symposium
Thurs 10th & Fri 11th September 2015
Crowne Plaza Hotel, Chester
The Nation's premier Acute Pain forum
Plenty of interesting content for anyone involved in Acute Pain management
See and hear what the innovators are doing around the country
PCA’s : Old and New
Pain in the ICU
Management of Patients Addicted to Opiates - A Patient Story
Role of the Clinical Psychologist in the Acute Pain Team
Managing Acute Pain in the Trauma Patient from Roadside to Recovery & Beyond
Shock of the Fall : Rib Fracture Management
Functional Abdominal Pain - Inpatient Management
Role of the Physical Therapist in Management of Surgical Patients with Acute Pain
Essential Pain Management - Experience in Uganda
Role of Ketamine in Modern Acute Pain Management
Pain Service Involvement in MSK Service Redesign
Poster Exhibition with short presentations by Competition winners
Acute Pain Special Interest Group Meeting
Please visit us at
www.acutepainsymposium.co.uk
for more information
PLEASE JOIN US AT THIS LANDMARK EVENT
Details & Bookings :
Georgina Hall
Tel : (0151) 522 0259
Mob : 07901 717 380
E-mail : medsymp@btinternet.com
Registration Fees :
Consultants
NCCG
SpR & SHO
Nurses
£345
£345
£275
£195
Arterial line safety
Arterial lines play a significant
role in monitoring accurate
blood pressure, titrating drug
treatments and obtaining
blood samples for bedside
and laboratory tests. Hence it
is crucial for staff involved to
be aware of factors influencing
the management of these
arterial lines.
What happened?
In August 2013, during the evening handover time in the
emergency maternity theatre, an arterial line was inserted as part
of the management of a severe post-partum haemorrhage prior to
transfer of the patient to the intensive care unit. The arterial line was
accidentally connected to an infusion pump with propofol attached
and a few millilitres of propofol were administered before the error
was detected. Fortunately, there was no harm to the patient.
Comprehensive Trade exhibition
Informal Delegate Dinner - Brazilian Restaurant
A wonderful relaxed and friendly evening.
A favorite amongst those who have attended before
8 CPD points from the Royal College of Anaesthetists applied for
24 Anaesthesia News August 2015 • Issue 337
1.
2.
3.
Why we think it happened
4.
The cause was multifactorial. It was an emergency situation with
high stress levels, several anaesthetists with varied experience were
present, and it was changeover time. Although an experienced
trainee, the person taking over was new to the hospital and
unfamiliar with the local arterial line set-up, there was an unlabelled
three-way tap on the arterial line set-up and the connections and
tubing employed were similar to those used for other intravenous
fluids.
5.
Why did we ask the question?
Following the above incident, we reviewed the literature about
incidents involving arterial line management and currently available
guidance on arterial line safety. There are a number of case reports
of accidental intra-arterial injections1,2 as well as reports of other
incidents3,4 relating to arterial lines.
Hear about & see the new & existing Acute Pain
related products
Box 1: Summary of NPSA Rapid Response Report
on Arterial lines in July 2008.
These included two incidents in which death occurred following
severe hypoglycaemia and neuroglycopenic brain injury. This was
caused by glucose contamination of arterial line blood samples
as a result of glucose containing solutions being attached to the
arterial line flush bag.3,4
In 2008, the National Patient Safety Association (NPSA) published
guidelines5 on arterial line management to improve safety (see
Box 1).
6.
Arterial blood sampling should be performed only by
competent and trained staff.
Arterial lines must be clearly identified by use of a labelling
system such as continuous coloured lines.
Any infusion attached to the arterial line must be prescribed
and checked before administration.
Further checks should be made at regular intervals such as
shift handover.
Only sodium chloride 0.9% should be used as the infusion fluid
for arterial lines.
Labels should clearly identify contents of infusion bags, even
when pressure bags are used.
More recently, the AAGBI published further guidance6 on blood
sampling from arterial lines, reiterating NPSA guidance. Further, the
AAGBI recommended use of closed arterial line sampling systems,
pressurising devices designed to permit unimpaired inspection of
the contained flush infusion bag and an unexpectedly high blood
glucose should raise suspicion of sample contamination and
prompt medical review prior to starting insulin.
In addition, removing three times the dead space prior to blood
sampling to prevent contamination of samples with flush fluid has
been recommended.3,7
We took this opportunity to explore experiences of adverse events
with arterial lines and to establish the level of awareness of the
NPSA guidance among anaesthetists across Scotland. We also
wanted to identify measures which different centres and individual
anaesthetists take to minimise the risk of such events occurring,
in the hope of adapting this knowledge and experience to reduce
further risk within our own hospital. At the time of the survey, the
NPSA guidance was the only national guidance available on
arterial line management.
25 Scotland-wide survey on arterial line management
Question 7: Have you ever had a near miss with use of arterial
lines in theatre? Some examples are mentioned in Box 3.
A set of questions were formed on the SurveyMonkey website and a link to the survey was distributed to all anaesthetic departments in
Scotland to forward on to their individual anaesthetists. We received a total of 273 responses in 4 weeks which included 192 consultants,
32 SRs (ST5–7), 17 ST3–4s, 20 core trainees and 12 anaesthetists of other grades.
After analysing the survey results, we reviewed practice within our
anaesthetic department and implemented the following changes:
Change 1: Arterial line labelling
Prior to the incident described, our arterial line set up at the
patient end in theatre included a short extension with three-way tap
(Figure 1).
Results
Question 1: Are you aware of the 2008 NPSA guidance on use
of arterial lines?
What did we do?
Question 5: What volume of dead space do you remove prior to
sampling?
Less than one-third
of the respondents
were aware of NPSA
guidance.
Figure 1: Three-way tap
Box 3: Examples of near misses related to arterial
line management
•
•
•
Question 2: How do you label arterial lines?
•
‘Other’ answers were mostly along the lines of specific volumes such as 10 ml,
5 ml, ml, ‘a couple of ml’ and ‘dead space and a bit’
Question 6: Have you experienced any critical incident with
arterial lines in theatre? Some examples are mentioned in Box 2.
•
•
•
•
•
Nearly attached the remifentanil infusion instead of the transducer
Near accidental drug injection (flucloxacillin, atracurium,
metariminol)
5% dextrose used as flush bag - not picked up until patient in ICU.
No harm occurred.
Injected metaraminol. Realised when the continuous BP trace was
transiently lost and hastily aspirated several ml before it reached
the patient
Taking over case, unlabelled line taped to pillow. Noticed it pulsing
before injection so took the three-way tap out
Inadvertent dextrose flush got picked up before insulin given for
hyperglycaemia
Almost did intra-arterial injection. Spotted error just before pushing
plunger. Distracted.
Midwife hung metronidazole on arterial flush line and contacted me
as drip not dripping
Absentmindedness - almost connecting a drug filled syringe to the
3 way port instead of the IV line - realised before injection occurred
Propofol infusion was attached to this three-way tap during the
incident. These connectors were removed from use with arterial
lines. However, we felt errors could still occur with the subsequent
set-up (Figure 2) and it did not comply with the national guidance
that recommended clear labelling of lines, for example with colour.
Figure 2: Arterial line set-up
‘Other’ methods included: ‘Arterial’ stickers applied to dressings/Red line on
tubing/Red three-way taps/Red bung
Question 3: Do you ever check what type of fluid is connected
to the transducer before connecting?
Finally, we asked for any other comments, and some interesting
responses are shown in Box 4.
Box 2: Examples of critical incidents related to
arterial line management
Box 4: Other comments
•
•
•
•
•
Question 4: Where do you take blood samples from usually?
•
•
•
•
•
•
•
•
‘Other’ methods in this case included ‘bung on end of arterial line itself’, ‘sampling
port at patient end’ and ‘three-way tap halfway’
26 Patient taken back to theatre for surgical removal of an arterial line
fragment that sheared off in recovery. Required a venous patch
Incorrect flush bag used: 0.18% NaCl + 4% glucose
Disconnection, limb ischaemia, antibiotic mistakenly given, air in
line, diluted samples etc.
Accidental injection of medications (heparin, magnesium,
atracurium, cefuroxime)
Cerebral air embolism. Amputation of arm following intra-arterial
injection of thiopentone
ITU patient – hypoxic brain damage from too much insulin guided
by falsely elevated blood glucose readings (glucose used for flush
bag)
Loose connection hidden by drapes leading to some blood loss
Brachial haematoma from heparin flush overdose
Moderate ischaemia of the hand at the end of surgery which
resolved in the recovery room after removal of the arterial line
Vented cap put on open three-way tap at transducer causing minor
blood loss
Treated high blood pressure because transducer had fallen to floor
Surgeons using intra-operative clamp, trapped the arterial line
tubing between the clamp and the operating table, transecting the
tubing completely. A flat arterial line trace prevented significant
blood loss
•
•
•
•
•
•
•
•
Danger arises when more than one anaesthetist in theatre and they
do things differently
Recommend closed sampling technique to avoid risk of
contaminating sample with dead space fluid which leads to
inaccurate results and may have contributed to hypoglycaemia
death in ICU case
Easy, clearly attached labels (standardised for ease of recognition)
would seem very sensible
Maybe we need incompatible connectors as for central neuraxial kit
We should check the fluid. We should have only one sample tap at
the transducer. Drugs should never be given at the transducer even
if into CVP line
We also prescribe the fluid on the fluid chart and there is a red
label on the flush bag, which says arterial line flush on it
Huge variability in practice is a risk factor for incidents or nearmisses, and that an accepted way of standardising labelling and
check listing would improve safety, which would be a welcome
development
Why can't manufacturers pre-label the lines/taps?
Standardisation of kit across sites would be helpful
The department reached a consensus view that alternative arterial
line tubing featuring a clear red line down the tubing along with red
three-way taps (Figure 3) should be introduced, initially in theatres
with the plan to expand their use in other areas where arterial lines
are routinely used.
Figure 3: New arterial line set up
27 Change 2: Flush bag prescribing and recording
Our second challenge was to explore ways of improving our process of
checking and prescribing the flush bag. There was much discussion about
how best to ensure that the flush bag is prescribed on fluid charts without
causing confusion to total daily fluid balance. It was agreed it would be
best to develop a sticker (Figure 4) for the theatre fluid chart which states
that fluid is for purely arterial administration and is 0.9% sodium chloride
solution. Prior to administration this bag should be checked and the chart
signed by two members of staff (nursing and/or medical). A compliance
audit will be carried out regularly and a monthly chart displayed.
Figure 4: Colour coded arterial
line prescription sticker on a fluid
balance chart
Discussion
The literature shows that critical incidents with arterial lines continue to
occur and can lead to death or serious harm. A third of anaesthetists
who responded to our survey had experienced either a critical incident or
near miss with an arterial line. In addition, there is still a lack of awareness
of the potential problems with arterial lines and a wide variety in current
practice in reducing risk. We have used this as an opportunity to increase
awareness of the risks this piece of monitoring equipment can pose within
our own department and have brought in two simple changes to our
current practice that we hope will reduce future risk and improve patient
safety.
Disclaimer: This survey was presented as a poster an NHS Scotland
Event last year.
Alison Kearsley
ST7 Anaesthetics
Pavan Raju
Consultant Anaesthetist
Ninewells Hospital & Medical School, Dundee
References
1.
2.
3.
4.
5.
6.
7.
Holley HS, Cuthrell L. Intraarterial injection of propofol. Anesthesiology 1990; 73: 183–4.
Samanta S, Samanta S. Accidental intra arterial injection of diclofenac sodium and their
consequences: report of two cases. Anaesthesia, Pain & Intensive Care 2013; 17: 102–3.
Gupta KJ, Cook TM. Accidental hypoglycaemia caused by an arterial flush drug error: a case
report and contributory causes analysis. Anaesthesia 2013; 68: 1178–87.
Sinha S, Jayaram R, Hargreaves CG. Fatal neuroglycopaenia after accidental use of a
glucose 5% solution in a peripheral arterial cannula flush system. Anaesthesia 2007; 62:
615–20.
National Patient Safety Agency. Infusions and sampling from arterial lines. Rapid Response
Report. NPSA/2008/RRR006
Woodcock TE, Cook TM, Gupta KJ, Hartle A. Arterial line blood sampling: preventing
hypoglycaemic brain injury. Anaesthesia 2014, 69: 380–5.
Burnett RW, Covington AK, Fogh-Anderson N, et al. Recommendations on whole blood
sampling, transport, and storage for simultaneous determination of pH, blood gases, and
electrolytes. International Federation of Clinical Chemistry Scientific Division. Journal of the
International Federation of Clinical Chemistry1994; 6: 115–20.
EVELYN BAKER
MEDAL
Digested
August 2015
AN AWARD FOR OUTSTANDING
CLINICAL COMPETENCE
Performance of manual ventilation: how to define its efficiency in bench studies?
A review of the literature
The Evelyn Baker award was instigated by
Dr Margaret Branthwaite in 1998, dedicated
to the memory of one of her former patients
at the Royal Brompton Hospital. The award
is made for outstanding clinical competence,
recognising the ‘unsung heroes’ of clinical
anaesthesia and related practice. The defining
characteristics of clinical competence are
deemed to be technical proficiency, consistently
reliable clinical judgement and wisdom and
skill in communicating with patients, their
relatives and colleagues. The ability to train
and enthuse trainee colleagues is seen
as an integral part of communication skill,
extending beyond formal teaching of academic
presentation. Nominees should normally still be
in clinical practice.
Khoury A, De Luca A, Sall FS, Pazart L, Capellier G.
Last year the award was won by Dr Sally Millett
(Worcester). Details of previous award winners
can be found on the website http://www.aagbi.
org/about-us/awards/evelyn-baker-medal
Nominations are now invited for the award,
which will be presented at WSM London in
January 2016. Members of the AAGBI can
nominate any practising anaesthetist who is
also a member of the Association. Examples of
successful previous nominations are available
on request. Nominations should include an
indication that the nominee has broad support
within their department.
The nomination, accompanied by a
citation of up to 1000 words, should
be sent to the Honorary Secretary at
HonSecretary@aagbi.org by 17:00
on Friday 18 September 2015
Reliability of manikin-based studies: an evaluation of manikin characteristics and
their impact on measurements of ventilatory variables
De Luca A, Sall FS, Sailley R, Capellier G, Khoury A.
Two articles critique the reliability of artificial physiological
measurements and, to some extent, the applicability of those
measurements to people. Manikins cannot die or suffer hurt. They
are therefore valuable when one tests the safety and provisional
performance of machines that might subsequently be attached to
people, who of course can die and be hurt. The results of manikin
experiments should not be extended beyond their remit: too often
manikin studies are presented as definitive evidence for the clinical
superiority of one device. When Ex Machina cyborgs pass the
clinical equivalent of the Turing’s test we might dispose of clinical
studies. Until then, mind the gap between the evidence and its
clinical application.
Laparoscopic sleeve gastrectomy in five awake obese patients using
paravertebral and superficial cervical plexus blockade
Kanawati S, Fawal H, Maaliki H, Naja ZM.
Might you be worried about anaesthetising a patient with a BMI of
54 for a sleeve gastrectomy? If so, don’t. That is, don’t anaesthetise
them, but you have to be good at numbing. Now, where did I put
that yellow pillow?
Evaluation of a new double-lumen endobronchial tube with an integrated
camera (VivaSight-DLTM): a prospective multicentre observational study
Koopman EM, Barak M, Weber E, et al.
I indulge my vanity by believing that, for most patients, I can see
the glottis as well with direct laryngoscopy as I can with indirect
laryngoscopy. I studiously ignore the interpretation of this sentence
that I’m just as bad at both. I don’t think that I can see the carina
from the mouth, even with a very bright torch. Koopman et al.
describe bronchial intubation with a double-lumen tube tipped by
a camera. One day we might have a self-driving subglottic airway
that follows the aroma of carbon dioxide to the lungs. Until then,
maintain your driving licence.
J. B. Carlisle,
Editor, Anaesthesia
N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)
29 Particles
Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrom LH.
De Jong A, Molinari N, Pouzeratte Y, et al.
Mishriky BM, Waldron NH, Habib AS
Diagnostic accuracy of anaesthesiologists'
prediction of difficult airway management in
daily clinical practice: a cohort study of 188
064 patients
Difficult intubation in obese patients:
incidence, risk factors, and complications in
the operating theatre and in intensive care
units
Impact of pregabalin on acute and persistent
postoperative pain: a systematic review and
meta-analysis
Anaesthesia 2015; 70: 272–81
British Journal of Anaesthesia 2015; 114: 297–306
Background
Although NAP41 and the American Society of Anesthesiologists recommend preoperative airway assessment there is no consensus on what assessment should
be undertaken. No single test reliably predicts difficult intubation.2 The Danish
Anaesthesia Database records compulsory data from 75% of anaesthetic
departments in Denmark. The authors utilised this quality assurance resource
to investigate if airway assessment accurately predicted difficult intubation or
mask ventilation.
Background
This study looks at the association between obesity and intubation, and life
threatening complications in both the intensive care unit (ICU) and in the operating
theatre (OT), and the incidence of difficult airways in both these settings. Raised
body mass index (BMI) has been associated with difficult intubation, in both
ICU1,2 and the OT.3,4 Major airway complications occurring in ICU5 and the OT6
involved obese patients in 47% and 40% cases, respectively.
Methods
This observational study included every patient undergoing attempted tracheal
intubation or mask ventilation in a three year period between 2008 and 2011.
‘Yes/No’ answers to two compulsory questions, ‘Is difficult tracheal intubation by
direct laryngoscopy anticipated?’ and ‘Is difficult mask ventilation anticipated?’
were recorded before induction of anaesthesia. An initial airway management
plan was documented before performing airway management and ease of
mask ventilation was recorded. Difficult intubation was defined as more than
two attempts at direct laryngoscopy, use of intubation adjuncts or specialised
equipment (e.g. video laryngoscopy) or failed intubation. Mask ventilation was
subjectively graded as easy or difficult.
Analysis was performed in three cohorts:
•
•
•
Patients who had intubation attempted using only direct laryngoscopy
(primary analysis)
Patients in the primary analysis plus those with anticipated difficult
intubation where use of specialised airway equipment was pre-planned
(sensitivity analysis 1)
All patients undergoing attempted intubation (irrespective of technique)
but using a stricter definition of difficult intubation of three or more
attempts (sensitivity analysis 2)
Results
A total of 188,064 patients were included. In the primary analysis 3,383 (1.9%)
intubations were difficult; 93% of these were unanticipated. Anticipated difficult
intubations were actually difficult in 25% of patients, 75% of difficult intubations
were not predicted in sensitivity analysis 1 and 91% were not predicted in
sensitivity analysis 2.
Difficult mask ventilation cases were identified in 857 patients, of which 94%
were unanticipated. A total of 49% of patients with difficult mask ventilation were
also difficult to intubate. Failed intubation occurred more frequently in cases of
difficult mask ventilation (3.7% vs 0.1%).
Discussion
This large study of Danish anaesthetic practice has clear applicability to UK
practice. Although the incidence of difficult intubation was lower than in previous
studies there was a surprisingly high incidence of unanticipated difficult
intubation. Most airways that were anticipated to be difficult were not.
This study has significant strengths including the number of patients studied
and compulsory database entry but also has limitations including potential
recording bias due to default settings in the database that may have resulted in
under-recording of anticipated difficulty. Nonetheless, this study confirms that
prediction of airway difficulty remains challenging and as such we must remain
aware of the potential for unexpected difficulties when managing even the most
straightforward airway.
Methods
This was a multi-centre prospective observational cohort study in ICU and the
OT in obese (BMI>30) patients. The primary endpoint was the incidence of
difficult intubation, defined by the ASA Task Force on Management of the Difficult
Airway.7 Secondary endpoints were the risk factors for difficult intubation, the
use of difficult airway management techniques, and severe life-threatening
complications related to intubation.
Results
In cohorts of 1,400 and 11,035 consecutive patients intubated in ICU and in the
OT, 20% and 19% were obese, respectively. In obese patients, the incidence of
difficult intubation was twice as frequent in the ICU as in the OT (16.3% vs 8.2%,
p = 0.01). In both cohorts, risk factors for difficult intubation were Mallampati
score III/IV, obstructive sleep apnoea syndrome, and reduced mobility of cervical
spine. Limited mouth opening, severe hypoxaemia, and coma were specific to
ICU. Specific difficult airway management techniques were used in 36% cases of
difficult intubation in obese patients in the OT and in 22% cases in ICU. Severe
life-threatening complications were significantly more frequent in ICU than in the
OT (41.1% vs 1.9%, RR 21.6, 95% CI 15.4–30.3, p<0.01).
Discussion
Limitations of the study included the use of two databases which were multicentre, possibly leading to information bias. However, multivariate models
were used. Pre-oxygenation and intubation position were not standardised. On
occasion the physicians recording the data variables were the same as those
performing the intubation, so the degree of difficulty may have been biased.
In obese patients, the incidence of difficult intubation was twice as frequent in
ICU as in the OT and severe life-threatening complications related to intubation
occurred 20x times more often in ICU in this group. The ICU setting was found
to be an independent risk factor of severe complications, in comparison with the
OT. The use of specific difficult airway management techniques was less in the
ICU compared with OT. In the OT, rapid sequence induction was used in 2% of
the patients vs 74% of patients in ICU. The higher rate of severe complications in
ICU may be explained by the increased risk of significant desaturation in critically
ill patients during rapid sequence induction.8
Shelley Barnes
CT2b, Severn Deanery
References
1.
2.
3.
4.
5.
Andrew Ray
CT2B ACCS, Severn Deanery
6.
References
1.
2.
30 Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major
complications of airway management in the UK: results of the Fourth National
Audit Project of the Royal College of Anaesthetists and the Difficult Airway
Society. Part 1: Anaesthesia. British Journal of Anaesthesia 2011; 106: 617–31.
Shiga T, Wajima Z, Inoue T, Sakamoto S, Sakamoto A. Predicting difficult
intubation in apparently normal patients. Anaesthesiology 2005; 103: 429–37.
7.
8.
De Jong A, Molinari N, Terzi N, et al. Early identification of patients at risk for
difficult intubation in ICU: development and validation of the MACOCHA Score
in a Multicenter Cohort Study. American Journal of Respiratory and Critical Care
Medicine 2013; 187: 832–9.
Frat J-P, Gissot V, Ragot S, et al. Impact of obesity in mechanically ventilated
patients: a prospective study. Intensive Care Medicine 2008; 34: 1991–8.
Langeron O, Cuvillon P, Ibanez-Esteve C, et al. Prediction of difficult tracheal
intubation: time for a paradigm change. Anesthesiology 2012; 117: 1223–33.
Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak
predictor for difficult and failed tracheal intubation: a cohort study of 91,332
consecutive patients scheduled for direct laryngoscopy registered in the Danish
Anesthesia Database. Anesthesiology 2009; 110: 266–74.
Cook TM, Woodall N, Harper J, et al. Major complications of airway management
in the UK: results of the Fourth National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency
departments. British Journal of Anaesthesia 2011; 106: 632–42.
Cook TM, Woodall N, Frerk C, et al. Major complications of airway management
in the UK: results of the Fourth National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British Journal of
Anaesthesia 2011; 106: 617–31.
Practice guidelines for management of the difficult airway: an updated report by the
American Society of Anesthesiologists Task Force on Management of the Difficult
Airway. Anesthesiology 2003; 98: 1269–77.
El-Orbany M, Connolly LA. Rapid sequence induction and intubation: current
controversy. Anesthesia & Analgesia 2010; 110: 1318–25.
British Journal of Anaesthesia 2015; 114: 10–31.
Background
Pregabalin is currently licensed for neuropathic pain and control of epilepsy;
however its use in the peri-operative period is increasing, but at present is off
licence. Pregabalin binds to the α-2-δ subunit of voltage gated calcium channels,
leading to a reduction in the release of excitatory neurotransmitters.1 Many
trials and meta-analyses have been conducted investigating the peri-operative
analgesic effects of pregabalin, with varying doses from 50 mg to 300 mg.
Mishriky et al aimed to provide an up-to-date review on the use of peri-operative
pregabalin and its effect on pain score and opioid consumption.
Methods
A search of MEDLINE, Cochrane Central Register, EMBASE and CINAHL was
made for randomised controlled trials comparing pregabalin with control patients
undergoing surgery, following the recommendations of the PRISMA statement.
Primary outcomes were pain scores and opioid consumption at 2 and 24 hours.
Secondary outcomes were duration of PACU and hospital stay, incidence of
persistent pain, pre-operative anxiety scores and side effects.
The visual analogue scale for pain and anxiety (0 no pain, 10 worst pain) was
used, and opioid consumption was calculated using standard morphine
equivalents. The incidence of persistent pain was compared at 1, 3, 6 and 12
months after surgery.
Results
Of the 695 eligible studies, 55 were included in the final analysis of the review,
comparing 2,270 patients who received pre-operative pregabalin with 1,885
controls.
Pain scores at 2 hours were reduced at rest [mean difference (MD) -0.81] and
on movement (MD -0.58) in the pregabalin group. At 24 hours, pain scores were
reduced at rest (MD -0.38) and on movement (MD -0.47). All pregabalin doses
>75mg showed a reduction in pain scores. Opioid consumption at 2 hours was
reduced (MD -2.09mg) with pre-operative pregabalin doses >100 mg. At 24
hours opioid consumption was reduced (MD -8.27mg) for all doses.
Single dosing was as effective as multiple dose regimes at reducing pain scores
and opioid consumption.
There was no difference in length of stay in the post anaesthesia recovery unit
[MD -2 mins (95% CI -9.76, 5.66)], but pregabalin medicated patients achieved
hospital discharge 13.75 hours earlier (95% CI -23.26, -4.24).
Reported side effects included: Sedation (46% increase), dizziness (33%
increase) and visual disturbance (3.5x more likely) were significantly more
common at 24 hours with a 300 mg dose, but not at a lower dose. However
pruritus and postoperative nausea and vomiting were significantly reduced by
51% and 38%, respectively.
The meta-analysis showed no difference in persistent pain at 1 and 3 months,
however reduced rates of persistent pain at 6 (4 vs 15%) and 12 months (9 vs
20%).
Discussion
Mishriky et al. have shown that pre-operative pregabalin administration can be
a useful adjunct in patients undergoing surgery – the meta-analysis indicates
that opioid use is reduced, postoperative nausea and vomiting and pruritis rates
reduced and time to hospital discharge significantly reduced. There is also some
evidence to suggest that this strategy can reduce the development of chronic
postoperative pain. Further work is needed to compare the efficacy of difference
doses and of single vs multiple dosing regimens of pregabalin to assess the ideal
dosing strategy.
Andrew Grant
CT2b, Severn Deanery
Reference
1.
Taylor CP, Angelotti T, Fauman E. Pharmacology and mechanism of action
of pregabalin: the calcium channel α2–δ (alpha2–delta) subunit as a target
for antiepileptic drug discovery. Epilepsy Research 2007; 73: 137–50.
31 Dear Editor
Figure 1
The ‘sartorius roll’: a reliable tactile landmark for fascia iliaca blocks
The traditional landmarks for the fascia iliaca block as described by Dalens et al.1 include
the pubic tubercle. Anecdotal evidence from our own practice suggests sometimes
the pubic tubercle is generally estimated, not palpated. In the absence of ultrasound
guidance, this may result in incorrect needle placement and an unreliable block.
The medial border of the sartorius forms the lateral border of the femoral triangle. The
injection point is medial to the medial border of the sartorius. Hence, we suggest a routine
fingertip roll of the sartorius muscle as an additional landmark to reassure a correct and
safe injection point (Figure 1).
SEND YOUR LETTERS TO:
The Editor, Anaesthesia News at anaenews.editor@aagbi.org
Please see instructions for authors on the AAGBI website
Mark Gotecha
ST3 Anaesthetics
Santosh Mehrotra
Dear Editor
Russel Emamdee
Anaesthetics: a health warning!
Broomfield Hospital, Chelmsford
Lumbar back pain is a common complaint in the UK with a one month period
prevalence of 28.5%.1 In 2014, I had the misfortune of experiencing an acute
episode of lumbar back pain; the sudden onset of which coincided with leaning
forwards to insert a cannula in theatre. Simple analgesia provided little relief and
associated muscle spasms rendered me frozen to the spot over a four week period.
Reference
1. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment
block with the 3-in-1 block in children. Anesthesia & Analgesia 1989; 69: 705–13.
Dear Editor
Dear Editor
A return to the dark ages?
During a recent laparoscopic nephrectomy, I was using a maintenance
technique of TCI propofol and remifentanil. To best guide the target
concentrations I was using a Bispectral Index (BIS) monitor. At knife to skin
I was alarmed to see the BIS reading leap from 32 to 70. I immediately
increased the concentrations of both propofol and remifentanil but this
brought no reduction in BIS. I gave a bolus of propofol but again without
effect. At no point did any other index suggest inadequate anaesthesia:
blood pressure and heart rate remained unaltered, a check of the patient’s
eyes found the pupils to be small and revealed no lacrimation.
As a recent new mother I had the unfortunate experience of developing
rigors one week post-delivery and needed to return to hospital. My
temperature was 41.2°C and my heart rate was 135 bpm. I was treated
promptly with IV co-amoxiclav and IV Tazocin and was taken to theatre for
an ERPOC. I continued with IV antibiotics until I was afebrile for 24 hours
and then switched to oral antibiotics. I returned home four days after being
re-admitted none the worse for my experience.
Having taken my treatment for granted my (non-medical) father pointed out
to me that if this had been 80 years ago, before the discovery of antibiotics,
I would most likely have died. After reading recent articles about the
growth of antibiotic resistance and the lack of funding for research into
new antibiotics it is possible that if this occurred in 80 years time I would
also have died.
Worryingly, Science Daily reported1 that only 1% of research funding goes
towards antibiotics. It could easily be that within our lifetime we see a time
where routine minor operations become potentially life-threatening or a
simple cut could mean loss of a limb.
Natalie Gray
CT2 Anaesthetist
Cheltenham General Hospital
Reference
1. Less than 1% of UK public research funding spent on antibiotic
research in past 5 years. Science Daily 25 July 2014.
http://www.sciencedaily.com/releases/2014/07/140725080339.htm
(accessed 13/6/15).
your Letters
A check of the BIS probe found it to be well applied, but in close proximity
to the hose of the warm air blanket which was draped on the patient and
had been turned on after the drapes had been applied. Wondering about
interference, I turned the blanket off and within seconds the BIS fell from 70
back to the high 20s – a number suggestive of deep anaesthesia.
The lay perception is that anaesthetists sit and read the newspaper or, in this
modern age, scroll through the internet on a tablet. Only after the onset of my back
pain did I realise that the physically active nature of our job was a likely contributing
factor. Whether leaning forward to intubate, doing cardiac compressions, carrying
large ITU transfer bags or lifting heavy oxygen cylinders – the constant flexion and
extension of the lumbar spine continued to exacerbate my back pain and made
relatively simple tasks very challenging. The manoeuvre that caused most difficulty
involved burying myself under the surgical drapes to insert a nasogastric tube
after an operation had started. I was fortunate that lumbar facet joint injections did
relieve the pain; however, I am conscious that it could recur and my experience has
encouraged me to reflect on how my anaesthetic practise should be changed. As
I started my CT2 year, I took particular note of the manual handling section of our
online trust mandatory training. For someone who is 190cm tall, simple changes
such as adjusting the bed height can minimise the mechanical stress placed on
the lumbar spine during cannulation and intubation. It is important to position
equipment carefully and consciously think about posture prior to doing procedures
in order to reduce excessive spinal movements. My GP did also recommend Pilates
– though this might require some further persuasion…
There is little in the literature about the prevalence of back pain among anaesthetists;
although the Labour Force Survey indicates that health professionals, when
compared to all occupations, had a statistically significant increased prevalence
of back disorders during 2009–2012.2 It is important to raise awareness of this
potential health hazard and, with simple measures, the negative professional,
social and economic consequences of work-related back pain can be reduced.
I re-arranged the warm air blanket and was able to return to lower target
concentrations of propofol and remifentanil without any further high BIS
readings. Throughout the case I regularly turned the warm air blanket off to
confirm the accuracy of the readings.
It seemed the warm air blanket was directly interfering with the BIS reading,
with the potential to cause alarm or unnecessarily injudicious anaesthetic
agent use to treat spurious readings. A PubMed search revealed no
previous descriptions of this phenomenon, although the manufacturers of
BIS do mention in their product literature of the potential for medical devices
(including electrocautery and warm air blankets over the patient’s head) to
cause interference with BIS readings.1
Ian Davies
ST5 Anaesthesia
Royal United Hospitals, Bath
Michael Robson
CT2 Anaesthetics
Western Sussex Hospitals NHS Foundation Trust
Reference
1. Macfarlane GJ, Beasley M, Jones EA, et al. The prevalence and management
of low back pain across adulthood: results from a population-based crosssectional study (the MUSICIAN study). Pain 2012; 153: 27–32.
His first induction had been turbulent due to failed cannulation
followed by a combative gas induction. His mother had been quite
distressed by this and requested a gas induction for this procedure.
The boy suffered from exercise induced wheeze for which he was
prescribed a salbutamol inhaler via a ‘spacer’ with a paediatric
facemask (Aerochamber Plus, Trudell Medical International, Canada).
The mother explained she had been practising with him at home
using this to prepare him for anaesthesia.
In the anaesthetic room we noted the soft material for insertion of a
metered dose inhaler port could easily accommodate the HME filter
connection (Flexicare, UK) attached to the common gas outlet via an
Ayre’s T-piece (Figure 1). The boy happily breathed the anaesthetic
mixture via his own spacer and anaesthesia was achieved with no
further distress to the boy or his mother.
Figure 1
Use of a spacer for gas induction has been described before1 but
the fact that the boy’s mother had already been preparing her child
with his own device and that it already had a close fitting facemask
that worked safely and effectively make this a useful option in anxious
children who are already familiar with asthma devices. This technique
can be useful to discuss in the pre-operative stage at the time of listing,
with parents helping to ease familiarity of anaesthesia induction by
practice with their own device. Having multiple techniques to achieve
a successful gas induction is part of the art of paediatric anaesthesia
and we have found this to be a useful trick to add to the repertoire.
Consent obtained.
Dr Therese Walsh
ST4 Anaesthesia
Dr Neil Oakes
Wirral University Hospital NHS Foundation Trust
Reference
1. Monitoring Consciousness Using the Bispectral Index™ (BIS™)
During Anesthesia (2nd edition) 2012. p19.
http://www.covidien.com/rms/products/brain-monitoring/bis-4electrode-sensor#resources (accessed 22/02/2015).
We report the use of a spacer device to facilitate a universally
stress free induction for all. Induction of anaesthesia in children
can sometimes be challenging because of previous unpleasant
experiences resulting in fear and apprehension of the next anaesthetic.
We recently anaesthetised a 3-year-old boy for a circumcision; a few
months previously he had had a grommet inserted.
2. Health and Safety Executive. Musculoskeletal Disorders in Great Britain 2014.
http://www.hse.gov.uk/statistics/causdis/musculoskeletal/msd.pdf (accessed
22/8/2014).
Reference
32 Dear Editor
1. Beringer R, and Robinson S. A familiar asthma spacer for
inhalational induction. Anaesthesia 2002; 57: 818–38.
33 28 September 1 October 2015
doctorsupdates
18th
Anaesthesia,
Critical Care
and Pain Forum
TM
www.doctorsupdates.com
Da Balaia, The Algarve
Portugal
education in a perfect location©
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