Anaesthesia

Transcription

Anaesthesia

ANAESTHESIA
The Newsletter
of the
Association
of Anaesthetists
of Great Britain
and Ireland
NEWS
INSIDE THIS ISSUE:
Professional cycling: pharmacology
and haematology update
Buddy Schemes for
New Starters to Anaesthesia
AAGBI Council
Elections 2013
ISSN 0959-2962
No. 308
MARCH 2013
Editorial Contents
03 Editorial
04 AAGBI Supporting Statement
05 AAGBI Council Elections 2013
06 Reflection on Reflection
04
10
06 Anaesthesia Digested
07 AAGBI Awards Honorary Membership
08 Etape du Tour
10 Professional cycling: pharmacology This month has a cycling theme, apologies to those members who
don’t cycle, but I know that many of you do, either as commuters,
with your family or as serious competitors in triathlons or organised
cycling events. In this issue there are a couple of articles relating to
the extreme end of cycling, and there is also an interesting piece on
the problems faced by a very famous US cyclist of recent years. This
article could grace the pages of a physiology journal and is written
by James Kenningham, a consultant in Wrexham, who is also the
inspiration behind the AAGBI cycling tops. Tom Green shows how
our understanding of one aspect of physiology has developed,
describing the development of cardiac output measurement.
14 Preoperative Association report 16 Venue Medical Management at the Last September, before the annual congress, I cycled in London
for the first time for 28 years, riding from Putney to Bournemouth
with 4 other colleagues. This experience brought home to me the
real problem of cycling in London. If cycling is to be made safer,
motorised traffic must be separated. I don’t think that the blue
lanes are any safer, what is required is a large kerb between motor
vehicles and bicycles. I would be reluctant to cycle in central London
now. What amazed me was seeing swathes of cyclists going over
Putney Bridge with earphones in and no helmets on.
London Olympics 2012
18 What is the future of SAS career 14
development Funding?
19 Because they’re there
20 Buddy Schemes for New Starters
to Anaesthesia
21 By the Heart’s Vigorous Beat
For those of less energetic bent, the article on venue medical
management at the Olympics gives an insight the challenges
for organisers of large sporting events. There’s an interesting
article about how one Trust used the development money for SAS
doctors, and a contribution from two trainees who have developed
buddying schemes, both showing what can be achieved by good
peer leadership.
I have commuted to work by bicycle for most of my career and have
been very lucky with accidents over the years. I was wiped out by
a lorry at Westminster Bridge roundabout in 1980, I was stationary
and he drove into me at about 10 mph, I escaped without a scratch
having gone over the handlebars. He put the crumpled mess of
my Dawes Galaxy into the back of the lorry and gave me a lift
home. This was way before the days of helmets or any cycle lanes.
I know that London is now a pretty dangerous place to cycle and
through the campaign run by The Times, I hope it gets safer.
and haematology update
16
25 The Prin Patient Safety Coma Scale
26 Support & Wellbeing Committee
29 Depth of Anaesthesia Monitors
31 AAGBI Recap
34 Your Letters
21
34 Particles
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650
Fax: 020 7631 4352
Email: [email protected]
Website: www.aagbi.org
Anaesthesia News
Chair Editorial Board: Felicity Plaat
Editors: Kate O’Connor (GAT), Val Bythell, Richard Griffiths, Nancy Redfern,
Sean Tighe, Iain Wilson and Tom Woodcock
Address for all correspondence, advertising or submissions:
Website: www.aagbi.org/publications/anaesthesia-news
Design: Christopher Steer
AAGBI Website & Publications Officer
Telephone: 020 7631 8803
Printing: Portland Print
Copyright 2012 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.
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.
Anaesthesia News March 2013 • Issue 308
3
Editorial continued
I am very lucky that I commute on country roads between Stamford
and Peterborough, which is pretty and has lots of wildlife on
show, usually deer, foxes, stoats and plenty of rabbits. However
I must indulge you in a description of my best commute to work,
which was from Sausalito in Marin County, over the Golden Gate
Bridge, through the Presidio, across Golden Gate Park to the
UCSF Hospital on Parnassus Avenue in San Francisco. This must
be the best cycle commute on the planet, and I only stopped on
one occasion, when I saw a US Aircraft carrier going under the
bridge to the Oakland Base (now closed), it was the Nimitz, and
it is a very big ship.
Most anaesthetic cyclists are also avid collectors of two wheeled
machines. At present, in our department, we have a young
anaesthetist who maintains that the amount of bicycles you need
is always “n+1”. I do confess to owning quite a few, but my
most treasured is a frame, custom made for me in 1989 by Barry
Bond, a Reynolds 531 with a Cinelli bottom bracket.
Barry Bond holding the custom made frame
Supporting statement for
Consultants, SAS Doctors and
trainees active in Specialist
Societies in Anaesthesia,
Pain Management and
Intensive Care Medicine
The Association of
Anaesthetists of Great
Britain & Ireland (AAGBI)
and the Royal College
of Anaesthetists (RCoA)
value and support the
work that is undertaken
by members of specialist
societies in the delivery
and promotion of
advances in patient
safety, education and
research, which in turn
greatly benefits patients
throughout the NHS.
The AAGBI and the RCoA endorse the letter dated 23rd
January 2012 from the four Chief Medical Officers, the Chair
of the General Medical Council and the Medical Director of
NHS England (appended), which asks NHS employers to look
favourably on requests from doctors for absence to undertake
national work for professional organisations such as specialist
societies that is of benefit to healthcare systems across the UK.
I hope that your Trust gives cyclists safe and secure bike storage,
good changing facilities and the ability to buy a bike through the
cycle to work scheme. If you are thinking about what to wear, the
AAGBI cycling jerseys are now available for purchase. They are
made in Scotland by Endura. The price includes a £10 surcharge
that goes towards Lifebox. Every donation to this worthy cause
is most welcomed, especially by anaesthetists who have not had
access to oximeters.
We believe that regular work performed for specialist societies
should be recognised and represented in individual job plans,
and that doctors doing this work should provide evidence of
specialist society activity and output to clinical managers. We
are aware that some NHS employers are restricting the time
allocated in job plans to Supporting Professional Activities
(SPA) to that work conducted directly on behalf of the
employing Trust or Board.
I am not convinced that the political will is there yet for us to turn
our backs on the internal combustion engine, there is too much
at stake with the powerful oil lobby and the jobs tied up in the
motor industry. I am sure that cycling could be made safer and
I know that cyclists also have a responsibility to cycle within
the laws of the Highway Code. I don’t even know if Cycling
Proficiency still exists, but I can remember doing the test in The
Primary School Car Park, when I was 8, the rather faded date on
the certificate is 1969. From memory most failed because of the
right turn, or failed to look behind them when setting off, habits
that were ingrained over 40 years ago.
We believe that such restrictions should be reconsidered and
reversed in view of the fact that work for specialist societies
enhances
I hope you forgive me for telling you a little bit about how I get
to work and commutes that I have known. At least the nights
are getting longer. I hope to see you all in Dublin. Perhaps you
might consider accompanying the president and me, making the
journey on 2 wheels.
The AAGBI are connected
with anaesthetists, industry
and public through online
social networks Facebook
and Twitter.
@AAGBI
AAGBI1
Richard Griffiths
4
AAGBI COUNCIL
ELECTIONS 2013
I have only been Hon Sec for six months but already I am writing
an article about the up and coming elections. The AAGBI Council
is a very stimulating environment to be in. There are anaesthetists
from all the devolved nations and from the Republic of Ireland, this
gives the organisation the ability to look at changes that may have
already taken place elsewhere. From 3rd December 2012 revalidation
became official, and, to help members with CPD, the AAGBI will be
providing educational resources at meetings, in print and online.
amount is done electronically and by teleconference. In addition
to the regular work in London, Council members will normally be
expected to attend WSM London in January, Annual Congress in
September and the Annual Linkman conference, may be invited to
attend other AAGBI events such as Seminars and Core Topics Days,
and to represent the AAGBI at external meetings, particularly at the
Royal College. Reasonable expenses are paid in accordance with
the expenses policy.
I have been very fortunate that my personal interests have been
adopted by the AAGBI during my five years on Council. The “Hip
Fracture Glossy” was a particular highlight and the forthcoming
“ASAP” audit, which is going to be a lot of hard work for consultant
and trainee members, will hopefully provide a valuable insight into our
everyday clinical practice.
The Association of Anaesthetists of Great Britain and Ireland is
more than just a membership organisation for more than 10, 000
members. It consists of two legal entities (a limited company and
a charity) employing nearly 30 staff, with turnover of ~£2.5 million/
year and several million pounds of assets. Council members are
automatically directors/trustees of both company and charity and so
must be eligible to serve in this capacity (undischarged bankruptcy
and court disqualification are not compatible; insanity not always, but
on occasion may help or be essential!) Governance functions and
oversight make up an important role of elected Council members –
you have been warned!
In 2013 three colleagues will complete their four year terms as
elected members of Council: Drs Barry Nicholls, Felicity Plaat and
Mansukh Popat. Each is well known in anaesthesia but for different
sub-specialties; regional anaesthesia, obstetric anaesthesia and
airway management respectively. They have already made significant
contributions to the AAGBI and anaesthesia and I am grateful for this
opportunity to pay tribute to each of them. Felicity will be staying on
council as she has been elected as Honorary Membership Secretary,
following on from Isabeau Walker in September 2013.
We have three new members on Council at present, Drs Rachel Collis,
Roshan Fernando and Matthew Checketts, with Wales, England
and Scotland represented. This year we need three new Council
members, who will be elected for a four year term. The AAGBI is a
very friendly organisation to work for and I have enjoyed every aspect
of my five years to date.
Candidates must be ordinary members of the AAGBI in good
standing. For details of the application process please see the
advert elsewhere in this issue. Although we hope that candidates will
come from varied backgrounds and many different sub-specialties,
as members of council they should represent and work for the whole
specialty. Council members are expected to attend council meetings,
some (but not all) of the standing committees (e.g. Safety, Education,
Research) and such Working Parties as they are appointed to. Council
members should expect to be at the Association’s Headquarters at
21 Portland Place, London, for at least two days a month; always the
first Friday of the month and usually one other Friday. A considerable
One final point to consider before you submit your nomination forms
is the support of your department and employing hospital; this is
essential and much better agreed before election. I am very fortunate
that my Trust sees representation on AAGBI Council as an advantage
for my department and the hospital. The election will be run by
the Electoral Reform Society with the results announced at June’s
meeting of Council. Candidates will have heard from the AAGBI
President before then. The deadline for submission of nominations
is Friday 12 April 2013. Now in my fifth year on Council, what has
really struck me is the continuity over the last five years, and I am now
onto my third President. The employees are very knowledgeable and
helpful and guide Council members through the processes. AAGBI
is in constant evolution and needs fresh blood in order to adapt and
change to a very different NHS, from even five years ago. It has
been a fascinating, rewarding experience to work nationally for the
specialty of anaesthesia, and hopefully to have made a difference. If
you have the time, enthusiasm and drive, give it a go and stand for
election. I wish you luck, and hope you enjoy your time on Council as
much as I have. See you at the Annual Members’ Meeting in Dublin
in September.
Richard Griffiths
Honorary Secretary
5
Anaesthesia
Reflection
on
Digested
Reflection
Anaesthesia March 2013
AAGBI awards Honorary Membership
to Dr Angela Enright and Professor Atul Gawande
In 2012 Council decided to award Honorary membership to two extraordinary leaders in medicine,
both well known to anaesthetists for their amazing contributions to our specialty. Neither could
be present at the Annual Congress in Bournemouth and so the awards were made when both
recipients were visiting 21 Portland Place for a Lifebox Board meeting.
Marr R, Hyams J, Bythell V.
Cardiac arrest in an obstetric patient using remifentanil
patient-controlled analgesia
Some of you reading this digest will have been bereft by the death of an
unborn child. How much more are lives shattered when women also die? In
this case report Marr et al. describe a 24 year old woman, induced to deliver a
child who had died in utero, who suffered a cardiorespiratory arrest associated
with a remifentanil PCA. As the architects of this technique we are obliged to
know more about the harms and benefits of remifentanil PCAs and how we
might affect their incidence; as mothers, fathers and friends, we would consider
this imperative.
Reflection is an essential aspect of
clinical practice and recorded reflection
an obligatory aspect of revalidation.
Recently a group of consultant colleagues attended the AAGBI
Annual Meeting in Bournemouth. We were all greatly helped
by the event “app’, which enabled us to record reflective
notes, during and after the lectures that we attended. Whilst
discussing how we might share any information or suggest
changes in practice to our department it was suggested that
we meet to reflect on what we had learned at the meeting in
order to determine the most relevant information to pass on to
the department. An evening meeting was arranged and about
half the consultants who attended the meeting also attended this
meeting. There was an agenda and minutes were taken (and
later circulated).
Each person presented those lectures, demonstrations or
workshops that had most taken their interest. A discussion then
ensued. If it was considered appropriate to change practice a
course of action was determined and action point and individual
responsibility for each action point attached to the minutes.
Much of the discussion centred on anaesthesia for the older
patient as this was not only a significant part of the meeting
but highly relevant to our practice. It was felt that improvements
needed to be made in both pre-operative assessment and post
operative care which needed to include the participation of our
surgical colleagues.
Those who participated found the process useful and enjoyable
and it will certainly be repeated for future meetings. This had
never happened before, when a group of us had gone to a
meeting together. The process of reflection has certainly made
us all look at what we were getting out of the meeting and also
made us want to share the information with others. I am sure that
we will repeat this procedure at future meetings.
Award presented by
Dr William Harrop-Griffiths,
AAGBI President
Dr Angela Enright
Professor Atul Gawande
Angela Enright is the immediate past President of the
World Federation of Societies of Anaesthesiologists and
her contributions are legendary in that role. She is the only
President to have received a sustained standing ovation as
she stepped down from her post in Buenos Aires at the World
Congress in 2012.
Atul Gawande is a Professor of Surgery at Harvard Medical
School where he practices surgery at Brigham and Women’s
Hospital in Boston. Atul also works as a Professor in the
Department of Health Policy and Management at the Harvard
School of Public Health.
Muchatuta NA, Kinsella SM.
Remifentanil for labour analgesia: time to draw breath?
This accompanying editorial discusses the issues surrounding remifentanil
use during labour. Muchatuta and Kinsella cite the other case reports of
cardiorespiratory arrest associated with remifentanil PCA use during labour,
as well as the experimental evidence that details efficacy but that is sparse
on safety. One case followed from incorrect dilution and labelling: perhaps
preloaded delivery systems should be mandatory. Continuous pulse oximetry
acts as a delayed monitor of hypoventilation: supplemental oxygen delays this
signal and induces hypoventilation (http://bja.oxfordjournals.org/content/
early/2013/01/04/bja.aes494.long). Saturations just below 90% may do little
direct harm, but they presage cardiorespiratory arrest. A fall in saturations
should disable the PCA, alert staff and (directly or indirectly) stimulate the
parturient, rather than trigger supplemental oxygen.
Various authors.
Abstracts from the AAGBI Annual congress and from the
Vascular Society
In this month’s Anaesthesia you have two sets of abstracts to peruse over
coffee and a bun. Reassuringly there are more topics than I can cover in a brief
digest. A number of abstracts from the Vascular Society were – unsurprisingly
– concerned with the treatment and outcome of patients with abdominal aortic
aneurysms (AAAs). Topics included rates of postoperative renal impairment,
attempts at preventing it and arterial blood pressure disparities between left and
right arms. I then thought about a portfolio study, led by Dr Ronelle Mouton
in Bristol, piloting remote ischaemic preconditioning before AAA repair: this
involves inflating a non-invasive blood pressure cuff on an arm, thrice for
five minutes. Dr Mouton is applying for a large multicentre RCT, so if you’re
interested email her at [email protected].
J.B.Carlisle,
Editor, Anaesthesia
Mike Weisz FRCA
Consultant Anaesthesia and ICM Peterborough
6
Award presented by
Dr William Harrop-Griffiths,
AAGBI President
After growing up in Ireland and studying medicine in Dublin,
Angela moved to Canada where she is presently the Clinical
Professor of Anaesthesia at the Royal Jubilee Hospital, Victoria,
Canada.
She developed a strong interest in international education and
served from 2000-2008 as Chair of the Education Committee of
the WFSA, in addition to chairing the Organising Committee for
the 12th World Congress in Montreal.
Angela has been honoured many times and in 2012 was
awarded the Queens Diamond Jubilee Medal in Canada and
also the Gold Medal from the College of Anaesthetists in Ireland.
Her passion for education has improved the opportunities for
anaesthetists everywhere, but in particular those working in less
wealthy parts of the world where she is a familiar face and name
to many. A tireless traveller, she has kept up a busy clinical
workload whilst fulfilling all the responsibilities she has carried
while working for the WFSA.
Angela was in London to attend the Board meeting of Lifebox –
the charity that AAGBI and WFSA had so much to do with setting
up. Angela was instrumental in bringing this work to fruition
as one of the founding Trustees. Outside of medicine Angela
plays the cello and piano, enjoys skiing and sea kayaking and
is fluent in French and Spanish!
From my personal position, Angela is a motivated, passionate
and inspirational leader to have worked with, more dedicated
to her vision than I can ever describe and I am so pleased that
she is now one of our Honorary members.
He is internationally renowned as a writer, surgeon, researcher
and broadcaster. His research focuses on systems innovations
to transform safety, cost, and performance in health care. He
serves as lead advisor for the World Health Organisation’s safe
surgery and safe childbirth programmes and received Academy
Health’s Impact Award for Health Services Research in 2010.
He has written three New York Times bestselling books:
Complications, (finalist for the National Book Award in 2002);
Better (selected as one of the ten best books of 2007 by
Amazon); and The Checklist Manifesto (another best seller).
In 2006 he was awarded a MacArthur Fellowship, which is a
$500,000, no-strings attached grant for individuals who have
shown exceptional creativity in their work and the promise to do
more. In 2010, Atul was selected by Foreign Policy Magazine
and TIME magazine as one of the world’s top 100 influential
thinkers.
Atul has been a staff writer at The New Yorker for 14 years where
he has published many insightful essays, which make brilliant
reading for those thinking through modern healthcare issues.
The Cost Conundrum essay was made compulsory reading
by President Obama for his health team! Atul is the founder
and chairman of Lifebox (www.lifebox.org), an international
not-for-profit implementing systems and technologies to
reduce surgical deaths globally. In this project he has been a
brilliant, committed leader, improving the safety of surgery and
anaesthesia internationally.
AAGBI are delighted to make Atul Gawande an Honorary
Member of the AAGBI.
www.gawande.com
Dr Iain H Wilson, Immediate Past President, AAGBI
7
PAEDIATRIC ANAESTHESIA UPDATE
Etape du Tour
Friday 22nd March 2013
20TH
ANNUAL
MANCHESTER
Manchester
Conference
Centre
Course Director:
Dr Davandra Patel
PAEDIATRIC
ANAESTHESIA
UPDATE
www.airmed.co.uk
www.airmed.co.uk
Friday 22nd March 2013
PROGRAMME
Manchester
Conference Centre
Course Director: Dr Davandra Patel
Full-time positions available
Full-time positions available
Anaesthetic consideration for children with congenital
hyperinsulinaemia
and diabetes
PROGRAMME
Cycling in big events takes preparation and to some extent a good deal of luck. Many of
you in anaesthesia will know Mike from the exhibitions at the major AAGBI meetings. He is
a keen cyclist but, despite lots of training, ended up in a French hospital, via a helicopter
flight. I will let him tell the rest of the story.
Anaesthetic
consideration
for children
with congenital
Advances
in paediatric
neurosurgery
hyperinsulinaemia and diabetes
Anaesthesia for children with neurological conditions
Advances in paediatric neurosurgery
Revalidation:
Paediatric
anaesthesia
Anaesthesia
for children
with neurological
conditions
Largest UK fleet of air ambulance aircraft, Oxford based 530
missions
during
2012,
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Largest
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Equipped and staffed
to UK Intensive
Care
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EURAMI
Care”
Fully “Special
Registered
with accreditation
the CQC
EURAMI “Special Care” accreditation
In summary: Mike Forster (Draeger Uk),
tells of his problems on a very hot day,
despite extensive preparations for the event.
Paediatric transfer: A DGH anaesthetists perspective
Managing anxiety in children
Managing anxiety in children
Approved for
Approved
5 CME
pointsfor
5 CME points
of a new challenge, some new skills or something different!
Further information: [email protected]
Further information: [email protected]
I’d ridden 150Km including a couple of Cat 1 climbs before I reached
the bottom of the Tourmalet when I got off the bike for the first time
to refuel in preparation for the 37Km / 6000ft climb to the summit.
Quickly into the climb we rode above the tree line so there was no
shelter from the 80 degree heat and, despite spectators offering to
pour cold water over me, this led to my pace dropping to barely more
than walking speed. I got to within 3Km of the summit (if only they
hadn’t extended the route by 7Km!) when I decided to rest and refuel
again. Soon after stopping I felt dizzy and was forced to lie down on
the road before trying to ride again. It was clear I’d hit the wall so I
flagged down a motorbike paramedic who took my BP, put 2x IV lines
in and called the ambulance. I had to abandon my bike (got it back
2 months later!) and when I got to the summit my BP was 48/28, HR
32bpm. Other vital signs data was collected – blood sugar and 12
lead ECG – following which they decided I needed to be admitted to
hospital. I know my own 12 lead ECG and was not concerned but they
weren’t happy with what they interpreted as ST segment changes.
Maybe the vomiting didn’t help?! The quickest / easiest transfer was
via helicopter to Tarbes Hospital for further tests and then onto Pau
Hospital. I was given 4 litres of saline had CXR’s, ECG’s kidney
function tests etc and left hospital after 36 hours.
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14th Annual Cork Cadaveric
Peripheral Nerve Block Course
April
2013
Department of Anatomy and ASSET Centre, University College Cork, Ireland.
Day 1: Cadaveric Anatomy
Monday 8th April 2013
Cadaveric Anatomy of Upper and Lower Limbs, Trunk
& Neuraxis Volunteer Ultrasonography (6 CME/PCS Points)
Day 2: Clinical Peripheral Nerve Block
Tuesday 9th April 2013
In hindsight, I think I refuelled with carb energy drinks & carbohydrate
gels at the rate of I gramme per Kg of body weight per hour as per
my plan but didn’t consider taking additional electrolytes on board.
With the effort / heat I think I suffered from electrolyte imbalances that
led to the kidney dysfunction, arrhythmias and vaso-vagal episodes.
I hope this sounds like a reasonable assumption from your medical
perspective?!
8
Review
of paediatric
devices
Paediatric
transfer:
A DGHsupraglottic
anaesthetists
perspective
We now have vacancies for full-time anaesthetists
Flexible appointments
from
2 weeks for
to 6full-time
months,
excellent rates of pay
We now have
vacancies
anaesthetists
Robust
clinical governance
with consultant-led
Flexible
appointments
from 2 weeks
to 6 months, management
excellent ratesteam
of pay
Minimum
qualifications
FRCA
(orconsultant-led
equivalent) and
ITU experience
Robust clinical
governance
with
management
team
This
is an exciting
prospectFRCA
for senior
trainees orand
consultants
in search
Minimum
qualifications
(or equivalent)
ITU experience
a exciting
new challenge,
new skills
or something
different!
This isofan
prospectsome
for senior
trainees
or consultants
in search
It was the Etape du Tour 2010 - Paul to the summit of the Col du
Tourmalet. It was pre-advertised as 174Km but at registration the day
before they announced it had been extended to 181Km – that change
was hugely significant to the end result!
Still wearing the cycling gear I’d first put on 48 hours previously I got
a taxi back to my hotel only to find I’d been checked out of my room
and my suitcase put into storage. There were no rooms available
in Pau so I caught a train to Biarritz leaving my very expensive bike
helmet on the train which compounded the misery of having lost my
very expensive Garmin computer in the helicopter. Of course, none of
this misery compared to the misery suffered as a result of telling my
wife that I planned to do the Etape again the following year! I did and
I completed it.
Review
of paediatric
supraglottic
devices
Revalidation:
Paediatric
anaesthesia
Ultrasonography of Upper and Lower Limbs, Trunk and Neuraxis
Needling Techniques on Phantoms (7 CME/PCS Points)
Day 3: Procedural Skills Intensive Tuition
Wednesday 10th April
Course fee: €250 per day;
€450 for 2 days (days 1&2)
Day 3 €250
(10% discount to ESRA and ESA members)
CME approved by the College of
Anaesthetists of Ireland. Approved
for ESRA Diploma on Regional
Anaesthesia (3 Credits).
Putting it all together, perform simulated ultrasound guided
blocks on fresh frozen cadaveric specimen under the guidance
of expert faculty (CME Approval Pending)
For further information and application form, please contact:
Dr. Brian O’Donnell
Department of Anaesthesia, Cork University Hospital, Cork, Ireland
E-mail: [email protected]
Annual Cork Cadaveric
14th Annual Cork14th
Cadaveric
9
Professional cycling:
pharmacology and
haematology update
The UK will host the first 3 stages of the 2014 Tour de France (TdF), and given the
propensity for cyclists to be involved in accidents it is not inconceivable that one or two
of us may be required to anaesthetise a member of the professional peloton. With that
in mind, and without casting aspersions on any current professional cyclists, readers
might appreciate a little background information on the sort of “preparation” used by
professional cyclists over the past century.
Enhanced recovery may be the current fashion
amongst anaesthetists and surgeons as NHS
hospitals compete to turf their post-operative
patients out on to the streets 5 minutes earlier than
was previously the case, but some professional
cyclists have been enhancing their own recovery
(and performance) for decades. They even
used intralipid to aid recovery decades before
LipidRescue™ was ever contemplated by
anaesthetists, (admittedly with mixed success
when one team gave themselves septicaemia
due to inadequate aseptic precautions and had to
withdraw from the 1991 TdF).
Lance Armstrong’s recent exposure is just the
latest example of a problem that dates back to the
very dawn of competitive cycling in the 1890s and
began with the death of several Welsh cyclists who
shared a common manager / trainer called Choppy
Warburton. Early pharmacological assistance is
reported to have involved the use of alcohol and
heroin for analgesia, and cocaine and low dose
strychnine as psycho-stimulants to get them
through 400km stages (twice the length of modern
Tour stages). There are also reports of them
applying chloroform to their gums presumably for
some mild anaesthetic effects. By the 1930s the
acceptance of doping at the TdF was so complete
that the founder, Henri Desgrange, reminded riders
in his rule book, that drugs would not be provided
by the organisers!
Asthma is more prevalent in elite endurance
athletes. Clinical studies show no compelling
evidence that salbutamol and other β2agonists used to treat asthma can increase
performance (over and above any psychostimulant effect) in healthy athletes, and
several routine asthma medications such as
salbutamol are no longer on the prohibited
list. After winning the 2010 TDF Alberto
Contador tested positive for a trace of the
sympathetic amine / β2 stimulant clenbuterol
in a urine sample taken during that year’s
race. Clenbuterol is said to be performance
enhancing because it increases aerobic
capacity, oxygen transportation and the
rate at which body fat is metabolized. It is
also a bronchodilator but it remains on the
prohibited list. Contador and his lawyers
suggested that the clenbuterol must have
entered his system via a contaminated steak.
Clenbuterol has been administered to cattle
to promote the production of leaner meat (this
practice is illegal in the EU) and there have
been instances of human contamination via
this route. However, Dr Michael Ashenden,
a member of the World Anti-Doping Agency
(WADA) Expert Panel for this case, has
outlined an alternative theory for the presence
of clenbuterol in Alberto Contador’s urine.
You can read his fascinating explanation in
the following interview http://nyvelocity.com/
content/interviews/2012/behind-scenescontador-cas-hearing-michael-ashenden
.
In 2012, after various hearings and appeals,
Contador was stripped of both his 2010 TdF
and 2011 Giro D’Italia victories.
Around the 1970s the benefits of taking
steroids, both cortico and anabolic, became
apparent. To stage racers the benefit of
corticosteroids lies in their ability to assist with
recovery. Riders have also used synthetic
ACTH to achieve the same effect while
evading tests for exogenous corticosteroids.
After the Second World War use of military surplus
amphetamines was widespread, and these were
often variously combined with caffeine/cocaine/
heroin in a cocktail known as Pot Belge or Belgian
Mix (Belgium has long been a heartland for
professional cycling in Europe). The collapse of
several high profile riders during the ascent of Mont
Ventoux in the 1955 TdF led the Tour organisers
to issue a set of recommendations for the team
10 managers, regarding treatment given to
their riders and the activities of the soigneurs
(cyclists’ carers). 24 hours later L’Equipe (the
newspaper of the TDF) announced that “the
fight against doping appears to have been
won.” Given the events of the subsequent halfcentury this may have been rather premature.
It took them another 11 years to finally get
round to having an anti-doping law and
instigating the first rudimentary anti-doping
controls. In protest many top riders stayed
away from the 1966 Tour. The following year
the Tour saw the death of Britain’s greatest
cyclist until recent times, Tom Simpson, from
heat stroke and dehydration while climbing
Mont Ventoux. Amphetamines were found in
his pockets and in his body.
Anabolic steroids such as testosterone
increase muscle strength and assist with
recovery. Human growth hormone (hGH) and
insulin-like growth factor 1 (IGF-1) have been
used for their ergogenic and anabolic effects,
while trying to evade tests for conventional
anabolic steroids. HGH exerts many of its
effects by increasing the secretion of IGF-1, it
also enhances the anabolic power of steroids.
There is now an immunoassay to detect
hGH abuse, although the first professional
cyclist to test positive was recently cleared
of doping charges when the WADA reference
values were shown to be unreliable.
Probenecid blocks the excretion of anabolic
steroid metabolites into the urine and has
therefore been used as a masking agent.
The 1988 TdF winner Pedro Delgado
avoided being sanctioned for a positive
test for probenecid as it was not yet a
banned substance on the UCI list despite
being included on the International Olympic
Committee’s list of banned substances.
a hospital setting, let alone when undertaken
in a clandestine manner in a hotel room or
in the back of the team bus. Inevitably over
the years there have been multiple incidents,
some times fatal, involving “bad blood”.
With the arrival of recombinant human
erythropoietin (rh-EPO) in the 1990s
transfusions fell out of favour. However,
once a test for rh-EPO was developed in
2000 athletes again began to turn back
to transfusions as an undetectable way to
enhance their performance. However, they
didn’t remain undetectable for long. In 2005
Tyler Hamilton (a former Armstrong team
mate and 2004 Olympic gold medalist) was
found (by examining red blood cell surface
markers) to have a third party’s red blood
cells coursing through his veins. He famously
claimed these cells came from a “vanishing
twin” foetus that he had absorbed while in
utero!
Some idea of how widespread this problem
was can be gained from the files of Operación
Puerto. In 2006 Spanish police raided the
premises of the infamous sports physician
Dr Eufemiano Fuentes. They allegedly found
many (some reports talk of 100) coded bags
of blood and associated paraphernalia. His
trial is finally due to start in January 2013!
Now it is even possible to identify those who
have received autologous transfusions by
testing for the presence of plasticizer residues
(these originate from the inside of the PVC
blood bags and besides keeping the bags
flexible also serve to keep the membranes of
stored red blood cells flexible too).
The Biological Passport System
Diuretics may also be used as masking
agents in an effort to dilute the concentration
of banned substances in an athlete’s urine.
A recent high profile example involved
Frank Schlek (brother and team mate of the
eventual 2010 TdF winner Andy Schlek) who
tested positive for the sulphonamide diuretic
xipamide during the 2012 TdF. He voluntarily
withdrew from the race and maintains that the
sample was contaminated or the presence of
the diuretic was accidental. The outcome of a
recent disciplinary hearing is pending.
Road racing is an endurance sport relying
mainly on aerobic metabolism and in the
run up to the 1968 Olympic games (held
at altitude in Mexico City) coaches, team
doctors and exercise physiologists began
to appreciate the importance of oxygen
delivery. There’s only so much that can be
achieved by (simulated) altitude training and
so further enhancement was achieved by the
use of blood transfusions (autologous and
homologous). As we all know, storing and
transfusing blood can be dangerous even in
The Biological Passport System is another
innovative strategy employed by the testing
authorities and involves collating profiles of
biological markers of doping and results of
doping tests over a period of time for each
athlete. Doping violations can be detected by
noting variances from an athlete’s established
levels outside permissible limits, rather than
testing for and identifying illegal substances.
For example the use of transfusions may be
inferred from the suppression of a rider’s
reticulocyte count.
Recombinant human EPO provided riders
with a safer but even more effective way to
raise their red cell mass. The speed of
the peloton (particularly uphill) increased
alarmingly making for some spectacular
racing. There were a number of thromboembolic deaths amongst professional cyclists
and in 1997, in the absence of a test for rhEPO, the UCI decided that any cyclist with
a haematocrit >50% would be temporarily
excluded from competition on health
grounds. Those riders engaged in doping
and their physicians quickly responded
11 by travelling with portable centrifuges and
suitable intravenous fluids to ensure that they
didn’t breach this threshold if called in for a
blood test.
on the WADA list of prohibited substances,
although since 2011 it has been illegal to sell
or import it in the USA and Canada.
The climbing specialist Marco Pantani,
winner of both the TdF and Giro d’Italia in
1998, was involved in a near fatal accident
in the 1995 Milano-Torino race. Some years
later, as part of a doping investigation, his
hospital medical records revealed that his
haematocrit on admission was >60%. Postoperatively he became extremely anaemic,
and it has been postulated that a contributory
factor may have been rh-EPO withdrawal
leading to neocytolysis (the physiologic
process in which immature erythrocytes are
selectively haemolysed).
“Tour of Renewal”
By 2000 a urine test for the presence of
rh-EPO had been developed using gel
electrophoresis to discriminate between
endogenous erythropoietin and rh-EPO.
However, the interpretation of the test was
complex and in order to reduce the probability
of false-positives, a threshold was set which
required >80% of the isoforms to be rh-EPO
in order constitute a positive test. This gave
the dopers ample scope to use new microdosing regimes (small intravenous doses
of rh-EPO instead of large subcutaneous
doses) while still remaining below the 80%
threshold. It also led some to suspect that the
sport’s governing body (the Union Cycliste
Internationale or UCI), was far from serious
about getting a grip on the problem. You can
find out more about the introduction of the
rh-EPO test and the controversy arising from
its retrospective application to the 1999 TdF
B-samples at http://nyvelocity.com/content/
interviews/2009/michael-ashenden.
The rh-EPO test also had another
consequence: transfusions came back into
fashion and rh-EPO switched from being
used as a performance enhancing agent
to a masking agent used in tiny doses
to “tickle-up” a reticulocyte count which
would otherwise have dropped following
an autologous transfusion and thus led
to a biological passport violation. There
is a misconception that if rh-EPO use is
widespread it does not alter the finishing
order in a race, it merely increases the speed
of all the doping riders equally. However,
individuals respond to rh-EPO differently
and those with naturally lower haematocrits
obtain a greater advantage from its use.
Actovegin is a deproteinised ultrafiltrate of
calf serum containing around 200 biological
substances that has enjoyed popularity
with some professional sportsmen. Various
claims have been made for its efficacy
including improved transport of glucose
across plasma membranes and improved
oxygen uptake into tissues. There is clearly
some doubt about just how effective it is, as
at the time of writing Actovegin is no longer
12 Until last year perhaps the most high profile
doping scandal was the 1998 Festina affair
when a team car being driven by their
soigneur Willy Voet, en route to Ireland for
the start of that year’s TdF, was stopped
by French Customs Officers and found to
contain: 86 vials of rh-GH, 60 capsules of
epitestosterone, 248 vials of normal saline,
8 pre-filled syringes of hepatitis-A vaccine,
60 tablets of ciprofibrate, 4 ampoules of
synacthen, 2 vials of amphetamine, 234
doses of rh-EPO, and a quantity of the
artificial oxygen transporter perfluorocarbon.
Following a series of police raids a number of
riders and officials were taken into custody,
the remaining riders went on strike in protest
at the raids and even the future of the race
looked in doubt.
power to weight ratio required to win the TdF
has dropped from 6.7 to 6.0 W/kg. However,
the anti-doping authorities cannot afford to
relax their guard, as the dopers will always
be looking for novel agents to enhance their
performance. There is currently concern
about several metabolic modulators (AICAR,
GW-501516 and the angiotensin receptor
antagonist telmisartan), which appear to be
able to increase exercise endurance through
effects on muscle gene expression leading
to mitochondrial biogenesis. There is also
said to be a growing level of interest in the
potential for genetic doping.
Finally, I’d like to leave you with this quote
from Fausto Coppi, the dominant cyclist of
the 1940s and 1950s, who, when asked if
he had ever taken drugs replied “only when
necessary”. When asked how often that was,
he said “nearly always”.
Gasman Jim
Self-confessed Tour Bore
The UCI claim that professional cycling is
cleaner now than it has ever been and this
is probably true as speeds have certainly
dropped when compared to the Armstrong
era. For example, the climb up Alpe d’Huez is
one of the toughest in the TdF, and in the late
1990s it was being completed in around 38
minutes, that is three minutes quicker than in
2011. Another indicator is that the sustained
Emergency Tracheal
Access Course (ETAC)
Dates for 2013:
Dates for 2013:
9th & 10th May 2013
14th June 2013
31st Oct & 1st Nov 2013
LEAT LEAT
ETAC:Emergency
Emergency Tracheal
Access Course
ETAC:
Tracheal
A
Lanarkshire Endoscopic Airway training
Lanarkshire Endoscopic Airway training
Course
Venue: Wishaw General Hospital, Course
LEAT
Thursday
25th/Friday 26th October 2012
Thursday 25th/Friday
26thCourse
October
50 Netherton Street, Wishaw
ML2
0DP
fee 2012
Course fee
Venue: METC, Kirklands Hospital, Bothwell G71
8BB2012 June 2012
Friday
15th June15th
Friday
Candidates Airway
£300
Lanarkshire Endoscopic
training
Candidates £300
Observers £400
Venue
Ronald
Miller Education Centre
Observers
£400
Course
Wishaw
GeneralCentre
Hospital
Venue
Ronald
Miller
Education
w A practical hands on course
for
learning
Wishaw
Wishaw General Hospital
Thursday 25th/Friday
October
Wishaw 26th
and consolidating a method
of upper
airway
Course fee
topicalisation and fibreoptic endoscopy skills
Candidates £300
for anaesthetists
Observers £400
Contact information
Enquiries to book a place to:
Elizabeth Bell
Contact information
Co-ordinator
Enquiries to book a placeTraining
to:
Medical Education training centre
Elizabeth Bell
Training Co-ordinator Kirklands hospital
Bothwell
Medical Education training
centre
Kirklands hospital
Tel: (01698) 855610
Bothwell
Further Information
Contact information
Enquiries to book a place to:
Elizabeth Bell
Training Co-ordinator
Medical Education training centre
Kirklands hospital
Bothwell
2012
w A one day practical course
on Emergency Tracheal Access
9.30-17.00 hourshours
(registration
from 9.15)
9.30-17.00
(registration
fr
METC, Kirklands
Hospital,Hospital,
Bothwell G71 8BB
METC,
Kirklands
Bothwe
w Lecturesandmanikinpracticefor:
A one practical
day practical course
on Emergency
Tracheal Access Tra
A one day
course
on Emergency
w Cricothyroidotomy: narrow, wide bore
Lectures
manikin practice
for:
Lectures
andand
manikin
practice
for:
and surgical approaches
• Cricothyroidotomy: narrow,
wide bore wide
and surgical
approaches
• Cricothyroidotomy:
narrow,
bore
and sur
• Jet and
ejector (‘Ventrain’)
ventilationventilation
• ventilation
Jet and
ejector
(‘Ventrain’)
w Jet and ejector (‘Ventrain’)
• Practice
all devices
available
in the UK in the UK
• Practice
ononall
devices
available
w Practice on all devices available in the UK
Venue Ronald Miller Education Centre
Wishaw General Hospital
Wishaw
w Aimedatallgrades
fromST3traineesto
consultants,including
specialtydoctors
Tel: (01698) 855610 Catherine Paton
Clinical skills Consultant
Further Information
Catherine.paton@lanarkshire .scot.nhs.uk
Catherine Paton
Based on NAP4 Key Recommendations
Based on NAP4 Key Recommendations
w BasedonNAP4KeyRecommendations
High faculty/
delegate ratioratio
High faculty/
delegate
w Highfaculty/delegateratio
For photos of the 2012 course
& further information please visit
www.medednhsl.com/
sites/LEAT251012
Tel: (01698) 855610
Further Information
Catherine Paton
w
The following year was supposed to be the
“Tour of Renewal” in which the organisers
claimed to want to clean up the sport and
took the unprecedented step of banning
certain teams, team officials and individual
riders. It now seems ironic that the winner
that year was Lance Armstrong, who 13
years later would be revealed as yet another
drugs cheat in a scandal to rival the Festina
affair.
Lance Armstrong famously claimed to be
the most tested athlete in history and to
have never failed a doping test. Along with
the infamous doping physician Dr Michele
Ferrari, he was eventually exposed not by
clever anti-doping tests but because the
initial investigation was conducted by the FBI
rather than the anti-doping authorities. This
meant that witnesses caught lying under oath
would be guilty of perjury and risked a prison
sentence rather than a slap on the wrist from
the UCI. For reasons unknown, the initial
Federal Inquiry was dropped. Armstrong’s
important works for charity via Livestrong
had made him a popular and influential figure
in the USA. However, the US Anti-Doping
Agency took up the case and the rest is
recent history. Details of the investigation can
be read at http://cyclinginvestigation.usada.
org/ . Having stripped Armstrong of his 7 TdF
titles it is telling that the UCI did not feel able
to reallocate the victories.
Lanarkshire Endoscopic
Airway Training (LEAT) Course
Places limited to: 8delegates
w Course fees: £200(participants)
£250(observers)
w10CPDcreditsapplied for
from The Royal College of
Anaesthetists for this event.
Keynote
Lecture: Dr
McGuire,
Chairman, Scottish
Airway
Keynote
Lecture:
DrBarry
Barry
McGuire,
Chairman
w SuitableforallgradesofAnaesthetists
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“Emergency tracheal access:
‘NAP4/access
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Dundee.
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andEmergencyMedicineStaff
perspective’
perspective’
For further information and booking enquiries
regarding both courses, contact:
Elizabeth Bell,TrainingCo-ordinator
by telephone on:01698 855510
or by email on: [email protected]
w Places limited to: 32delegates
Suitable
for allgrades
grades of Anaesthetists
and Emergencyand
Medicine
Suitable
for all
of Anaesthetists
E
w Course
Staff fees: £100
Staff
w5CPDcreditsapplied for
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fee £10
is approved byby
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credits credits
AAGBI
MEMBERSHIP
THE ASSOCIATION OF ANAESTHETISTS OF GREAT BRITAIN & IRELAND
Membership to the
AAGBI provides
you with essential
information support
and resources
for every stage of
your professional
development.
N.B.: I have no “inside knowledge” of doping
practices amongst professional cyclists, this
article has simply been compiled from various
books / articles / biographies I have read.
If you want to know more the following
books are a good place to start:
•
Bad Blood by Jeremy Whittle.
The secret life of the Tour de France.
•
Breaking the Chain by Willy Voet.
Drugs and cycling: the true story.
•
The Death of Marco Pantani
by Matt Rendell.
•
The Secret Race by Tyler Hamilton.
Inside the hidden World of the Tour de
France: doping, cover-ups and winning at
all costs. (Winner of the William Hill Sports
Book of the Year 2012).
ARE YOU TAKING
ADVANTAGE OF
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BENEFITS?
Booking enquiries
to: Elizabeth Bell,Bell,
TrainingTraining
Co-ordinator Co-ordinator
01698 855510
Booking enquiries
to: Elizabeth
01698 855510
[email protected]
[email protected]
• Personalinjuryandlifeinsurancecoverofupto£1millionfor
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• Essentialpublicationsavailableinbothonlineandhardcopy
These include:
- AcclaimedmonthlyjournalAnaesthesia
- Popularmembers’magazineAnaesthesiaNews
- Fortnightlye-Newsletter@AAGBI
- Practicalhandbooks,guidelinesandlaminatesonissues
affectinganaesthetists
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06/12/2012 10:36
reduce the risk of acute kidney injury in the perioperative setting e.g.
maintaining good hydration. Although optimising renal protection
in the preoperative period with ACEI is important, especially in
diabetics, withdrawal for 24-48 hrs over the operative period is a
wise precaution together with avoidance of the “devil’s medicine”
NSAID’s! In addition, exercise therapy could be utilised to improve
lipid metabolism, anaerobic threshold and eGFR.
What’s been happening this year
at the Preoperative Association
Annual Conference?
This year’s Preoperative Association Annual
Conference was held at the Royal College of Surgeons
with great success. This London venue played host to a
big turnout of preoperative enthusiasts, who enjoyed a
day of varied lectures, discussions and demonstrations.
Enhanced recovery was a central theme, with Mrs Jane Jackson & Mrs
Sylvia Nawathe sharing the experience & success they have enjoyed
with the programme developed in West Hertfordshire Hospitals NHS
Trust. A partnership programme was described whereby stakeholders
were all engaged in the development, planning & execution of the
ERP. Over 2000 patients have now gone through different disciplines
of orthopaedics, gynaecology & colorectal surgery. These patients
have seen decreased length of hospital stay, less re-admissions,
and overall positive feedback of their journeys. They also highlighted
the need for continued support, with specialist Enhanced Recovery
nurses playing a great role in patient preparation and education with
development of the hip & knee schools. They concluded that overall
sustainability of the programme require regular stakeholder group
meetings, adapting to new emerging evidence, patient feedback &
audit results, and finally marketing and promotion of positive results. It
is hoped that their programme will expand to include emergency work
and to decrease their overall opiate use.
Dr Cathryn Eitel, Consultant Anaesthetist, from St. Richard’s Hospital,
inspired a breakout session group, on the business of putting
together an Enhanced Recovery Programme for Orthopaedics in
Chichester. She took us through the process of getting together all
interested stakeholders & developing the programme, and most
importantly the business case to the trust of the potential cost
savings by implementation of the programme. Since starting in July,
she highlighted the reduction in patients’ length of stay, improved
mobilisation, less blood transfusion requirements and reduced opioid
usage.
The medical implications of anaemia, alcohol dependence and renal
disease for patients having surgery were other topics of interest.
Dr Julia Saunders, registered nurse & Head of Clinical Research for the
Institute for Human Health & Performance at UCL, presented anaemia
as a common preoperative condition, affecting 30 to 60% of patients
undergoing elective surgery. As part of the Enhanced Recovery
Partnership Programme, anaemia is considered a correctable
condition to be addressed preoperatively with the aim of reducing
morbidity and hospital length of stay. The importance of iron in both
14 The issue of consent for anaesthesia and surgery & the role of
preoperative assessment were explored by Dr Stuart White, Consultant
Anaesthetist from Brighton. With his additional background in medical
ethics & law and as a serving member on the AAGBI council working
party on consent, he was invaluable in educating the audience on the
legal consent process. He also highlighted the problems of seeking
consent during preoperative assessments, and argued that, instead it
should be a time for the valuable provision of information to patients.
Again, this year we enjoyed many abstract submissions of
high calibre. The best oral presentation was awarded to Claire
Frank for “Use of ambulatory blood pressure monitoring and the
implementation of non-medical prescribing to improve patient care
for patients with hypertension attending the preoperative assessment
clinic”. The best abstract poster was “Audit of the Epworth sleepiness
in a DGH preoperative assessment clinic & a pragmatic approach to
the preoperative diagnosis of obstructive sleep apnoea” from a group
at The Queen Elizabeth Hospital NHS Trust.
Mentoring - Achieving
your full potential
Opportunity for a ‘taster session’
with a trained experienced mentor
Other breakout sessions enjoyed live demonstration of CPX testing,
and a Q&A on some difficult preoperative dilemmas.
Dr Jonathan Cracknell, a reknown veterinarian & Director of Animal
Operations at Longleat Safari & Adventure Parks, ended the day
with his humerous talk on the comparative difficulties of assessing &
anaesthetising his usual patients, who ranged from the African toad
to Siberian polar bears. The audience was enthralled by his videos
ranging from the preoperative visit/assessment of a lion in Africa, to
overall anaesthetic care of bears in China undergoing laparoscopic
cholecystectomy.
iron deficiency anaemia and anaemia of chronic disease has been
a main focus of research, and it is advocated that intravenous iron
preparations are now available as a single short infusion treatment,
which can increase haemoglobin levels preoperatively and reduce the
need for perioperative blood transfusions.
Dr Lynn Owens, Nurse Consultant & Honorary Research Fellow
from Liverpool, discussed the problems surrounding routine alcohol
screening in the preoperative setting. Coming from Liverpool, where
their football team has a renowned alcohol intake & where the local
Spar shop across the hospital routinely sells alcohol to in-patients, it
is an unenviable task. However, with her combined clinical & research
enthusiasm, she stressed to the audience the importance of alcohol
screening, utilising a simple validated screening tool, the Alcohol Use
Disorders Identification Test (AUDIT), during preoperative assessment.
This simple tool can be used to identify dependence and initiate
steps to undertake ‘detox’ and reduce morbidity postoperatively. A
collaborative primary & secondary care focus has been the focus of
her research, with the aim to have an effective and responsive service
for such patients.
Dr Lui Forni, Consultant Renal Physician from Worthing Hospital,
addressed the issue of ageing & its impact on renal function in
his characteristically entertaining style. He discussed the elderly
patient with renal dysfunction presenting for surgery, and told us
that although these patients are often classified as CKD stage 3, it’s
really only stage 3B (eGFR <45) that we should be concerned about.
However the presence of associated proteinuria was highlighted as
a bad prognostic indicator. Simple measures can be undertaken to
Presentations from the meeting are available for viewing by
Preoperative Association members on our website (www.preop.org)
In addition, there are many regular study days arranged across the
country in the coming year, ranging from CPX testing, respiratory &
cardiovascular diseases, and focused groups such as foundation
doctors, nurses & anaesthetic trainees. Please see our website for
further details.
11th February 2013 Advanced respiratory study day for nurses
Watford General Hospital, Watford
25th April 2013
POA study day for anaesthetic trainees
AAGBI, London
13th May 2013
POA study day for nurses / foundation doctors
Harrogate District Hospital, Harrogate
22nd May 2013CPX study day
AAGBI, London
27th June 2013
Advanced cardiac study day for nurses
St Richard’s Hospital, Chichester
7th November 2013 Preoperative Association Conference
York Racecourse, York
Next year’s conference
will be held at York Racecourse.
Please save the date November 7th 2013.
Looking forward to meeting up again next year!!
Dr Sharon Avery and Dr Rob Hill
Consultant Anaesthetists, Western Sussex Hospitals NHS Trust
Following the success of mentoring sessions at GAT last year, we
are offering 30 sessions at this year’s GAT conference. Book now
if you want to take a strategic look at your career. The GMC’s draft
Good Medical Practice 2012 guidelines state that
GAT are offering conference participants of a one hour mentoring
session with one of a team of highly trained and experienced
mentors all of whom use mentoring for themselves. The mentors
are senior anaesthetists who have, between them held posts
of Royal College Tutor, Deputy or Regional Adviser, and AAGBI
Council members. Mentoring conversations are confidential.
Sessions will be most useful to conference participants who
•
Are strategic about your own development
•
Want to discuss a potential opportunity or a dilemma
•
Have specific educational or work needs
•
Are at a cross road in your career - Career / life planning
For further details please visit:
www.gatasm.org
Venue Medical Management
at the London Olympics 2012
I started working backstage on theatre
shows and student balls at university
and ever since I have volunteered or
been employed at events such as
Glastonbury Festival, the Proms at the
Royal Albert Hall and Bristol Balloon
Fiesta to name but a few. I found I really
enjoyed the team camaraderie and the
sense of ‘putting on a great show’ and
the occasional added benefit of a free
crew t-shirt! Over the years I built up a
steady portfolio of event management
skills but I never dreamed that I’d be
able to combine my ‘hobby’ with my
medical career.
My daily commute involves a proportion
of time spent on the London Underground.
I reach for my iPod whilst summoning
my blank ‘commute face’ alongside
everyone else. I think back to a less bleak
time – the time of the London Olympics &
Paralympics. Feeling cold and windswept,
it’s as if it didn’t happen. But it did. And I
am proud to have been a (small) part of
the ‘greatest show on Earth’.
16 I necessarily curtailed the number of
events I was involved in when I started
as a Foundation Doctor and threw
myself into clinical work. However, when
the volunteer recruitment for Olympics
‘GamesMakers’ opened in 2010, 5 years
after the bid was won, as a Londoner,
I couldn’t resist and signed up straight
away. At the same time, I started
looking at the job descriptions for paid
employment with the London Organising
Committee of the Olympic & Paralympic
Games (LOCOG) and in 2011 - my FY2
year - I successfully applied to become
a Venue Medical Manager (VMM).
With job offer secured, the next hurdle
was to somehow get the time off work.
I decided against applying for core
anaesthetics training at the time and
instead I would take a year out, doing
my own ACCS-like rotation until the
Olympics. Reactions to my decision
seemed to fall into either sheer horror or
bemused incomprehension categories.
Interestingly, the trainees I spoke to
seemed to think it would be detrimental
to delay getting a NTN for something
so fleeting whilst senior clinicians/
consultants were invariably positive and
told me to go for it! The most memorable
moment was an interview where two
(surgical) consultants took each side
of the argument and had a heated
discussion amongst themselves! In the
end, I did stints as a clinical fellow in
critical care and cardiothoracic surgery.
In telling people I was working full-time
at the Olympics, I had to emphasize
that it was a management role, not
clinical and indeed, was not actually
employed to treat anybody. “And what
exactly WILL you be doing then?” was
the most frequent reply. Basically the
VMM has overall responsibility for the
provision of medical services at a given
venue – managing all the volunteers
and their rotas; setting up, stocking
and breaking down medical rooms and
equipment; volunteer training; liaison
with all the other ‘Functional Areas, FAs’
such as logistics, event services, sport;
ensuring the appropriate storage of
controlled drugs… the list goes on. My
venues were Box Hill, Surrey for the road
cycling, Hampton Court Palace for the time
trial cycling, Earls Court for indoor volleyball
and the Mall for the marathons and race
walk – though not all at the same time on
the same day!
On meeting the other VMMs (there were 32
in total), I was surprised to see that doctors
were in the minority, there were some
nurses but about half were not medically
qualified and were made up of healthcare
managers or executives in the sports
sector, which emphasises the management
component of the role but I did feel that
having a medical background was helpful.
We were immediately bombarded by
LOCOG acronyms to learn. You could quite
reasonably expect to overhear people
saying things such as, “Have you spoken
with PALESTRA about whether they need
representation in the VCC as well as the
ECR or just in the MOC?” Due to the number
of venues I had (most VMMs only had 1
or 2), I spent the first 10 days or so based
at the LOCOG offices in Canary Wharf
in a whirlwind of meetings, introductions
and stacks of reading. Obviously as there
has been no precedent in living memory
about how one goes about organising an
Olympics, those first weeks were very much
self-directed and I sort of picked things up
as I went along, which reminded me of being
an FY1 – I was sure there was something
important I was meant to be doing but not
exactly sure what!
The next stage involved moving out to site.
As the days went by, the offices became
more deserted as staff de-camped to their
respective venues. A decree came from
above – ‘Gamesmaker uniform to be worn’.
My first day on the Tube with uniform on
was met with smirks and finger pointing.
Fast forward 2 weeks later, we were in the
majority. I felt as if I’d started some major
fashion trend. Box Hill, Hampton Court and
the Mall were all temporary infrastructure
venues = lots of building work. Hard hat,
hi-viz and steel toes on top of my uniform
donned, I commenced my rounds of the
venues and started the complicated task
of locating my kit, unpacking it and putting
it together; I am now queen of Swedish flat
pack furniture construction.
The roll-out of medical Venue Specific
Training (VST) heralded the exciting arrival of
the volunteers. Hurrah! With it I discovered
a new source for apprehension – I would be
overseeing a number of senior clinicians with
many years more clinical and managerial
experience than me… Not helped that
the uniform made me look even younger
than normal (I was ID’d trying to buy some
trouser hemming tape with pins). In actuality,
my volunteers were amazing. Whether
a first-aider with 2 months experience to
experienced sports physician to consultant
anaesthetist, the professionalism and team
ethic they exuded was humbling and made
me extremely proud.
As we had been preparing for so long,
I was soon keen for the sporting events
to start, which for me kicked off with the
men’s road race and I was stationed at
Box Hill for the duration. Mostly things ran
smoothly, although there were a few minor
issues resolved with some creative problem
resource management such as extricating
a gentleman with a possible ankle fracture
halfway up a hill using a mobility scooter! By
the end of that first day, I felt confident I’d be
able to manage the rest of the Games. In
terms of clinical encounters, thankfully there
were lots on number but few in severity. We
did have intubation kit backpacks but I don’t
think any were used across all the venues.
The endurance sports (marathon, race walk)
resulted in the most number of athletes
collapsing due to exhaustion/dehydration.
Initial resuscitation was carried out at venue
and if they required further treatment, they
were transferred to the Polyclinic at Olympic
Park.
My main highlight of the Games was
watching Bradley Wiggins cross the line at
the Hampton Court Palace time trial. I was
based in the Event Control Room and so I
could see his stage times and when I could
see he was in the lead, I headed to the finish
line to see him come through. The roar of
the celebratory crowd in the sunshine was
phenomenal. Then I got to see the Wiggins
family clan up close in the Athlete Lounge,
adjoining my medical room!
Beyond my comfort zone
I’ve learned so much from this experience
that is transferable to anaesthetic practice
- the ability to multi-task; negotiating with
people with different agendas; coping
beyond my comfort zone and fundamentally,
how to manage people without resorting to
monetary motivation! I’ve met incredible
volunteers and colleagues along the way
– thanks for putting up with me, you know
who you are! Although it did take me a
little longer than planned to get back onto
the training programme treadmill, overall
I’d absolutely recommend taking the time
out to do something different. At the very
least I’ll have something to discuss with my
consultant on that robotic list…
Dr Angela Lim,
Currently Clinical Education Fellow,
Chelsea & Westminster Hospital
(CT1 Anaesthetics at Basingstoke Hospital from 06/02/13)
Disclaimer: The views and opinions expressed in
this article belong to the author only and in no way
represent the IOC or LOCOG.
17 money was to be allocated. SAS grade staff are becoming more aware of the potential of this funding. The introduction of Local Education and Training Boards in the Health and Social Care Act, and the changing financial climate in the NHS may lead to scrutiny of the benefits of this funding provision. on per
the annum
use of twas
he funding within my own Trust may help shed light on this area. I am an InReflection 2008 £12m
provided
for the
shed light on this area. I am an SAS Tutor in a larger rural multi-site
SAS Tutor a larger rural multi-‐site Trust for
in tSAS
he East Midlands. Over the lMidlands.
ast 3 years 108 152 AS 108 of 152 SAS
provision
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Trust in
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Over
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grade
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he SAS and
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have
some
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Northern
Ireland
does
courses run within the Trust and also to support individual bids. also to support individual bids.
not
yet
have
such
provision,
despite
lobbying.
Generic courses Generic courses
The
funding wentat from
Department
Health
to Deaneries
and each and Attendance
these courses
and contact
Attendance these courses ofhas promoted networking, contact at
between SAS shas
taff promoted
working networking,
on Deanery decided how the money was to be allocated. SAS grade between SAS staff working on different sites who had never met
different sites who had never met before. A good support network has developed which has been staff are becoming more aware of the potential of this funding. The before. A good support network has developed which has been
good for m
and has eand
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he introduction
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and
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for
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courses, which are run on a regular basis. NHS may lead to scrutiny of the benefits of this funding provision. basis. 105 staff have accessed the generic courses, with several of
105 staff have accessed the generic courses, with several of them attending more than one. Reflection on the use of the funding within my own Trust may help them attending more than one.
Courses run between June 2009-‐June 2012 (freq ) Benefits Train the Trainer (3) Enhanced skills Organisational skills (incl business plans) (1) Greater understanding, business cases written : see below Job Planning (2) Better understanding CESR (2) Knowledge of process improved. One has applied successfully and is now a consultant in the region. Others are working towards getting CESR How to review clinical papers (2) Better discrimination of evidence Revalidation and Appraisal (4) Knowledge of process gained Leadership and Management (3) Better understanding of teamwork and motivation Empowering SAS Grades (1) Self awareness improved, better self management, and more job satisfaction gained Clinical Supervision (2) + on-‐line Better teaching and assessments Communication skills (2) Fewer complaints noted Introduction to Mentoring (1) Much interest in this Human Factors Training (1) Improved patient safety Clinical Governance (1) Improved patient safety, and increased notification of incidents with the potential to cause harm to patients The The funding funding The hsupport
as h
funding as also also bheen bas een aulso sed used been for for individual uindividual sed for individual support support for sfor upport areas areas sfor uch such areas as as locum lsocum uch b
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Individual support. secondments, secondments, secondments, for for supporting supporting for supporting fees fees for for postgraduate p
fees ostgraduate for postgraduate qualifications qualifications qualifications in in both both clinical cilinical n both and acnd linical in in educational educational and in educational What is the future of SAS career development Funding?
Because
they’re there
He remembers the exact moment his mania
started: 21st July, 1986, about teatime. Channel
4 had started showing the Tour de France
that year, and he was already hooked on the
incomprehensibility and romance of the event.
Before the Tour, Bernard Hinault, the 5 time
winner and defending champion, had promised
to support his younger team mate, Greg Lemond,
in winning the Tour, but had reneged on the deal,
attacking the American on stage 18 at the foot
of the Col du Galibier (35km at 5.5%, majestic).
Lemond followed, and the two rode away from
everyone else to finish hand in hand at the top
of the Alpe d’Huez (13.2 km at 8%, iconic),
Hinault finally conceding the Tour on the line.
The mountains were steep and glorious, the
commentators were in raptures, Kathy Lemond
was in tears – these things had an effect on the
impressionable 16 year old, who fell in love with
Alpine cycling in that instant.
The funding has also been used for individual support for areas such as locum backfill for clinical secondments, for supporting fees for
postgraduate
qualifications
both
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in educational
areas,
andfor fororsupporting
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pecialty octors doctors in idn foctors ees fees for for in relevant rfees elevant verseas oelevant verseas sotudy sverseas tudy leave leave study courses. courses. lin
eave ourses. leave courses.
Individual Individual Individual funding funding analysis a
funding nalysis analysis Fund Fund award award Fund June June award 2009-‐June 2009-‐June June 2009-‐June 2012 2012 2012 Numbers Numbers Numbers awarded awarded awarded PG PG Education Education PG Eqducation ualification qualification qualification fees fees fees 4 4 4 PG PG DD
ip/MSc ip/MSc PG fD
ees fip/MSc ees (clinical) (clinical) fees (clinical) 10 10 10 Clinical Clinical skills sClinical kills courses courses skills courses 24 24 Locum Locum backfill bLocum ackfill for fb
or ackfill secondment secondment for secondment 16 16 24 16 Benefits Benefits Benefits Enhanced Enhanced Enhanced delivery delivery odf oelivery tf eaching teaching of teaching Increased Increased Increased knowledge knowledge knowledge to to enhance enhance to peatient pnhance atient patient care care care Improved Improved Improved range range of osf rkills sange kills for foor f psatient pkills atient for care cpare atient care Increased Increased Increased skills skills for for psatient pkills atient for care. cpare. atient care. Progress Progress tProgress o to CESR. CESR. to CESR. Enabled Enabled setting Enabled setting up usp etting of on
f ew new usp ervices. so
ervices. f new services. More More gained gained More from from gained courses courses from courses Better Better teamworking teamworking Better teamworking Enables Enables SG/SDs Enables SG/SDs to tSo aG/SDs ttend attend tro elevant relevant attend crourses. celevant ourses. courses. Study Study aids aids Study aids 3 3 3 Leadership Leadership Leadership training training training 8 8 8 Overseas Overseas Overseas courses courses courses 5 5 5 Conclusion
Conclusion Conclusion Conclusion Overall the use of the funding has allowed provision of new services, better patient care, increased skills and confidence. Continuation of
Overall Overall the tOverall he use use of othe tf he the ufse unding funding of the has h
funding as allowed allowed has parovision pllowed rovision porovision f on
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confidence. confidence. confidence. Continuation Continuation Continuation of otf his this funding funding of this ww
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would would sDr
trengthen strengthen would trengthen the the argument argument the afrgument or for this. this. for this. If you have used SAS Career Development Funding
Associate Specialist Anaesthesia and Chronic Pain, Pilgrim Hospital,
Boston,
in your Trust and can help provide further evidence of its
part of United Lincolnshire Hospitals Trust (ULHT).
Put Put this this in iPut n a ab Ttox bhis ox ait an t the athe beox nd end ao
t f othe tf he the ea
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March o
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308
usefulness, usefulness, usefulness, please please let let ptlease he the AA
AGBI lAGBI et the know know AAGBI at at kx now xxxxxxx xxxxxxxx at ex exxxxxxx m
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SAS ail committeee cfommitteee or SAS committeee Flash forward 20 years and numerous Tour mountain highlights in
the interim, and that same boy is nervously lining up in Gap, about
to embark on his first journey into the mountains, as part of the 2006
Etape du Tour, finishing 186km later in 400C heat at the top of the
21 hairpin bends of the Alpe d’Huez, after crossing the Col d’Izoard
(15.9km at 7%, the best ascent) and the Col de Lauteret (28km at 3%,
the best descent). ‘Never again!’ he swears in his heat-exhausted
state, as he falls off his bike over the finishing line, such is the
murderous, masochistic brutality of climbing so high for so long.
And yet … and yet he’s back again in 2008 for another fix, better
prepared – lighter by 5kg, more realistically geared, with a nutrition
plan and the words of the famous Spanish climber Lucien van Impe
in his head ‘Start a climb in a lower gear than you think you need,
establish a good pedalling and breathing rhythm, and then change
up’ - climbing 101. It still hurts – Christ, it hurts – the Tourmalet (lit.
‘bad route’, 17km at 7.4%, grim) is wet and forbidding, the Hautacam
(17 km at 6.8%, also grim) as unpleasant to descend in 00C sleet as it
was to ascend – but he finds a perverse pleasure in the pain, a sense
of self, a sense of achievement, so much so that he’s back the same
year to climb the Col de Marie Blanc (9.5 km at 7.5%, horrible) and the
Aubisque (17 km at 7.2%, spectral), on holiday.
Altitude lust
But even bad climbs infect him with altitude lust, every consecutive
ascent of his local training hill (Ditchling Beacon, 1.5km at 10%, a
pimple) fuelling his obsession with marginal gains in weight reduction
and power output, ready for his next summer in the Alps or Pyrenees.
2009 brings the big one for British cyclists – Mont Ventoux (the Giant
of Provence, 23 km at 7%, monstrous), where Tom Simpson died so
close to the summit in the 1967 Tour, a beast of a climb, but only
after 150km of blissful French lavender fields. 2010’s Swiss Ironman
foothills don’t cut it; he feels cheated, enters the 2011 Marmotte, and
makes his peace with Alpe d’Huez, after climbing the Col du Glandon
(24 km at 4.8%, utterly beautiful) and the Galibier. He climbs the Alpe
‘fresh’ the next day, in Stendhal tears.
Stung by the
Croix de Fer, 2012
Dwarfed on the Col
de Glandon, 2011
He finally cracks on the bitter, wet
descent off the Aubisque in 2012,
shivering to a halt, and is too
humbled by the prospect of the
Tourmalet, Aspin and Peyresourde
to continue. Instead, he seeks
solace a week later on the Col de
la Croix de Fer (28 km at 4.7%,
unutterably beautiful) and the
Alpe. He’s done with racing, but
there are still hills to climb, and
he knows he’ll be drawn back
next year ‘just because they’re
there’ – Madeleine, Sestriere,
Stelvio - moth to a flame.
Quod me non necat
me fortiorem facit.
Dr Stuart White, Consultant,
Royal Sussex Hospital Brighton
www.climbbybike.com
19 s
e
m
e
h
Buddy Sc
s
r
e
t
r
a
t
S
for New
a
i
s
e
h
t
s
to Anae
This article aims to prov
ide a background
into buddy schemes,
what their role is within
anaesthesia, and then
to discuss and compa
re
two established schem
es in the UK.
The working life of the junior trainee in
anaesthesia has changed over the last
5 years. Hospitals are now forced to run
rotas with a reduced number of trainees
resulting in pressure on the daytime
elective experience. There is an increased
requirement to complete examinations
early, as full completion of the Primary
FRCA is now required for ST3 interview1.
The European Working Time Directive
means that trainees spend proportionately
more of their time working on-call and
many new trainees feel worried about
joining the on-call rota. In 2009, a survey
conducted by the Group of Anaesthetists
in Training (GAT), revealed that some
trainees felt that peer support had been
reduced by new working arrangements.
High stress levels were also highlighted
amongst junior trainees2. The situation has
continued to evolve since then.
Free hospital accommodation has not
been provided to newly qualified doctors
since 2008. This has coincided with a
progressive erosion of working in firms, in
favour of full shift on-call working patterns.
There is a general consensus that it is
harder to establish informal and supportive
relationships between colleagues that
historically were integral to a junior hospital
doctor’s survival.
20 Peer support may help new starters to
better understand their role and plan
their careers. Furthermore, the General
Medical Council’s ‘Good Medical Practice’
document states that ‘you should seek out
a mentor during your first years working
as a doctor and whenever your role
changes significantly throughout your
career’3. Although there is a move towards
mentorship becoming a part of our regular
clinical practice, a considerable time and
training investment is needed before
formal mentoring schemes can be offered
to all junior doctors.
In response to these changes there has
been an increasing interest in peer support
networks amongst trainees. As a result,
‘buddy schemes’ have been introduced
in some deaneries. Buddy schemes may
be able to bridge some of this gap, but
there is certainly not a fixed model through
which they are currently run. Therefore,
to promote discussion, we describe two
established but contrasting schemes run
in the Northern Deanery and the North
West Deanery.
Mentorship is a skilled task, requiring both
the acquisition of skills through training
and the maintenance of these skills, with
regular support, practice and training.4
Complexities arise not only in the provision
of this training, but in lines of accountability
when there are issues. There have been
significant moves to develop mentoring
within the AAGBI over recent years.
Neither scheme described is intended to
provide mentorship. Both schemes are
clear that the primary aim is for buddies
to provide confidential, informal, nonsupervisory peer support. The secondary
aim is to direct any trainee who requires
more formal support to systems already in
place.
The process of establishing a buddy
system has been previously described on
the Association of Anaesthetists website
by Alex Beckingsale, who established
the Northern School of Anaesthesia’s
(NSA) buddy scheme5. The deanery or the
school of anaesthesia must be involved to
provide administrative support, to assist
with ethical considerations and to ensure
that the professional responsibilities and
lines of support are clear and agreed.
Adequate interest is essential for a
successful buddy scheme. In 2009,
informal questioning revealed strong
interest in buddying amongst senior
trainees in the Northern Deanery. Neither
scheme has encountered problems
in attracting senior trainees to act as
buddies.
Where the two schemes differ is in
the pairing and training of buddies.
Administration of the NSA’s buddy
scheme is relatively simple. It involves
the pairing of new starters with buddies,
ensuring that all parties are clear on the
process, keeping the school informed
and acting as an avenue of support
for the buddies. The system is paper
free in respect to buddy contacts and
requires no formal documentation.
Buddies are paired together centrally
by the administrator. The aim is to pair
those with similar interests (especially
less than full time trainees and military
trainees) and nearby geographically
locations to facilitate contact. Buddies
were previously paired with new starters
in different hospitals to provide a point
of contact outside of their working
department. Feedback has revealed
that within hospital pairing is a more
convenient method.
The NSA’s buddy scheme is very flexible.
Following initial e-mail contact, new
starters are free to participate or not as
they choose. Further contact is guided
by the new starter, or by the buddy, and
is often little more than an initial social
meeting, followed by regular, rarely more
than monthly, contact. Many new starters
need little support, whilst others require
a great deal, being keen to continue
the scheme beyond the year. Support is
provided for buddies if needed, but there
is no specific training. This has allowed
successful handover of the scheme,
which is essential for its longevity.
Voluntary training for buddies is under
consideration, depending on interest, but
this will not become a requirement. The
scheme is a peer support network, rather
than a mentoring or coaching service.
Feedback from this scheme has been
overwhelmingly positive from both new
starters and buddies, with a desire to
continue the pairing and for continued
support, particularly during the Primary
and Final FRCA examinations.
The North West School of Anaesthesia’s
Buddy Scheme is somewhat more
structured. It uses an online system for
registration and matching. Junior trainees
register and are asked to state any areas
of specific concern or interest that may
facilitate matching, such as an interest in
out of programme training. Meetings can
be within or outside the work environment,
depending on personal preference.
Again, home and work locations are
registered to avoid pairing people at the
geographical extremes of the deanery. If
a junior trainee has met a senior buddy at
work and wishes to be paired up (termed
‘offline matching’) there is also the facility
to do this.
The North West senior buddies
The North West senior buddies have all
completed a one-day training programme
both to improve their awareness of
the support structures that exist for
juniors and most importantly to develop
their value as listeners in providing
peer support. Like the NSA’s buddy
scheme, the system is not a mentorship
programme, however the training of the
senior buddies is integral to the model.
The scheme is not about senior trainees
advocating the old-fashioned approach
of ‘this worked for me so you should
do it too’, but instead recognising that
all trainees bring different strengths and
weaknesses to the workplace. The goal
is to empower the junior trainee to identify
their own issues and find their own
solutions. Feedback has been excellent
and it is anticipated that both junior
and senior buddies will find the scheme
beneficial. Key features include flexibility
for both parties, continuing to pair all new
starters with a senior buddy and trying to
expand buddy schemes to help other UK
trainees.
rence
At this year’s GAT confe
d) we are
for
Ox
(3rd-5th April 2013,
ed at those
holding a workshop, aim
setting up
who have an interest in
ultaneously
a buddy scheme. Sim
ation about
we are collecting inform
s and would
existing buddy scheme
could email
be very grateful if you
m to let us
[email protected]
in your
know what is happening
u at GAT!
region. Hope to see yo
Dr Pete Ricketts
ST7, Northern Deanery
Dr Alex Bonner
ST6, North West Deanery & Fellow in
Education
Thank you to Dr Sam Burnside
and Dr Alex Beckingsale for their
help in producing this article.
References
1.
Modernising Medical Careers.
Person Specification: Application
to enter Specialty Training at ST3 in
Anaesthesia; 2013 [accessed 6 Jan
2013]. Available from: http://www.mmc.
nhs.uk/pdf/PS%202013%20ST3%20
Anaesthesia_1.pdf
Since publicising our schemes, contact
has been received from many other
deaneries that would like to expand
into this area. We would encourage all
anaesthetists to consider the potential
advantages of having a similar scheme in
your region. This is a mutually beneficial
process, whereby both junior and senior
trainees gain in developing non-clinical
skills, which are vital within the workplace.
2.
Shewry L. The GAT Annual Trainee
Survey; 2009 [accessed 6 Jan 2013].
Available from: http://www.aagbi.org/
sites/default/files/oct09_0.pdf
3.
General Medical Council. Good Medical
Practice; 2011 [accessed 6 Jan 2013].
Available from: http://www.gmc-uk.org/
Good_Medical_Practice_2012___Draft_
for_consultation. pdf_45081179.pdf
We have tried to outline the context and
organisation of two buddy schemes,
which, although in their infancy, are
proving popular and successful. It is our
expectation that peer-support models
such as these will become commonplace
and recommended by the bodies
responsible for postgraduate medical
training. We do not profess to be experts
however, and your thoughts, feedback
and questions are most welcome.
4.
General Medical Council. Guidance
on Good Practice; 2012 [accessed
6 Jan 2013]. Available from: http://
www.gmc-uk.org/guidance/ethical_
guidance/11825.asp
5.
Gibb S. Buddy Scheme for New
Starters to Anaesthesia: A Model; 2012
[accessed 6 Jan 2013]. Available from:
http://www.aagbi.org/professionals/
welfare/buddy-schemes
21 Anaesthesia History Prize Winning Essay
Pulmonary Artery Catheters
By the Heart’s Vigorous Beat
A History of Cardiac Output Monitoring from its Origins to the Present
Cardiac output measurement in its many
guises is now ubiquitous in intensive care
units and is finding an increasing role in
the anaesthetic management of high risk
patients. Techniques employed in these
measurement systems are based on
physiological principles developed over the
last 150 years and refined with the advent of
improved technology. In 1628, William Harvey
debunked Galen’s classical viewpoint by
establishing the circulatory pattern of blood
in the cardiovascular system.
The Swan-Ganz PAC was introduced in 1970 and rapidly gained
widespread usage. The quality of the catheter and balloon,
relatively straightforward insertion and the ease of withdrawing
mixed venous blood made Swan-Ganz catheters extremely
popular. Some 2 million PACs per annum were sold worldwide in
the mid to late 1980s. So popular were the PACs that, on intensive
care ward rounds at least, ‘to Swan’ became a verb adopted into
the English language.9
‘For it is by the heart’s vigorous beat that
the blood is moved.’1
Harvey Arm
By multiplying stroke volume and heart rate, Harvey’s mechanical
approach to his proof represented the first attempt at assessing
cardiac output in a scientific fashion. But it was here that the story
lay, largely untouched, until it was re-awakened in 1870, at the start
of the golden age of German science.
also anaesthetic gases were found to complicate measurements.
Much more practicable in the operating theatre were found to be
methods involving indicator dilution.4
Indicator Dilution Techniques
Adolf Fick offered no experimental data in 1870 when he
first proposed that cardiac output equals oxygen
consumption divided by arterio-venous oxygen
difference. This succinct description has been
described as a turning point in the quantitative
measurement of blood flow; but in the
nineteenth century proving it presented near
insurmountable technical obstacles in man.2
In 1898, some three years before Fick died,
the first experiments were described in which
the cardiac output of horses in various states
Adolf Fick
of rest and exertion was measured. However, this
was the only foray into the measurement of cardiac
output until interest was re-kindled in the 1920s.3
At around this time, the pieces required to use the direct Fick
method in man were slowly appearing. In 1924, a method for
determining oxygen content accurately in arterial blood was
described and five years later Forssmann famously cannulated his
right atrium. However, it was not until 1930 that the combination
of mixed venous blood sampling and accurate oxygen content
analysis finally enabled the verification of Fick’s principle.
Despite this, the direct Fick method did not gain acceptance as
a useful technique during anaesthesia. Not only were the errors
inherent in not sampling at steady state potentially greater; but
22 The story goes that whilst sitting on the beach, Swan struck upon
the idea that a balloon tipped right heart catheter could ‘sail’
through the right side of the heart into the pulmonary vasculature.
He and his colleague Ganz have since been immortalised with
their eponymous PAC, but the use of right heart catheterisation
to determine cardiac output through the application of the direct
Fick method had been going on for years prior to this. Use of
the early catheters was restricted by the difficulty presented by
insertion and ongoing care of an indwelling catheter. It took over
a minute to aspirate a 1ml sample through the 0.5mm bore of the
early catheters.8
The use of injected indicators to investigate the
cardiovascular system had been around for
more than a century before Stewart published
his seminal work in 1897. He pioneered
the constant injection of indicator method to
measure cardiac output and his contribution is
remembered as one half of the famous StewartGN Stewart
Hamilton equation. The other half comes from a
group led by Hamilton who simplified the technique
by addressing the problem of recirculation of indicator to
eventually allow for its use in clinical practice.5
The problem that investigators had wrestled with since Stewart’s
original experiments was in the choice of indicator. In 1954, the
first reports of thermodilution as a tool to measure cardiac output
were made. It was said that initially there was a reception of ‘polite
incredulity’ despite the good correlation between thermodilution
and the direct Fick method.6 However, efforts continued and
thermodilution was finally demonstrated in man by Branthwaite
and Bradley in 1968. Assisted by this and the introduction of
Seldinger’s technique for cannulating vessels, the laboratory and
tentative clinical work of the previous seventy years was about to
enter widespread clinical practice in the form of the Swan-Ganz
Pulmonary Artery Catheter (PAC).7
In the mid 1980s concerns were first raised as to whether the
unquantified benefits of knowing, amongst other things, the
cardiac output outweighed the significant risks. Could it be that
this quest for bedside cardiac output monitoring that had begun
more than 100 years previously was not of benefit to patients? The
decline and fall of the Swan-Ganz PAC has been ongoing since
the mid 1990s and it seems likely that one of the factors that has
contributed to this is the arrival of novel, less invasive ways of
measuring cardiac output.
Pulse Analysis
Not long after Stewart’s original publication, it was suggested that
pulse pressure analysis could be used to measure cardiac output
in humans. Despite the efforts of a number of investigators, it was
found that significant individual intervariation in elasticity of the
proximal arterial tree meant that no reasonable technique using
pulse contour appeared.
In 1953 Hamilton suggested using a proven output method,
such as an indicator dilution curve, as a means of calibrating the
distensibility of a patient’s arteries but this did not gain widespread
usage.2 A number of formulae were proposed, but although the
correlation between pulse contour, Fick and indicator dilution was
high; variability was also substantial. This led to a conclusion that
pulse contour analysis could only be recommended as a ‘very
approximate’ alternative to established methods.
In the early 1990s a number of attempts were made at refining
the model with impedance and capacitance of the patient’s arterial
system estimated from patient sex, age and the pulse pressure
waveform. Commercially available systems that are commonly
used today employ an algorithm based on this with a StewartHamilton analysis to further refine these values. These systems
avoid the need for a PAC but the quest for progressively less
invasive methods has not stopped and it is with these techniques
that the story continues.
Oesophageal Doppler & Bioimpedance Monitoring
The Doppler effect was enunciated nearly thirty years before Fick
made his famous statement. In 1842 Doppler stated that the
frequency emitted or reflected by a moving object was proportional
to the velocity of the object such that if the Doppler shift in frequency
can be measured then flow velocity can be derived. Measuring
cardiac output using the Doppler effect first began in humans in
the late 1960s. Initially transthoracic probes were described, with
the first description of trans-oesophageal measurement made by
Side and Gosling in 1971.10
Bioimpedance plethysmography describes the method by which
a change of tissue volume in the body is measured based on its
impedance to an electrical current. Plethysmography as a technique
to measure cardiac output has been used since the 1930s but was
only possible in experimental animals as it required enclosing the
heart in a plethysmograph in order to measure change in volume
during systole. Bioimpedance was first described in the detection
of blood flow in the arm in 1943. Measurement of blood volume
and hence flow in the limbs at rest and exercise continued and
the technique was refined over the next twenty years with its use
to measure thoracic fluid volume described in 1966 by Kubicek.11
Conclusions
The story of clinical cardiac output measurement is one of laboratory
physiology translated into the operating theatre and intensive care
unit. It began with a flash of genius from Fick and continued with
the search for the means to make his direct method possible. The
development of right heart catheterisation, the refinement of the
indicator dilution technique and the introduction of thermodilution
set the stage for the PAC. This device brought the widespread use
of cardiac output measurement to the bedside. Novel methods,
not involving PA catheterisation, have now largely superseded
this. The future of cardiac output monitoring lies with the quest
to find a truly non-invasive device that is accurate in both health
and disease. Whether that future lies with Doppler, bioimpedance
monitoring or another technique remains to be seen. What seems
certain is that these devices will remain rooted in the physiology of
Fick, Hamilton and others with great insight in the past.
Dr Tom Green,
ST6 Anaesthetics, Wessex Deanery
The full version of this
essay is available on
the
www.aagbi.org websi
te
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Harvey W. Exercitatio anatomica de motu cordis et sanguinis in animabilis. Frankfurt:
Fitzer; 1628. Movement of the heart and blood in animals. Trans. Kenneth J Franklin.
Oxford: Blackwell Scientific Publications for the Royal College of Physicians; 1957.
Hamilton WF. The Lewis A. Connor memorial lecture: the physiology of the cardiac
output. Circulation 1953; 8: 527-543.
Shapiro E. Adolf Fick – forgotten genius of cardiology. American Journal of
Cardiology 1972; 30: 662-665.
Payne JP, Armstrong PJ. Measurement of Cardiac Output. British Journal of
Anaesthesia 1962; 34: 637-645.
Fox IJ. History and developmental aspects of the indicator-dilution technic.
Circulation Research 1962; 10: 381-392.
Dow P. Estimations of Cardiac output and central blood volume by dye dilution.
Physiology Review 1956; 36: 77-102.
Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization
of the heart in man with the use of a flow-directed balloon-tipped catheter. New
England Journal of Medicine 1970; 283: 447.
Sykes M. Clinical measurement and clinical practice. Anaesthesia 1992; 47: 425432.
Chatterjee K. The Swan-Ganz catheter: past, present and future: a viewpoint.
Circulation 2009; 119: 147-152.
Singer M. Oesophageal Doppler. Current Opinion in Critical Care 2009; 15: 244-248.
Kubicek WG, Patterson MEE, Witsoe MEE. Impedance cardiography as a noninvasive method of monitoring cardiac function and other parameters of the
cardiovascular system. Annals of the New York Academy of Sciences 1970; 170:
724-732.
23 Hull and East
Hospitals
NHS Trust
HullYorkshire
and East
Yorkshire
Hospitals NHS Trust
ORDER
FORM
Enhanced
After
Orthopaedic
Enhanced
RecoveryRecovery
After Orthopaedic
Surgery
(ERAS) Study Day
Surgery (ERAS) Study Day
Enhanced Recovery After Orthopaedic Surgery (ERAS) Study Day
Safer Journey, Speedy Recovery
Date: Wednesday, 24th April 2013
Date: Wednesday, 24th April 2013
Safer Journey, Speedy Recovery
Venue: ERMEC, Hull Royal Infirmary, HU3 2JZ
Venue: ERMEC, Hull Royal Infirmary, HU3 2JZ
AAGBI
Open to All Anaesthetists, Orthopaedic Surgeons,
Nurses,
Physiotherapists
and
Venue: ERMEC,
Hull Royal Infirmary,
HU3Managers
2JZ
OpenDate:
to All Anaesthetists,
Orthopaedic
Surgeons,
Nurses, Physiotherapists and Managers
Wednesday,
24th April
2013
Programme
5 CPD points
ENDURA ROAD JERSEY
Open to All Anaesthetists, Orthopaedic Surgeons, Nurses,
Physiotherapists
approved
by RCOA and Managers
Programme
•and NHS
ERASandNHScommissioning
ERAS
commissioning
• in
ChallengesinSurgicalField:Surgeon’svisionforERAS
Challenges
Surgical Field: Surgeon's vision for ERAS
Programme
Theanaesthetist:lostcolleagueorcentralplayer
The•
anaesthetist:
lost colleague or central player
The Prin Patient
e
l
a
c
S
a
m
o
C
y
t
e
Saf
Rate your manager’s/clinical head’s safety consciousness
Safety culture in complex organisations such as the NHS is an important subject. Classifying functional and dysfunctional managerial
attitudes to safety may help us understand why some organisations tend to learn from adverse events and improve while others do
noti,ii. This scale was developed in an attempt to make this concept a little more engaging and relevant to clinicians.
• riskReducingrisk-Prehabilitationandproperpre-assessment
Reducing
Prehabilitation and proper pre-assessment
ERAS
and NHS
•
SpinalPrilocaine;astepforwardforERASandLowerLimb
Spinal
Prilocaine;
a stepcommissioning
forward for ERAS and Lower Limb Orthopaedic Procedures
Stavros Prineas
The Prin Patient Safety Coma Scale Rate your manager’s/clinical head’s safety consciousness Obstacles
toOrthopaedicProcedures
Change
hurdlesField:
in setting
up the ERAS
practice
Challenges
inand
Surgical
Surgeon's
vision
for ERAS
ObstaclestoChangeandhurdlesinsettingupthe
Live•
Video-link
from theatres of Local Infiltration Techniques for Lower Limb Arthroplasty procedures.
The anaesthetist: lost colleague or central player
ERASpractice
Reducing
risk- Prehabilitation and proper pre-assessment
•
LiveVideo-linkfromtheatresofLocalInfiltration
SpinalTechniquesforLowerLimbArthroplastyprocedures.
Prilocaine; a step forward for ERAS and Lower Limb Orthopaedic Procedures
5 CPD points
Course Fees: £ 100 for Consultants, Specialty doctors and Managers
(‘afferent limb’) approved by
Obstacles
to Change and hurdles in setting
the ERAS
£ 75 forup
Trainees,
PA (A),practice
Nurses, Physiotherapists
RCOA
Course Fees: £100forConsultants,SpecialtydoctorsandManagers
Live
Video-link
from
theatres
of
Local
Infiltration
Techniques
for Lower Limb Arthroplasty procedures.
£75forTrainees,PA(A),Nurses,Physiotherapists
6 enquiries
should
be directed
to:Chatwin,
Jenny Chatwin,
ERAS
All All
enquiries
should
be directed
to: Jenny
ERAS lead,
Wardlead,
9, Castle Hill
Ward Hull,
9, Castle
Hospital, Hull, HU16 5JQ.
Hospital,
HU16Hill
5JQ.
NAME:
Telephone: 07879 638737
or
[email protected]
5 CPD points
Course Fees: £ 100 for Consultants, Specialty doctors and Managers
ADDRESS:
approved by
Telephone: 07879638737
£ 75 for Trainees, PA (A), Nurses, Physiotherapists
RCOA
Webpage:
www.hulleras.co.uk
5 Webpage: www.hulleras.co.uk
All enquiries should be directed to: Jenny Chatwin, ERAS lead, Ward 9, Castle Hill
Hospital, Hull, HU16 5JQ.
POSTCODE:
2013
Telephone: 07879638737
NATIONAL SCIENTIFIC
CONGRESS
OF THE
Webpage:
www.hulleras.co.uk
AUSTRALIAN SOCIETY
OF ANAESTHETISTS
4 EMAIL:
TEL:
MEN’S
3 WOMEN’S
SIZE REQUIRED:
XS
S
M
L
The NSC 2013 organising committee headed by
Drs Mark Skacel and Paul Burt have developed a
program that will appeal to a wide audience and further
explore how our understanding of the basic sciences
improves clinical outcomes for our patients.
XL
ONLY
includes a
£10 donation to
1 Saving lives through safer surgery
Payment can be made via PayPal to: [email protected]
or by cheque made payable to: Richard Griffiths
Please allow up to 12 weeks for your shirt to be delivered.
Please mail cheques with a completed order form to:
Dr Richard Griffiths, Michaelmas House, First Drift,
Wothorpe, Stamford, Lincolnshire, PE9 3JL
Australian Society of Anaesthetists
NSC AIC ADVERT 216x282.indd 1
2 £50
11/8/2012 11:00:30 AM
Best Verbal Response (‘central processing’) Best Motor Response (‘efferent limb’) Obeys Commands Champions global safety initiatives spontaneously N/A N/A N/A Oriented, converses normally Articulates a coherent proactive safety agenda Localises well to pain Initiates substantive safety efforts in response to adverse events Utters inappropriate words Blames and shames Decorticate response Takes punitive action; ‘performance-‐manages’ all adverse events Opens eyes spontaneously Proactively seeks out and elicits safety relevant information Confused, disoriented Articulates an inconsistent or incomplete safety agenda Open eyes to pain Only investigates serious (‘sentinel’) adverse events Makes incomprehensible sounds Grunts or changes subject Opens eyes to voice Investigates whenever safety concerns /near misses are presented No response No adverse event reporting system in place Makes no sounds Ignores /eschews safety discussions Localises vaguely to pain Makes ‘band-‐aid’ repairs in response to adverse events Decerebrate response Takes purposeless action e.g. ‘be more careful‘ memos No response Takes no action Score 13-‐15 – Safety-‐Conscious Manager/Clinician ✃
Special areas of interest will include neuroscience and
consciousness, fluid therapy, and outcomes for the high
risk surgical patient.
Invited Speakers include
Professor Martin Smith
Queens Square London
Professor Colin Mackenzie
University of Maryland, Baltimore
Professor Mike Grocott
University of Southampton
Professor Tony Quaill
Newcastle University, NSW
Best Eye Response Score 13-15
Safety-Conscious
Manager/Clinician
Score 9-12
Impaired Safety
Consciousness
Score 3-8
Safety Coma
(Intubate Immediately)
©Stavros Prineas
References:
Score -‐12 Organizational
– Impaired Safety Consciousness i Westrum, R. & Adamski,
A.J. 9
(1999)
Factors
Associated
with Safety and Mission Success in Aviation Environments. In D.J. Garland,
J.A. Wise & V.D.Hopkin (Eds.) Handbook of Aviation HumanFactors. Lawrence Erlbaum, Mahwah, NJ.
Score 3-‐8 – Safety Coma (Intubate Immediately) ii Hudson, P. (1999) Safety Culture – Theory and Practice. Accessible at http://ftp.rta.nato.int/public//PubFulltext/RTO/MP/RTO-MP-032///
MP-032-08.pdf (accessed 03.01.2013)
25 Support & Wellbeing Committee
what do we do?
We all know that, when we work with a good team in an organisation that values and respects us, we
provide better quality care. There is much management literature to confirm thisi. NHS organisations
that pay attention to the wellbeing of staff deliver higher quality of care, make better use of resources,
have lower patient mortality and have more satisfied patientsii. The Support and Wellbeing committee
aims to help AAGBI members to make this a practical reality wherever they work.
What Committee do you Chair?
What were your three biggest achievements from last year?
I chair the Support & Wellbeing committee. We encourage all
members to regard their own wellbeing and that of colleagues as
an important priority and to provide practical support and resources
for individuals and departments. There are four components to
wellbeing: a good working environment and work arrangements,
support for staff to maintain good physical and mental health, good
working relationships and good personal supportiii.
Establishing the opportunity to have a ‘taster’ mentoring session with
a trained experienced mentor at the annual congress, GAT and Winter
Scientific meetings. Mentoring is a practical way to work out how
to take advantage of opportunities, manage dilemmas or overcome
problems. A conversation with a mentor gives you the confidence
to have a go, strategies to tackle the situation and a realistic plan of
action. A team of trained mentors, anaesthetists from different parts
of the UK who have completed a full skills development programme,
offered the opportunity to try mentoring at the GAT meeting in
Glasgow. These were a great successiv; mentoring ‘taster’ sessions
will be offered again at GAT and at the Winter Scientific meeting.
Elected council members
• Val Bythell – Vice president (experience of trainee issues as
Programme Director)
• Sarah Gibb – GAT member (experience of flexible training &
balancing work & family)
• Felicity Plaat – Hon Membership secretary elect (experience
Past Chair of Wellbeing + Vice Chair of Trust Clinical Ethics
Committee)
• Paul Clyburn – Hon Treasurer (experience of managing
Department as Clinical Director)
• Iain Wilson – Immediate Past President (experience as Medical
Director & AAGBI president)
• Andrew Hartle - Immediate Past Hon Secretary (expertise in
ethical issues, working with media)
• Rachel Collis – AAGBI Council Member
• Steve Yentis – Editor Anaesthesia
• Abhiram Mallick - AAGBI Council Member
• Isabeau walker – Hon Membership Secretary
• Richard Griffiths – Hon Secretary
• William Harrop Griffiths – President
Co-opted members
• Ruth Mayall – expert on recognition management and support
of addicted doctors, councellor doctors4 doctors
• Mike Peters – BMA (Head of BMA Doctors for Doctors Unit.
Responsible for provision of BMA Counselling. Acting Chair UK
Association for Physician Health))
• Richard Marks – RcoA (founder member of Remedy which drew
attention to the difficulties trainees faced with MMC; experience
of working with the media)
Staff members
• Christine Tabano - AAGBI Secretariat
• Karin Pappenheim – AAGBI Executive Director
26 All enquiries to the Support & Wellbeing committee were analysed,
and common themes identified. These are being used to inform the
development of ‘Ask AAGBI’ as a service to members.
An excellent 24 hour counselling service is offered to all doctors
through ‘doctors4doctors’. However, some people want more
practical help. Felicity Plaat, who chaired the committee last year, and
Karin Pappenheim, (AAGBI Executive Director) are investigating the
possibility of offering AAGBI members a bespoke phone line service
which might, for example, including access to an expert Occupational
Physician or legal advisor and to an industrial relations officer, as well
as to the telephone counselling service.
What current challenges are you facing?
The main challenge is changing attitudes. Support and Wellbeing
has been seen as a service vital to a small number of members
who are facing difficulties. In reality, good working relationships
and good support are fundamental to everyone’s practice; the
Francis Report on Mid Stafford shows what happens when things go
wrongv. We are good at spotting the ‘dysfunctional department’ or
the ‘difficult colleague’. We should recognise that this is a colleague
or a department in difficulty – good people, doing their best under
circumstances that don’t suit them. What we need are the skills,
confidence and motivation to raise concerns and to change the
culture to one that is effective and fun to work in.
But changing culture takes time and effort. People need leadership
and change management skills, and the bravery to have a go.
Anaesthetists are well placed to do this; good departments have a
powerful voice in a Trust, individuals are skilled at negotiating and
influencing surgical colleagues. The challenge for the Support and
Wellbeing Committee is not only to provide practical support to those of us
who find ourselves in difficult circumstances, but also to provide the range
of practical skills development, tools and techniques so everyone feels
able to contribute – to raise concerns, to make changes and to champion
good organisational culture. This should be everyone’s agenda.
AAGBI COUNCIL
ELECTIONS 2013
What are your priorities for the coming year?
Creating a healthy workplace and a good organisational culture that
supports the wellbeing of all staff, involves all of us, whatever our position
in an organisation. The Support and Wellbeing Committee is looking into
how best the AAGBI can support members with resources to help them
achieve this – information, a network of contacts, training opportunities for
those managing change or intending to take up leadership roles.
1.
2.
3.
Establish a mentor development programme for AAGBI members to
train as mentors. We hope this will attract members from throughout
the UK, hence developing a scheme that makes mentors available
to members, wherever we work.
To make ‘ASK AAGBI’ into a significant membership benefit, visible,
relevant and well-used by all members. We aim to develop the AAGBI
website so as to signpost useful articles and information on different
aspects of wellbeing. This will include topics such as negotiating
and leadership as well as practical advice such as how to achieve a
good work-life balance, and returning to work after maternity leave or
illness. If you find something useful that you think we should include,
please contact us via [email protected]. Council members are
working on two ‘glossies’ relevant to anaesthetists’ wellbeing. The
Occupational Physician and the Anaesthetist will be ready later this
year and the Good Department Guide is due out in 2014.
To include a session or workshop on an aspect of wellbeing,
leadership development and support at all AAGBI national scientific
meetings, and to run some seminars at 21 Portland Place on relevant
topics. If you have something you would like to contribute, please
[email protected].
We’d like to hear your views: the committee is conducting a survey to
find out more about members’ needs and preferences in terms of
wellbeing and support Information will be available on our website shortly:
www.aagbi.org/professionals/welfare
Dr Nancy Redfern
Chair of the Support and Wellbeing Committee
References
i Boorman S NHS Health and Wellbeing: Final report November 2009, Department of Health
ii West M, Dawson J, Admasachew L and Topakas A. NHS Staff Management and Health Service
Quality August 2012 Department of Health
iii Harrison J. Orchestrating the health and wellbeing of doctors Occupational Health (at work) June /July 2011 pp 14 -17
iv Aiming higher at GAT: success of mentoring sessions. Anaesthesia News No 302 Sept 2012 pp 20-21
v Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009 London: The StationeryOffice Crown Copyright http://www.midstaffsinquiry.com/assets/docs/Inquiry_
Report-Vol1.pdf
CALL FOR
NOMINATIONS
Nominations are now
invited from members of
the Association wishing
to stand for election.
Further information and nomination
forms are available from Gemma
Campbell on 020 7631 8855,
[email protected]
or can be downloaded from
the AAGBI website
www.aagbi.org/about-us/council
Closing date – Friday 12 April 2013
27 West of Scotland Subcommittee in Anaesthesia
ANAESTHETICS STUDY
DAY: UPDATE FROM THE
Nicola Heard
INSTITUTE: NEURO AND Educational Events Manager
Direct Line: +44 (0) 20 7631 8805
TRAVEL GRANTS/IRC FUNDING
AIRWAY TIPS FOR THE
GENERALISTThe Association of Anaesthetists
of Great Britain & Ireland
T: +44 (0) 20 7631 1650
19-21 Relations
Sept 2012Committee
The International
(IRC) offers travel grants to members who
are seeking funding to work, or to deliver
educational training courses or conferences,
in low and middle-income countries.
ANNUAL CONGRESS
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Thursday 16 May 2013
Venue: Kelvin Conference Centre, w: www.aagbi.org
West of Scotland Science Park, Glasgow
BOURNEMOUTH
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REGISTRATION
FEE: International
£75
attendance at congresses or meetings of learned societies.
Bournemouth
Centre
THIS STUDY DAY CARRIES 5 CME POINTS
Application
This year’s Annual Congress comes to one of England’s
forms
further
information
from:
mostand
vibrant
and cosmopolitan
seaside
resorts.
Miss Lillian Cumming
Administrative Assistant (Courses)
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3rd Floor, 2 Central Quay
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Lecture
topicsG3
include:
Exceptionally, they may be granted for extension of travel in
association with such a post or meeting. Applicants should
indicate their level of experience and expected benefits to be
gained from their visits, over and above the educational value
to the applicants themselves.
Bournemouth has seven miles
of beaches, award winning
gardens and a vast variety of
shops, restaurants and bars.
For further information and an application form
please visit our website:
Scientific programme
http://www.aagbi.org/international/irc-fundingtravel-grants
Multiple streams of lectures
•
National
Audits
(including
NAP5)
•
The
older
patient
or
email
[email protected]
Debates
Telephone: 0141 223 1504
Hands-on workshops
• Pain management • Shared decision making in high risk surgical patient
or telephone
020 7631 8807
223 1480
•Fax:
Law 0141
and Ethics
• Obstetrics • Revalidation • Papers you should know about
• Wellbeing • Problem-based learning and Critical Incident case reports
• Plus sessions organised by the Association of Surgeons of Great Britain
and Ireland (ASGBI) and the British Geriatric Society
Industry exhibition
Poster and abstract presentations
Closing
date:0128March
May 2013
Closing
date:
2013
CPD approved
www.annualcongress.org
2013
AC-FutureLocations.indd 1
AC 2013 Advert.indd 1
A summary of recently issued guidelines
Awareness is a topical subject at the moment with the ongoing National Audit Project on accidental
awareness. In November, NICE issued guidelines for use of depth of anaesthesia monitors, focusing on
three models in particular: E-Entropy, Narcotrend-compact M and the Bispectral index (BIS) monitor.
The guideline begins by describing the three EEG-based depth of anaesthesia monitors and states that they
are all broadly equivalent. It is added that there is greater uncertainty of clinical benefit for the E-Entropy
and Narcotrend monitors compared to BIS but that they are all still recommended as option
At-risk groups
The monitors are recommended as options, but not mandatory, for two main groups
undergoing any type of general anaesthesia. Firstly, those at risk of awareness
during GA and secondly those at risk from excessively deep levels of anaesthesia.
Those patients at risk of awareness are listed as those with high opiate or alcohol
use, airway problems, previous awareness experience and anaesthesia with
muscle relaxants. Also included are those undergoing obstetric, cardiac, airway or
emergency trauma surgery for the reason that lower levels of anaesthesia may be
used due to the greater risk of haemodynamic instability.
Total intravenous anaesthesia
SAVE THE DATE! 18-20 SEPTEMBER 2013
www.annualcongress.org
Depth of Anaesthesia Monitors:
The latter group is classified as the elderly, patients with liver disease, high BMI
and those with poor cardiovascular function. The reason for their recommendation
is that an excessively deep level of anaesthesia is linked to adverse postoperative
outcomes such as prolonged recovery, MI, stroke and cognitive dysfunction.
Annual dinner and dance
DUBLIN
Guideline Update
NICE guideline DG6 (November 2012)
E-Entropy
Combines EEG and scalp
electromyography
Output is two readings:
Response entropy (RE) and State
entropy (SE).
Both have target ranges 40 to 60.
Narcotrend-Compact M
With regards to TIVA, again a depth of anaesthesia monitor is ‘recommended as an
option’ but is not mandatory. The reason given for recommendation is that an endtidal anaesthetic concentration cannot be measured and because it is cost effective
to use. Of the evidence that NICE examined, TIVA was found not to put patients at
higher risk of adverse outcomes relative to volatile maintenance.
Uses spectral analysis to analyse EEG
Output is EEG index between 100
(awake) and 0.
Evidence based guidance
BIS
NICE state that the advice they issue is based upon systematic review of the evidence
currently available. However it is stressed that despite many studies there is still
uncertainty to the extent to which the monitors actually reduce adverse outcomes.
EEG analyser
Produces a number between 100
(wide awake) and 0.
Target range 40 to 60.
In summary, NICE has given the green light to the option of using depth of anaesthesia
monitors in high risk patients but they are a still not a mandatory requirement.
19/03/2012 10:34
Dr William J Packer
Welsh Deanery
SAVE THE DATE
18-20 SEPT 2013
References
http://guidance.nice.org.uk/DG6
http://guidance.nice.org.uk/DG6/Guidance/pdf/English
09/01/2013 09:46
29 CORE
AAGBI 2013
The Association of Anaesthetists of Great Britain & Ireland
TOPICS
Dublin 08 February
@AAGBI
recap
Last chance to book for the GAT
Annual Scientific Meeting 3-5 April
2013, Oxford
Exclusive new AAGBI membership
benefit. Discount on FRCAQ.com
and 30% off all Cambridge
University Press books!
AAGBI members are entitled to significant discounts on access
to the FRCAQ.com website. FRCAQ.com is an online self-testing
website for both Primary and Final FRCA examinations. Now with
over 4,000 questions in SBA and MTF formats, these sites allow
you to tailor revision to your specific needs, as well as providing
you with expanded notes and explanations as a background to
each answer.
Liverpool 22 February
Newcastle12 March
Cambridge 22 March
This is the last month for trainees to book their study leave for the
GAT Annual Scientific Meeting. The registration fee is just £195 for the
entire three day meeting and preferential rates have been negotiated
for accommodation at halls of residence to keep the costs down.
Exeter 26 April
Belfast 14 June
www.gatasm.org
AAGBI members are also now entitled to receive a 30%
discount off the retail price on all Cambridge University
Press print books.
www.aagbi.org/about-us/becoming-amember/member-benefits/cambridgeuniversity-press
Manchester (2 Day) 28 & 29 June
Latest safety updates
Leeds 12 July
View the latest safety updates and Medical
Device Alerts on the AAGBI website
Nottingham 27 September
www.aagbi.org/safety/incidents-and-alerts
Birmingham 18 October
Glasgow 01 November
For breaking news and
event information follow
@AAGBI on Twitter
Cardiff 22 November
GAT Committee & RCoA Trainee
Committee workforce planning
survey results
The joint survey results regarding the ‘Shape of the Medical
Workforce’ paper are now available. The survey asked both
anaesthetic trainees and those anaesthetists within 5 years of CCT
about potential ways they would like to work in the future, as it is
believed that any prospective changes would primarily affect these
two groups.
www.aagbi.org/professionals/trainees/
gat-news
London (2 Day) 29 & 30 November
For further information and prices please visit:
www.aagbi.org/education
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CoreTopics2013.indd 1
18/12/2012 09:29
31 Anaesthesia News
Anaesthesia News now reaches
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21 PORTLAND PLACE
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Room Hire & Private Dining
I was recently on call at our maternity unit. As is our normal practise I
went to the fridge in theatre to refresh the previous 24 hours’ emergency
drugs. On removing the tray I found that the sodium thiopentone was
frozen solid. It appeared at a glance yellow in colour, and the outer
syringe chilled as it would normally.
On reviewing the maximum and minimum temperature over the
preceding 12 hours from the refrigerator temperature gauge, I found it
had reached as low as minus 3 degrees. This is 5 degrees lower than that
recommended by local and national guidelines.
After a brief further investigation (looking at the previous months recording
on the ‘fridge temperature chart) I found that this range of temperature
readings had been a frequent occurrence. These reading had also been
reported to our Estates department on numerous occasions, without
examination or indeed replacement of the faulty equipment.
This represented a significant clinical risk, and prompted our immediate
action and replacement of the faulty fridge.
Dear Editor,
We’d like to report what we believe to be a
small but useful innovation in the practical
aspects of performing an epidural blood
patch (EBP).
The performance of an EBP has many important steps. These
include deciding when and on whom to perform the procedure,
accurately identifying the epidural space and finally the blood
sampling. In the author’s experience, the sampling of blood can
occasionally be a challenge, especially for those women unlucky
enough to have been in hospital for a few days having repeated
venepuncture. There is also the need for continued secure i.v.
access during the procedure, together with the pressure of having
to sample blood after the epidural space has been identified by the
other operator. We have adapted a common piece of anaesthetic
equipment – the FloSwitch™ Arterial Cannula Becton Dickinson
Critical care Systems Pte Ltd, Singapore – for use during EBP of
late. We feel it has many advantages over the traditional ‘cannula
in the back of the hand, and a green needle in the antecubital
fossa’ technique. Venepunture and i.v. access are performed at the
beginning of the procedure, with no pressure of time. Only one
stab is required, as the cannula stays in situ during and after the
procedure. There is no wait for blood after the epidural space has
been located. Following positioning the patient in the left lateral
position, the arterial cannula is aseptically placed into a vein
in the left antecubital fossa. The tourniquet is then loosened (by
an assistant); the cannula flushed with 0.9% saline and switched
off. Once the epidural space had been identified, the tourniquet
is tightened, the cannula switched on and blood aspirated from
the line. In our experience, the use of the FloSwitch for EBP has
lead to a smoother and slicker procedure – better for the patient
and both anaesthetists involved.
Dr Victoria Duffin-Jones
ST4 Anaesthesia, Royal Gwent Hospital, Newport
Dr Matt Turner
Consultant Anaesthetist, Royal Gwent Hospital, Newport
Dear Editor,
The death of atracurium?
With the advent of sugammadex, an effective and rapidly acting
reversal agent for rocuronium1, we postulate that the future use of
atracurium in routine practice will need justification. If a “can’t
intubate, can’t ventilate” (CICV) scenario in which atracurium
was used resulted in death or injury, the prosecuting counsel
might reasonably ask: “Why use a muscle relaxant with no
immediate reversal agent when one with such a reversal agent
is readily available?” Several case reports now exist detailing
the successful use of sugammadex in the reversal of such a
scenario.2,3
We believe the future role of atracurium should be limited to
specific indications such as renal or hepatic impairment.
For availability or to make a booking, please contact our Facilities Manager
on 020 7631 8809 or email [email protected]
www.aagbi.org/about-us/venue-hire
John Rae (CT2)
Ken Barker (Consultant)
I write to urge fellow anaesthetists to remain vigilant when discovering
something as seemingly unimportant, and to take responsibility for the
upkeep and repair of important equipment, aside from the obvious such
as an anaesthetic machine or monitoring equipment.
Dr Elizabeth Beattie
ST3 Anaesthetics, West of Scotland
Raigmore Hospital, Inverness
1.
Abrishami A, Ho J, Wong J, Yin L, Chung F. Sugammadex, a selective reversal medication
for preventing postoperative residual neuromuscular blockade. Cochrane Database of
Systematic Reviews 2009, Issue 4. Art. No.: CD007362.
2.
Desforges JC, McDonnell NJ. Sugammadex in the management of a failed intubation in a
morbidly obese patient. Anaesth Intensive Care. 2011;39(4):763–764
3.
Calixto, L.; Almeida, A. ‘Can’t intubate, can’t ventilate’: the use of sugammadex as a rescue
technique : a case report: 19AP38. European Journal of Anaesthesiology. 2012;29:234
33 Particles
West CR, Romer LM and Krassioukov A.
Merry AF, Webster CS, Hannam J et al
Freeman B and Morris P
Autonomic Function and Exercise Performance in
Elite Athletes with Cervical Spinal Cord Injury.
Multimodal system designed to reduce errors
in recording and administration of drugs in
anaesthesia: prospective randomised clinical
evaluation
Tracheostomy practice in adults with acute
respiratory failure
Medicine and Science in Sports and Exercise 2012, August 20.
Introduction
The London Paralympics 2012 proved to be the most popular to date with Channel 4 coverage
reaching 39.9 million people in the UK1. Of the sports, wheelchair rugby- also known as
‘murderball’ due to its ferocious nature- attracted a peak audience of 3.49 million2. Athletes
with tetraplegia or tetra-equivalent function are able to participate in the sport. The eligible
impairment of athletes for the sport is classified by the international wheelchair rugby federation
(IWRF). This encompasses motor and sensory function, and the functional ability of athletes .
Primarily designed for participants with cervical spinal cord injuries (SCI), wheelchair rugby has
attracted scientific interest with regards to the physiological responses of athletes to exercise.
Individuals with complete cervical SCI experience autonomic dysfunction secondary to loss of
tonic supra-spinal sympathetic control. Cardiovascularly, they are not expected to achieve the
exercise-induced tachycardia seen in uninjured individuals. However, unpublished data by the
authors has seen cervical SCI athletes with heart rates exceeding 120 beats per minute (BPM)
during exercise.
Aim
The purpose of this research was two-fold. Firstly, to determine the physiological basis of
exercise induced tachycardia in athletes with cervical cord injuries; secondly to investigating
the associations between autonomic function, IWRF classification, and indices of exercise
performance in athletes3.
Methods
Following ethical approval seven male wheelchair rugby players with motor complete cervical
SCI (C6-C7) were classified according to the IWRF classification (seven point scoring system;
0.5= least function to 3.5= most function). Autonomic function was assessed by recording
sympathetic skin response (SSR) to electrical stimulation of the median nerve at the wrist in
both hands and feet. Five recordings were taken at each site. Responses were quantified
by the number of SSRs elicited at each site. Cardiovascular function was assessed by a sit
up tilt test. Blood pressure measurements were taken in a supine position and then upright
seated position. Orthostatic hypotension was defined as a systolic drop in blood pressure of
20 mmHg on assuming upright position. Indices of exercise performance were assessed by
measuring peak heart rate (HRpeak) and distance covered during a field based 4-minute push
on a 140m straight track, and peak oxygen uptake (V02peak) and HRpeak during laboratory
based maximal incremental arm crank exercise. V02peak and HRpeak were defined as highest
V02 and heart rate averaged over a 30 second period.
Results
Four athletes scored a total of 2.5 on the IWRF classification system. A further two scored 2
and one athlete scored 1.
All athletes demonstrated an intact SSR (2.7± 1.2 responses), and little or no change in systolic
blood pressure in response to sit up tilt test ( -22 ±16 mmHg ).
All athletes exhibited an exercise induced tachycardia ( HRpeak 152 ±20 BPM). HR during field
activity exceeded that of laboratory based activity ( p<0.001)
Autonomic function (SSR) correlated with indices of exercise performance: HRpeak in field
activity, 4 minute push distance and V02peak ( p<0.001).
IWRF did not significantly correlate with indices of exercise performance: HRpeak in field
activity, 4 minute push distance and V02peak.
There was no association between average preservation of SSR and IWRF classification
(p=0.421).
Conclusion
The authors conclude that participants demonstrated partial preservation of descending
sympathetic control, and that SSR and not IWRF classification correlated with indices of
exercise performance in athletes. The authors expressed that intact sympathetic function
could impact on athletic performance, and that autonomic testing should be considered in the
classification process of athletes with SCI (above T6 level) as other studies have suggested4.
Discussion
These findings are at odds to that expected in cervical SCI. Further investigation would be
required to determine whether the results could be applied to a general population with cervical
SCI; this study was limited to only seven participants at athletic level performance. If such
physiological responses could be reproduced in non-athletic SCI patients it could prove of
relevance to the anaesthetist who understands the significance of autonomic changes in SCI.
Reet Nijjar
CT1 anaesthetics, Oxford Deanery
References
1.
Channel 4. (2012 ). Paralymics closing ceremony watched by 7.7 million on channel
4. Available: channel4.com/info/press/news. Last accessed 15th September 2012.
2.
Channel 4. (2012 ). Paralympic games 2012: swimming, athletics, wheelchair
basketball, and wheelchair rugby. Available: www.channel4sales.com. Last
accessed 15th September 2012.
3.
Ed: Hart A, Altmann V. (2011). IWRF classification maual. Available: www.iwrf.
com/?page=classification. Last accessed 15 September 2012.
4.
Mills PB, Krassioukov A. (2011). Autonomic function as a missing piece of the
classification of paralympic athletes with spinal cord injury. Spinal Cord. 49 (7),
768-76.
34 Anaesthesia News March 2013 • Issue 308
British Medical Journal 2011;343:d5543
Background
Iatrogenic harm is an important public health problem with high human and
financial costs.1,2 In anaesthesia, errors in drug administration are particularly
problematic, and ought to be preventable.3-7 This prospective randomised
open label clinical trial aimed to evaluate a new patented system (SAFERsleep)
designed to reduce errors in the recording and administration of anaesthesia.
The new system included the following elements:
•
Customised drug trays
•
Prefilled syringes, with individualised barcodes
•
Large legible colour coded drug labels
•
A barcode reader linked to a computer, speakers, and touch screen
to provide visual and auditory confirmation of drug choice before
administration.
•
Automatic compilation of an anaesthetic chart, printed at the end of
anaesthesia.
Methods
Data were collected from five designated operating theatres in Auckland
City Hospital between March 2008 and February 2009. A total of 1748 cases
were managed by eighty nine anaesthetists in which there were 10764
drug administrations. Theatres were randomised to either the new system
or conventional methods at the start of each week and remained so for the
duration of week. Primary endpoints were the number of errors in administration
and documentation of intravenous drugs, and vigilance lapses. The former
were detected by direct observation in theatre and comparison of recorded
administrations with contents of used drug vials. The latter were recorded by
documenting the interval between the illumination of an easily visible bright light
and acknowledgement by the anaesthetist. Secondary endpoints were outcomes
in patients; analysis of anaesthetist’s tasks and assessment of workload; legibility
of anaesthetic records; evaluation of compliance; and ratings of the respective
systems by the participants
Results
The mean rate of drug errors per 100 administrations was 9.1% (95% confidence
intervals 6.9 to 11.4) with the new system and 11.6% (9.3 to 13.9) with conventional
methods (P=0.045). Lapses in vigilance occurred in 12% (58/471) of cases with the
new system and 9% (40/473) with conventional methods (P=0.052). The records
generated with the new system were more legible, and anaesthetists preferred
the new system. There were no differences between the new and conventional
systems in respect of outcomes in patients or anaesthetists workload.
Conclusions
In this study the new system was associated with a reduction in errors in the
recording and administration of drugs in anaesthesia, attributable mainly to a
reduction in recording errors. Automatic compilation of the anaesthetic record
increased legibility but also increased lapses in vigilance latency and decreased
time spent watching monitors.
Strengths of the study include its prospective randomised nature, the use
of dedicated observers and the large numbers of anaesthetics observed.
Weaknesses included a lack of blinding and the fact that the “new” system had
been used for most anaesthetics at Auckland City Hospital for three years prior
to the trial; most anaesthetists were therefore more familiar with its use than
conventional methods.
Critical Care Medicine 2012; 40:2890-6
Tracheostomy in critical care promotes oral hygiene and pulmonary
toilet, enhances patient comfort, provides airway security, allows oral
nutrition and facilitates speech and communication. Tracheostomy
often reduces sedation requirement and has been postulated to
enhance weaning from mechanical ventilation.
Percutaneous dilational tracheostomy (PDT) or an open surgical
approach may be used. Evidence suggests that PDT is superior in
terms of convenience, speed of procedure, blood loss and infection.
PDT has become the predominant technique in many centres and in
appropriate patients should be the preferred technique. Important
caveats accompany this recommendation, however. PDT has been
associated with a significant number of highly morbid complications
that would be unusual with a surgical approach. Contraindications to
PDT include ambiguous surface anatomy, a clinically difficult airway and
the presence of an unstable cervical spine. It is suggested that experts
in surgical airway management should be immediately available in the
event of significant complications.
Three recent studies1,2,3 suggest that tracheostomy can be performed
safely in critically ill patients: no deaths or serious complications related
to tracheostomy placement were reported in over 1000 patients.
Timing of procedure had no effect on mortality, prevalence of ventilator
associated pneumonia or length of hospitalisation. Tracheostomy was
associated with greater comfort, decreased sedative and antipsychotic
medication and lower rates of unplanned extubation.
Tracheostomy potentially facilitates optimisation of critical care
resources by allowing transfer of patients requiring long term ventilation
to less resource intense settings. However these studies also confirm
how difficult it can be to predict the continued need for ventilation.
Around half of patients randomised to late tracheostomy in two of the
studies failed to undergo the procedure due to successful weaning
from ventilation or death in the time interval.
Dr Jonathan Price
North Central London School of Anaesthesia
References
1.
Terragni PP, Antonelli M, Fumagalli R, et al: Early vs late tracheotomy
for prevention of pneumonia in mechanically ventilated adult ICU
patients: A randomized controlled trial. JAMA 2010; 303:1483–1489
2.
Trouillet JL, Luyt CE, Guiguet M, et al: Early percutaneous
tracheotomy versus prolonged intubation of mechanically ventilated
patients after cardiac surgery: A randomized trial. Ann Intern Med
2011; 154:373–383
3.
Young D: Early tracheostomy reduces sedative use but does not
affect mortality: Presented at ISICEM. 29th International Symposium
on Intensive Care and Emergency Medicine. 2009. Ref Type: Abstract
Dr Stephen Mowat
CT2 Anaesthesia, Northern Deanery
References
1.
Department of Health. An organisation with a memory—report of an expert
group on learning from adverse events in the NHS. Stationery Office, 2000.
2.
Institute of Medicine. To err is human: building a safer health system.
National Academy Press, 2000.
3.
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency
and nature of drug administration error during anaesthesia. Anaesth
Intensive Care 2001;29:494-500.
4.
Abeysekera A, Bergman IJ, Kluger MT, Short TG. Drug error in anaesthetic
practice: a review of 896 reports from the Australian incident monitoring
study database. Anaesthesia 2005;60:220-7
5.
Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law.
N Z Med J 1995;108:185-7.
6.
Merry AF, Weller JM, Robinson BJ, Warman GR, Davies E, Shaw J, et
al. A simulation design for research evaluating safety innovations in
anaesthesia. Anaesthesia 2008;63:1349-57.
7.
Webster CS. The iatrogenic-harm cost equation and new technology.
Anaesthesia 2005;60:843-6.
35 3
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esthetists in Traini
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Prizes include:
Workshops include:
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Interactive lectures include:
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