A case for ‘doing it in theatre’

Correspondence

Global performance measuresin intensive care

I welcomed the paper (Leary et al.

Anaesthesia 2002; 57: 751–5) regarding

the use of NHS Modernisation Agency

Global Measures to compare the per-

formance of Intensive Care Units in

different hospitals. I have been using a

similar approach since 1998 to compare

the year on year performance of the

Intensive Care Unit at Burnley.

The difficulty with all service depart-

ments is choosing measurable parame-

ters that are easily collectable,

reproducible and verifiable; but which

also reflect the daily functioning of the

service as a whole. It is certainly valid

to use the ‘Global Measures’ to achieve

this as they are reported back to the

Department of Health for just this

purpose. However, it can be argued

that the measures do not reflect the way

in which the unit is actually functioning.

The graphs in Ridley’s study therefore

illustrate how well the units are meeting

Modernisation Agency targets, not their

actual performance.

It is essential to choose performance

measures that can be assumed to have

some kind of target to which the unit in

question can be compared. At Burnley,

we have used measures that can be

obtained both locally, and from data

collected and verified by outside agen-

cies. Table 1 illustrates the data used for

this purpose. The percentage of ITU

sessions scheduled to be part of a con-

sultant’s job plan (x%) can be used as a

proxy for the general quality of the

service, on the grounds that a consultant

should bring greater experience and

attention to detail to the medical cover

than any type of junior or trainee grade.

If a target of 100% is chosen as the ideal,

the ratio x ⁄ 100 will allow progress

towards the target to be assessed., Simi-

larly, a unit that is functioning well will

only ever transfer ITU patients for

expert management, or for repatriation

back to the referring unit. Expressing

expert ⁄ repatriation transfers as a pro-

portion of total transfers allows us to see

how close we are to achieving this ideal.

If 100% of transfers were of this type, the

figure would be 1. If 50% of transfers

were for this reason, the figure would be

0.5, and so on. In the north-west, this

data is collected by the Intensive Care

Bed Information Service (ICBIS), an

independent body based in Manchester.

Capacity information is also collected by

ICBIS, who contact units daily, asking

about bed state, cancellations and trans-

fers. The percentage of times that the

unit declared that no beds were available

when contacted can be used as a crude

measure of total capacity. This is not

based upon accepted definitions of oc-

cupancy. However, it is collected, proc-

essed and verified by an independent

body, and can therefore be assumed to

be reliable. The figures used are the

average of a year’s data. In ideal condi-

tions, an ITU would never reach 100%

occupancy at any time, as this would

allow it the capacity to deal with unex-

pected emergencies, and to ensure that it

would never transfer a patient due to

lack of capacity. The Fig. 1 ) (x ⁄ 100)

will allow us to see how close we are to

reaching this target. If average occu-

pancy for the year is 100%, the figure

arrived at is 0; if it is 50%, 0.5. Another

indication of capacity is the time of

discharge. A unit with adequate capa-

city should not be discharging patients

earlier than necessary to make room for

emergency admissions. If we make the

assumption that discharges from ITU

between the hours of midnight and

08 : 00 occur for this reason, we can

adapt this figure for plotting on a radar

chart in the same way. Patient readmis-

sion rates could be assumed to be

determined by the way in which the

unit functions. In fact, we have found

this not to be the case, the number of

readmissions per annum remaining

between 4% and 6% of total admissions.

However, after establishment of an

outreach service, we found that the

level of dependency of the patients

readmitted was reduced. Therefore, it

is more likely that the number of

readmissions who return to the unit

with level 3 dependency is a better

indicator of the quality and range of

care and services available to patients.

Expressing the number of level 3 read-

missions as a percentage of total read-

missions gives a ratio, x. If all admissions

were level 3, the number 1 – x would

be 0; if half were level 3 dependency,

the figure would be 0.5. Finally, an

ideal ITU should be able to function

without turning away those patients

having elective surgery who require its

services. The target to be achieved in

this case can be expressed as (number of

elective operations cancelled due to no

ITU bed ⁄ total annual elective admis-

sions) ¼ x. Number 1 ) x can be

All correspondence should be addressed to Professor M. Harmer, Editor of Anaesthesia, Department of Anaesthetics, University of

Wales College of Medicine, Heath Park, Cardiff CF14 4XN UK.

Letters (two copies) must be typewritten on one side of the paper only and double spaced with wide margins. In addition, please

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must follow the advice about references and other matters contained in the Notice to Contributors to Anaesthesia printed at the back

of each issue. The degree and diploma of each author must be given in a covering letter personally signed by all the authors.

Correspondence presented in any other style or format may be the subject of considerable delay and may be returned to the author for

revision. If the letter comments on a published article in Anaesthesia, please send three copies; otherwise two copies of your letter will suffice.

Anaesthesia, 2003, 58, pages 84–105.....................................................................................................................................................................................................................

84 � 2003 Blackwell Publishing Ltd

Figure 1 Burnley Intensive Care UnitGlobal Performance Charts 1998–2001.

Anaesthesia, 2003, 58, pages 84–105 Correspondence......................................................................................................................................................................................................................

� 2003 Blackwell Publishing Ltd 85

plotted on the graph easily. It is possible

that other clinicians have found that

different parameters reflect more accu-

rately the performance of their own

departments. However, data like that

described above, expressed in appropri-

ate graphical form, has been successfully

used to assist in the planning of service

provision at Burnley Healthcare NHS

Trust, reflecting as they do, the global

performance of the department.

J. C. Watts

Burnley Health Care Trust

Burnley BB10 2 PQ, UK

A reply

Thank you for the opportunity to reply to

Dr Watts’ comments on our paper. We

are encouraged to see that Dr Watts has

also found radar charts useful in quanti-

fying critical care performance. As we

clearly stated in our discussion, the

parameters chosen and theorder inwhich

they are displayed will affect the area of

the central polygon. The performance of

critical care is a multidimensional con-

cept reflecting the range and depth of

support and care provided. Formally

measuring the calibration and validity of

any parameters purporting to assess crit-

ical care performance will be a difficult

task. However, it would appear that from

ourownandDrWatts’ experience,graphical

representation using radar charts may be a

method worthy of further exploration.

T. Leary

S. Ridley

Norfolk & Norwich University

NHS Trust

Norwich NR4 7UY, UK

Magnetic resonance compatibleequipment: read the smallprint!

An anaesthetic monitor was recently

acquired for use in the magnetic reson-

ance (MR) unit of our hospital to

comply with current standards including

inspired oxygen concentration and agent

monitoring. While being moved from

the stored position to an operational

position within the scanning room, the

monitor was rapidly attracted towards

the bore of the 1.5 Tesla (T) magnet.

The monitor, which weighs 25 kg and

measures 45 cm · 35 cm 45 cm, be-

came wedged in the mouth of the

magnet. The force of attraction was

such that five personnel were required to

extract the monitor from the magnet. It

was difficult to get adequate purchase,

and therefore traction, due to the sharp

edges of the monitor. Inserting a sheet of

bed linen around the monitor and

pulling the sheet, while supporting the

monitor as it left the force of attraction

of the magnetic field, facilitated this

process. Thankfully, no patient was

involved in this incident.

In retrospect, the user’s manual that

accompanied the monitor was consul-

ted. The section entitled General Warn-

ings and Precautions states that the

monitor must be installed in the area

around the magnet where the fringe

magnetic field is less than or equal to 40

mT. The manual advises users to mark

the 40 mT limit on the floor surround-

ing the magnet.

The definition of MR compatibility,

as contained in the recent guidelines

from the Association of Anaesthetists

[1], makes no mention of inherent

ferromagnetic properties. Equipment is

designated MR compatible if it presents

no safety hazard, functions normally and

does not interfere with the scan

PROVIDING INSTRUCTIONS

CONCERNING ITS PROPER USE

ARE CORRECTLY FOLLOWED.

Although we may be criticised for

not having read the user’s manual in its

entirety, it must be pointed out that at

no time during the demonstration of

the monitor or during its installation

was this extremely dangerous scenario

brought to our attention.

In an attempt to prevent a recur-

rence, all appropriate staff have been

made aware of this incident and a red

line has been marked on the floor to

indicate the 40 mT limit. The line is

75 cm from the structure of the magnet.

Consideration is being given to anchor-

ing the monitor in such a way that there

is no possibility of it coming too close to

the magnet.

It is obvious that as stronger magnets

become commercially available, so the

compatibility of equipment will need to

be reviewed. A less obvious fact is that

newer magnets are smaller in size and

have better shielding. The rate of

change of the fringe magnetic field in

proximity to the magnet is affected by

the shielding of the magnet, so newer

magnets with improved shielding may

have a more rapid increase in field

strength close to the magnet aperture.

Therefore, it is possible to take objects

closer to the magnet before they are

attracted.

As fatal accidents have been reported

as a result of the projectile effect of

Table 1 Burnley Intensive Care Unit Performance Data.

Source 1997 1998 1999 2000 2001Sessions covered by consultant unit data 50 50 70 86 93Expert ⁄ repatriation transfers ICBIS 15 24 39 74Times when unit ‘full’ ICBIS 63.5 68.5 63.5 36.75Non admitted elective as percentage all elective unit data 17 0 0 11Discharge 00 : 00–08 : 00 ICNARC 6 6 8All figures are percentagesAfter adaption for plotting on graph

adaption Code 1998 1999 2000 2001Sessions covered by consultant x ⁄ 100 A 0.5 0.7 0.86 0.93Expert ⁄ repatriation transfers x ⁄ 100 B 0.15 0.24 0.39 0.74Times when unit ‘full’ 1 ) x C 0.365 0.315 0.365 0.633Non admitted elective as percentage all elective 1 ) x D 0.83 1 1 0.89Discharge 00 : 00–08 : 00 1 ) x E 0.94 0.94 0.92

Correspondence Anaesthesia, 2003, 58, pages 84–105......................................................................................................................................................................................................................


cylinders in MR units [2], it is imper-

ative that all staff understand the precise

limitations for the use of equipment. If a

patient had been harmed by this inci-

dent, it is clear that we would have faced

potential liability had a case ensued.

During the demonstration of new

equipment prior to purchase, and the

subsequent training process, manufac-

turers should ensure that all appropriate

staff are aware of any potential hazard.

The need to mark safety limits on the

floor cannot be over emphasised.

P. Farling

M. E. McBrien

Royal Victoria Hospital,

Belfast BT12 6BA, UK,

E-mail: [email protected]

R. J. Winder

University of Ulster,

Newtownabbey BT37 0QB, UK

References1 Provision of Anaesthetic Services in Mag-

netic Resonance Units. The Association

of Anaesthetists of Great Britain and

Ireland 2002.

2 Chaljub G, Kramer LA, Johnson RF,

Johnson RF, Singh H, Crow W. Pro-

jectile cylinder accidents resulting from

the presence of ferromagnetic nitrous

oxide or oxygen tanks in the MR suite.

American Journal of Roentgenology 2001;

177: 27–30.

Immediate postanaestheticrecovery

I have just read ‘Immediate Postanaes-

thetic Recovery’ [1]. Unfortunately it

fails to recognise the role recovery areas

can and do play in the care of critically ill

postoperative patients. ‘Comprehensive

Critical Care’ [2] recognised that each

trust would have to review its provision

of post anaesthesia care to ensure that

critically ill patients in recovery areas are

cared for appropriately within a com-

prehensive critical care service. It rec-

ognised that recovery areas will need to

have the necessary skills and personnel

available to care for such patients.

Depending on local circumstances,

this may involve the patient remaining

in the recovery area for a period of

monitoring. This is particularly so for

the Level 1 or 2 patient, who does not

require ventilatory support. Occasion-

ally, this may mean a Level 1 or 2 patient

staying overnight in a ‘24-h recovery’.

In other units, this may mean caring for a

patient ventilated for a short period of

time after major elective surgery. Whilst

the Critical Care Unit Consultant

should be involved in the care of such

patients, in most of these situations the

operative team should have the neces-

sary skills to enable them to retain

primary responsibility for the patient.

Unfortunately, this role of recovery does

not appear to have been appreciated by

the working party that wrote ‘Immedi-

ate Postanaesthetic Recovery’. It fails to

recognise that a recovery area has an

important role in the efficient running of

a critical care service. For example, it

may enable elective operations to be

undertaken which may otherwise have

to be cancelled due to a lack of intensive

care unit beds. It is not just about

‘maintaining the flow of surgical lists’.

One of the key aims of the Royal

College of Anaesthetists is to ensure that

all anaesthetists in training have the

necessary skills to enable them to safely

stabilise all critically ill patients having

acquired intermediate training in Inten-

sive Care or its equivalent. It is surpri-

sing therefore that the impression given

by this document is that the operative

team does not possess the necessary skills

to care for a critically ill patient post

operatively and is dependent on the

critical care team to provide immediate

postoperative care.

J. S. Bewley

Bristol Royal Infirmary,

Bristol BS2 8HW, UK,

E-mail: Jeremy.Bewley@

ubht.swest.nhs.uk

References1 Immediate Postanaesthetic Recovery.

Association of Anaesthetists of Great

Britain and Ireland 2002.

2 Comprehensive Critical Care. Department

of Health 2000.

A case for ‘doing it in theatre’

I congratulate the authors for their

recent survey (Bromhead & Jones.

Anaesthesia 2002; 9: 850–4) and reopen-

ing the debate concerning the use of

anaesthetic rooms for induction. I

should like to describe a case that

happened to me recently, which illus-

trates a point made by Drs Bromhead

and Jones in their paper, that critical

incidents can occur just after induction

of anaesthesia and at the time that the

patient would be unmonitored during

transfer between anaesthetic room and

theatre. Previously a staunch defender

of anaesthetic rooms, as a result of this

experience, I have changed my views.

Whilst working in a hospital that had

abandoned the use of anaesthetic rooms

in their entirety, a patient I anaesthe-

tised (in theatre) for an elective proce-

dure suffered an anaphylactic reaction

some 5 min post induction with fenta-

nyl, propofol (containing lidocaine) and

rocuronium. Had she been induced in

an anaesthetic room, this would have

been about the time that monitoring

would have been disconnected and

ventilation paused to move her into

theatre, as she had been intubated and

no further anaesthetic interventions

were planned. She developed the clas-

sical triad of bronchospasm, cardiovas-

cular collapse and florid erythematous

rash. I was first alerted to a problem by

an increased stiffness of the lungs, which

I would have been unaware of had she

been disconnected from the breathing

circuit. The resultant tachycardia and

hypotension (and subsequent cardiovas-

cular recovery) were monitored con-

tinuously throughout, and it may even

have been a member of the scrub team

who first commented upon the colour

of the patient!

Happily a single dose of intravenous

epinephrine resolved the situation, and

besides a short admission to a high

dependency unit, and the postpone-

ment of her operation, she came to no

harm. An elevated serum tryptase level

of 65 nmol.ml)1 confirmed an anaphy-

lactic reaction, and skin prick testing

performed some weeks later confirmed

rocuronium as the responsible agent.

I agree with the authors that con-

tinuing use of anaesthetic rooms for

induction does raise important clinical

governance issues. It really doesn’t make

a lot of sense to disconnect all monitors,



interrupt ventilation, risk displacing

tubes and cannulae, and all at a time

where ‘bad things’ could be happening

fast. As a result of this incident, I feel

safer inducing anaesthesia in theatre and

commend the practice.

R. Thomas

Southampton General Hospital,

Southampton SO16 6YD, UK

A new device to facilitate blindtracheal intubation

I would like to draw your attention to a

new device that I have developed to

facilitate blind tracheal intubation. It

consists of two J-shaped pieces, one

metal (an open structure, consisting

mainly of 5 mm steel) and the other

plastic (preformed to allow a tracheal

tube to slide in it). The plastic part slides

within the metal part and displaces it

longitudinally, which is controlled step

by step by a ratchet mechanism.

Another locking mechanism enables

the plastic part to be removed out of

the metal. The J-curve resembles that

of a Guedel airway. The combination of

the assembled device together with a

tube is 1 mm larger than the diameter of

the tube.

Provided a patient is able to open his

mouth 1 cm, it is possible to insert the

device following a J-curve along the

hard palate over the tongue to the val-

lecula. The metal part will stop in the

vallecula (Fig. 2) and palpation of the

throat just above the thyroid cartilage

will confirm this. Using the ratchet

system the two parts slide along each

other and longitudinal movement places

the plastic part just beyond the epiglottis

(Fig. 3) enabling a tracheal tube to

curve along the plastic part with a high

probability of entering the trachea

(Fig. 4). An unlocking mechanism

separates the two parts. The tube is

manually held in place while the plastic

part is removed first, followed by the

metal part, both with a curving motion

(Fig. 5).

The principle advantages are related

to the difficult laryngoscopic intuba-

tion. The device will allow intubation

in the difficult airway patient with

limited mouth opening or restricted

neck extension. Most notably the cer-

vical vertebrae remain stable and this

device overcomes the difficulty of a

patient who cannot achieve a ‘sniffing’

position. The other features are that

there is no pivotal stress on the front

teeth and palpation of the throat con-

Figure 2 The intubator in the neutral position after introduction.

Figure 3 The intubator after longitudinal displacement.



firms the position of the device at the

vocal cords without the need to see

them.

A preliminary study of 20 patients, 10

edentulous and 10 with teeth was un-

dertaken with a protocol approved by the

hospital ethical committee. We succee-

ded in introducing a tube into 19 patients

at the first attempt. Postoperative seque-

lae were restricted to three patients

mentioning a sore throat and one with

a hoarse voice for an evening, which

disappeared the following day. Further

clinical trials are planned to confirm the

clinical value of this device and its place

in the difficult airway situation.

The device is not commercially

available yet.

P. Tjong Joe Wai

Onze Lieve Vrouwe Gasthuis,

PB 95500, 1079 HM Amsterdam,

Holland.

Wrong blood in theatre

Transfusion of the wrong blood to

patients is the commonest adverse event

reported to the Serious Hazards of

Transfusion (SHOT) reporting scheme

and can be fatal if there is ABO

incompatibility. Failure to identify the

correct patient, or the correct unit of

blood for the patient at the bedside,

prior to administering blood, is the

commonest source of error [1].

In a recent case, several units of blood

were obtained for a patient in theatre

and were checked by staff to establish

that the patient identification details on

the units of blood corresponded to

those on the patient. All units were

placed in the theatre refrigerator prior

to use. An Operating Department

Assistant later collected what he be-

lieved was one of these units but in fact

it was a unit intended for another

patient. The anaesthetist did not carry

out a final bedside check of the patient

identification details on the unit against

those on the patient as he had checked

all the units earlier. The patient was

group B and received group A blood.

(personal communication – Dr P

Hewitt)

It is not uncommon practice in

operating theatres for patient identifica-

tion checks on units of blood to be

carried out at the start of surgery to

ascertain that blood is available quickly if

required: it is then stored in the theatre

transfusion refrigerator. The British

Committee for Standards in Haematology

Figure 4 The tracheal tube is introduced through the slide.

Figure 5 After tracheal intubation both parts are disconnected and removed.



guidelines for the administration of

blood and blood components state that

the patient’s surname, forename, date of

birth and unique patient identification

number should be checked on the blood

unit, the accompanying compatibility

form and the patient’s wristband, to

ensure that they tally before commen-

cing transfusion of blood [2]. To avoid

an error such as in this case, there must

be a final comparison of the patient

identification details on each unit of

blood against the patient’s identification

details immediately before the blood is

connected. Responsibility for this

should lie with the person who is

connecting the unit of blood to the

patient. We are aware of several other

hospitals in which this final check is not

routine (personal communication –

Fiona Regan). In keeping with the

clinical governance principle of prevent-

ing similar future incidents, we propose

that all hospitals should promptly review

their procedures to ensure that such a

final patient identification check is car-

ried out at the point of connecting a unit

of blood to a patient.

The authors wish to clarify that this

incident occurred at an unnamed Trust,

and not at any hospital at which we are

employed.

F. Regan

P. Hewitt

National Blood Service, London NW9

5BG, UK, E-mail: fiona.regan &

[email protected]

References1 Usha D, Atterbury CLJ, Chapman C et al.

Serious Hazards of Transfusion Annual Report

2000 ⁄ 2001. Manchester SHOT Office.

2002.

2 Guidelines for the Administration of

Blood and Blood Components. British

Committee for Standards in Haema-

tology, Blood Transfusion Task Force.

Transfusion Medicine 1999; 9: 227–38.

Fibreoptic equipment and priondisease

A 43-year-old-woman was referred to

us for airway management due to

worsening upper airway obstruction

following a neck haematoma. Her past

history included hypopituitrism secon-

dary to a craniopharyngioma, which

had been treated surgically and with

cadaveric growth-hormone replace-

ment 22 years previously. She had a

severe learning disability and was cared

for by her sister.

She had been admitted to hospital on

this occasion with renal failure from

nephrotic syndrome requiring haemo-

dialysis. A 11 French gauge double

lumen dialysis catheter had been inserted

into the right internal jugular vein by the

nephrology service. There was no ob-

vious arterial puncture and a chest X-ray

showed a correct position. The patient

was anticoagulated and underwent

dialysis. Over the next 24 h, she devel-

oped a swelling in the right side of the

neck, which increased sufficiently to

compromise her breathing. As the Renal

Unit was on a remote site without

resident anaesthetic cover, the anaes-

thetic service from the supporting hos-

pital was contacted for advice regarding

airway management and interhospital

transfer. Examination revealed a patient

who, despite being slightly drowsy,

needed to invest considerable effort to

generate a meagre inspiratory airflow.

She was tachypnoeic and had inspiratory

stridor. The trachea could not be palpa-

ted due to the haematoma, which

extended inferiorly to the level of the

right nipple. Oxyhaemoglobin satura-

tion was 94%, despite receiving high-

flow oxygen via a facemask, and her

chest X-ray was unremarkable. She was

known to have marked prognathism as a

result of her developmental abnormalit-

ies. In addition, her mouth opening was

2 cm, Mallampati was class 3 and neck

movement was limited due to the

haematoma.

It was clear that the patient needed

urgent tracheal intubation prior to

interhospital transfer to the Intensive

Care Unit, and an awake fibreoptic

intubation technique was considered to

be the best means of achieving this. An

inhalational induction was considered

but rejected because any degree of

sedation would be likely to suppress

the intense effort she was investing in

maintaining her airway and generating

airflow.

Having made this plan, we were now

faced with an unusual dilemma. The

patient’s case-notes were marked with a

hazard label to the effect that, since she

had been treated with cadaveric growth

hormone 22 years ago, she was consid-

ered to be at risk of transmitting new-

variant Creutzfeld-Jakob disease (which

has previously been reported following

prion transmission via cadaver-derived

growth hormone and pituitary gonad-

otrophins [1,2]). We were able to take

advice from the microbiology depart-

ment, which confirmed that all equip-

ment used in this patient was to be

incinerated.

We considered that once a manage-

ment plan has been decided based upon

clinical grounds, it would be illogical

and indefensible to revise this merely on

the grounds of our reluctance to sacri-

fice valuable equipment. After some

thought, we decided to use an old LF-2

(Olympus�) flexible fibrescope which

had been decommissioned from clinical

use because of minor mechanical dam-

age, but was kept by one of us (MP) for

teaching purposes (on manikins).

The patient was transferred to the

operating theatre, accompanied by her

sister in view of her severe learning

disability. Intravenous glycopyrronium

and topical anaesthesia was given prior

to the procedure and no sedation was

used. Tracheal intubation was achieved

with a 7-mm reinforced tube passed

nasally after a ‘spray as you go’ tech-

nique through the working channel of

the fibrescope. The patient was then

transferred to the Intensive Care Unit in

the John Radcliffe Hospital.

As prions are not inactivated by

conventional disinfection or heat steri-

lisation, particular precautions have to

be taken with all affected patients and

those at risk of carrying infection [3].

Prions are highly resistant to standard

physical and chemical methods of inac-

tivation and decontamination but fibre-

optic equipment is too expensive to be

disposable. This case highlights the

problem of finding suitable fibreoptic

equipment for a patient at risk of CJD.

In our department, it was possible to

find an alternative solution on this

occasion. However, having sacrificed

this ‘teaching scope’, we would not be



able to do so again. It would be

interesting to hear views from col-

leagues in other departments about

managing such a case.

A. Dombrovski

M. Popat

A. Farmery

The John Radcliffe

Oxford OX3 9 DU, UK

References1 Brown P, Gajdusek DC, Gibbs CJ Jr,

Asher DM. Potential epidemic of

Creutzfeld-Jacob disease from human

growth hormone therapy. New England

Journal of Medicine 1985; 313: 728–31.

2 Johnson RT, Gibbs CJ. Creutzfeld-

Jacob disease and related transmissible

spongiform encephalopathies. New

England Journal of Medicine 1998;

339: 1994–2004.

3 Budka H, Agazzi A, Brown P et al.

Tissue handling in suspected Creutz-

feld-Jacob disease and other human

spongiform encephalopathies. Brain

Pathology 1995; 5: 319–22.

Awareness and traumatic recallof cricoid pressure

A 54-year-old-man underwent general

anaesthesia for a sinus tract endoscopy

during the course of his treatment for

acute pancreatitis following cholecys-

tectomy. On pre-operative assessment,

he was judged to be at risk of aspiration,

and the discussion of the anaesthetic

with him included an explanation of

cricoid pressure. For the procedure, a

standard rapid sequence induction

(RSI) was conducted. The operation

proceeded largely uneventfully, al-

though some regurgitation during the

procedure confirmed that an RSI had

indeed been indicated. At the postop-

erative visit by the anaesthetist, the

patient stated that he had an unpleasant

recollection of the induction of anaes-

thesia and in particular the application

of cricoid pressure. He had no recall of

being intubated or of any subsequent

intra-operative events. The anaesthetist

reassured the gentleman, reiterated the

nature and purpose of cricoid pressure,

and offered to arrange formal counsel-

ling, though this was declined.

The anaesthetic team was requested

to visit the gentleman again 10 days

later as he had complained of persistent

and intrusive recall of these events. At

this visit, he described remembering a

nurse tapping on his neck prior to

induction followed by her ‘clamping’

his throat in her hands. He remembered

feeling he was unable to breath and

attempting to bring up his hands to

release the pressure on his neck. He felt

extreme distress and anxiety before

losing consciousness shortly after. Since

then, the recall of these events was

triggered whenever he was falling

asleep, causing him to awaken with

feelings of panic, and although these

symptoms seemed to be slowly improv-

ing, they had resulted in him actually

fearing the onset of normal sleep. He

also now expressed a profound and

regrettable apprehension regarding any

necessary anaesthesia in the future.

Several further follow up visits prior to

his discharge from hospital confirmed

that his symptoms steadily improved.

He continued to decline referral for

formal assessment and support; a letter

was therefore sent to his General Prac-

titioner in anticipation of a possible

need for further care regarding this

matter in the future.

The rationale for the application of

cricoid pressure necessitates that it is

applied at the loss of consciousness

during rapid sequence induction, and

indeed some authors recommend that it

be partially applied before loss of con-

sciousness [1]. During rapid induction,

however, it may not be possible to

determine the precise moment when

sufficient ‘loss of consciousness’ has

occurred to render the patient insensate

to cricoid pressure. Cricoid pressure

therefore, may be fully applied at a level

of anaesthesia where awareness, and

possibly recall, of the manoeuvre

occurs. It would be natural for a patient

who is unprepared to be extremely

distressed should they be aware of this.

Intra-operative awareness under anaes-

thesia is known to be associated with

significant emotional morbidity, inclu-

ding post-traumatic stress disorder [2,3].

Awareness of cricoid pressure, though

not reported and not obviously prevent-

able, could also contribute to the same.

Most anaesthetists in our department

routinely explain cricoid pressure to

patients at some point prior to a planned

rapid sequence induction, as happened

in this case. Perhaps more emphasis

should be placed on the pre-operative

explanation of cricoid pressure, and in

particular firm reassurance given to the

patient that if they are not asleep at the

time of its application they should not

fear being choked or strangled. As

incorrect application of cricoid pressure

may indeed obstruct the airway, perhaps

distressingly, we must also ensure that

our assistants are correctly performing

the technique [1].

A. J. Cadamy

C. Bong

Glasgow Royal Infirmary,

Glasgow G4 0SF, UK


References1 Vanner RG, Asai T. Safe use of cricoid

pressure. Anaesthesia 1999; 54: 1–3.

2 Bergman IJ, Kluger MT, Short TG.

Awareness during general anaesthesia: a

review of 81 cases from the Anaesthetic

Incident Monitoring Study. Anaesthesia

2002; 57: 549–56.

3 Osterman JE, Hopper J, Heran WJ,

Keane TM, van der Kolk BA. Aware-

ness under anaesthesia and the devel-

opment of posttraumatic stress disorder.

General Hospital Psychiatry 2001; 23:

198–204.

Tension gastrothorax

We read with interest the recent letter

outlining a case of tension gastrothorax

(Ni et al. Anaesthesia 2002; 57: 828–30)

and wish to raise the following points.

The diagnosis of simple pneumotho-

rax is made through a combination of

clinical history, examination and a plain

chest X-ray. A tension pneumothorax

however, is a medical emergency and is

diagnosed on clinical suspicion alone. If

a tension pneumothorax is suspected,

particularly if associated with haemody-

namic disturbance, the appropriate

action is emergency needle thoracocent-

esis in the 2nd intercostal space. This

procedure will be life saving in a tension

pneumothorax, and will be unlikely to



cause harm in the case of gastrothorax.

Tension pneumothorax remains the

more serious and easily treatable condi-

tion and a high index of suspicion should

thus be maintained. We would therefore

question Dr Ni’s conclusion that gastro-

thorax is an important differential diag-

nosis of tension pneumothorax, as the

initial treatment is the same.

It was interesting to note that the

medical registrar in the case described

opted to aspirate the ‘pneumothorax’

rather than insert a chest drain. The

authors suggest that percutaneous aspir-

ation of gastric contents (the procedure

which was actually performed) can be of

benefit in tension gastrothorax. It would

appear however, that despite a brief

respite, the patient’s clinical condition

deteriorated after the thoracocentesis

was performed, and she developed signs

suggestive of perforation of a hollow

viscus. We would be interested to know

if a site of perforation was found at

laparotomy and whether the thoraco-

centesis was the cause.

Our final point relates to the inser-

tion of chest drains in cases such as

this. One of the authors (ORD) was

involved in a similar case in 1983,

which was later written up as a case

report [1]. An 18-year-old-primagrav-

ida had documented dyspnoea during

pregnancy but had not had an ante-

partum chest X-ray. The woman

required general anaesthesia for emer-

gency Caesarean section at term,

which was administered by a registrar

who noticed unequal air sounds in the

chest on auscultation, although endo-

bronchial intubation was excluded.

After the delivery of the child, an

on-table chest X-ray was performed,

which showed the stomach and loops

of gut in the left side of the thorax

dilated, we thought, through the diffu-

sion of nitrous oxide.

The patient was successfully extubated

and maintained on nasal oxygen ther-

apy, breathing spontaneously. The

loops of gut decreased in size over the

following 24 h, and the anaesthetists

involved made a working diagnosis of

delayed presentation of congenital

diaphragmatic hernia. The surgical team

was consulted and 4 days post partum,

referred the patient for thoracotomy to

another institution, at which time there

was massive gastric dilatation in the

thorax.

After transfer, it was learnt that the

original diagnosis was doubted by the

receiving hospital and a chest drain

inserted with a trocar. Stomach contents

were drained and the referring diagnosis

was thereby confirmed. The patient

decompensated, and required emer-

gency thoracotomy. The stomach was

repaired and the abdominal contents in

the thorax were restored to their ana-

tomical position. The diaphragm was

also repaired. The patient did well post

operatively.

Dr Ni et al. suggest that the diagnosis

of gastrothorax is important as inadvert-

ent insertion of a chest drain and trocar

into the stomach will cause potentially

severe added morbidity. In our case of

20 years ago, a trocar-assisted chest

drain insertion did indeed cause the

patient significant morbidity.

Although the use of trocars was

commonplace in 1982, it is now almost

universally recommended that a blunt

dissection [2] technique is safer [3]. We

believe our case, and that of Ni et al.

highlight the point. It would be difficult

to introduce a drain into a thoracic

stomach without using a trocar, and thus

associated morbidity can be avoided.

O. Pratt

O. R. Dearlove

Royal Manchester Children’s Hospital,

Manchester M27 4HA, UK

References1 Reed M, de Silva P, Mostafa S, Collins

F. Diaphragmatic Hernia in Pregnancy.

British Journal of Surgery 1987; 74: 435.

2 American College of Surgeons;

Advanced Trauma Life Support Manual.

1997, 6th edn. 154.

3 Haggie JA. Management of Pneumo-

thorax, Trocar Unsafe and Unnecessary.

British Medical Journal 1993; 307: 443.

‘Continuous saline flowtechnique’ prevents airentrainment during intrapleuralblock

Intrapleural block is a useful analgesia

technique for the management of acute

postoperative, post-traumatic and chro-

nic pain of non-malignant and malig-

nant origin [1]. Despite being an

effective technique, it has failed to find

favour with anaesthetists because of up

to 2% reported incidence of pneumo-

thorax associated with it. The intra-

pleural space can be identified either by

loss of resistance to an advancing needle

upon puncturing the parietal pleura, or

on account of its negative pressure. This

space, because of its negative pressure,

can be safely and reliably identified in

the following two ways. In the first, the

piston of a well-wetted syringe is pas-

sively sucked down on entering the

space. In the second, entry into the

space is indicated by a sudden onset of

free flow of saline from an attached

saline bag. Tension pneumothorax, a

potentially serious complication, has

been reported [2] and was related to

the identification of the intrapleural

space by the loss of resistance technique.

It is reported that in every patient, a

small amount of air is inevitably sucked

into the pleural space during the place-

ment of a catheter. This is asymptomat-

ic, rapidly absorbed and is of no clinical

importance. It may, however, enlarge if

nitrous oxide is used to supplement the

block [3]. A self-sealing haemostatic

valve or catheter sheath adapter has

been used to prevent air entrainment,

but this type of valve is not always

available and we therefore describe a

simple technique using an ordinary

three-way tap, to avoid air being sucked

into the pleural cavity during placement

of a catheter.

A 16-gauge Tuohy needle is

advanced to the preselected rib. The

stylet is removed and a sterile assembly

consisting of a half litre saline bag, and

fluid administration set attached to the

right angle port of a three-way tap is

connected to the needle. The bag is

suspended at least 60 cm above the level

of the patient. The stopcock of the set is

opened fully. All further advancements

of the needle are performed in the

expiratory phase of respiration. A few

drops of saline flow while the needle is

traversing the tissues in the intercostal

space, which turns into a rapid flow as

the needle tip pierces the parietal pleura.

The three-way tap is then adjusted to



open all the three ports thus allowing

saline to jet out of the open port away

from the patient, towards the anaesthet-

ist. With the saline jetting out force-

fully, a catheter primed with saline is

then threaded into the pleural cavity. A

pressure of at least 60 cm of water,

corresponding to the height of the

saline bag above the patient, is created

at the three-way tap. Care is needed

while threading, to prevent the catheter

being thrown out of the tap due to the

force of the saline flow. Due to the

wider bore of the tap as compared to

that of the needle, saline preferentially

flows out of the tap towards the anaes-

thetist rather than into the interpleural

space. The flow is stopped only after

removing the needle from the thorax.

P. Nalwaya

R. Dravid

Kettering General Hospital,

Kettering NN16 8UZ, UK

References1 Stromskag KE, Minor B, Steen PA.

Side effect and complications related to

interpleural analgesia: an update. Acta

Anaesthesiologica Scandinavica 1990; 34:

473–7.

2 Gomez MN, Symreng T, Johnson B,

Rossie NP, Chiang CK. Interpleural

bupivacaine for interaoperative anal-

gesia – dangerous technique? Anesthesia

and Analgesia 1988; 67: S1–S266.

3 Ananthanarayan C, Kashtan H. Pneu-

mothorax after interpleural block in a

spontaneously breathing patients.

Anaesthesia 1990; 45: 342.

Flash forward: the newflashback?

During venous cannulation using a

cannula-over-needle technique, the

flashback of blood into the hub of the

stylet is an indication of intravenous

placement. It is not, however, infallible;

placement of the tip of the cannula in a

haematoma can still cause a flashback

and reliance on this sign could lead to

the extravasation of injected drugs. I use

an additional piece of evidence of

intravenous placement: ‘flash forward’.

As in many institutions, the anaes-

thetic assistants in my hospital helpfully

act as tourniquets during cannulation.

When the cannula has been placed and

as the stylet is removed, the assistant,

using his or her thumb, routinely

occludes the tip of the cannula within

the vein. This prevents blood tracking

back through the cannula. With the tip

occluded, a luer lock cap is placed on

the proximal end of the cannula. As the

assistant releases pressure on the tip of

the cannula, if, and only if the cannula is

within a vein, the blood that previously

entered the cannula during ‘flashback’

then flashes forward out of the cannula.

This can be observed at the point where

the cannula enters the skin. I postulate

that this occurs as the flattened vein re-

expands under elastic recoil. This causes

a momentary drop in pressure at the tip

of the cannula, ‘sucking’ the blood back

into the vein, and leading to the

characteristic ‘flash forward’ sign.

M. H. Coupe

Royal Gwent Hospital,

Newport NP20 2UB, UK

Glass particle contamination:is it here to stay?

We would like to bring attention to the

problem of glass particle contamination

of contents of single-dose glass

ampoules that could occur upon open-

ing of such ampoules, and which if

injected parenterally, would be a hazard

to the patient. This risk is particularly

high for patients in the operating theatre

and intensive care unit as they receive

medications almost exclusively in par-

enteral form.

Glass particle contamination of glass

ampoules is a known hazard [1] but

because glass particles used to be large

enough to be easily visible, they could

be avoided during aspiration of the

drug. It is now rare to find grossly

visible remnant glass particles in opened

ampoules. We wonder if this is due to

the absence of glass particles or that glass

splinters are now too minute to be

grossly visible. If it were due to the

latter, it would create a false reassurance

among medical practitioners and anaes-

thetists, leading to the inadvertent

aspiration of glass particles while draw-

ing up the ampoule contents.

To investigate this problem, used

single-dosed glass ampoules were col-

lected from operating theatres at the

end of each theatre list. A visual

inspection for grossly visible glass par-

ticles was carried out. Large glass par-

ticles were seen in three of the sampled

glass ampoules. One millilitre of sterile

water was then injected into each glass

ampoule. The glass ampoules were then

gently swirled for 15 s, to ensure that

all glass particles, if any, were washed

off the wall of the ampoule. To derive

the average number of glass particles

per ampoule for each group of drug

ampoules (for example, 1 ml, 10 mg

morphine ampoule), only the contents

of ampoules from the same group were

aspirated using the same 3 ml syringe

and the same 18G (1.2 mm · 40 mm)

non-bevelled (B. Braun�) drawing-up

needle. To ensure that all glass particles,

if any, that had settled to the bottom of

the ampoule were drawn out, the

needle was pointed downwards, touch-

ing the base of the ampoule, with the

ampoule slightly tilted during aspir-

ation. With the needle still attached,

the contents of the ampoule were then

pushed out of the syringe and emptied

onto a spread out, clean, green towel.

Once the towel had absorbed the

water, the towel was then visually

examined closely for any shimmering

of glass particles. The number of glass

particles observed was noted. After

counting, all glass particles were care-

fully removed and discarded into the

sharps bin. Next, a vernier calliper

(accuracy to nearest 0.02 mm, Mitu-

toyo�) was used to measure the thick-

ness of the wall of the neck of the

ampoule. Three readings were taken

from each ampoule and an average was

recorded.

The results of our study showed that,

out of 510 glass ampoules, a total of 113

glass particles were found, giving an

average of 0.22 particle per ampoule.

When sampled ampoules with matching

wall thickness (0.70–0.80 mm) and type

(metal-etched) were compared, we

found that those with a larger size

(larger than 2 ml capacity, n ¼ 13) have

a greater averaged number of glass

particles per ampoule (0.46), compared

to that of smaller ampoules (0.14),



where n ¼ 162. For sampled ampoules

with matching wall thickness (0.80–

0.90 mm) and size (larger than 2 ml

capacity), we found that metal-etched

ampoules (n ¼ 55) have a greater aver-

aged number of glass particles per

ampoule (0.47), compared to that of

colour-break ampoules (0.24), where n

¼ 93. These results are in concordance

with other studies [2,3].

Furthermore, of all the ampoules

with comparable size (less than or equal

to 2 ml capacity) and type (metal-

etched), we found that those with

thicker wall (more than 0.80 mm,

n ¼ 20) have a greater averaged number

of glass particles per ampoule (0.35)

compared to that of ampoules with wall

thickness less than 0.80 mm (0.14), n ¼162. We would also like to highlight

the particularly high averaged number

of glass particles per ampoule found in

the nine sampled glass ampoules con-

taining etomidate emulsion (0.56).

Being a white emulsion, the presence

of remnant glass particles is not easily

seen, hence might lead to reduced

vigilance of glass particle contamination

during aspiration of the drug. Other

injectable non-glass particles found

include paint particles from the white

ring marker of colour-break protamine

sulphate ampoules.

The data from our study clearly

demonstrates that even with the use of

an 18G needle for drawing up the

contents of the ampoules, smaller glass

particles can still pass through the needle

into the syringe. Glass particles of this

size can easily be injected into patients.

This is particularly so if drugs are

routinely administered via the injection

port of the intravenous cannula, which

is a safety measure designed to decrease

sharps injury to the medical staff.

As ampoules for medical use are

made of type I borosilicate glass [2],

the sequelae of glass particle contamin-

ation requires a considerable time to

develop. Previous animal studies had

demonstrated that the infusion of glass

particles led to pulmonary silicotic

changes and nodular fibrosis of the

liver, spleen and small intestines as a

result of foreign body reaction [2].

Even though our method of visual

eyeballing for glass particles may not be

very sensitive as some fragments may

only be visible under light microscopy,

those visible to the naked eye are

probably over 75 lm in diameter [4]

and would have lodged in the pulmon-

ary capillaries if administered. Pulmon-

ary capillaries have an average diameter

of 10–12 lm.

Besides being chemically inert and

possibly recyclable, one advantage of

packaging drugs in glass ampoules is the

ability to vacuum-seal. However, as

plastic is just as comparable in these

aspects, and as the manufacturing pro-

cesses still cannot prevent fragmentation

of glass, there is an urgent need to call

for drug manufacturers to move to-

wards using plastic ampoules as an

alternative packaging for drugs now

available in glass ampoules. Not only

might this overcome the problem asso-

ciated with infusion of glass particles

but this would also prevent problems of

sharps injury to staff, such as laceration

of fingers.

In the meantime, to minimise admin-

istering glass particles to patients, we

recommend either the use of in-line

filter [5], or aspiration through a fine-

bore needle [6] as well as avoiding

aspiration from the most dependent area

of the glass ampoule [5]. All that said, the

practicality of using filters and fine-bore

needles for aspirating large volumes

might be a consideration, when imple-

menting these recommendations. There

is also a need to look into effects of paint

particles contamination from the col-

oured ring marker of colour-break am-

poules. We would like to hear from the

rest of the anaesthetic fraternity.

S. T. Lye

N. C. Hwang

Singapore General Hospital,

Singapore

References1 Brewer JH, Dunning JH. An in vitro

and in vivo study of glass particles in

ampoules. Journal of the. American

Pharmacy Association 1947; 36: 289–93.

2 Sabon RL Jr, Cheng Er, Stommel KA,

Hennen CR. Glass particle contamin-

ation: influence of aspiration methods

and ampoule types. Anesthesiology 1989;

70: 859–62.

3 Carbone-traber KB, Shanks CA. Glass

particle contamination in single dose

ampoules. Anesthesia and Analgesia

1986; 65: 1361–3.

4 Walker DG, George CF. Ampoules,

infusions, and filters. British Medical

Journal 1986; 291: 714–15.

5 Furgang FA. Glass particles in

ampoules. Anesthesiology 1974; 41: 525.

6 Katz H, Borden H, Hirscher D. Glass

particle contamination of solutions.

Journal of the American Medical Association

1974; 229: 1169.

Injection cap with missingseptum

During the insertion of a multilumen

central venous catheter (Arrow interna-

tional, USA) in a patient from the

medical wards, a fault was noted with

one of the injection caps provided.

While two of the injection caps used

to seal the end of each of the three

lumens contained the usual septum, in

the third cap this was missing. Figure 6

shows a normal injection cap on the left

and the faulty one on the right. This

fault was not immediately obvious.

Close inspection prevented the cap

being connected to the patient, with

the subsequent risk of air embolus. The

manufacturer was contacted and replied

that 10 million such caps are manufac-

tured each year and only two such cases

had been reported previously. While

the venous access equipment in use

today is normally of a very high stand-

ard, this incident reinforces the import-

ance of always checking equipment

thoroughly.

Although central venous cannulation

is a relatively straightforward procedure

in experienced hands, the risk of com-

plications should never be forgotten [1].

B. Fitzwilliams

Royal Perth Hospital,

Perth 6847, Western Australia

Reference1 Mansfield PF, Hohn DC, Fornage BD,

Gregurich MA, Ota DM. Complica-

tions and failures of subclavian-vein

catheterisation. New England Journal of

Medicine 1994; 331: 1735–8.



Anaesthesia managementin a patient with Aicardi’sSyndrome

Aicardi’s Syndrome is an epileptic

encephalopathy characterised by agen-

esis of the corpus callosum, epileptic

attacks, retinal lesions and mental retar-

dation [1,2]. It occurs only in females

and, as has been hypothesised, could be

due to genetic anomalies linked to the

X chromosome. Our research of the

literature concerning problems of

anaesthesia in patients with Aicardi’s

Syndrome did not reveal any published

papers. We describe the case of a

2-year-old-female child affected by this

syndrome who underwent general

anaesthesia for muscle biopsy.

She was admitted to the Paediatric

Intensive Therapy ward and underwent

treatment with sodium valproate (Dep-

akin), clonazepam (Rivotril) and ethos-

uximide (Zarontin). She continued to

suffer numerous daily convulsive

episodes. Two weeks prior to the

operation, she suffered a bronchitic

episode with apnoeic episodes. The

child appeared scarcely reactive at pre-

operative examination. She entered the

operating room without premedication

and general anaesthesia was induced

with a mixture of oxygen, nitrous oxide

and sevoflurane at concentrations in-

creasing up to 8%, using a facemask.

Cannulation of veins in the limbs was

impossible and it was necessary to

cannulate the left external jugular vein.

After induction of anaesthesia, the child

was placed in the lateral decubitus

position to perform a caudal block,

which also proved impossible due to

alterations to the sacral anatomy ren-

dering common landmarks (postero-

superior iliac spines, cornua sacralia)

unrecognizable. Anaesthesia was there-

fore carried out with a facemask under

spontaneous respiration using an inha-

lation mixture of oxygen, nitrous oxide

and sevoflurane at concentrations

between 1.5% and 2%. Ketorolac

1 mg.kg)1 was administered as anal-

gesia. While under anaesthesia, the child

was monitored with ECG, pulse oxi-

metry, and non-invasive BP. The op-

eration was completed without any

anaesthetic complications. For the first

24 h after the operation, the child was

kept under observation in the Paediatric

Intensive Care Unit.

On the basis of our experience with

this patient affected by Aicardi’s Syn-

drome, we may conclude that the

problems we encountered were: severe

generalised hypotrophia of subcuta-

neous tissues causing impossible venous

access in the limbs (cannulation of

external jugular vein was performed),

severe malformation of vertebrae ren-

dering impossible a caudal block, con-

vulsive spasms poorly controlled by

therapy, respiratory infection prior to

surgery with apnoeic attacks, which led

to electively managing the patient in the

Paediatric Intensive Care following sur-

gery. The choice of inhalation anaes-

thesia with oxygen, nitrous oxide and

sevoflurane proved to be safe and

allowed complication free muscular

biopsy.

T. Iacobucci

M. Galeone

G. de Francisci

Catholic University ‘Sacred Heart’,

00168 – Rome, Italy


References1 Aicardi J, Chevrie JJ, Rousselie F. Le

Syndrome spasm en flexion, agenesie

calleuse, anomalies chorioretiniennes.

Arch. Fr. Pediatr 1969; 26: 1103–20.

2 Haslam RHA. Congenital anomalies of

the central nervous system. Nelson

Textbook of Paediatrics. (eds Behrman,

Kliegman, Arvin), 15th edn, W.B.

Saunders Co, Philadelphia 1996.

Isoflurane and coronary steal

We read with interest the recent review

article on isoflurane and coronary heart

disease (Agnew et al. Anaesthesia 2002;

57: 338–47). We would like to share an

experience, which we think demon-

strated the coronary steal phenomenon

clinically.

For the coronary steal syndrome to

occur, the following conditions have to

be present:

Presence of steal-prone anatomy: de-

fined as a total occlusion of one coron-

ary artery and a greater than 50%

stenosis of a second artery that supplies

collateral blood vessels to the former

vessel [1].

Direct coronary arteriolar vasodilatation

in the absence of a significant decrease

in systemic arterial pressure [2].

Our patient was a 60-year-old man

presenting for coronary artery bypass

surgery. He had hypertension as the

only cardiovascular risk factor. He pre-

sented with a 3-month history of

angina. A coronary angiogram found

that he had 100% occlusion of the left

Figure 6



main coronary artery and 70% stenosis

of the right coronary artery on coronary

angiogram. Collaterals were provided to

the distal left main by the right coron-

ary. The ejection fraction was 50%. The

patient was not premedicated. Anaes-

thesia was induced with intravenous

fentanyl 1000 lg and midazolam 5 mg

and paralysis with rocuronium 50 mg.

ECG monitoring showed sinus rhythm

of 60 to 70.min)1 during induction and

following intubation. The mean inva-

sive arterial pressure were 70 mmHg.

Isoflurane was started 3 min after intu-

bation and the end-tidal isoflurane

concentration reached 0.5% in 100%

oxygen. Within 4 min, the ST segments

in leads II and V were found to be

depressed by 0.7 mV with T wave

inversion. A rapid search for a cause of

ischaemia was started. There was no

change in the heart rate, mean arterial

pressure or saturation on continuous

pulse oximetry. Surgery had not started.

The ST depression remained and was

soon associated with a rise in central

venous pressure from 4 to 8 mmHg.

Since the only change discernable was

the initiation of isoflurane inhalation,

we promptly discontinued it and started

an infusion of glyceryl trinitrate (GTN).

This restored the ECG to baseline after

5 min.

Authors have asserted that as long as

coronary perfusion is maintained, iso-

flurane does not cause coronary steal or

ischaemia; our patient reacted other-

wise. While recent studies showed that

isoflurane has myocardial protective

properties (ischaemic preconditioning

involving the opening of adenosine

triphosphate-dependant potassium

channel), we would urge caution in

patients with steal prone anatomy.

A. Teo

K. F. Koh

National University Hospital

Singapore 119074

References1 Hogue CW, Pulley DD, Lappas DG.

Anesthetic induced myocardial isch-

aemia: the isoflurane-coronary steal

controversy. Coronary Artery Disease

1993; 4: 413–19

2 Hartmann JC, Kampine JP, Schmelling

WT, Warltier DC. Alterations in col-

lateral blood flow produced by isoflu-

rane in a chronically instrumented

canine model of multivessel coronary

artery disease. Anesthesiology 1991; 74:

120–33.

Total intravenous anaesthesiawithout muscle relaxant for eyesurgery in a patient withKugelberg–Welander Syndrome

Kugelberg–Welander Syndrome (type

III Spinal Muscular Atrophy) has a late

onset and benign course, characterised

by episodic deterioration. Average age

at death is 51 years [1–3]. It is an

autosomal recessive condition, and

commoner in females. The primary

abnormality is thought to arise in the

q11.2–13.3 region of chromosome 5,

causing mutation of the ‘Survival motor

neurone gene’ and the ‘neuronal ap-

toptosis inhibitory gene’ [4].

A 25-year-old-female with Kugel-

berg–Welander Syndrome presented for

urgent corneal grafting due to kerato-

globus. She was barely mobile, with

limitation of neck movement due to

contractures. Blood tests and ECG were

normal. Lung function tests were not

available, although a significant scoliosis

was present.

Very little information is available in

the anaesthetic literature regarding the

management of such cases, except to

confirm that muscle relaxants, opioids

and thiopental could all a have pro-

longed duration of action [5]. It was the

surgeon’s opinion that surgery was

urgent and that general anaesthesia was

required. It was decided to use total

intravenous anaesthesia (TIVA) using

propofol and remifentanil in an attempt

to avoid exposure to long acting drugs

and to reduce the need for muscle

relaxation.

Anaesthesia was induced using

0.5 mg of alfentanil and 100 mg of

propofol. A size 3 laryngeal mask was

inserted uneventfully. The patient’s

lungs were ventilated with an oxy-

gen ⁄ air mixture (FiO2 0.4) through a

circle system. Airway pressure did not

exceed 13 mmHg at any time. Anaes-

thesia was maintained using propofol

and remifentanil infusions. The surgeon

reported excellent operating conditions.

The procedure lasted 55 min, and con-

trolled ventilation was possible through-

out the operation without the

administration of any muscle relaxation.

In total, 1 mg of remifentanil and

510 mg of propofol were administered.

There were no cardiovascular or respir-

atory instabilities at any time.

Spontaneous respiration returned

almost immediately that the two infu-

sions were stopped. The laryngeal mask

was removed within 5 min, and the

patient was ready for discharge back to

the ward 20 min later. Postoperatively,

analgesia was provided by paracetamol,

and Feldene Melt 20 mg sublingually, as

required. Oxygen therapy was admin-

istered for 24 h. No adverse effects,

nausea, vomiting or pain were reported

and the patient was discharged on the

fifth postoperative day.

The life span of these patients makes

it inevitable that they will present for a

variety of procedures. TIVA using short

acting drugs may provide an ideal way

of avoiding longer acting medication,

the action of which can be unpredict-

ably prolonged by the underlying con-

dition. For peripheral procedures, or

operations that are largely not stimula-

ting, it may be the method of choice

when general anaesthesia is needed.

J. C. Watts

Burnley General Hospital,

Burnley, UK

References1 Brown J, Minns R. Disorders of the

central nervous system. Forfar and

Anniel’s Textbook of Paediatrics (eds

Campbell, A, McIntosh, N), 5th edn.

Churchill Livingstone 1998, 441.

2 http://www.worldortho.com/data-

base/etext/neuromuscular.html.

3 http://www.pakdoctor.com/health-

rofessional/orthopaedic/NEURO-

MUSCULAR.htm

4 Orrel, RW, Habgood, JJ, de Beller-

oche, JS, Lane, RJ. The relationship of

spinal muscular atrophy to motor

neurone disease. Investigation of SMN

and NAID gene deletions in sporadic

and familial ALS. Biojournal of the Neu-

rological Sciences 1997; 145: 55–61.

5 Rushman CD, Davies NJH, Cashman

JN. Lee’s Synopsis of Anaesthesia, 12th

edn. Butterworth. – Heinnam. 1999.



Carbon dioxide pneumothoraxduring laparoscopicfundoplication

Laparoscopic fundoplication is com-

monly used to treat medically refractory

gastroesophageal reflux disease. One of

the recognised complications following

laparoscopic fundoplication is a pneu-

mothorax. This could be due to carbon

dioxide pneumothorax introduced

through a hole in the pleura or due to

actual injury to the lung parenchyma.

We would like to report a case of

pneumothorax during redo laparoscopic

fundoplication and its unusual manage-

ment.

A 46-year-old-lady, who was essen-

tially fit and healthy, presented for a

laparoscopic redo fundoplication. For

induction propofol, fentanyl and

rocuronium were given and a size

8.0 tracheal tube was passed. Anaes-

thesia was maintained with oxygen,

nitrous oxide and isoflurane. A low

thoracic epidural was inserted with the

patient anaesthetised in case it became

an open procedure. For epidural top

up, bupivacaine 0.125% with fentanyl

5 lg was used. After 2 h into the

operation, oxygen saturation was noted

to fall from 99 to 85% and airway

pressures increased from 17 to 30 cm

H2O. Clinical examination suggested a

reduced left hemithorax excursion and

reduced air entry; we suspected a

pneumothorax. The oxygen saturation

picked up with increasing inspired

oxygen from 33% to 44%. At the

end of the 2½ h operation, slightly

reduced air entry was still noted on the

left side of the chest. Oxygen satura-

tion remained at 96% on FiO2 0.44.

We were concerned that the patient

would have respiratory compromise if

woken up; therefore, we kept the

patient anaesthetised. An image inten-

sifier was used to locate the site and

size of the pneumothorax. It was

noted that the size of the pneumotho-

rax was 40% on the left side. A 14G

cannula was passed into fifth intercostal

space in the anterior axillary line with

an aspiration set. The image intensifier

confirmed successful treatment of the

pneumothorax. The patient’s neuro-

muscular blockade was reversed and

she was kept in recovery until fully

recovered.

We believe that that this technique of

using the image intensifier at the end of

the operation with the patient anaes-

thetised avoided unnecessary discomfort

for the awake patient from respiratory

distress secondary to the pneumothorax,

and from the treatment of the pneu-

mothorax. Also, it avoided the use of

indwelling chest drains, since the most

likely cause was a CO2 pneumothorax,

from a pleural opening rather than

pulmonary parenchymal injury and

once drained was unlikely to recur.

L. M. C. Leong

A. Ali

Good Hope Hospital,

Sutton Coldfield B75 7RR, UK

Safety and effectivenessof epidurals

Epidural infusions of bupivacaine and

diamorphine for postoperative analgesia

are widely and successfully used [1].

During the year 2000, our hospital used

bupivacaine 0.15% and diamorphine

100 lg.ml)1 epidural infusions on 196

patients, and had three episodes of

respiratory depression (respiratory rate

of 8 breaths.min)1 or less) requiring

naloxone (incidence of 1.5%). The

results of a national survey of epidural

practice for postoperative pain relief

were recently published in Anaesthesia,

and showed a wide variation in different

solutions being used [2]. Based on this

national survey, and our unacceptably

high rate of respiratory depression, we

changed our dose of diamorphine to

50 lg.ml)1, whilst keeping the bupiva-

caine as 0.15%.

Since changing to this concentration,

we have managed 315 epidurals on the

wards and have only had two episodes

of respiratory depression (0.6% vs.

1.5%). Patients were also less sedated

(GCS of 13 or less) with the lower

concentration of epidural diamorphine

(0.3% vs. 1.5%).

The lower concentration of epidural

diamorphine has a higher incidence of

poor block (16.5% vs. 3%). This is

backed up by the fact that the conver-

sion to a morphine PCA was higher in

the 50 lg.ml)1 group than the

100 lg.ml)1 group (11% vs. 4%). Any

treatment requires a balance of risk vs.

benefit. Even a relatively low incidence

of respiratory depression is important

given the potential harm to the patient.

We have seen a marked reduction in

respiratory depression by halving the

diamorphine concentration in our epi-

dural infusions. However, this lower

diamorphine concentration also appears

to be less efficacious, with a higher

incidence of failure and conversion to

PCA. For these reasons, we have now

converted to using patient controlled

epidural analgesia (PCEA) devices with

the bupivacaine 0.15% and diamor-

phine 50 lg.ml)1. We are auditing

our results, and hope that this will

provide better analgesia whilst main-

taining the lower incidence of respirat-

ory depression.

M. R. Duffy

R. J. Wood

M. Alexander-Williams

Broomfield Hospital,

Chelmsford CM1 7ET, UK,


References1 Hobbs GJ, Roberts FL. Epidural infu-

sion of bupivacaine and diamorphine

for post-operative analgesia- use in

general surgical wards. Anaesthesia

1992; 47: 58–62.

2 Bannon L, Alexander-Williams M,

Lutman D. A national survey of epi-

dural practice. Anaesthesia 2001; 56:

1021.

Table 2 Comparison of side effects withdifferent epidural solutions.

Bupivacaine

0.15% anddiamorphine100 lg.ml)1

N = 196

Bupivacaine

0.15% anddiamorphineto 50 lg.ml)1

N = 315

Poor block 6 (3%) 50 (16.5%)Respiratorydepression

3 (1.5%) 2 (0.6%)

Sedation 3 (1.5%) 1 (0.3%)Conversionto PCA

7 (4%) 34 (11%)



Recurrent positional ventriculartachycardia in a patient withcarcinoma of the oesophagus

A previously fit 40-year old female was

scheduled for oesophagectomy for car-

cinoma of the oesophagus. Her general

physical examination, routine haemato-

logical and biochemical investigations

were normal. Twelve lead ECG showed

normal sinus rhythm with occasional

premature ventricular complexes

(PVCs) and a normal QTc interval.

She was premedicated with pentazocine

30 mg and atropine 0.6 mg intramus-

cularly. Anaesthesia was induced with

thiopental 250 mg with succinylcholine

75 mg given to facilitate tracheal intu-

bation. Anaesthesia was maintained with

isoflurane 0.5–1.0% and nitrous oxide

60% in oxygen. Neuromuscular block-

ade was achieved with pancuronium

bromide. While being turned to the

lateral decubitus position for thoracotomy,

she developed ventricular tachycardia.

She was immediately returned to the

supine position. Surgery was abandoned

for further cardiac evaluation, as she had

recurrent episodes of ventricular tachy-

cardia.

Her echocardiography showed nor-

mal valvular sizes and function. Dobu-

tamine stress echocardiography was

normal. Holter monitoring showed

heart rate variations between 58 and

196.min)1 with an average of

97.min)1. The 24 h record also re-

vealed multiple runs of ventricular

tachycardia with a total load of 1478

PVCs and 19 short episodes of ven-

tricular tachycardia (VT), one lasting

11 beats. To confirm the postural

relationship, she was turned repeatedly

to each lateral side in an attempt to

reproduce the ventricular tachycardia.

Ventricular tachycardia was reprodu-

cible most times on change of posture,

and was sustained for 2–3 min in each

episode, with few intervening normal

complexes. However, haemodynamics

remained stable throughout.

She was again scheduled for surgery

for completion of oesophagectomy after

5 days. As she was asymptomatic, no

anti arrhythmic drug was given in the

peri-operative period. General anaes-

thesia was conducted with the same

protocol as used previously. Monitoring

included continuous ECG, SpO2, non-

invasive blood pressure, CVP and urine

output. Surgery was completed success-

fully in 7 h. Although the ECG trace

showed multiple runs of ventricular

tachycardia during the course of sur-

gery, her haemodynamics remained

stable throughout.

Ventricular tachycardia is a serious

arrhythmia because of its potential to

degenerate into more malignant

arrhythmias with catastrophic collapse.

It is often caused by underlying isch-

aemic heart disease or other organic

cardiac pathologies such as cardiomy-

opathy, cardiac tumours, prolonged

QT syndrome, electrolyte disturbances

and pheochromocytoma [1,2]. Rarely,

it may present as recurrent benign

episodes. Lu and coworkers found

females to be more prone to ventric-

ular arrhythmias [3]. Recently, the

benign nature of this arrhythmia has

been questioned [4]. The management

of cases with asymptomatic ventricular

tachycardia is controversial. It becomes

even more of a dilemma when such

cases are subjected to anaesthesia and

surgical stress. The risk-benefit ratio of

treating each specific type of VT has

to be considered before beginning

therapy, as anti arrhythmic drugs also

have pro-arrhythmic effects and can

even worsen the stable ventricular

rhythms. Our patient had recurrent

asymptomatic ventricular tachycardia,

which was associated with change of

posture. Although position related par-

oxysmal supraventricular tachycardias

(PSVTs) are well known in patients

with mitral valve prolapse [5] and

autonomic neuropathies, positional re-

current ventricular tachycardia is un-

known. It is difficult to postulate an

explanation and a correlation with

carcinoma of the oesophagus, as there

was no direct tumour invasion of the

pericardium. We suggest that anti

arrhythmic therapy can be avoided

unless patients with these arrhythmias

show haemodynamic instability. Pro-

phylactic anti arrhythmic therapy

should be reserved where minor

haemodynamic fluctuations for a brief

period may be disastrous, such as

transplant and microvascular surgery.

P. L.Gautam

S. Kathuria,

D. Sood

TeJ. K. Kaul

Dayanand Medical College and

Hospital,

Ludhiana (141 001), Punjab, India

References1 Josephson ME, Zimetbaum P, Buxton

AE, Marchlinski FE. The Tachyar-

rhythmias. In: Harrison’s Principles of

Internal Medicine. 14th edn., ed. Fauci

AS, Braunwald E. Isselbacher KJ, et al.

McGraw-Hill 1998.

2 Petit T, de Lagausie P, Maintenant J

et al. Thoracic pheochromocytoma

revealed by ventricular tachycardia.

Clinical case and review of the litera-

ture. European Journal of Paediatric

Surgery 2000; 10: 142–4.

3 Lu HR, Remeysen P, Somers K, Seals

A, De Clerck F. Female gender is a risk

factor for drug induced long QT and

cardiac arrhythmias in an vivo rabbit

model. Journal of Cardiovascular Electro-

physiology 2001; 12: 538–45.

4 Raitt MH, Renfroe EG, Epstein AE

et al. ‘Stable’ ventricular tachycardia is

not a benign rhythm: insights from the

antiarrhythmics versus implantable

defibrillators (avid) registery. Circulation

2001; 103: 244–52.

5 Falk RH, Tarko HB, Levine PA.

Positional supraventricular tachycardia.

New England Journal of Medicine 1981;

304: 1364.

A postoperative respiratoryarrest in a post poliomyelitispatient

A 51-year-old woman underwent gen-

eral anaesthesia for correction of a foot

deformity consequent to poliomyelitis

contracted at 2 years of age. In the pre-

operative evaluation, she did not show

motor deficits, obesity, chest deformit-

ies or any health problem except recur-

rent headaches; for this reason

subarachnoid anaesthesia was avoided.

Her status was classified ASA 2.

Anaesthesia was induced with prop-

ofol 150 mg and fentanyl 0.1 mg and

was maintained with propofol and

remifentanil infusions. Atracurium



20 mg was used for intubation and

maintenance of relaxation. Her lungs

was mechanically ventilated and during

the procedure she had 10 mg subcuta-

neous morphine for postoperative anal-

gesia. The intervention lasted 30 min.

The patient was extubated and trans-

ferred to her room when her vital

functions were stable and she was able

to talk. Fifty minutes later she was

found in her room apnoeic, cyanotic

and pulseless. She was promptly resus-

citated with chest compressions, intu-

bation and ventilation. Her vital

functions recovered but her neurolog-

ical status did not improve.

She was transferred to the intensive

care unit and ventilated using pressure

support ventilation to maintain a

PaCO2 < 30 mmHg to prevent brain

oedema. She was sedated with propofol

and anti epileptic drugs following an

episode of status epilepticus after ad-

mission. A percutaneous tracheotomy

was performed and the patient was

weaned from mechanical ventilation

after about 3 weeks, although her

neurological status has not improved

and 3 months after the acute episode

her GCS is 5. Since she was breathing

spontaneously, she shows hypercapnia

(PaCO2 45–50 mmHg) without acid-

osis or significant hypoxaemia. Her

electrolytes are in the normal range

and there are no clinical reasons to

suspect metabolic alkalosis. No clinical

or radiological findings of pulmonary

disease or alteration of pulmonary

compliance or airways resistance were

found. A magnetic resonance imaging

(MRI) scan of the brain 19 days after

the acute event showed altered signals

in the cerebral peduncles without alter-

ations in the lower regions of the brain

stem. In our patient, the absence of

detectable neurological lesions in the

ventral portions of the brain stem, the

increase of bicarbonate until the first

days after the acute event and a per-

fectly compensated hypercapnia soon

after the discontinuation of mechanical

ventilation, suggest that she was chron-

ically hypoventilating.

Patients with chronic hypoventila-

tion and hypercapnia can be quite

asymptomatic or present vague com-

plaints like somnolence or headache,

but general anaesthesia or sedation can

provoke acute deterioration of their

respiratory function.

Previous poliomyelitis is a condition

with increased risk of chronic hypo-

ventilation and sleep-related disordered

breathing usually related to the post

polio syndrome (PPS) whose occur-

rence ranges from 28.5% to 64% with

an average time from acute onset of

about 35 years (range 8–71). Respirat-

ory insufficiency has been reported in

36–42% [1,2].

We searched the medical literature

for respiratory problems and related

anaesthetic risk in patients with previous

poliomyelitis and no respiratory symp-

toms, chest deformities, major disability

or overt postpolio syndrome using the

Medline data base and the key words:

poliomyelitis, postpolio, anaesthesia.

We found only one article reporting a

case of unexpected postoperative com-

plication [3]. A 79-year-old male de-

veloped ventilatory failure after

cholecystectomy. He had had poliomy-

elitis at the age of 8 years with only a

slight residual handicap, a mild pareses

of the left limbs.

These cases remind us that previous

poliomyelitis itself can be considered as

a condition of increased risk for respir-

atory failure after sedation, opioid anal-

gesia, or in the postoperative period,

even in the absence of chest deformities,

major motor deficits or respiratory

symptoms. Thus, adequate pre-opera-

tive evaluation, including measurements

of respiratory muscle strength and blood

gas analysis, and strict peri-operative

monitoring are necessary in these

patients.

E. Magi

C. Recine,

B. Klockenbusch

E. A. Cascianini

Hospital S. Donato,

Arezzo, Italy,


References1 Jubelt B, Agre JC. Characteristics and

management of postpolio syndrome.

Journal of the American Medical Association

2000; 284: 412–14.

2 Dean E, Ross J, Road JD, Courtenay L,

Madill KJ. Pulmonary function in

individuals with a history of poliomy-

elitis. Chest 1991; 100: 118–23.

3 Gaul C, Winterholler M. Post polio

syndrome and weaning failure 40 years

after the last polio epidemic. Anaesthetist

2002; 51: 378–82.

Drug syringe labelling

I would like to comment on the report

on syringe labelling (Christie and Hill

Anaesthesia 2002; 57: 778–817).

To the best of my knowledge, this

code was first registered in South Africa

(SABS 0207–1985) [1]. The original

concept for this was introduced about

1982 and tested in the Tygerberg Hos-

pital of the University of Stellenbosch

Medical Faculty. The code was to apply

primarily to anaesthesia drugs in oper-

ating theatres where virtually all rou-

tinely used injectables become ‘orphans’

when drawn up into syringes from the

manufacturer’s original container. Such

syringes are sometimes used in more

than one case, or are kept available for

up to 24 h. The original label size was

selected to apply to 2, 5, 10, and 20 ml

syringes. Colour coding was found to

be a more reliable identifier than prin-

ting when viewing syringes from any

angle and under stress, and size is often

used to confirm the class of agent. Apart

from depolarizing and non-depolarizing

agents, two drugs from the same class

are rarely combined; and syringes are

not always lined up for reading left to

right. Colours were chosen to reflect

drug effect: red for the most deadly �relaxants; deep blue for opiates; yellows

and oranges for hypnotics and sedatives.

Brown was avoided because of its

similarity to povidone or blood on

paper. Conventions were defined for

subgroups of a main category and for

antagonists. Colour blindness has not

appeared to be practical disadvantage.

Avery Labels undertook the original

development and production of test

samples. They specified the original

Pantone numbers, but were not inter-

ested in marketing.

Tygerberg Hospital, as a major teach-

ing hospital, attracted foreign visitors



(including many from the UK) among

whom was Dr Leslie Rendell-Baker

who introduced the idea to New York

State. This later became the basis of a

Californian and the US National code.

Through the offices of Dr I.A. Sloan of

the World Federation of Societies of

Anaesthesiologists (WFSA) the code has

now become an International Standard.

Nine drug classes have been defined:

(1) Induction agents

(2) Tranquillisers – Orange 151

(3) Neuromuscular blockers with sub-

group Relaxant Antagonists – Fluores-

cent Red805

(4) Narcotics with subgroup Antago-

nists – 297 Blue

(5) Major Tranquillisers – Salmon 156

(6) Vasopressors with subgroup Hypo-

tensive Agents – 256 Violet

(7) Local Analgesics – 401 Grey

(8) Anticholinergics – 367 Green

(9) Other Agents – Transparent White

There is one addition that should be

motivated for this code. It is the

inclusion of a barcode identifier of the

drug beneath the printed name. This

allows the drug to be read into a

computer record when the syringe is

attached to an injection port. Such an

input terminal can detect syringe size

and plunger travel, so marking the time

and dose injected.

It is intriguing that an idea that seems

to be widely favoured has taken so long

in becoming almost accepted, despite

lawyers breathing down the necks of

those who have once slipped. In part

this appears to be due to commercial

opposition from drug companies who

object to their livery colours being

submerged beneath a common code

colour. It would, in fact, be a great and

positive contribution to patient safety if

each manufacturer included with pack-

age insert, enough syringe labels inten-

ded for use in operating theatres and

intensive care units.

P. Foster

Penn State College of Medicine,

PO Box 850,

Hershey, Pennsylvania 17033, USA

Reference1 Foster FA. Roelofse JA. Databook of

Anaesthesia and Critical Care. Berlin:

Springer-Verlag, 1987: 187–8.

Pain control in day-case surgery

We read with interest the recent article

on pain control in day-case surgery

(McHugh & Thoms. Anaesthesia 2002;

57: 270–5) and subsequent correspon-

dence (Montgomery & Donovan.

Anaesthesia 2002; 57: 727–8), and

would like to further contribute to this

discussion.

Pain in the immediate postoperative

period can be severe, requiring paren-

teral opioid administration. We have

recently started using intravenous fent-

anyl in such a situation. It not only has

the theoretical advantage of faster onset,

but also a shorter duration of action.

This means that if a patient is comfort-

able in the day unit, having been

established on oral analgesia, they are

less likely to benefit from residual

parenteral opioids, whose effect will

decline at home. In addition, a pros-

pective double-blind randomised trail in

day-surgery has shown a decreased

incidence of postdischarge nausea and

vomiting when compared to morphine

[1].

We have been administering fenta-

nyl in two recovery units within our

trust, using a nurse-directed protocol

(Fig. 7), which is based on that des-

cribed by Gould et al. [2]. As part of

an introductory audit of its use, we

studied 40 patients (ASA I-III) under-

going gynaecological, orthopaedic and

general surgery as day case procedures.

In 37 cases, a reduction in pain scoring

to satisfactory was obtained with

100 lg or less (median 100 lg; mean

73 lg). Three patients, all undergoing

laparoscopic sterilisation, required fur-

ther doses, up to a total of 200 lg.

One patient developed hypotension,

and one was over sedated (both

received 100 lg). Each of these prob-

lems was short-lived and resolved in

the recovery room. A total of 10

patients developed nausea or vomiting

in recovery, although two of these

were vomiting prior to fentanyl ad-

ministration.

Figure 7 Protocol for the Nurse Administration of Fentanyl in Recovery.



From this data, together with feed-

back from recovery staff, we believe

that the use of protocol-led, nurse-

administered fentanyl is a safe and

effective way of establishing early post-

operative analgesia in the day-surgical

setting. We are now in the process of

assessing whether the predicted postdis-

charge benefits are realised. Addition-

ally, it may be possible to improve

outcomes further. Firstly, by reducing

the time interval between doses to

3 min (as suggested by the pharmaco-

kinetic profile of fentanyl), and secondly

by adopting a similar protocol for anti-

emetic use [3].

D. S. Earl

S. Grimes

S. M. Kinsella

Bristol Royal Infirmary,

Bristol, UK.


References1 Claxton AR, McGuire G, Chung F,

Cruise C. Evaluation of morphine

versus fentanyl for postoperative anal-

gesia after ambulatory surgical proce-

dures. Anesthesia and Analgesia 1997; 84:

509–14.

2 Gould TH, Crosby DL, Harmer M,

Lloyd SM et al. Policy for controlling

pain after surgery: effect of sequential

changes in management. British Medical

Journal 1992; 305: 1187–93.

3 Paech MJ, Pavy TJ, Kristensen JH,

Wojnar-Horton RE. Postoperative

nausea and vomiting: development of a

management protocol. Anaesthesia and

Intensive Care 1998; 26: 152–5.

Postoperative cough-inducedrecurrence of spinal anaesthesiain the parturient

The literature documenting recurrence

of spinal anaesthesia is limited to one

case report [1]. We report a similar case

(and the first in association with preg-

nancy) documenting recurrence of spi-

nal anaesthesia in a parturient following

uneventful spinal anaesthesia with

lidocaine for an immediate postpartum

bilateral tubal ligation (BTL).

A 29-year-old, 162 cm, 68 kg, grav-

ida 3, para 3, healthy female in the

immediate postpartum period, following

an uneventful vaginal term delivery

without anaesthesia, required anaesthe-

sia for a BTL. A 1000-ml preload of

lactated Ringer’s solution was given and

a spinal block with 85 mg of 5%

lidocaine and 10 lg of fentanyl was

induced in the sitting position (L2-L3

interspace) with a 25 gauge Pencan

needle on the first attempt. A T4 sensory

pinprick level was established, the BTL

was uneventfully accomplished and the

patient was taken to the postanaesthesia

care unit (PACU) 65 min after the

induction of spinal anaesthesia. At

95 min after induction of spinal anaes-

thesia (patient in the PACU), the block

had receded to a L5 pinprick level. At

107 min post spinal anaesthesia, follow-

ing an episode of coughing while breast-

feeding the baby, the patient reported

‘recurrence of bilateral leg heaviness’.

Indeed, repeated pinprick testing now

revealed a T9 sensory level. The block

receded again over the next 50 min.

MRI of the thoracolumbar spine (to rule

out haematoma) was normal. Her fur-

ther hospital course was uneventful.

Sacral pooling of hyperbaric lidocaine

has been associated with transient rad-

iculopathy and cauda equina syndrome.

Donielson et al. has concluded that

retching can cause sudden remixing of

hyperbaric lidocaine that has pooled in

the sacral area with the rest of the

cerebrospinal fluid (CSF), which then

results in the recurrence of spinal

anaesthesia [1]. We speculate that sim-

ilar mixing of CSF associated with

position changes while breastfeeding

and an episode of coughing in our

patient caused circulation of the CSF so

that lidocaine pooled in the dependent

sacral dural sac mixed with the rest of

the CSF and resulted in the recurrence

of a high spinal block.

We believe that this case is a good

example of a Valsalva manoeuvre-

induced circulation of the CSF so that

previously pooled hyperbaric local

anaesthetic in the sacral area suddenly

mixes with virgin CSF resulting in the

recurrence of a high spinal block.

K. M. Kuczkowski

J. L. Benumof

University of California San Diego,

San Diego, California, USA,


Reference1 Donielson DW, Palmen BD. A case of

reappearance of spinal anaesthesia.

Anesthesia and Analgesia 1994; 79: 811.

Post dural puncture headache

Professor Sprotte used his needles and

avoided radiological headaches for years

before his secret, the benefits on non–

Quinke tip needles, was revealed to

anaesthetists. The Neurology ward in

this hospital has a 50% spinal headache

rate in patients following diagnostic

lumbar puncture by junior doctors

who use 20 or 22 gauge Quinke tip

needles. Patients remain bed-ridden for

two days before going home, still with

postural headaches. Telephone calls to

other neurology wards in this area

revealed similar headache rates. No

age data was available

Could your readers, by gentle per-

suasion and teaching, try to change

practice and improve patient care?

Today’s lumbar puncture may be

tomorrow’s spinal or epidural anaes-

thetic on an unwilling patient.

M. J. Clark

W. F. S. Sellers

Pinderfields General Hospital,

Wakefield, UK

Hypno-analgesiafor a labouring parturient withcontra-indications to centralneuraxial block

A very anxious 21-year-old primagrav-

ida at 37 weeks gestation was referred

for anaesthetic advice regarding labour

analgesia three days prior to planned

induction of labour. Pregnancy Induced

Hypertension was being treated with

nifedipine and methyldopa, and a right

calf deep vein thrombosis (DVT) was

being managed with a heparin infusion.

The patient refused to consider epidural

catheter placement above an old surgi-

cal scar over the lumbar-sacral spine

from T9 to S3. Although other forms of

analgesia were discussed, the patient

remained extremely concerned about

her ability to cope with labour pain.

The patient and her partner stated their

willingness to try hypnosis when this

was raised as a possible analgesia



adjunct. Following hypnotic induction

in the presence of her partner and a

ward midwife, positive suggestions

were given regarding the forthcoming

labour as recommended by McCarthy,

Goldman, Waxman and Bejenke [1–4].

Post-hypnotic suggestions were also

given regarding the initiation of a

comfortable trance state following the

onset of regular uterine contractions.

The rest between contractions was

emphasised. The stretching of the peri-

neum at delivery was used as a post

hypnotic suggestion for deepening her

state of relaxation. On the following

day, ego strengthening suggestions were

reinforced during a further 20 min of

hypnosis. Following trance termination,

the patient was amnesic, looked very

relaxed and comfortable and had started

to feel more positive about her forth-

coming labour.

On arrival at the labour ward, the

patient demanded a Caesarean section

for delivery. However, she eventually

agreed to allow induction of labour to

proceed. Soon after the onset of

uterine contractions, the patient ap-

peared to be sleeping with short

periods of arousal. Four hours after

commencing the oxytocin infusion,

the midwife was surprised to find the

cervix to be 8 cm dilated. Despite

offers of pethidine and fentanyl, the

patient insisted these weren’t required

but began using Entonox. Blood

pressure remained less than

130 ⁄ 80 mmHg throughout the 6 h

35 min labour. Anticoagulant therapy

was recommenced following unassisted

vaginal delivery of a 3450 g healthy

live male infant.

The patient stated at postnatal review

the next day that labour pain did not

exceed 6 ⁄ 10. She noted discomfort

with the initial few uterine contractions

and during pushing following full cer-

vical dilatation, but crowning of the

head was considered comfortable. The

initial anxiety on arrival to the labour

ward was probably secondary to inad-

vertently omitting posthypnotic sugges-

tions of relaxation on arrival in the

labour ward. Although an unusual

intervention in anaesthetic practice,

hypnotherapy may minimise the stresses

of labour and vaginal delivery. This

report challenges the assumption that

prolonged training antenatally or con-

tinuing support of a hypnotherapist

during labour is necessarily required [5].

A. M. Cyna

Women’s and Children’s Hospital,

Adelaide, SA 5006, Australia,


References1 McCarthy P. Hypnosis in Obstetrics

and Gynecology. In. The Use of

Hypnosis in Surgery and Anesthesiology:

Psychological Preparation for the Patient.

Fredericks, LE. CC Thomas., eds.

Springfield Illinois: WW Norton 2001,

163–211.

2 Goldman L. Childbirth suggestions. In.

Handbook of Hypnotic Suggestions and

Metaphors. Hammond DC., eds.

London: WW Norton 1990, 278.

3 Waxman D. Management of antenatal

hypnotic training. In: Handbook of

Hypnotic Suggestions and Metaphors.

Hammond DC, eds. London: 1990,

WW Norton, 279–81.

4 Bejenke CJ. Obstetrics. In. Hypnosis and

Suggestion in the Treatment of Pain: a

Clinical Guide. Barber J., eds. London:

WW Norton 1996, 250–5.

5 Minnich ME. Childbirth preparation

and nonpharmacologic analgesia. In:

Obstetric Anesthesia, 2nd edn. Chestnut

DH ed. New York: Mosby 1999,

336–45.

Scary white stuff

It is common practice following epidu-

ral analgesia to assess the height of

sensory block with ethyl chloride spray.

Also, in eight years of anaesthetic train-

ing, I have never been involved in the

management of an epidural catheter in a

parturient with black skin.

Recently, on DGH-rotation, I was

on call for the maternity unit. One of

the women in labour was a 26-year-

old black African primagravida. On her

request, a colleague had already placed

an epidural catheter for pain relief. The

woman was known to have latent

syphilis and was on high dose intraven-

ous penicillin for that reason. I was

asked to give a top-up for a planned

forceps delivery. After introducing my-

self and assessing her motor function, I

took some ethyl chloride spray to test

for sensory block. It is my usual practice

to give an impression of cold by spray-

ing some of the vapour onto the

forearm and then proceed to test

my way up from the legs to the

abdomen. The light in the room was

dim but I noticed that the skin of the

arm had completely gone white! Closer

inspection of the abdomen revealed just

the same; the skin gave the impression

as if I just had poured out some bleach,

a rather frightening appearance. I have

tested ethyl chloride spray on my own

skin in the past and the slight change to

white did not normally last long and

seemed to be ‘rubbed off’ easily.

The drug information sheet for ethyl

chloride states that the skin turns pink,

then deep red and finally white. The

change from red to white may not

always occur. It certainly did in this

case! Also, there was no way to rub or

wipe it off. Consequently, I changed to

ice cube and cotton wool testing. After

an uneventful top-up, a healthy baby

was delivered. The skin remained

bleach-white for at least another

30 min. All I could do was try to

reassure the mother as well as I could,

certainly not the easiest job under the

circumstances. Then I was called away

to another emergency.

When I returned, the black skin

looked perfectly normal again. Not a

single trace of any of the scary white

discolouration to be seen.

The drug information sheet does not

mention black skin as a contraindication

to the use of ethyl chloride, nor does it

particularly warn of an exaggerated

response. According to the letter I

received from Roche Products Limited,

there appears to be no known difference

in Caucasian and coloured skin reac-

tion. The white skin deposit that occurs

is purely dead skin cells that have been

shed and become more obvious when

exposed to ethyl chloride. Whether the

marked and persistent discolouration in

this case was due to the concomitant use

of high dose intravenous penicillin or

because of underlying latent syphilis or

both remains a matter of speculation.

Nobody came to any harm but the

event definitely left me with a fright.



Any lessons to be learnt? Know your

basics well and always be prepared for

the unexpected.

A. Kopka

Western Infirmary,

Glasgow, UK

Email: [email protected]

‘Hold up’ and the gum elasticbougie

We report a case in which ‘clicks’ and

‘hold up’ were not useful in confirming

tracheal placement of a gum elastic

bougie.

A 77-year-old man presented for

elective stapling of a pharyngeal pouch.

Following induction of anaesthesia, a

grade 3 view was obtained at direct

laryngoscopy. A gum elastic bougie was

used to aid intubation. ‘Hold up’ was

noted but no ‘clicks’ were felt. A

tracheal tube was inserted over the

bougie and tracheal intubation was

confirmed with capnography.

We then considered that the combi-

nation of ‘hold up’ and no ‘clicks’ could

have occurred with the bougie inserted

in the pharyngeal pouch. Sellers and

Jones [1] described ‘clicks’ (the tracheal

rings as the bougie slides over them) and

‘hold up’ (as the bougie reaches the small

bronchi). Kidd and colleagues studied

the reliability of these signs [2]. ‘Hold

up’ was observed in 100% and clicks in

90% of tracheal placements. Both were

absent in all 22 oesophageal placements.

They suggested that ‘hold up’ might

occur with oesophageal placement of a

bougie in cases of oesophageal stenosis

or with cricoid pressure. It is possible

that hold up may occur in a pharyngeal

pouch and, depending on the size of the

pouch, it is feasible that this could occur

at a distance within the range 24–40 cm

described for ‘hold up’ in the trachea [2].

When ‘hold up’ occurs without

clicks, the anaesthetist should be aware

that ‘hold up’ can happen in the

oesophagus and that a pharyngeal pouch

is a potential cause of this.

L. E. Dagg

P. Jefferson

D. R. Ball

Dumfries and Galloway Royal Infirmary,

Dumfries DG1 4AP, UK

References1 Sellers WFS, Jones GW. Difficult tra-

cheal intubation. Anaesthesia 1986; 41:

93.

2 Kidd JF, Dyson A, Latto IP. Successful

difficult intubation. Use of the gum

elastic bougie. Anaesthesia 1988; 43:

437–8.

Development of the‘gum-elastic bougie’

Your correspondent (Toyoyama et al.

Anaesthesia 2002; 57: 932) seek infor-

mation about the development of the

‘gum-elastic bougie’. I have researched

this subject for a chapter ‘Intubation

techniques for unanticipated difficult

direct laryngoscopy: Stylets and intro-

ducers’ in a forthcoming book ‘Der

schwierige Atemweg, ed. Paschen and

Dorges’, to be published by Springer.

There is a historical explanation for the

inaccurate and confusing terminology

relating to the ‘bougie’. The ‘gum-elastic

bougie’ used so widely in the UK is not

made of gum-elastic, and is not used by

anaesthetists as a bougie (a device for

serial dilation of strictures). The so-called

‘bougie’ is an introducer and the product

used in the UK is described by the

manufacturers as an introducer. Before

introducers designed specifically to faci-

litate tracheal intubation were available,

anaesthetists would use whatever was

available in the operating theatre, often a

gum-elastic bougie.

Macintosh is given credit for the first

use of introducers to facilitate tracheal

intubation [1], and his publication was

followed by similar descriptions [2–4]

(although Duckworth used the term

stilette, she described use of a ‘gum

elastic olivary tipped bougie’). How-

ever, others were already using intro-

ducer techniques. For example, a

textbook published the year before

Macintosh’s description of the tech-

nique states in relation to passage of a

tracheal tube with the Macintosh lar-

yngoscope: ‘This is an easy matter when

a semirigid gum elastic catheter is

passed’ [5]. Use of the introducer tech-

nique did not become widespread until

the Eschmann introducer was available;

there is no mention of the technique in

the 1968 edition of ‘Lee’s Synopsis’ [6].

Some details of the development of

the Eschmann introducer are already

published [7] and I am grateful to Dr

Venn for further information. Dr Paul

Hex Venn, when a consultant in East-

bourne District General Hospital, acted

as anaesthetic adviser to Eschmann Bros.

& Walsh Ltd. of Shoreham-by-Sea.

Several of Dr Venn’s inventions were

successful for a number of years. One of

these, the Intravenn, was a self-sealing

LuerLok disposable valve for which

multiple uses were suggested. This

device was ahead of its time; modern

equivalents are widely used to allow

needle-free injections into cannulae.

One Friday afternoon in the early

1970s, Dr Venn considered the design

of a tracheal tube introducer. It had

long been recognised that angled (coude)

tips could help the user to steer devices

past obstructions, for example in ure-

thral catheterisation. Dr Venn was

familiar with the ‘Toronto catheter’, a

long, angled rubber suction catheter,

which he used for bronchial suction

during thoracic anaesthesia. Coude and

bicoude prototype introducers were

made, but the tip of the bicoude device

tended to double up on itself. The

superiority of the coude device was

clear and Eschmann accepted this design

in March 1973. Dr Venn’s introducer

went into production shortly thereafter.

It was called an ‘endotracheal tube

introducer’ when it was marketed by

Eschmann Bros. It is now called the

‘Eschmann Tracheal Tube Introducer’

and is marketed by Smiths Instruments

Medical Systems (Portex Ltd). There is

no doubt that the angled tip contributes

to the success of the device [8,9].

However, it differs from the introducer

used by Macintosh in design features

other that the angled tip. The material

probably contributes to its success. It

gives moderate stiffness yet holds a new

shape at body temperature. It is flexible

enough to follow a tortuous course but

to yield if pressed gently against soft

tissues. Perhaps even more important

than the material is its length. Early

introducers were relatively short, and

were passed with the tracheal tube as a

single unit, the tip of the introducer

protruding several centimetres beyond

the tip of the tracheal tube. Dr Venn



describes such a technique of using his

introducer [7]. However, the greater

length of Dr Venn’s introducer led to

development of a technique, described

in the manufacturer’s original literature,

of first positioning the introducer in the

trachea and then passing (‘railroading’)

the tracheal tube over the introducer

into the trachea. Initial passage of the

introducer alone probably uses its char-

acteristics to their best advantage as

gentle passage allows verification

[10,11] of blind placement in the

trachea, and the angled tip and narrow,

flexible nature of the introducer con-

tribute to successful entry into the

trachea.

Dr Venn’s contribution, much greater

than the angled tip alone, has never

been properly recognised. Dr Venn is

now 80 years old, but he has accepted

our invitation to be a guest at the

Difficult Airway Society meeting in

Glasgow in December 2003. A guest

lecture on the ‘bougie’ is planned for

that meeting.

J. J. Henderson

Western Infirmary,

Glasgow G11 6NT, UK

References1 Macintosh RR. An aid to oral intuba-

tion. British Medical Journ 1949; 1: 28.

2 Barnard J. Difficult intubation. Anaes-

thesia 1952; 7: 119.

3 Alsop AF. Non-kinking endotracheal

tubes. Anaesthesia 1955; 10: 401–3.

4 Duckworth SI. The Oxford non-

kinking endotracheal tube. Anaesthesia

1962; 17: 208–14.

5 Minnitt RJ, Gillies J. Textbook of anaes-

thetics. 7., eds. Baltimore: The. Williams

& Wilkins Co. 1948.

6 Lee JA, Atkinson RS. A synopsis of an-

aesthesia. 6., eds. Bristol John Wright and.

Son Ltd 1968.

7 Venn PH. The gum elastic bougie.

Anaesthesia 1993; 48: 274–5.

8 Mushambi MC, Iyer GA. Gum elastic

bougies. Anaesthesia 2002; 57: 727.

9 Sellers WFS. Gum elastic bougies.

Anaesthesia 2002; 57: 289.

10 Sellers WFS, Jones GW. Difficult tra-

cheal intubation. Anaesthesia 1986; 41:

93.

11 Kidd JF, Dyson A, Latto IP. Successful

difficult intubation. Use of the gum

elastic bougie. Anaesthesia 1988; 43:

437–8.

Gum elastic bougies

In response to the query of your

correspondent (Toyoyama et al. Anaes-

thesia 2002; 57: 932) the angled tipped

bougie was of course derived from the

hollow bicoude catheter of the same

material, used by urologists. They came

in a variety of sizes unlike the anaes-

thetic version. Dr Bill Wilkinson, at the

Whittington Hospital in 1975, used to

tie two together end to end with a silk

thread. This was then long enough even

to use with double-lumen tubes.

M. J. Boscoe

Harefield Hospital,

Harefield UB9 6JH, UK

Remifentanil infusion ratecalculation

Remifentanil is a short acting intraven-

ous opioid gaining widespread use. The

dose of remifentanil when used as an

infusion is calculated in lg.kg)1.min)1.

Certain infusion pumps can calculate

the rate in ml.h)1 when the concentra-

tion of the drug and the dose required

are entered. When you do not have one

of these clever pumps, you need a

calculator or one of the infusion rate

tables supplied by Ultiva. Alternatively,

you could ‘fly by the seat of your pants’

and adjust the infusion rate based on

your experience and the patient’s

response. Here is a simple method to

quickly calculate the dose in ml.h)1

mentally.

Step 1: Approximate the patient’s weight

to the nearest l0 kg

Step 2: Divide by 10

Step 3: Multiply the result by 6

Step 4: Now divide the product by 5

This gives the rate in ml.h)1 for

0.1 lg.kg)1.min)1 when the concentra-

tion of remifentanil in the syringe is

50 lg.ml)1. From this, 0.05, 0.15, 0.2.,

etc. lg.kg)1.min)1 can be easily calcula-

ted for that patient. For example, in a

72-kg patient, 70 ⁄ 10 ¼ 7, 7 · 6 ¼ 42

and 42 ⁄ 5 ¼ 8.4. Hence, for

0.1 lg.kg)1.min)1, an infusion rate of

8.4 ml.h)1 is necessary. When using the

more concentrated remifentanil infusion

of 100 lg.ml)1, the calculation is even

simpler. Step 4 will then be division of

the product by 10 instead of 5.

Although it seems like hard work,

when used regularly one can get very

comfortable with this calculation. It is

essentially a simplification of the proper

calculation itself. It is not very accurate

as there is an approximation of the

patient’s weight. Anaesthetists who use

remifentanil on an occasional basis need

to remember all the variables, especially

drug concentrations before applying the

formula. I have used this formula hun-

dreds of times and find it very useful.

Even when using an infusion pump that

can calculate the rate, it is worthwhile

doing as a quick mental check that the

pump-calculated infusion rate is correct.

Certainly on one occasion, I found the

pump-calculated rate to be too high.

When the pump was checked, it came

to light that it had been accidentally set

in 0.1 mg.kg)1.min)1 instead of 0.1 lg.

kg)1.min)1 by my junior colleague. An

impending critical incident was averted.

If you would rather search for a calcu-

lator then remember that regular mental

maths can delay Alzheimer’s.

S. Chelliah

Glenfield Hospital,

Leicester LE3 9QP, UK

An unusual problem with pulseoximetry

An unusual problem occurred with an

elderly gentleman presenting for repair of

his fractured neck of femur. Although he

suffered from moderately severe demen-

tia, he was calm and co-operative enough

to undergo spinal anaesthesia plus seda-

tion with midazolam 1 mg.

All was progressing well until the

pulse oximetry trace went flat. The

probe could not be found on either

hand, and frantic rummaging under the

blankets also failed to locate it. I traced

the lead along from its source right to

the patient’s mouth, only to discover

that he had in fact eaten it! Having

secretly slipped the probe off his finger

he had proceeded to swallow it and the

red light could now be seen glowing in

his throat.

He appeared to be significantly less

troubled by this than me, who was torn



between the embarrassment of an ENT

referral and the horror of explaining to

the Clinical Director how I had man-

aged to lose an expensive piece of

equipment. Fortunately, the probe was

retrieved by hauling on the cable and

with the aid of much yelling at the

gentleman to open his mouth. He had a

good go at biting through the lead with

his few remaining teeth but no one came

to any harm, not even the orthopaedic

surgeon who laughed rather more than

was good for him. The pulse oximeter

also still appeared to be functional,

although we didn’t let him have it back!

I expect whilst some of my more

serious colleagues may want to debate

the potential for deliberate self-harm

offered by our monitoring, the more

cynical amongst us may reflect that

whilst the standard of hospital food

remains so poor, the gentleman may

simply just have viewed the oximeter as

a more palatable option.

R. Spencer

Redland

Bristol BS6 6SA, UK


Erratum

The use of anaesthetic rooms for induction of anaesthesia: a postal survey of current practice and attitudes in Great Britain and

Northern Ireland. Anaesthesia 2002; 57: 850–54.

The column headings were incorrectly transposed in the second question of Table 2, please note the correct version below:

Training in airway management. Anaesthesia 2002; 57: 967–83.

Please note that the following two references were incorrectly cited in the above article, they should have appeared as

follows:

Page 976, row 14 – reference 88 should have read 93

Page 979, row 14 – reference 101 should have read 106

The use of the laryngeal mask airway in maxillofacial surgery. Anaesthesia 2002; 57: 826.

In the above correspondence an unfortunate spelling mistake occurred which altered the meaning of the letter. The opening

sentence should read:

We read with interest the case report (Wilson et al. Anaesthesia 2002; 57: 190) in which the cuff of a laryngeal mask airway

was seen intruding into the surgical field during the removal of a branchial cyst in a female patient.

Table 2 Survey results of attitudes and opinions regarding use of anaesthetic rooms. Results are numbers of respondents (%).

In your opinion, what are the effects on the following, of inducing all patients in theatre, as compared with in the anaesthetic room?Anaesthetic Room Group In-Theatre GroupBetter Worse Same Better Worse Same

Efficient running of the list 19 (8.0) 173 (73.0) 43 (18.1) 1 (10) 5 (50) 4 (40)Patient anxiety* 9 (3.8) 159 (67.1) 65 (27.4) 0 (0) 3 (30) 7 (70)Patient safety* 85 (37.6) 15 (6.3) 129 (54.0) 9 (90) 0 (0) 1 (10)Teaching environment* 20 (8.4) 150 (63.3) 64 (27.0) 3 (30) 2 (20) 5 (50)* Anaesthetic Room Group believe in-theatre induction results in increased patient anxiety (p ¼ 0.018), worse teaching environment (p ¼ 0.015)and no improvement in patient safety (p ¼ 0.001) in comparison with In-Theatre Group.



Documents

A case for ‘doing it in theatre’