OCTOBER 2015 INSIDE THIS ISSUE:

ISSN 0959-2962 No. 339

OCTOBER 2015

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

INSIDE THIS ISSUE: Controlled drugs Addiction in anaesthesia – a personal perspective

Successful leadership and management in the NHS

A Silver Lining Through the Dark Clouds Shining: the Development of Anaesthesia During the First World War

Missed the AAGBI Annual Congress?Video lectures now available on Learn@AAGBI

Visionary.Bringing advanced ultrasound to the bedside.

FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners. ©2015 FUJIFILM SonoSite, Inc. All rights reserved. 2170 07/15

Improve quality of care, efficiency, patient safety, patient satisfaction, and reduce complications and costs.

To learn more about SonoSite Point-of-Care Ultrasound Solutions or request a product demonstration email us at [email protected] or visit www.sonosite.co.uk

The Value of Visualisation

www.sonosite.co.uk www.sonosite.co.uk/education

Anaesthesia News October 2015 • Issue 339 3

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contents03 editorial 04 President's report

07 importance of the human touch 08 A silver lining Through the dark clouds shining: the development of Anaesthesia during the first world war 10 wsM london 2016 12 i, Anaesthetist 12 Book review: The 5-Minute Anesthesia consult 13 AAGBi wylie medal runner-up essay 2015: safety in numbers 16 controlled drugs 18 Addiction in anaesthesia – a personal perspective 21 safety Matters 23 Anaesthesia digested 24 successful leadership and management in the Nhs 26 Particles 28 Your letters

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The Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London W1B 1PYTelephone: 020 7631 1650Fax: 020 7631 4352Email: [email protected]: www.aagbi.org

Anaesthesia NewsManaging Editor: Upma MisraEditors: Phil Bewley (GAT), Nancy Redfern, Richard Griffiths, Sean Tighe, Tom Woodcock, Mike Nathanson, Rachel Collis, Felicity Platt and Gerry KeenanAddress for all correspondence, advertising or submissions: Email: [email protected]: www.aagbi.org/publications/anaesthesia-news

Editorial Assistant: Rona GloagEmail: [email protected]

Design: Chris SteerAAGBI Website & Publications Officer Telephone: 020 7631 8803Email: [email protected]: Portland Print

Copyright 2015 The Association of Anaesthetists of Great Britain and Ireland

The Association cannot be responsible for the statements or views of the contributors. No part of this newsletter may be reproduced without prior permission.

Advertisements are accepted in good faith. Readers are reminded that Anaesthesia News cannot be held responsible in any way for the quality or correctness of products or services offered in advertisements.

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Editorial

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As I write this in the third week of July, the news silly season appears to be upon us. The Medical Director of NHS England made the headlines in the Sunday Telegraph with the tired old factoid that up to 15% of the treatments provided by the NHS lack evidence of benefit. I am disappointed that a fellow Charing Cross Hospital Medical School alumnus should describe this as profligate waste and an unwarranted risk to patients. To note that 15% is about par for all the western health services did nothing to change my view that Professor Keogh is attempting to soften us all up for news of service cuts to come as the financial vice tightens. The Good Thinking Society (http://goodthinkingsociety.org) has had to threaten legal action to persuade the NHS to stop spending up to £5 million per annum on homeopathy. Acupuncture is widely prescribed within the NHS at an estimated cost of £25 million per annum.1 How do you set budgets for placebo therapies?

Then the Secretary of State for Health railed against consultants who are causing 6,000 deaths per annum by not working for standard rates at weekends and bank holidays.2 We are fortunate to have our anaesthetist colleagues Dr Mark Porter and Dr Tom Dolphin at the British Medical Association leading the consultant response to this ill-informed nonsense.

Then it became clear to me; Professor Keogh and the SoSH were grabbing the headlines in order to obscure the damning Lord Rose NHS Report that puts no feathers in their caps.3 As Rose discovered, the committed and passionate workforce of nearly 1.4 million people are often working on good will in a tough environment. Through no fault of their own, they are often ill-equipped to deal with the rapid changes being expected of them, and are let down by poor management and excessive bureaucracy. Rose prescribes some commonsense solutions.

It is timely therefore to read in this issue of Anaesthesia News Drs James and Heinink’s report of an interview with their Chief Executive at Nottingham, Professor Peter Homa CBE, one of the major shapers of current NHS management. Worries about our own health service are put into perspective with reports of the successful international use of equipment designed by Drs Fenton and Eltringham. I couldn’t resist offering you a label and an ampoule anecdote as I move on from the Safety Chairmanship, and finally a poem to remind us that our everyday practice delves deep into the unresolved mysteries of consciousness.

Tom woodcockAAGBI Council Member

References1. What’s the point of acupuncture? Daily Mail 14 September 2013. http://www.

dailymail.co.uk/health/article-2420717/Whats-POINT-acupuncture-It-costs-NHS-25million-promises-cure-morning-sickness-ache--just-placebo.html (accessed 20/07/2015)

2. Jeremy Hunt: Doctors ‘must work weekends’. BBC News 16 July 2015. http://www.bbc.co.uk/news/health-33542940 (accessed 20/07/2015).

3. Lord Rose. Better leadership for tomorrow. NHS Leadership Review. June 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445738/Lord_Rose_NHS_Report_acc.pdf (accessed 20/07/2015).

disclaimerThe views expressed above are those of Dr Woodcock and not those of the AAGBI.

Visionary.Bringing advanced ultrasound to the bedside.

FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners. ©2015 FUJIFILM SonoSite, Inc. All rights reserved. 2170 07/15

Improve quality of care, efficiency, patient safety, patient satisfaction, and reduce complications and costs.

To learn more about SonoSite Point-of-Care Ultrasound Solutions or request a product demonstration email us at [email protected] or visit www.sonosite.co.uk

The Value of Visualisation

www.sonosite.co.uk www.sonosite.co.uk/education

Course features: Live theatre link demonstrating techniques of upper limb blocks

Small group workshops on scanning techniques on human models

Practical hands-on training in probe handling and needling techniques on animal models and gel-phantoms

thursday 26 November 2015royal Derby Hospital

We work on the premise “the right block in the right place works every time!”the programme is dedicated to upper limb regional

anaesthesia with an emphasis on practical, hands-on ultrasound training experience.

12th royal Derby Hospital upper Limb regional anaesthesia Course

Course Organisers: Dr Adrian Searle and Dr Zahid SheikhApplication forms and more information from:Course secretary Mrs. Shirley [email protected] tel. 01332 787195Royal Derby Hospital, Anaesthetic Office, Uttoxeter Road, Derby DE22 3NE

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the leading centre in the delivery of awake upper limb regional anaesthesia in the uK presents:

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Course fee: £150

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13 Oct 2015Venue: Medical Education Training Centre, Kirklands Hospital, Fallside Rd, Bothwell, Glasgow, G71 8BB

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What you need to know about safe Airway ManagementFollowing on from the very successful National Audit Project 4 (NAP4), Airway Leads Day, and several new ‘Airway’ guidelines, Difficult Airway Society is pleased to announce the second of a series of Airway Revalidation Courses to be held on 13 Oct 2015. The course is specifically designed to meet the airway CEPD requirements of UK Anaesthetists.

It benefits from DAS standardisation, peer review and quality control. It is based on latest evidence and draws upon the experience and consensus of experts in airway management. DAS experts and high profile airway trainers have developed the full day course consisting of up-to-date lectures on various aspects of airway management which include

• Airway Assessment• Decision making in Airway management • Choosing The Right Equipment• Managing The Correct Technique• Extubation • Human Factors and Non Technical Skills• Airway management outside theatre environment

The Course is specifically designed to meet the Airway CPD requirements of UK anaesthetists.

CPD approved meeting5 CPD points

Local coordinator - Dr Raj Padmanabhan, Consultant Anaesthetist, NHS Lanarkshire

Anaesthesia News is the official magazine of the Association of Anaesthetists of Great Britain & ireland.

Anaesthesia News now reaches over 10,700 anaesthetists every month and is a great way of advertising your course, meeting, seminar or product.

For further information on advertising

Dr Les GemmellImmediate Past Honorary Secretary

21 Portland Place, London W1B 1PYT: +44 (0)20 7631 1650F: +44 (0)20 7631 4352E: [email protected]

W: www.aagbi.org

Tel: 020 7631 8803or email chris steer: [email protected]

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PRESIDENT'S REPORT


Because of the print schedule for Anaesthesia News I would normally be writing the President’s Report for the October issue about now. However because this issue is so vital to the overwhelming majority of AAGBI members, and so urgent, I am releasing this report early, direct to the members via the website, although an expanded print version of the report will still appear in October's edition. The AAGBI Board has approved the official response to the DDRB Report, which will be released at the same time as this report, which represents my own interpretation of events and their implications. Inevitably when representing almost 11,000 members, and 16% of NHS consultants, not every member will agree with my interpretation.

Although not party to contract negotiations, the AAGBI has engaged throughout with the DDRB, and I am pleased to note that the AAGBI’s contributions were acknowledged within the DDRB report (more than any other ‘staff side’ organisation apart from the BMA), particularly in areas such as fatigue, ageing and wellbeing.

The AAGBI is committed to achieving the highest standards of patient care, and entirely agrees that those patients who need a consultant should have one, but it is a gross oversimplification to suggest that all that is needed is increased consultant presence on Saturday and Sunday when access to diagnostic laboratory and imaging services is reduced, when discharge planning goes on hold, when pharmacy services cease, and diagnostics, catering, therapies, cleaning and portering services are all run at a lower level. A seven-day NHS requires appropriately funded expansion in all of these services (together with primary and social care) and must recognise that those who work Saturday and Sunday (and all seven nights) will not also work Monday to Friday 8–6 – without investment and expansion the services will be stretched. Seven-day services for the NHS cannot mean individual consultants working all seven days.

Contract renegotiation must go hand-in-hand with intelligent workforce planning and service reconfiguration. Anaesthesia has been at the forefront of recognising the significantly improved patient outcomes for specialist services in units with higher caseloads (trauma, vascular, paediatrics, cardiac). It is time for ministers to be honest with the public – not every hospital can provide every service, and they should be as honest with their own constituents as they are with the whole electorate.

I wanted to comment not only on the DDRB report, which on the whole was balanced and reasoned, but also on the resultant Government response and ensuing reports in the media. It is disingenuous for elected holders of High Office of State to seek to blame the core workforce of the NHS for a lack of professionalism,

or for being responsible for excessive deaths, when that is not what the evidence supports.

The BMA Junior Doctors Committee (JDC) has voted not to re-enter contract negotiations, and I understand the anger and frustration that led to this decision. I have already seen some detailed economic modelling suggesting that anaesthetic trainees would come off significantly worse from some of the DDRB proposals. I would urge consultant colleagues, and the BMA Consultant negotiators, to consider carefully whether following the JDC’s lead is also appropriate for the Consultant contract. My own view is that any negotiated contract must be better than one that is imposed, and history suggests we will have to live with whatever contract results for a very long time. We must acknowledge the current parliamentary strength of the government, but I believe this is when the political quality and character of the Government will emerge. If the Government engages with consultants, most of whom will work for the NHS for an entire career of 30–40 years (compared with the average few years in office of a minister), and without whom no reform of the NHS can be successful, it can achieve great things. If it chooses to impose change, despite the evidence and ignoring the expertise of the only people who can deliver healthcare, it risks a loss of confidence and respect which will take generations to recover; if the NHS as we know it can survive long enough to permit that.

I’m inclined to be an optimist so I believe the next few months present a generational opportunity to improve emergency and urgent care for hospital medicine in the NHS to a level that will truly be the envy of the world; a chance to implement all the changes needed to deliver world class seven-day emergency care. The next step of achieving seven-day elective care will require massively increased investments in people, infrastructure and money. My view would be that the Government should prioritise those goals that are achievable within (or almost within) the current NHS budget, and prepare those other changes for a time when the country can afford it.

At this stage in a broadcast programme, you would hear the voiceover ‘If you have been affected by this programme, please contact the support number on…’ At this stage in the negotiations, what is unknown is how many of us will be affected to what extent. I do not envy the BMA its task of negotiating, particularly when it is being asked to negotiate with so little detail.

As (if?) the detail becomes clearer, the AAGBI will update its members on how it believes it will impact on them. In the meantime, if you have been, or will be affected, please contact [email protected]

The single most important issue facing members of the AAGBi (apart from consultants in scotland, and members in ireland, who have already been through contract turmoil) is the doctors and dentists review Body (ddrB) report into consultant and trainee contracts, and the Government’s response to it.

AAGBI Foundation: Registered as a charity in England & Wales no. 293575 and in Scotland no. SC040697Lifebox: Registered as a charity in England & Wales (1143018)

The target: The AAGBI wants to raise £96,000 which will buy 600 Lifebox Pulse Oximeters over the next 2 years - the same as the number of Team GB athletes attending the Olympic and Paralympic Games in Rio de Janeiro in 2016.

The aim: To save thousands of lives around the world where patients are at risk of death from hypoxia.

Help us to reach the target! Join the campaign and become a Lifeboxes for Rio fundraiser

Bake, bike ride, run or walk – or devise your own fundraising concept.

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Rio_Poster.indd 1 19/01/2015 10:31

Much of the preceding Report was made available online almost two months ago, as it seemed to me that the topic under discussion (contracts) was important enough not to await the print timeline of Anaesthesia News. In doing so however I confirmed that these Reports are (of course) written sometime before they are read, and that I, like most Presidents before me, had employed the sophistry of describing events as having being successful when they had yet to occur!

By the time this Report finally appears in print, no doubt we will know much more about the state of contract negotiations (on non-negotiations) but until then let me comment on other recent (or future!) events. Re-reading my last report (written in June, published in August) is slightly un-nerving. Almost everything I wrote about has happened, or is about to. The ‘emergency budget’ did indeed announce particularly bad news about pensions for most NHS Consultants.1 The PA(A) debate has taken up more time at the AAGBI Board in recent months than any other issue at any other time that I can remember. One member has resigned (again for the first time I can remember) over their perception of the AAGBI’s policy towards PA(A)s – this was particularly disappointing to me as the AAGBI had yet to agree its policy.

Not all recent events have been gloomy. I’m delighted that the AAGBI Foundation, in partnership with the WFSA and local partners has been successful in both THET grants it applied for from the Department for Overseas Development. This is particularly exciting news for many reasons. First, it’s

fantastic news for anaesthesia in Uganda, Kenya, Ethiopia, Malawi, Zambia. Second, it’s independent recognition of the tremendous work done already by the AAGBI Foundation and its International Relations Committee (and particular recognition of Isabeau Walker, Rachel Collis and Karin Pappenheim at AAGBI). Finally it gives the opportunity for further expansion of the AAGBI’s work in this field; up to now we have been dependent on our own income to fund this work, this is the first time we have brought in external funding. This also illustrates that even when Government intentions close to home may not always be supported by the AAGBI and its members, there are areas where we can work together effectively to achieve some our aims and objectives.

And so following what was (or what I’m sure will prove to be!) another highly successful Annual Congress in Edinburgh, I start my second year as President as excited by the role as I was in my first year, looking forward to a busy diary, but reassured that I am supported by an outstanding Board, extremely capable staff, and almost 11,000 members.

Andrew hartle President, AAGBI

Reference1. Pensions taxation – summer budget 2015. http://bma.org.

uk/practical-support-at-work/pensions/summer-budget-2015-taxation (accessed 26/8/2015).

Anaesthesia News October 2015 • Issue 339 7 Anaesthesia News October 2015 • Issue 339 7

Once upon a time there was a happy farmer who looked after a herd of cows. He had milkmaids to lead the cows in from the fields to the cowshed twice a day for milking. In the milking parlour there were big metal machines which the happy farmer attached to their udders. This always made the cows restless and distressed so the milkmaids sang softly to them and coaxed them gently into place with laughter and kind words. Then, with firm fingers, the milkmaids held the teats in the best position for the farmer to connect the attachment. This would prevent them from wobbling about and slipping out of position. The cows hardly noticed what was going on and let down their milk gratefully so that it flowed quickly and the farmer was happy in his work. In fact everybody was happy on the farm. The milkmaids sang and put flowers in their hair, the cows became the most productive in the land and the farmer was content. Then one day a dark cloud settled over the farm. An important dignitary arrived from the palace and said the way they were milking was old fashioned. There was a new way of working from the common agricultural committee. She was the Cynical Government Dictator and she announced that in future the milkmaids were not allowed to hold the cows’ horns to reassure

them or to squeeze the teats for the farmer to connect. In future, instead of the milkmaids’ gentle fingers, the famer would have to use a bit of string which he could hold in his teeth while connecting the milking machine. This made the farmer’s job a lot more awkward and less pleasant for the cows. He needed three hands and when the cows pulled away just at the wrong moment some of the precious milk spilled onto the floor. The milkmaids stopped singing and the cows ran off. The farmer was cross and protested to the Milk Marketing Board saying the old ways were better and the cows preferred the human touch to the tight string. However the cynical governess was adamant about the new rules and added that anyone breaking them would be severely punished. The farmer was no longer happy and the farm became a stressful place to work. Production fell and the farmer wondered why he had gone into dairy farming in the first place, and whether he would be better off as a management consultant.

Patrick strubeIndependent Consultant, Thames Valley

Importance of the human touch

8 Anaesthesia News October 2015 • Issue 3398 Anaesthesia News October 2015 • Issue 339


Marshall vs Boyle: who developed the machine?The First World War was the first major war where spinal anaesthesia was employed (using Stovaine) and in which nitrous oxide was later extensively used for general anaesthesia. Early in the War, open-drop chloroform and ether were administered but with high mortality in shocked patients. Anaesthetists were advised to employ spinal anaesthesia with Stovaine (amylocaine), but Geoffrey Marshall, a physician, found that this also produced profound hypotension in patients with significant haemorrhage – and again the patients succumbed. It was found that the only suitable anaesthetic in these patients was ‘gas’ (nitrous oxide) and oxygen, which needed an anaesthetic machine for administration.1 The exhibition features the early prototypes for the anaesthetic machines used in the War: Gwathmey’s, Marshall’s and Boyle’s.

Edmund (‘Cocky’) Boyle, St Bartholomew’s Hospital, probably met the American James Tayloe Gwathmey at the 17th International Congress of Medicine held in London in August 1913. Through Boyle, two Gwathmey continuous flow anaesthetic machines were imported from the USA (apparently arrived in 1916) and were used at Barts. Boyle found problems with Gwathmey’s machine, especially in attaching British gas cylinders to American apparatus; so he began to modify it.2 Boyle (aged 42) presented a paper on the use of nitrous oxide and oxygen with rebreathing in military surgery at the 1st London General Hospital in 1917, acknowledging Gwathmey.3

In the meantime, Captain Geoffrey Marshall (aged 27) had gone to France with the Royal Army Medical Corps at the outbreak of the First World War. In the period up to 1917 he found that shocked patients did better with nitrous oxide and oxygen, compared with deep ether or spinal anaesthesia. He administered the nitrous oxide and oxygen with a Hewitt’s (dental) apparatus, though found it unsatisfactory for longer cases.4

Around May 1917, the allies in France were joined by American forces, including JT Gwathmey who used his machine at a Red Cross Hospital. After almost certainly meeting Gwathmey, Marshall designed apparatus based on Gwathmey’s. A tinsmith in France made a rough model, drawings of which Marshall passed to Coxeter who made a machine for him and also cut some printing blocks illustrating the details of the machine.5 According to an interview with Marshall (by Barbara Evans nearly 50 years later), he was urged by Coxeter to publish because Dr Boyle had borrowed the illustrative blocks and Coxeter was concerned that Boyle might publish these. Marshall said ’I didn’t mind because I wasn’t going to be an anaesthetist anyhow‘.6

The main advantage that both Marshall’s and Boyle’s apparatuses had over Gwathmey’s was in the use of Hewitt’s 3-way stopcock for gas delivery, as it helped to avoid rebreathing during maintenance.5

‘[There’s] A silver lining, through the dark clouds shining’ is from Keep the Home-Fires Burning, composed by Ivor Novello in 1914, with lyrics by Lena Gilbert Ford.

This was chosen as the title of the AAGBI Heritage Centre’s exhibition on the development of anaesthesia during the First World War, suitably marking the centenary of the outbreak of that war. The exhibition will be on display at WSM London 2016.

There will be a series of temporary exhibitions honouring the work of the doctors who gave anaesthesia and pain relief to wounded people during the First World War. The exhibitions, each lasting a year, will explore the development of anaesthesia and pain relief and how the status of anaesthesia changed during this time. The exhibitions will cover the following areas:

developments in the understanding and treatment of shock

2015–2016The Battle of the somme

2016–2017Magill and rowbotham and their contributions

2017–2018The theme of medical development through war is explored in oral history interviews. Doctors who have provided medical assistance in more recent conflicts have been interviewed and these interviews can be accessed via the AAAGBI’s website and give insights into the work of anaesthetists in conflicts such as the Falklands War and Afghanistan – http://www.aagbi.org/education/educational-resources/oral-history-project

Henry Edmund Gaskin Boyle Geoffrey Marshall


Boyle published his ‘Nitrous-oxide-oxygen-ether outfit’ under New Inventions in The Lancet of 8 February 1919, with ’thank(s) to Capt Geoffrey Marshall RAMC for many and valuable suggestions …’.7 Marshall did not publish details of his apparatus until 1920.8 Boyle subsequently made innovative modifications and developments – the name Boyle stuck and a series of machines evolved.

Marshall became a famous respiratory physician at Guy’s Hospital. Many years later (in 1942, after Boyle’s death, and 1974) he wrote letters to Sir Robert Macintosh and Dr Bryn Thomas, (copies in the Heritage Centre) which suggest he was disappointed by Boyle.9 This story tends to polarise anaesthetists and historians to support either Marshall or Boyle. Are we dealing with salutation of Marshall or slander of Boyle – you decide!

Visit and learn more…

The Anaesthesia Heritage Centre, AAGBI Foundation, 21 Portland Place, London W1B 1PY is open Monday to Friday 10am until 4pm (last admission 3.30pm). Appointments are recommended: email [email protected] or phone 0207 631 8865. Admission is free. Group visits for up to 20 people can be arranged at a small cost per person.

Alistair McKenzieConsultant Anaesthetist, Edinburgh (Hon Archivist)

Trish willisHeritage and Records Manager, AAGBI

sarah dixon-smithHeritage Assistant, AAGBI

References1. Restall J. Anaesthetics in British military practice 1914–18. In: Atkinson RS,

Boulton TB, eds. The History of Anaesthesia (Proceedings of the 2nd International Symposium on History of Anaesthesia). London: RSM Press, 1989; 192–5.

2. Wilkinson DJ. Henry Edmund Gaskin Boyle (1875-1941). In: Diz JC, Franco A, Bacon DR, et al. eds, The History of Anaesthesia (Proceedings of the 5th International Symposium on History of Anaesthesia). Amsterdam: Elsevier, 2002: 269–76.

3. Boyle HEG. The use of nitrous oxide and oxygen with rebreathing in military surgery. (Presentation to the Medical Society of London on 29 October 1917 with discussion). British Medical Journal 1917; ii: 653–5.

4. Marshall G. Anaesthesia at a Casualty Clearing Station. Proceedings of the Royal Society of Medicine 1916-17, Section of Anaesthetics; 10: 17–38.

5. Boulton TB. Sir Geoffrey Marshall, shock and nitrous oxide. Survey of Anesthesiology 1992; 36: 40–5.

6. Evans B. A doctor in the Great War – an interview with Sir Geoffrey Marshall. British Medical Journal 1982; 285: 1780–3.

7. Boyle HEG. Nitrous-oxide-oxygen-ether outfit. Lancet 1919; i: 226.8. Marshall G. Two types of portable gas-oxygen apparatus. Proceedings of the Royal

Society of Medicine 1919-20, Section of Anaesthetics; 13: 16–23.9. Zorab JSM. Sir Geoffrey Marshall (1887–1982): the early years. In: Drury PME et al.,

eds. The History of Anaesthesia (Proceedings of the 6th International Symposium on History of Anaesthesia). Reading: Conservatree, 2007: 439–46.



Boyle apparatus, 1917

James Tayloe Gwathmey

Marshall apparatus

Gwathmey apparatus

Hewitt’s regulating stopcock

10 Anaesthesia News October 2015 • Issue 339

13 -15 JANUARY 2016

We have gathered a wide range of topics and speakers from the UK, Europe and Australia. The WSM is a ‘one-stop-shop’ for all of your continuing professional development and educational needs in 2016. As ever there will be a range of social events, including a glamorous dinner and dance at the world famous Savoy Hotel, to give you the chance to meet friends and make new ones from the world of anaesthesia and beyond. With over 1000 delegates at last year’s WSM, registration filled up quickly, so we advise you to book your study leave and register now at the WSM London website, www.wsmlondon.org, to make sure you get your place and the workshops you want ahead of the pack. The meeting runs from Wednesday 13 until Friday 15 January 2016 in its usual venue, the QEII Centre, which is a mere stone’s throw from Big Ben and the Houses of Parliament in central London. There are a huge range of options for accommodation with preferential negotiated rates to suit all tastes and budgets. Please visit the WSM London website to view the hotels and rates on offer. London is an exciting and vibrant city to visit at any time of year so why not take the opportunity to come and join the fun.

So what of the programme? As promised we have put together a varied range of topics, providing something for everyone. We have keynote lectures from Sir Bruce Keogh, National Medical Director of NHS England, whose stated ‘number one priority’ is to introduce 7-day services in the NHS. The content of his lecture will no doubt be interesting and perhaps even a little contentious. We also have a keynote from another big hitter, Professor Dame Sally Davies, Chief Medical Officer of the Department of Health, who will speak on ‘The importance of research in the NHS’. Professor Steve Yentis will deliver his Featherstone Oration titled ‘Research

not Research’ and last but not least, Dr David Wilkinson, President of the World Federation of Societies of Anaesthesiology, will deliver the final keynote lecture. The core Topics themed day on wednesday 13 January includes lectures on many subjects such as: • Anaphylaxis – Dr Nigel Harper, NAP6 Clinical Lead• Peri-operative management of patients on oral

anticoagulants – Dr Henry Watson, the always entertaining haematologist, Aberdeen

• Top tips for the occasional obstetric anaesthetist – Dr Nuala Lucas

• Consent and the Duty of Candour – Dr Kate McCombe• How to manage the severely burned patient – Professor

John Kinsella• Ultrasound for all – Professor Colin Royse, Melbourne,

Australia • Stabilisation and transfer of the critically ill child – Dr

Richard Skone There are many other top quality sessions on the Thursday and friday on topics such as:• Hip Fracture – ‘The 5 Year Plan’. Dr Richard Griffiths is

organising this exciting and thought-provoking session to look at how and why we need to modify and improve our management of patients with hip fracture in the face of a projected doubling of cases by 2023

• What it Takes to Win. We are delighted to welcome Simon Dennis, who is a British Olympic gold medallist in rowing, to speak at this cracking session

The AAGBI’s WSM London 2016 at the QEII Centre in London promises to be another stunning, eclectic, contemporary and entertaining conference for anaesthetists to gather, learn, debate and network.



13 -15 JANUARY 2016

• The 21st century NHS. This session explores some exciting innovative new hospitals and services in the NHS. It may be a preview of how secondary and tertiary care is provided in the future

• Updated Guidelines on Blood Transfusion. This session will be presented by Dr Andy Klein and colleagues from the AAGBI Working Party

• Other new AAGBI guidelines on topics such as Vascular Access, Standards of Monitoring and Pre-Hospital care will also be previewed

• The new UK Resuscitation Council Guidelines will be showcased in a session organized by Dr Jerry Nolan, so this is a great chance to tick this box in your Personal Development Plan for 2016

• New ways of learning will be explored in the ‘Learning From...’ session

• Your chance to put some of the movers and shakers on the spot comes at the ever popular Question Time panel discussion with Dr Andrew Hartle, President, AAGBI; Dr Mark Porter, Chair, BMA Council; and Dr Liam Brennan, President, RCoA

we also have lots of workshops you can sign up to attend covering a wide range of areas of professional and clinical practice including: • Vascular Access – Dr Andrew Bodenham leads this

informative, and practical workshop• ‘How to publish a paper’ led by the team from Anaesthesia • Ultrasound in regional anaesthesia (organised by RA-UK) led

by Dr Morne Wolmarans

• Difficult Airways by the Difficult Airway Society team• Mentoring sessions led by Dr Nancy Redfern and her

excellent team of trained mentors

There will be interactive sessions themed on Innovation and Independent Practice and, after the Honours & Awards and Presidential Address by Dr Andrew Hartle, there will be a lively debate on ‘This house believes that difficult airway guidelines are more trouble than they're worth’ This is a subject close to all our hearts and will be a fitting climax to WSM London.

Trainees and SAS doctors – don’t forget our poster competition for your research, audit or quality improvement projects. You can also submit case report posters. The trainee lunch will again be hosted by the AAGBI Council. There will be a huge exhibition by the anaesthetic industry so grab your chance to see that latest bit of kit you fancy trying and then persuade your Trust to cough up.

There will be lots more happening but you will have to come along to experience the whole thing. I hope you can come to London in January; book that study leave now before all your colleagues beat you to it and you’re left back at base doing all the flexi lists and covering the on-call!

Matthew checkettsChair, Education Committee

The AAGBI’s WSM London 2016 at the QEII Centre in London promises to be another stunning, eclectic, contemporary and entertaining conference for anaesthetists to gather, learn, debate and network.


I, Anaesthetist I don’t want you to feel trepidationsimilarly, any anxietyRelax, I’ve come to explainHow with profound sedationI’ll drain your synapses of electricity,To create a state of dissociationYes it’s true, it’s what we doTemporarily abolish your sentience,Take over your physiologyUntil there’s not much left of you

And when you are where I need you to beI’ll stay with you, diligentlythrough Alpine fluctuations of muscle tone and circulationbelow raging tempests of nociceptionof which you’ll have no recollectionAs I said, you will be fineI’m out of sight, you’re out of mind

And when the filleting is doneand suturing, and cauteryI’ll bring you’re back up from the abyssbut you’ll have no idea of thisand you’ll open eyes, without pain and ask have you had your surgery?as recovery nurses say your nameand offer you a cup of tea

Michael duncanConsultant in Anaesthesia Guys and St Thomas' NHS Foundation Trust

Book Review

This book is from the popular series The 5-Minute Clinical Consult. As with a lot of modern reference books the buyer is granted access to a companion website (www.anesthesialibrary.com) with fully searchable text. There is also a Kindle edition.

The list of contributors exceeds 300 and represents may distinguished colleagues from across the USA and some international contributions from Australia, Canada, Denmark, Germany, Greece, Italy, Israel, Spain and the UK.

According to the editors, the book’s target readership ranges from nurses, medical students and anaesthesiology trainees to clinical practitioners, not excluding intensive care personnel.

The idea is rather simple and consists of an attempt to provide practically useful but not overwhelming information on a given topic on two pages. Each chapter starts with Basics and finishes with Clinical Pearls. The reader will be able to find information on epidemiology, pathophysiology, anaesthetic goals, pre-operative assessment and preparation, intra- and postoperative principles of care. Some references as well as cross-references to other topics in this book are also provided.

Several hundred topics are listed in the table of contents, mainly concentrating on co-existing diseases, popular drugs used in anaesthesia, surgical procedures, physiology and equipment. The layout is a well-known one and seems like an expansion of a popular A to Z format or Core Topics series. The selection of topics is an interesting attempt at amalgamation of some basic science with clinical anaesthesia.

Despite liking the original 5-minute idea, it is obvious that the task of trying to include even only the most important information in only two pages comes with the drawback of using a very small font that makes it difficult to read without magnification. Illustrations clearly lost the competition for space in this book and are provided in black and white rather than colour. However, there are a lot of pages that are quarter or even half empty, therefore a lot more illustrations could have been included and a larger font chosen. Compared to books like the popular Handbook series this one cannot really be carried in the pocket of a resident for a quick consultation, but requires to be kept on a shelf of a departmental library.

It is difficult to recommend this book for an individual as I struggled to understand which healthcare professional it is best suited to. It may serve its purpose for a departmental library and the companion website with search functionality makes it more user-friendly for a lot of modern specialists who are familiar with mobile internet technology.

Andrey Varvinskiy

The 5-Minute Anesthesia consult Nina Singh-Radcliff (editor)Wolters Kluwer/Lippincott Williams & Wilkins, USA

978-1-4511-1894-0£70.001190 pps


Safety in NuMBERS

AAGBI WyLie MeDaL RUnneR-UP eSSay 2015Tom ChadLeicester Medical School

Is the quantitative approach sufficient for measuring safety in anaesthesia? Anaesthesia has long been praised as being at the vanguard of patient safety improvement,1 with good reason. No other specialty routinely induces muscle paralysis and respiratory arrest in seriously ill patients. But what does safety mean in the context of anaesthesia? Safety in healthcare, more broadly, can be taken to mean absence of complications. However, this definition may not be sufficient in anaesthesia. Here ‘the occurrence of an unanticipated complication or death during or following anaesthesia that may be attributable to anaesthesia’ may be more appropriate.2

The outcome of an intervention or practice is central to its efficacy. Ever since Navy surgeon James Lind first systematically quantified the effect of citrus fruits on scurvy, measurement of outcome has proved an indispensable research tool in medicine. However, unlike administration of citrus fruits, administration of an anaesthetic is not therapeutic per se. Therefore outcomes in anaesthesia are inextricably linked to safety.

Having defined safety as a key outcome in anaesthesia, the next question is what to measure and how? Studies with large numbers of participants have been used previously to good effect. This is often quoted as the best way to increase the statistical power of a study (thus ability to make inferences from the data). Benhamou et al.3 describe how such studies provide invaluable data sets for identifying unsafe practice and implementing improvement on a local and national level. However, studies using large participant numbers, which employ only quantitative analysis, may not be sufficient in anaesthesia.

Mortality

Using death from anaesthesia as an indicator of safety may seem logical as its classification is clear and certification is mandatory. A large systematic review indicated that anaesthetic mortality plummeted from 357 per million pre 1970s to 34 per million in the 1990s–2000s despite a general trend of increasing patient risk scores (the ASA score).4 This of course testifies to the safety advances in the specialty but demonstrates that vast numbers of anaesthetic administrations (21.4 million in the mentioned review) are needed to collate meaningful numbers. Indeed modern anaesthesia is so unlikely to result in death that it renders this outcome neither sensitive nor specific.5 This clearly detracts from its usefulness as a safety indicator, particularly if wishing to measure individual practice. This study also illustrates that, despite large numbers, measuring mortality from anaesthesia is hindered due to the lack of agreement regarding timing. Is the relevant measurement intra-operative death from anaesthesia, death within 24 hours post-op, 48 hours post-op or 30 days?

Therefore would a qualitative approach be more beneficial? Such an approach has been used effectively (for example in monitoring maternal deaths from anaesthesia),6 where expert analysis of cases was central. This may be more appropriate as ‘death occurs at the end of the process in which multiple actions have been undertaken and in which prevention or damage containment have failed’.3 The National Confidential Enquiry into Patient Outcome and Death, originally conceived to measure anaesthetic mortality, now exemplifies this expert-led approach, conducting in-depth analysis of quality and safety.7


Other safety indicators

Haller et al.8 identified 108 clinical indicators used in anaesthesia. Of these, 55 untangled involvement from other specialties (namely surgery), with 34 considering safety in some aspect. Only 7 were concerned solely with safety. The vast majority were concerned with outcome indices (26 vs 8 process and 0 structural). However, only 18 of the 34 indicators had been validated to a level above ‘expert opinion’ (examples below).

• Problem with airways in the post-anaesthesia care unit• Transfusion reaction• Dental trauma• Postdural puncture headache after anaesthesia

Such outcomes also occur more often than death and may therefore be more useful in quantitative monitoring of safety. However, unlike death, the reporting of these outcomes is not mandatory. Under-reporting of adverse events in medicine is well documented, for example only 6% of adverse drug reactions were reported in one study of a voluntary incident reporting system.9 Another study indicated a general reluctance to report adverse events to senior colleagues, particularly among doctors (compared to nurses or midwives), and this was thought to be due to lack of safety culture, uncertainty over what should be reported, and lack of knowledge on how to report incidents.10

This hampers the ability of any study, regardless of scale, to draw meaningful conclusions from data. Such extreme under-reporting may be less common in anaesthesia due to the development of incident reporting systems (e.g. Safe Anaesthesia Liaison Group eForm, Anaesthesia Incident Reporting System). Their development has been heavily influenced by non-medical reporting systems (particularly aviation).11 However, underpinning the translation into better practice is an effective peer-review system, employing approaches such as root cause analysis.12

A holistic approach

Ralston and Larson13 suggest five ‘key elements’ in improving safety that are not only applicable to anaesthetics but healthcare more widely:

• Build and maintain a culture of patient safety• Provide leadership for patient safety that establishes a blame

free environment• Proactively survey and monitor for adverse events• Continually engineer patient safety into healthcare• Provide information and communication technologies to

support patient safety

A focus on numbers alone can fulfil only one of these key elements; therefore quantifying such events should form one part of a wider framework in which to improve safety in anaesthetics. Adopting a wider focus could in itself improve quantity and quality of data when it comes to surveying and monitoring, leading to increased reporting. Another parallel between aviation and anaesthetics may be shown, whereby increased reporting of adverse events led to fewer adverse outcomes.14 Attaining sufficient numbers in safety research will remain central in anaesthetics and will improve monitoring through sensitive, specific and valid indicators. But importantly this will arise from a rounded approach to data analysis, where qualitative and quantitative methods complement each other to inform us what anaesthetics is doing and how well. Indeed ‘If you do not know what you are doing and how well you are doing it, you have no right to be doing it at all’ (Professor Sir Bruce Keogh).

Tom chadLeicester Medical School

References1. Gaba D. Anaesthesiology as a model for patient safety in health care. British

Medical Journal 2000; 320: 785–8.2. Lee A, Lum M. Measuring anaesthetic outcomes. Anaesthesia and Intensive

Care 1996; 24: 685–93.3. Benhamou D, Auroy Y, Ambalberti R. Monitoring quality and safety in

anaesthesia: are large numbers enough? Anaesthesia and Analgesia 2008; 107: 1458–60.

4. Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012; 380: 1075–81.

5. Murphy P. Measuring and recording outcome. British Journal of Anaesthesia 2012; 109: 92–8.

6. Mhyre J, Riesner M, Polley L, Naughton N. A series of anaesthesia-related maternal deaths in Michigan. Anaesthesiology 2007; 106: 1096–104.

7. Lunn JN, Muchin WW. Mortality associated with anaesthesia. Anaesthesia 1982; 37: 856

8. Haller G, Stoelwinder J, Myles P, McNeil J. Quality and safety indicators in anaesthesia. Anaesthesiology 2009; 110: 1158–75.

9. Cullen D, Bates D, Small S, Cooper J, Nemeskal A, Leape L. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Joint Commission Journal of Quality Improvement 1995; 21: 541–8.

10. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Quality and Safety in Healthcare 2002; 11: 15–8.

11. Barach P, Small S. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal 2000; 320: 759–63.

12. Dutton R. Improving safety through incident reporting. Current Anaesthesiology Reports 2014; 4: 84–9.

13. Ralston J, Larson E. Transforming healthcare organizations for patient safety. Journal of Postgraduate Medicine 2005; 51: 61–7.

14. Button K, Drexler J. Are measures of air-misses a useful guide to air transport safety policy? Journal of Air Transport Management 2006; 12: 168–74.

The AAGBI is looking to appoint a new Assistant Editor for Anaesthesia Cases – our online case report resource:

http://www.anaesthesiacases.org

The work is mostly email and web-based, and involves reviewing submitted case reports and editing them in preparation for online publication. The successful applicant should have a history of publication and be able to write coherent and elegant English. Previous editorial experience is not necessary, but experience of acting as an assessor/referee for papers submitted to peer-review journals would be an advantage.

As well as the opportunity to work with an excellent and cohesive editorial team, rewards include free registration at major AAGBI meetings. Applicants should submit a brief note, of up to 500 words, on ‘The value of case reports in anaesthesia’ by email to the Editor, Dr Craig Bailey, at [email protected], together with a short curriculum vitae (no more than two A4 pages).

Shortlisted candidates may be asked to perform a small number of editorial tasks as part of the selection process.

We would particularly welcome applications from anaesthetists who are within the first ten years of their substantive appointments and looking to develop their reviewing and editing skills.

Applicants who wish to discuss this post are advised to contact the Editor by email: [email protected]

The closing date for applications is 31 October 2015

Assistant Editor for Anaesthesia Cases

LIFEBOX FELLOWSHIP FOR SENIOR ANAESTHETIC TRAINEES

An exciting opportunity to make a signi� cant contribution to quality improvement and anaesthesia care in Uganda or Ethiopia.

Lifebox Foundation in collaboration with the Association of Anaesthetists of Great Britain and Ireland, the Di� cult Airway Society, World Anaesthesia Society and the Royal College of Anaesthetists are looking to recruit two exceptional ST6+ UK anaesthetic trainees to undertake Fellowships in Uganda and Ethiopia.

The Fellowships will commence in August 2016 or February 2017 and will be of 6–12 months duration. The Fellows will be supported to develop and deliver a sustainable and high-impact QI project in collaboration with local colleagues, in addition to taking part in delivery of anaesthetic care. Upon completion of the Fellowship, Fellows can expect to have completed the ‘Anaesthesia in developing countries’ and ‘Improvement Science, Safe and Reliable Systems’ units within the RCoA 2010 Curriculum.

Application deadline: Friday 4 December 2015.

Further details, including how to apply, can be found on the RCoA International Programmes webpage: www.rcoa.ac.uk/international-programmes

Saving lives through safer surgery

The Royal College of Anaesthetists

Association of Anaesthetists of Great Britain and Ireland

Lifebox-AnaesthesiaNews.indd 1 27/08/2015 15:40

drugsControlled

during my working life, i have known a handful of fellow anaesthetists who have abused controlled drugs (cds) they had stolen from their workplace.* one is dead. one was saved at the very point of death and left the job. Two are back at work and remain some of the best colleagues one could hope to work with. i didn’t have the merest inkling what any of them was doing; in fact i would have said they were some of the least likely people to abuse drugs that i knew. i only wish any of us had spotted what was going on in time to save the first two. i have probably known others but not known of their predicament. The people i know about may have been the ‘tip of the iceberg’, especially if one believes the useful and comprehensive AAGBi guidance – drug and Alcohol Abuse amongst Anaesthetists - Guidance on identification and Management.1,2


A recent death in the Midlands should prompt us all to do better with custody of CDs. As a death it was not unique, but one of a steady trickle of shortened lives and family bereavements. After the inquest, the coroner issued a Regulation 28 Report to Prevent Future Deaths to the doctor's employer concerning medicines control, saying ‘it was accepted that there were documentary deficiencies which meant it could not be precisely ascertained what controlled medication had been taken or used or administered to patients ’. These events seem to have had serious consequences for at least one senior member of staff.

Tight CD custody will go some way to protecting us all, as it makes casual experimentation less easy and detection of diversion of CDs a little more likely. Established abuse means a life of deceit and, I am sorry to say, criminality – it is theft after all. A clever criminal on his or her own territory will always be difficult to detect and so good practice in CD custody will only ever go so far, but it ought to make systematic theft easier to detect and protect most of us from the temptation of casual experimentation. I think I have an addictive personality. Many of us do, and we need the protection of good procedures even if most do not.

Good local CD custody is simply described by the RCoA3 (my italics):

• Drugs should only be issued for the current patient, normally only when the patient is in the anaesthetic room or theatre

• CDs should only be issued against a signature in the CD register by a practitioner authorised to administer CDs and issued as close as practical to the time of administration. Two people sign of course. I think these signatures should attest to both the issue and the stock level which should therefore be checked by both signatories on each occasion

• CDs should remain under the direct supervision of this signatory until administered or destroyed

• CD doses recorded on the anaesthetic record or the medicines record should be congruent with the doses recorded in the CD register, which should record the dose issued, administered and destroyed. Destruction should be signed for as witnessed, the regulations have actually demanded this for nearly a decade; it is not practical to insist on witnessing of actual administration to the patient without huge changes to anaesthetic practice

• CD drug ampoules should not be split between different patients. It means drugs out on the bench for long periods

We all know these basics of good custody, and it now appears professionally hazardous to ignore them. What is less well-known is that the fallout from Harold Shipman's crimes led to changes in what is recommended as good practice. There is little primary legislation; most of the changes were made as statutory instruments. There are minor differences between all the nations of the UK, but for practical purposes it is enough to speak of English (and in places English and Scottish) requirements. The Controlled Drugs (Supervision of management and use) Regulations4 require the appointment of Controlled Drugs Accountable Officers and require the Care Quality Commission to inspect CD custody against standards.

A change in the recommended documentation was made explicit in 2007 but seems to have been little publicised. Guidance on the Safe Management of Controlled Drugs in Secondary Care in England5 makes numerous recommendations but, for the anaesthetist, these are:• the practice of issuing ‘active stock’ to the anaesthetist and

then returning the unused portion to stock (recording both issues and returns in the theatre CD record book) should be avoided; and

• a requirement that destruction of unused drugs should be both witnessed and recorded.

These two requirements mean in effect that CDs should only be issued at the point and time of use and that any un-administered drug is destroyed before an appropriate witness and this destruction should be documented in the CD register. Many units are using registers which allow this, but not universally and this leaves colleagues open to criticism. Unfortunately the current AAGBI recommendations (Controlled Drugs in Perioperative Care 20066) predated this, though they do anticipate the new guidance on destruction of CDs saying: ‘The Department of Health is expected to issue guidance on the disposal of controlled drugs shortly ’. Much of the guidance on witnessing destruction of CDs is complicated by the differences between destroying stock no longer needed and part or whole doses prepared at the point of administration and not needed.

Controlled drug custody only takes us so far. Despite my inability to spot their problems it is likely that people ‘knew’ something was amiss with my abusing colleagues. Some warning signs are obvious, but others less so. Some less obvious ones from Drug and Alcohol Abuse amongst Anaesthetists1,2 are:

• Regular absences from theatre• Volunteering to draw up drugs for others• Patients in excessive amounts of pain• Insisting on personally administering opioids in the

recovery room• Excessive or unnecessary or unusual prescribing of opioids• Incorrect recording of drug administration• Improper recording on the anaesthetic record• Failure to discard wastage properly• Over-anxious to give breaks• Presence in hospital out-of-hours• Enthusiasm for long, difficult or complicated cases• Volunteering to work extra shifts or to do extra or late cases

on a list• Offering to stay late, or working overtime especially if likely

to be working alone

Additionally, beware of unusual patterns of wastage or breakage and particularly of unusual patterns of CD prescribing or administration, especially short-acting drugs at unusual points in a case.

It seems that in many cases, staff, often the anaesthetic assistants, have an inkling or even frank suspicion that something is wrong yet seem unable to report their fears.

We all feel it isn't the done thing to sneak on, grass up, betray or shop friends and colleagues, but the longer it goes on the

drugs


more likely it is to harm the colleague or their patients, so my last point is the most difficult. We need to be able to assure people with suspicions that we will be fair and even handed with anyone about whom they have concerns and that the primary way we will deal with problems is one of health, not conduct or capability. Speaking with my nursing and ODP colleagues they expect abusers to be immediately dealt with as a conduct issue and dealt with severely. All those I spoke to were clear that anyone other than a doctor would be dismissed and lose their livelihood. The profession needs to use its influence to make discipline less likely and help and rehabilitation more likely. By doing this, people will be more likely to report concerns before a patient or colleague is harmed. Most of all, we need to ensure that all professional groups are treated in the same way.

It seems that medical staff who come forward for help have a good prognosis, perhaps much better than the general public. Knowing whom to go to and feeling able to report fears saves lives and careers. It should not end them.

*Since 1979, the author has worked in four deaneries and 16 hospitals and has been closely connected through educational work with at least 10 more so feels no-one will work out who he has in mind. References1. Drug and Alcohol Abuse amongst Anaesthetists – Guidance

on Identification and Management. London: AAGBI, 2006.2. Drug and Alcohol Abuse amongst Anaesthetists – Guidance

on Identification and Management. London: AAGBI, 2011. http://www.aagbi.org/sites/default/files/drug_and_alcohol_abuse_2011_0.pdf (accessed 22/07/15).

3. Colvin JR, Peden CJ. Raising the Standard: a compendium of audit recipes for continuous quality improvement in anaesthesia. 3rd edn. London: RCoA, 2012. http://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_0.pdf (accessed 22/07/15).

4. Controlled Drugs (Supervision of management and use) Regulations 2013. London: Department of Health, 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/214915/15-02-2013-controlled-drugs-regulation-information.pdf (accessed 22/07/15).

5. Safer Management of Controlled Drugs. A guide to good practice in secondary care (England). London: Department of Health, 2007. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074511.pdf (accessed 22/07/15).

6. Controlled Drugs in Perioperative Care. London: AAGBI, 2006. http://www.aagbi.org/sites/default/files/controlleddrugs06_0.pdf (accessed 22/07/15).


Addiction in anaesthesia – a personal perspective

My journey through the system took a lot longer than anyone thought it would. After I was caught using drugs at work, it took several months for the criminal process against me to be resolved. It was two years before a fitness to practice panel was convened by the GMC and also two years for a disciplinary hearing to be conducted by my employer. During this time I was suspended from work with no real idea of what was happening or what would happen. At the end of the downhill part of the journey I had lost my job, my home, my car and my ‘professional standing’. I had, however, gained recovery from addiction and an emotional toolbox that I had not had previously; one which became well tested but ultimately saw me through the adversity.

Before becoming unwell I, perhaps naively, believed that there would be some kind of formal system in place to help drug addicted professionals. I found quite quickly that this was not in any way the case. My GP and psychiatrist, while well meaning, were very poorly equipped to help me recover in any meaningful way. I was no longer using drugs but I felt far from better. As specialist addiction treatment would only be available to me privately, I felt that with crumbling employment prospects I could simply not afford this. The BMA sick doctor’s helpline refused to help me as I was not a member. The RCoA and AAGBI have what I can only assume to be either a lack of remit, interest or adequate resources to help with this type of problem – despite me asking.

My help instead came from the message of hope I heard, and from the recovery skills I gained, attending hundreds of hours of voluntary recovery group meetings – specifically Narcotics Anonymous and the British Doctors and Dentists Group. I figured out that I was not the only drug addict, or indeed drug addict doctor, and that there was a way out of this mess if I was prepared to work at it. The silver lining to the years of being unemployed was that I was able to commit serious time and energy to getting myself well.

The rest of the journey was a matter of gradually improving my professional position while at the same time staying active within the recovery community. I worked unpaid for a year to show I was safe in an anaesthetic room – working without the ability to prescribe controlled drugs, taking a job in a different region – before finally returning to work eight years later as a consultant in my home region.

None of this would have been possible for me without the unwavering support of my partner and family and a number of professional colleagues who took it upon themselves to stand by me and fight for me to a degree well beyond what could have been expected of them.

I’m now many years clean, have a family that I love and have been back working as an anaesthetist for several years. During this time I’ve seen many others recover and return to work successfully, and sadly others not make it through this. Several people I knew have died from their illness, and while those empowered to make decisions about what happens to drug addicted professionals are always quick to declare this a tragedy, there is less concern and help forthcoming for the care and support of those who are actually still alive and who are trying desperately to get back to good health and to work.

Name withheld

2

Drug and Alcohol Abuse amongst Anaesthetists

Guidance on Identification and Management

Published byThe Association of Anaesthetists of Great Britain and Ireland21 Portland Place, London, W1B 1PYTelephone 020 7631 1650 Fax 020 7631 [email protected] March 2011

Further reading AAGBI. Drug and Alcohol Abuse amongst Anaesthetists: Guidance on Identification and Management, 2011. http://www.aagbi.org/sites/default/files/drug_and_alcohol_abuse_2011_0.pdf

DATES FOR YOUR DIARY

All meetings & seminars are held at 21 Portland Place, london unless otherwise stated.

Check availability and book online today

www.aagbi.org/education

delegates can register for one or

both days

special fees apply

Trainees

All AAGBi seminars are priced as listed below unless otherwise stated

£133 - AAGBI members£88 - AAGBI trainee members

£66.50 - Retired members£260 - Non-members

SEMINARSNOVEMBER 2015

Anaesthesia for trauma and orthopaedic surgeryMonday 02 November 2015 organisers: Dr Santhosh Babu, Manchester

History – Anaesthesia & resuscitation in unusual environments: Past, present and futureTuesday 03 November 2015organisers: Dr Alistair McKenzie, Edinburgh & Dr Mark Harper, Brighton

Infectious outbreakswednesday 04 November 2015 organisers: Dr Jonathan Handy & Prof Steve Yentis, London

Perioperative management of the surgical patient with diabetes mellitusMonday 09 November 2015organisers: Dr Nicholas Levy, Bury St Edmunds & Dr Bev Watson, Kings Lynn

Better practice in emergency laparotomywednesday 11 November 2015 organiser: Dr Dave Saunders, Newcastle

Access to safe surgery and anaesthesia in low and middle income countriesThursday 12 November 2015 organiser: Dr Bruce McCormick, Exeter

Perioperative complications in anaesthesia – Prevention & cureThursday 19 November 2015 organisers: Drs Jane Sturgess & Kamen Valchanov, Cambridge

AAGBI Management & leadership courseMonday 23 – Tuesday 24 November 2015 organisers: Dr Jonathan Price, London & Dr Nancy Redfern, Newcastle upon Tyne

Ultrasound in anaesthesiaThursday 26 November 2015 organiser: Dr Andrew McEwen, Torquay

DECEMBER 2015Training of the trainers – The SAFE experienceMonday 07 december 2015organiser: Dr Kate Grady, Manchester & Dr Isabeau Walker, London

Anaesthesia for non-cardiac surgery in congenital heart disease – Paediatric anaesthesiaTuesday 08 december 2015organiser: Dr Raju Reddy, Birmingham

11th Bleeding, clotting and haemorrhage – An update Thursday 10 december 2015organiser: Dr Ravi Rao Baikady, London Venue: De Vere West One, 9-10 Portland Place, London, W1B 1PR

JANuARY 2016Providing a fascia iliaca block service for fractured neck of femurThursday 21 January 2016organiser: Dr Victoria Ferrier, Redhill

GAT Consultant interviewTuesday 26 January 2016organisers: Dr Deirdre Conway, Glasgow & Dr Surrah Leifer, Manchester

FEBRuARY 20162 day ENT anaesthesia Tuesday 02 – wednesday 03 february 2016organisers: Drs Catriona Ferguson & Anil Patel, London

Professional development - What really mattersThursday 04 february 2016organiser: Dr Olivera Potparic, London

Ultrasound guided spinal & paraspinal blocks for anaesthetistsTuesday 09 february 2016organiser: Dr David Pappin, Torquay

Traumawednesday 10 february 2016organiser: Lt Col Rhys Thomas, Swansea

Orthopaedic anaesthesiaThursday 18 february 2016organiser: Dr Jan Cernovsky, Stanmore

The Wylie Medal will be awarded to the most meritorious essay on this year’s topic: Anaesthetist or perioperative physician? written by a medical student at a university in Great Britain or Ireland.

Prizes of £500, £250 and £150 will be awarded to the best three submissions.

The overall winner will receive the Wylie Medal in memory of the late Dr W Derek Wylie, President of the Association 1980-82.

For further information and to apply please visit our website: www.aagbi.org/undergraduate-awards or email [email protected] or telephone 020 7631 1650 (option 3)

Closing date: 08 January 2016

THE WYLIE MEDALUNDERGRADUATE ESSAY PRIZE 2016

Applications are invited from medical students studying in Great Britain and Ireland (subject to confirmation of eligibility) to apply to the AAGBI Foundation for funding towards a medical student elective period taking place between April and September 2016. A further round of funding will be advertised in the autumn for electives taking place from October 2016 onwards. Overseas students should ensure that they are permitted to apply for charitable funding.

Preference will be given to those applicants who can show the relevance of their intended elective to anaesthesia, intensive care or pain relief. Applicants may wish to note that a key focus of the AAGBI is support for projects in the developing world.

For further information and to apply please visit our website: www.aagbi.org/undergraduate-awards, email [email protected] or telephone 020 7631 1650 (option 3)

Undergraduate elective funding 2016Up to £750

Closing date: 08 January 2016 for consideration at the February 2016 Research & Grants Committee meeting

THE ROYAL COLLEGE OF ANAESTHETISTS

RCOA WINTER SYMPOSIUMA REVIEW OF TRENDS AND CONTROVERSIES IN CURRENT PRACTICE

Thursday, 19 November to Friday, 20 November 2015RCoA, London£395 (£295 for RCoA registered trainees)Event organiser: Dr R Alladi

Sessions include: ■ Cardiovascular ■ Regional anaesthesia ■ Dilemmas and disasters ■ New challenges ■ Outside theatres ■ Management issues ■ Critical issues ■ Review of routine practice

EVENT ONLINE SERVICESEVENT ONLINE SERVICES

CPDCREDITS

10

[email protected] | 020 7092 1673 www.rcoa.ac.uk/events

an-oct15.indd 2 05/08/2015 11:30

Paediatric BEAST Bristol Emergency Airway Simulation Training

Friday 11th December 2015 At Bristol Medical Simulation Centre

Expert-‐led teaching on: • Recognition and management of Paediatric

airway emergencies that could present to any hospital.

• Equipment and techniques. Followed by:

• Emergency Paediatric airway simulation scenarios and debriefing.

Open to all post-‐FRCA Anaesthetists £192 (incl VAT)

Awaiting CPD approval

Please contact [email protected] 0117 3420108 or visit www.bmsc.co.uk

Paediatric BEAST Bristol Emergency Airway Simulation Training

Friday 11th December 2015 At Bristol Medical Simulation Centre

Expert-‐led teaching on: • Recognition and management of Paediatric

airway emergencies that could present to any hospital.

• Equipment and techniques. Followed by:

• Emergency Paediatric airway simulation scenarios and debriefing.

Open to all post-‐FRCA Anaesthetists £192 (incl VAT)

Awaiting CPD approval

Please contact [email protected] 0117 3420108 or visit www.bmsc.co.uk

This course has been accredited

with 5 cPd Points from The royal college of

Anaesthetists


SAFETY MatteRSDatix and beyondEpidural failure

Dear Editor,

We report an unusual failure of an epidural system which illustrates an unintended benefit of a practice we use to reduce other causes of failure. A routine epidural for labour was sited (Portex Epidural Minipack, Smiths Medical, Watford, UK). As is normal practice for the operator a ‘TegadermTM sandwich’ (using a 10 x 12cm Transparent Film Dressing, 3M Healthcare, Neuss, Germany) was placed around the filter, EpiFuseTM connector and a short length of the epidural catheter (Figure 1). Our rationale for this practice is to reduce the likelihood of unintended disconnections.

The filter and EpiFuse connector were at the lower end of the delto-pectoral groove. The epidural was managed routinely and initially provided good analgesia. Several hours later the patient required assistance moving in the bed and was assisted by her partner gripping her under the axilla and lifting. A crack was heard but as nothing was seen to be amiss he did not mention it. Subsequently the epidural effect receded; at review fluid was found contained within the sealed ‘sandwich’ and on removal the filter was found to have snapped (Figure 2). As sterility of the system had been maintained a new filter and EpiFuse were flushed and connected, a loading dose administered and the system reconnected. Good analgesia was again achieved and the epidural was later successfully topped-up for instrumental delivery in theatre.

We reported the incident locally, to the MHRA and to the manufacturer. Following local discussion we have reaffirmed the recommendation within our department to wrap the epidural filter assembly in this way. We would like to take this opportunity to recommend consideration of this practice to colleagues.

dr Jon PearsonST4 Anaesthesia

dr Andrew MaundST5 Anaesthesia

dr Tim MeekConsultant Anaesthetist

James Cook University HospitalMiddlesbrough

Figure 1 Figure 2

Dear Editor,

We wish to report the case of an oxygen leak that caused no visual or auditory alarm other than that of an attentive theatre nurse who insisted on being listened to. A hissing sound was heard coming from a bank of gas valves in a busy theatre complex by a passing theatre nurse. On closer inspection from the resident engineers this was diagnosed as a loose bolt leading to a problem with the piped oxygen supply to the neighbouring operating theatre and indirectly the rest of the theatre and recovery complex.

As it was part of the mains gas supply no oxygen failure alarm was activated as no pressure drop had been detected. In addition regular maintenance work had given the gas system a clean bill of health. On questioning the engineers it was revealed that no gas sensors for detecting leaks are included in the bank of valves. This abides by national standards. It seemed the most sophisticated way of detecting this leak remained the human ear (or presumably mass hysteria in the case of nitrous oxide?)

However, this had failed us on a number of occasions. Firstly in a busy hospital department it was hard to hear the hissing that had been apparently ongoing for a number of months. The night staff had heard the leak (when the theatre complex was much quieter) several months earlier but their concerns had been ignored by more senior human ears. The engineers had never heard the theatre staff’s concerns and the datix forms were never answered. The engineers explained that the only way they would suspect a leak is to look for a higher than average weekly usage of gas. This would be difficult to detect for a small oxygen leak and if the leak had happened with the nitrous oxide valve would have led to unrecognizably high staff and patient exposure to nitrous oxide. No alarms sounded because of the insignificant drop in pressure in piped gas supply from the VAE tank.

The system failure remained in place until it affected daytime elective work. Then, after direct meetings with estates about what is involved with the maintenance of the pipework and the failings of the “oxygen failure” system, local policy was changed to allow direct communication with the engineers out of hours. We still rely on the human ear to detect this problem although now it appears better listened to. Our datix forms remain unanswered.

dr Jennifer MacleanST7 Anaesthetics

dr Manisha shahConsultant Anaesthetist

Medway NHS Foundation Trust


BRITISH OXYGEN COMPANY RESEARCH GRANT

In 1958, the British Oxygen Company (BOC), made a charitable donation in support of anaesthesia research. The BOC Chair of Anaesthesia Fund was created using this donation and is a subsidiary charity of the Royal College of Anaesthetists. The object of the charity is the endowment of a research fellowship in a department of Anaesthesia. On behalf of the Royal College of Anaesthetists, the National Institute of Academic Anaesthesia (NIAA) is inviting applications for this grant.

The RCoA wishes to utilise these funds in support of an anaesthetist who is working towards a senior fellowship or developing a credible application for a Chair in Anaesthesia (or related specialties) in the next five years. Applications from basic scientists with a similar ambition are also invited.

Funding of £60,000 per annum is available. This can support the costs of research sessions, projects or infrastructure. The grant is available for four years (reviewed after two years).

Applicants must demonstrate an existing research record, the support of a senior mentor/supervisor, a credible research proposal and evidence of a supportive research environment.

Application forms are available from the NIAA website (www.niaa.org.uk). The deadline for applications is 8 am on Monday 16 November 2015.

For more information please contact Miss Clare Bunnell, NIAA Administrator, at [email protected].

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October 2015

Digested

N.B. the articles referred to can be found in the September issue of Anaesthesia

Paternalism and consent: has the law finally caught up with the profession?McCombe K, Bogod DG.

This editorial focuses on the Criminal Justice and Courts Act 2015. If McCombe and Bogod’s paper generates interest, musing and debate, I think this one strikes terror into the hearts of a reader. When faced with an adverse outcome after treatment, doctors already potentially face a triple jeopardy: investigation by employer, GMC and the police. The 2015 Act adds a fourth jeopardy. Even when there is no adverse outcome at all, a doctor might now be prosecuted for their actions if these are construed to constitute ‘ill-treatment or wilful neglect’. It remains to be seen, for example, if cancelling (or proceeding with) a high-risk surgical case might be viewed as meeting these criteria (e.g. cancellation constituting wilful neglect by withholding lifesaving treatment; proceeding thus constituting ill treatment by subjecting the patient to needless harm).

Most worryingly, White makes clear that it is easier under the Act to prosecute individuals than institutions. Is there any glimmer of hope or reassurance in this piece? Well sort of. The Act does not require us (nor help us) to change our behaviour or practice in any specific sense at all. To that extent, for good citizens, this editorial is about a hypothetical fear over which we as individuals are unlikely to have much control. All readers can do is continue to behave within their professional competence, according to their best judgement and in line with guidance from their professional organisations. However, even in doing so, they must now bear in mind that those charged with overseeing the Act are more likely than not to test its limits by bringing prosecutions, many of which will be unfounded. That is why I found this such a sobering read.

Caveat doctor

White SM.

This is a beautifully written piece explaining the potential impact of the recent Montgomery decision by the UK Supreme Court. Although some have described Montgomery as a ‘landmark’ – perhaps one of the most important rulings in medico-legal practice – the authors explain that, in fact, the judgement can be viewed as a logical progression of the way the relevant case law has progressed over the years. Furthermore, they argue that professional practice has already been years ahead of the law, and the Montgomery ruling merely reflects good practice on consent that is already enshrined in documents such as the AAGBI’s own 2006 glossy on consent and the GMC's guidance of 2008. I am slightly surprised by the last claim; I would not have foreseen Montgomery from what is written in the 2006 glossy. Nevertheless, the emphasis on the

‘prudent patient’ test will – or should – impact on the daily practice of every anaesthetist. The authors note, for example, that (even if an anaesthetist might disagree) it is quite prudent for a patient to choose general anaesthesia for a caesarean section (or indeed elect to have one in the first place over natural delivery). Similarly, it is quite prudent for a patient to refuse a thoracic epidural for postoperative analgesia, when clear alternatives exist. These and other issues will stimulate much debate in the near future. For other questions, the impact of Montgomery remains unclear: the ruling almost certainly mandates a discussion of, say, the risks of awareness during general anaesthesia. But in many cases, regardless of the risk, what is the alternative?

J. J. Pandit, Editor, Anaesthesia

This month’s Digested highlights two editorials with a medico-legal focus which were published in the September issue of Anaesthesia.


We were recently afforded the opportunity to meet with and discuss management, leadership and the NHS with the Chief Executive of Nottingham University Hospitals NHS Trust (NUH). NUH is a large teaching hospital Trust that employs upwards of 14,500 staff, caring for 2.5 million people. Mr Peter Homa (CBE) has been in post since 2006, having previously held a number of management roles in both the NHS and the Commission for Health Improvement. In the spirit of collaboration we invited our anaesthetic trainee peers to pose questions to Mr Homa on management, leadership and the NHS. This is an account of our conversation with Mr Homa, in which he describes some of the qualities and skills which he feels promote effective management and leadership in the healthcare sector.

It is well known that an engaged workforce is a workforce that performs well.³ When asked what strategies can be employed to ensure this, Mr Homa pointed to ‘stable and clear leadership’, transparency and a demonstration of clear progress despite extraneous constraints. Over the last two years, our Trust has invited several thousand staff to give face to face feedback to senior management in the ‘Event in a tent’. This is an approach that can work for any team, big or small, as a way to enhance engagement.

Consistency in leadership is equally important. Mr Homa explained that much of this is based on ‘building personal relationships’ and creating ‘mutual trust’. The average length of tenure for an NHS Chief Executive is roughly 28 months; at eight years with NUH Mr Homa bucks the trend. He attributes this longevity to the fostering of relationships and is a ‘huge amount to do with the people he works with’. He was keen to highlight

that ‘getting to know people and allowing people to get to know you gets stuff done’.

Morale in the NHS can be variable. Most of us can recall teams that work well, and those that do not. Good quality leaders and managers recognise and manage low morale by creating a culture that encourages staff to voice concerns, and responds to genuine concern appropriately and promptly. Mr Homa felt that the onus should be on the managerial team to create opportunities to meet and discuss current issues with frontline staff and to promote good morale. Ultimately this requires leaders and manager to be approachable and nurture good relationships.

On his personal strategy for success, Mr Homa ‘…always tries to appoint people more able than myself’; identifying this as the most important thing that he has learnt in management to date. Changes, improvements and positive results in healthcare are not the product of one individual but a team. Recognising and embracing that the team is key, is fundamental to good leadership. Therefore, having the ability to recognise one’s own strengths and weaknesses, and recognising these attributes in others is a vital leadership tool. There are tangible parallels with clinical working too; it is impossible to be good at everything, sometimes asking for help gets the best patient outcomes.

We discussed ways to create and enhance a culture of safety in the NHS, and whether the current trend to transplant ideas from other safety conscious industries was detrimental to creating bespoke healthcare related solutions. Mr Homa felt the role of a good manager was to balance the need for patient safety with a culture that does not stifle innovation. He believes firmly that

Successful leadership and management in the NHSThe King’s Fund report The Future of Leadership and Management in the NHS, published in 2011, highlighted the need to engage clinicians in the process of developing leadership from the ‘board to the ward’.1 The prominence of medical leadership and management in the current iteration of the RCoA curriculum reflects this drive.2 Despite the expectation from early in training that trainees should grasp the basics of management in the NHS, it isn’t until becoming a more senior trainee that we (and perhaps many others) have appreciated the impact that good (and bad) leadership has on teams, the working environment and, ultimately, patient care. With innumerable books and articles to choose from, seeking to understand what a good ‘leader’ or ‘manager’ is and, perhaps more importantly, how to become one, is a daunting task.


creating a highly controlled environment which allows these two to prosper will enhance patient care and propagate excellent patient outcomes. He did not think that looking at management of safety outside the NHS detracted from tailor-made healthcare solutions. There is a lot to be learnt from other industries and an important facet of successful management and leadership is to recognise and to adopt those philosophies which can be translated into healthcare . But important lessons can also be learnt ‘closer to home’, looking at aspects of care in other hospitals, departments or other specialities.,

When asked what advice he would offer to a newly appointed consultant, Mr Homa suggested ‘becoming a role model’. As we achieve seniority we have to be mindful of the fact that people around us model their behaviour on ours. In his view, past successes can only carry you so far, but treating others with respect, and in a way you would wish them to interact with staff and patients will carry you much further. Developing a career plan and a personal plan with good work/life balance is important, trying to ensure that our social and family lives don’t become a casualty of our work. . Asked how his advice would differ if it was offered to a more junior colleague the reply was simple, irrespective of grade one should ‘Never be afraid to ask for help’.

We asked Mr Homa about social media and particularly the ability to use it to disseminate damaging negative press rapidly and widely. Mr Homa felt that embracing social media, as so many hospitals now do, was a positive step, and cited individual examples where patient care had been rapidly enhanced through a its use. Social networking sites can be employed as a way to help engage staff, patients and relatives, and to publicise positive news.

Many of us will adopt formal management roles in an increasingly challenging environment with an ageing population, dwindling resources and ever increasing public expectations,. From our discussion with a longstanding and successful senior NHS executive, it would appear that the ability to promote staff participation and involvement; encourage appropriate staff autonomy; ensure staff ‘voices’ are heard; encourage staff to be innovative and proactive and, most importantly, to have humility, are the qualities we will need to be future medical leaders.

dr Paul T James, dr Thomas P heinink Specialty registrar year 7Nottingham University Hospitals NHS Trust

On behalf of the East Midlands InSPIRE group (Innovation, Safety, Practice, Improvement, Research, & Education) References1. The King's Fund. The Future of Leadership and Management in the NHS.

London: The King's Fund, 2011. http://www.kingsfund.org.uk/sites/files/kf/ Future-of-leadership-and-management-NHS-May-2011-The-Kings-Fund.pdf (accessed 3/12/2014).

2. Royal College of Anaesthetists. CCT in Anaesthetics - Teaching & Training, Academic & Research (including audit) & Management for Anaes, CC & PM (Annex G). London: RCoA, 2010. http://www.rcoa.ac.uk/CCT/AnnexG (accessed 3/12/2014).

3. NHS Leadership Academy. Talent and Talent Management Insights. 20144. West MA, Dawson JF. Employee engagement and NHS performance. London:

The King's Fund, 2012. http://www.kingsfund.org.uk/sites/files/kf/employee engagement-nhs-performance-west-dawson-leadership-review2012-paper.pdf (accessed 3/12/2014).

5. NHS Chief executives 'Bold and Old' London: hoggettsbowers, 2009. http:/ www.nwacademy.nhs.uk/sites/default/files/bold_and_old.pdf (accessed 3/12/2014).

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West MA, Loughney L, Lythgoe D, et al.

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma. The ProPPr randomized clinical trialBritish Journal of Anaesthesia 2015; 114: 244–51

BackgroundThe UK National Bowel Cancer Audit showed ASA Score as the strongest predictor of death following surgery. Previous interventions to improve peri-operative outcome have largely been intra- or postoperative, while pre-operative physical training has multiple benefits to patients, but its effects on physical performance have not been measured with cardiopulmonary exercise testing (CPET).

The aim of this study was to objectively measure the changes in physical fitness following neoadjuvant chemoradiotherapy (NACRT) and a structured pre-habilitation programme undertaken after NACRT, in patients awaiting colorectal cancer surgery.

MethodsA prospective pilot non-randomised study recruited patients from a local cancer multidisciplinary meeting. Subjects were allocated to exercise if they accepted joining the exercise arm, or were recruited as controls if they could not commit to the programme or lived more than 15 miles from the hospital.

Patients underwent CPET two weeks before and immediately after NACRT, then at multiple intervals up to surgery. The intervention group underwent structured individual static cycle interval training for 6 weeks immediately following NACRT. Fitness was then assessed using CPET. Physical activity was measured using a step counter.

resultsA total of 39 patients were recruited, 22/22 completed the intervention, and 13/17 the control assessments. The intervention group were younger, of lower ASA category and had a lower CR-POSSUM predicted mortality score. Baseline peak work-rates measured were lower in controls. The intervention group attended 96% of the exercise sessions. No adverse events were reported.

There were statistically significant declines in maximal oxygen uptake and oxygen consumption at aerobic threshold from baseline to immediately post NACRT in both groups. Following the pre-habilitation exercise intervention, maximal oxygen uptake and oxygen consumption at aerobic threshold improved in the intervention group, but declined further in controls. Physical activity declined following NACRT in both groups, and recovered following NACRT cessation.

discussionThis study found objectively measureable declines in indices of cardiorespiratory fitness and daily physical activity following NACRT. Further declines were observed in patients not enrolled to the training programme, whereas improvements were seen in the intervention arm, but these groups were not randomly allocated and may have self-selected according to pre-existing exercise behaviours or against exercising on account of worse health state (demonstrated in the controls by ASA grade and peri-operative risk scoring). The authors suggest the intervention was safe and, as far as can be ascertained allowing for the trial design, effective. Units using CPET for risk stratification pre-NACRT may fail to identify some at risk patients, whose aerobic fitness declines following NACRT.

conclusionThis pilot study has demonstrated the adverse impact of NACRT on cardiorespiratory fitness. Its non-randomised design renders it hypothesis-generating, but it has shown randomised control trials of peri-operative exercise are warranted, with robust controls and broad inclusion criteria, studying both peri-operative outcome and the long-term implications for cancer treatment.

Phillip howellsST5 Anaesthetics, Birmingham School of Anaesthesia


Schmidt AR, Buehler P, Seglias L, et al.

Gastric ph and residual volume after 1 and 2 h fasting time for clear fluids in childrenBritish Journal of Anaesthesia 2015; 114: 477–82

BackgroundCurrent guidelines still suggest a fasting time of 2 hours for clear fluids in paediatric patients.1,2 In reality, patients are often fasted beyond this. The authors set out to determine if a shorter fasting time (1 hour) resulted in any difference in gastric pH or residual gastric fluid volume (GFV) compared with the usual 2 hours.

MethodsASA I–II patients aged 1–16 years without any gastrointestinal motility disorder undergoing elective surgery requiring endotracheal intubation were recruited. Patients were allowed to drink 5 ml/kg of clear fluid (up to 150 ml) up to 1h or 2h pre-induction. GFV and pH was established by orogastric tube placement and aspiration post intubation. Patients were excluded if there was deviation from fasting times or inappropriate fluid consumption (> 50% of volume permitted or failure to consume any at all). Patient reported hunger and thirst pre-induction; postoperative nausea and vomiting and postoperative agitation, pain and parental satisfaction were studied as secondary outcomes. Power calculation suggested 63 children were required in each group to detect a significant difference in pH of 0.5.

resultsA total of 149 children were enrolled, with 18 excluded during the trial, leaving 59 children in the 1h and 61 in the 2h group.

Gastric pHMean ph was 1.44 in the 1h group (range 0.51–2.20) compared with 1.55 in the 2h group (range 0.35–5.53). Mean difference was 0.1 (95% CI 0.3–0.07, p = 0.66).

Residual gastric fluid volumeMean GFV (ml/kg) was 0.64 (1h) and 0.50 (2h), with a mean difference of 0.14 (95% CI 0.04–0.32, p = 0.47), and a range of 0.00–3.39 and 0.00–1.89 respectively.

The only secondary outcome to show a statistically significant difference (including pre-operative hunger and thirst) was a small improvement in parental satisfaction with clear fluid fasting times in the 1h group.

discussionThis is the first study to investigate shorter fasting times than currently recommended in a clinical context, and shows no significant difference in gastric pH or residual volume between 1h or 2h fasting times for clear fluids in pediatric patients. However, gastric pH and residual volume are only surrogate markers for pulmonary aspiration, and there was no improvement in patient hunger, thirst or immediate postoperative outcomes between the two groups, despite improving these presumably being the rationale for shorter fasting times.

conclusionA 1h difference in fasting time is short, yet shown as far as possible by this study to be safe. My own hospital is in the process of relaxing its fasting policy to allow elective and emergency paediatric patients to drink clear fluids up until being sent for by theatre. It is possible that future studies into this ’zero fasting time‘ may provide enough evidence for improved child satisfaction and/or outcomes to drive forward a change to current national and international guidelines.

Aidan MeliaCT2 Anaesthetics, Torbay Hospital

References1. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and

children: guidelines from the European Society of Anaesthesiology. European Journal of Anaesthesiology 2011; 28: 556–69.

2. APA Consensus Guideline on Perioperative Fluid Management in Children. v1.1. September 2007. http://www.apagbi.org.uk/sites/default/files/Perioperative_Fluid_Management_2007.pdf (accessed 06/08/2015).

McNab S, Duke T, South M, et al.

140 mmol/l of sodium versus 77 mmol/l of sodium in maintenance intravenous fluid therapy for children in hospital (PiMs): a randomized controlled double-blind trialLancet 2015; 385: 1190–7

Background/introductionTraditionally, hypotonic solutions containing approximately 30 mmol/L of sodium have been used for paediatric maintenance fluids.1 Recent guidelines recommend using fluids with higher sodium concentration (75 mmol/L) to prevent hyponatraemia in hospitalised children. Although increased antidiuretic hormone release occurs in sick and postoperative children, hyponatraemia could be attributed to the use of hypotonic fluids. Children are vulnerable to electrolyte disturbance with neurological sequelae occurring frequently.

The Paediatric Intravenous Maintenance Solution (PIMS) study was a single centre randomised controlled trial examining whether isotonic fluids reduced the risk of hyponatraemia compared with hypotonic fluids, without incurring more adverse effects.

MethodologyChildren over 3 months old attending The Royal Children’s Hospital, Melbourne, Australia, were recruited if the treating physician thought they required intravenous hydration fluids for 6 hours or longer. Patients received either isotonic intravenous fluid (140 mmol/L sodium) or hypotonic fluid containing (77 mmol/L sodium) for 72 hours or until their intravenous fluid rate decreased to less than 50% of the standard maintenance rate. Healthcare providers were blinded to the randomly allocated solutions.

Hyponatraemia during the treatment period was the primary endpoint (serum Na < 135 mmol/L and a > 3 mmol/L fall from the pre-study baseline level). Secondary outcomes included overhydration, dehydration, intravenous cannula reinsertion, symptomatic hyponatraemia and hypernatraemia (Na > 145 and an increase of > 3 mmol/L from baseline).

resultsThe treatment groups had similar baseline characteristics. Overall 690 patients were recruited. Fewer patients in the hypertonic (Na 140) group developed hyponatraemia (11% vs 4% in the Na 77 group, 95% CI 0.16–0.61; p -0.001). Children who developed hyponatraemia received similar median total fluid volumes to those remaining eunatraemic. No child developed symptomatic hyponatraemia. Hypernatraemia occurred similarly in each treatment group (Na 77 6% vs Na 140 4%). Other secondary endpoints were identical. Fewer children developed hyponatraemia in the hypertonic group in subgroups analysis for age, surgical intervention or critical care admission. The first 6 hours of treatment carried the highest risk of hyponatraemia for both groups. The Na 77 group were at a higher risk of hyponatraemia for longer than the Na 140 group.

discussionThe authors concluded that isotonic paediatric maintenance fluids have lower risk of hyponatraemia, without an increased risk of hypernatraemia. They suggest caution using 0.9% saline with 5% glucose to avoid inducing hyperchloraemic acidosis, but recommend more balanced isotonic solutions (Ringers lactate/plasma-lyte148).

conclusionMeta-analyses comparing isotonic and hypotonic fluids reported similar findings in critical care and postoperative patients.2,3 This randomised controlled trial on a heterogeneous group contributes significantly to the debate on paediatric maintenance fluids for patients over 3 months old. Despite being adequately powered to detect hyponatraemia, greater study numbers are required to detect cases of symptomatic hyponatraemia.

Jeremy Astin ST6 in Anaesthesia and Intensive Care, Severn Deanery

References1. Holliday MA, Segar WE. The maintenance need for water in parenteral

fluid therapy. Pediatrics 1957; 19: 823–32. 2. Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in

hospitalized children: a meta-analysis. Pediatrics 2014; 133: 105–13. 3. Foster BA, Tom D, Hill V. Hypotonic versus isotonic fluids in hospitalized

children: a systematic review and meta-analysis. Journal of Pediatrics 2014; 165: 163–9. e2.


AAGBI responseOn behalf of the AAGBI, thank you for the opportunity to respond to the letter by Drs Barker and Robinson regarding PA(A)s in UK anaesthesia practice1 and to Dr Mehmood’s reply to them (published here). Ten years on the subject still provides that ’marmite-split‘ between anaesthetists and across departments and so it is with a little trepidation that I add some comment.

I represent the AAGBI on the RCoA Anaesthesia Related Professionals Committee (ARPC). The training of PA(A)s continues from a single Higher Education Institute (University of Birmingham) with an annual programme output of about 18–22 practitioners; total numbers qualified and practising are roughly 120. The 2011 AAGBI review noted that following completion of training many PA(A)s are today delivering service outwith the published scope of practice. Departments involved have developed local governance processes with the aim of ensuring safe service delivery. Possibly the most important feature underpinning successful PA(A) introduction is substantial physician support for the role. With antibodies still circulating in many departments across the country, I cannot see pan-country adoption of the role happening any time soon.

That said, I also think the role is here to stay albeit in small but increasing numbers. There is a political imperative to expand all non-physician roles wherever possible as a means of addressing manpower and service delivery shortages across healthcare.2

In 2007 the DoH published a toolkit designed to support departments who were considering introducing the PA(A) role as an adjunct to their services. The ARPC has been updating that document and hope to re-publish in late 2015. The review has been delayed while the AAGBI and RCoA work towards a new joint position statement on the scope of practice. Commentary on the scope has spilt the two organisations in the past (the AAGBI was not able to support the comments on extending the scope) and considerable compromise will be required if the two are to agree on a joint statement. We are working on it.

This leads onto the matter of role extension and advancement as alluded to in the letter by Drs Barker and Robinson where they refer to increasing case complexity within practice based on a points calculator for case allocation. Currently, qualified and practising PA(A)s seek to advance (undertake more complex aspects of roles already within the scope – distant supervision of induction and emergence) and extend (undertake regional anaesthesia, sedation, invasive monitoring techniques) their roles. The debate about this has been intense and it is fair to say that the AAGBI has not achieved a consensus; it might be expected that an elected Board would reflect the diversity of opinion of its constituent members. We have the basis of an objective tool to consider anaesthesia skills based on safety and effectiveness. It’s hoped this will facilitate the ongoing debate.

All these changes are happening when the practitioner role is without statutory regulation. The PA(A)s hold a voluntary register (approximately 50% of qualified PA(A)s are signed up) but there is nothing stopping Trusts/Health Boards employing whoever they choose to fulfil this role. The RCoA, the AAGBI, the Association of Physician Assistants (Anaesthesia) and the RA-UK have written to Health Education England and the Health and Care Professions Council on the matter. It appears that the government would prefer to avoid statutory regulation favouring the option of self-regulation. Where this leaves this debate in the meantime, who knows?

The AAGBI Board feel that it is important our membership organisation is represented at the ARPC and that we remain engaged in any discussion on PA(A) role development.

Kathleen ferguson Honorary Treasurer, AAGBI

AAGBI representative, RCoA ARPC

Reference

1. Barker K, Robinson H. Letter to the Editor. Anaesthesia News 2015; 335: 31.

2. Five Year Forward View. NHS England, October 2014. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 08/08/2015).

Dear EditorThe letter by Drs Barker and Robinson referring to the Scandinavian model of anaesthesia provision was fascinating.1 I was aware of the team approach of anaesthesia provision in Scandinavia; however, I was particularly intrigued by the points system to score the complexity of cases to be supervised by a doctor. Such a system, I feel, could be integrated into the UK healthcare system with Physician’s Assistant’s (Anaesthesia) [PA(A)] employed to allow supervision by one doctor for more than one patient being anaesthetised. The current Scope of Practice document limits the complexity of cases to ASA 1 and 2 patients undergoing minor to intermediate surgery only, where one case involves a PA(A) being supervised. The points based system may provide a more objective and flexible approach to the supervision and scope of practice for PA(A)s for a changing healthcare system.

The PA(A) programme has not stalled and in recent years there have been increasing numbers of trainee PA(A)s being employed and an increasing demand for qualified PA(A)s. Trusts are able to train/employ PA(A)s and develop the role to what is required for service provision in their Trusts. PA(A)s complete an intensive 27 month training curriculum but that does not allow PA(A)s to practice in all areas of anaesthesia. With local development and training coordinated by Anaesthetic Departments, a PA(A)’s core knowledge can be built on to allow safe provision of anaesthesia provision in other areas such as sedation and regional anaesthesia. The benefits of such initiatives were highlighted in the AAGBI report on the role in 2011.

Interested parties are invited to contact the Association of Physicians’ Assistants (Anaesthesia) (APAA), the Royal College of Anaesthetists (RCoA) and the University of Birmingham who still facilitate the training programme. Local Trusts that employ PA(A)s are also an excellent source of information.

The current DoH Toolkit to plan the introduction of the role is currently being reviewed by the APAA, the RCoA and the AAGBI and will be available later in the year.

irfan Mehmood

Physician’s Assistant (Anaesthesia), Salford Royal Hospitals, Salford & Chairman of the Associations of

Physicians’ Assistants (Anaesthesia)

Reference

1. Barker K, Robinson H. Letter to the Editor. Anaesthesia News 2015; 335: 31.


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We have started a monthly lottery where employees can buy a ticket for £2 giving them a chance to win a day’s annual leave. As you can imagine, this lottery is thriving!

We also organised a senior management car wash – no-one could resist paying £10 towards Lifeboxes for Rio AND getting to see the boss scrubbing cars!

We would encourage other similar organisations to Go With The Flow and launch their own lottery in order to boost Lifebox’s ability to continue their life saving work.

Maria Giljam Senior Product Manager, Fisher & Paykel Healthcare Limited,

Maidenhead, Berks

Dear EditorAmpoule dwarfism and sharps injuries

We note with some concern an increasing frequency of ampoule anomalies detected in our clinical practice. As in the photograph supplied, this frequently takes the form of ‘dwarf’ ampoules with a defective neck or head. As the neck is the site at which the ampoule is designed to break, the deformation makes the defective ampoule much more likely to break unpredictably and injure the user. Ampoule injuries are already commonplace: one article reports an incidence higher than one laceration per 20 ampoules broken.1

In our experience this trend has been associated with a change in pharmaceutical manufacturers. The issue has been reported locally, but in the meantime we recommend vigilance and caution to all those drawing up drugs from ampoules, especially following a change in supplier.

Toby reynolds ST3 Anaesthetics

simon stacey Consultant Anaesthetist

The London Chest Hospital, Barts Health NHS Trust

Reference

1. Stoker R. Preventing injuries from glass ampoule shards. Managing Infection Control Oct 2009; 45–7

Dear EditorHow refreshing to read the ‘Safety Point’ article by Tom Woodcock.1 He concludes that, ‘after reflection, he is going to change his practice to safer sharps whenever a colleague is being kind enough to squeeze the patient’s arm.’

Dr Woodcock’s aim is very laudable, but I fear he may fall foul of his local ‘Protocol Police.’ Before I retired, various protocols began to appear on venepuncture, obtaining blood samples, and inserting i.v. cannulae, etc. And, like Dr Woodcock, I noted that squeezing a patient’s arm was not mentioned, except in relation to certain paediatric situations: the relevant protocols for the latter being ‘Restraining, holding still & containing children and young people’ (Guidance for Nurses, RCN 2003) and our local policy, Gaining Consent from Children and Young People Guidelines, Family and Women’s Health Group. I specifically asked the authors of the relevant protocols about our practice in theatre, whereby a nurse or ODP would squeeze the patient’s arm while we inserted an i.v. cannula. I was told in no uncertain terms that it was not allowed – that was classified as restraint!

For simplicity, and taking things slightly out of context, the AAGBI point out that ‘Restraint should only be employed under the strict control of written policies that have been developed, agreed and implemented after clinical, legal, and managerial input, and which must take account of relevant legislation.’ (AAGBI Position Statement on Hospital Restraint Policies September 2013).

Incidentally our local Trust policy on venous cannulation and obtaining blood samples has 34 other policies and protocols which require to be read and understood ‘so that venous access devices can be inserted in a safe and effective manner according to local policy and national initiatives.’

So there you have it Tom! Happy reading during those long tedious surgical procedures – but STOP – I suspect that breaches some other protocols – the reading, not the long tedious surgical procedures unfortunately.

ian f russell Retired Anaesthetist, Hull & East Yorkshire NHS Trust

Reference

1. Woodcock T. Safety point: needlestick injuries. Anaesthesia News 2015; 332: 24

Dear Editor‘recuronium’ – further evidence of the danger posed by neuromuscular blocking drugs

It can be argued that neuromuscular blocking drugs (NMBDs) are the most dangerous drugs in anaesthetic use. It is estimated that NMBDs account for 50–70% of allergic reactions during anaesthesia1 and NAP5 reinforced their importance in the genesis of awareness during general anaesthesia and in subsequent psychological sequelae.2

We have come across further evidence to add to the danger of this class of drugs. At one of our local hospitals we have taken delivery of a batch of red (NMBD) labels for ‘recuronium’ (Figure 1). This perhaps offers a subliminal reminder to the user of the dangers associated with (unnecessary) use of NMBDs. Alternatively, as the label is equally applicable to rocuronium and vecuronium, it is possible it is part of yet another efficiency drive?

sarah steynberg and Tim cook Royal United Hospital,

NHS Foundation Trust, Bath

References

1. Peroni DG, Sansotta N, Bernadini R et al. Muscle relaxants allergy. International Journal of Immunopathology and Pharmacology 2011; 24 (Suppl): S35–46.

2. Pandit JJ, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089–101.

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