SEPTEMBER 2015 INSIDE THIS ISSUE:

ISSN 0959-2962 No. 338

SEPTEMBER 2015

The NewsleTTer of The

AssociATioN of ANAesTheTisTs of GreAT BriTAiN

ANd irelANd

INSIDE THIS ISSUE: Sixth National Audit Project (NAP6): Perioperative Anaphylaxis Anaesthesia goes to the (movie) theatre AAGBI Wylie Medal winning essay 2015: Safety in numbers

Anaesthesia News September 2015 • Issue 338 3

16

contents03 editorial 04 on being managing editor

05 sixth National Audit Project (NAP6): Perioperative Anaphylaxis 06 Anaesthesia goes to the (movie) theatre 09 A huge thank you to our Lifeboxes for Rio supporters 10 Banishing the booze 13 AAGBi wylie Medal winning essay 2015: safety in numbers 17 wound shock 1914–18 18 ‘Utrinque Paratus’ – ready for Anything 21 safety Matters 23 Anaesthesia digested 24 designing an international Anaesthesia Machine - Part 2 26 Particles 28 Your letters

06

09

17

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.

3

Editorial

18

13

It is reported, perhaps apocryphally, that Benjamin Disraeli was often sent unsolicited manuscripts to which he sent the ambiguous reply ‘Many thanks, I shall lose no time in reading it’. As the summer holidays come to an end, and the first leaves start to paint themselves red prior to partying on the pavement, this issue of Anaesthesia News will arrive through your letterbox. We hope you enjoy reading it!

I remember one of my very conscientious colleagues telling me of a terrifying experience in theatre recently, when he was inducing a young ASA 1 patient for an elective operation. In the time it has taken to read this, she was in full blown Grade 5 anaphylaxis. This was mid-morning, and eight theatres were running simultaneously on the same floor. Two other anaesthetic consultants arrived within minutes, an hour later the patient was safely transferred to intensive care, and the following morning was back on the ward with no residual ill-effects. How frequent is this occurrence? Which agent causes it most frequently? Are they all reported to the MHRA? The plain answer is that no one really knows and, to address some of these issues, NAP6 will commence in November 2015. Professors Nigel Harper and Tim Cook report on the matter in the article on page 5.

I thoroughly enjoy relaxing with a glass of wine and a good movie, and both these matters are highlighted by Matthew Down and Rachel Black. Matthew searches for the anaesthetic hero in the archives of cinema, and we would like to hear from you if there are significant films he might have overlooked where there is an anaesthetist we could use as a role model. Rachel Black (pseudonym), on an altogether more serious note, describes how a glass of wine morphed from a relaxation to a requirement. In our stressful lives, the blurred distinctions between socially acceptable drinking and dependence are outlined as seen by a colleague and her journey to return to the fold.

Chengyuan Zheng, a first year medical student at Imperial College London, carried away the Wylie Prize 2015 for an article on the critical analysis of numbers and methodology in published literature. I found his analysis both thoughtful and thought-provoking. If it encourages us to be a little more critical in our reading of peer-reviewed anaesthesia publications, it can surely only be a good thing.

The very British habit of dealing with the shock of bad news with a cup of tea is traced back to the Great War. An article from the Heritage centre at AAGBI looks at how modern management of battlefield trauma evolved from humble beginnings with Ernest Starling.

Nancy Redfern reflects on her time as managing editor of Anaesthesia News and the editorial team would like to thank her for all the hard work she has put in. There is plenty more, including letters to the editor regarding issues raised in previous issues of Anaesthesia News, and I welcome your thoughts and feedback on the items published in this issue.

Upma MisraManaging editor and AAGBI Council Member

FUJIFILM is a trademark of FUJIFILM Corporation. SONOSITE and the SONOSITE Logo are trademarks of FUJIFILM SonoSite, Inc. All other trademarks are the property of their respective owners. ©2015 FUJIFILM SonoSite, Inc. All rights reserved. 2262 07/15

ProgrammeDAY 1• Ultrasound a ppearance of the nerves• Machine characteristics and set-up• Imaging and needling techniques• Common approaches to the brachial

plexus / upper / lower limb• Workshops – using phantoms / models /

cadaveric prosections

DAY 2

• Consent / training and image storage• Upper / lower limb techniques• Abdominal / thoracic techniques • Cervical plexus / spinal / epidural /

pain procedures• Workshops – using phantoms / models /

cadaveric prosections

Ultrasound Guided Regional Anaesthesia – beyond introductoryThese courses are organised by Regional Anaesthesia UK (RA-UK) in conjunction with SonoSite Ltd for training in ultrasound guided regional anaesthetic techniques. Previous experience in regional anaesthesia is essential.

2015 COURSE DATES LOCATION ORGANISERS27-28 November Nottingham Dr Nigel Bedforth & Dr James French

Faculty will vary depending on location

10% Discount for ESRA members – 15% Discount for RA-UK (FULL) members.

FEES: £500 including a CD with presentations and course notes. Pre-course material can be downloaded once registered on the course – including US physics, anatomy of the brachial / lumbar plexus, current articles of interest and MCQ’s. A pre-course questionnaire will be sent 30 days before each course.

For further information and to register logon to :

www.sonositeeducation.co.uk

Ultrasound Training CoursesSonoSite, the world leader and specialist in hand-carried ultrasound, has teamed up with some of the leading specialists in the medical industry to design a series of courses, for both novice and experienced users, focusing on point-of-care ultrasound.

COMPLETE ULTRASOUND GUIDED REGIONAL ANAESTHESIA EDUCATION (CURE)This two-day course is based on intensive small group hands-on training. Mini lectures complement the practical training with live model scanning and needling practice on phantoms and also features the unique “Focussed Assessment of Procedural Skills” to gauge your progress. 2015 COURSE DATES: 5-6 October

ULTRASOUND GUIDED VENOUS ACCESSThis one-day course is aimed at physicians and nurses involved with line placement and comprises didactic lectures, ultrasound of the neck, hands-on training with live models, in-vitro training in ultrasound guided puncture and demonstration of ultrasound guided central venous access. The emphasis is on jugular venous access, but femoral, subclavian and arm vein access will also be discussed.2015 COURSE DATES: 8 October

CRITICAL CARE ULTRASOUND – FICE APPROVEDThis one-day course is aimed at all critical care physicians and surgeons. The programme is suitable for those who already have some basic ultrasound experience as well as those who are new to the clinical applications of focused ultrasound at the patient bedside. The point of care (POC) application of ultrasound complements other POC diagnostic aids in helping clinicians provide more focused and appropriate care in a timely fashion.2015 COURSE DATES: 25, 26 & 27 November

FEES:£375 (two-day courses) includes VAT, lunch, refreshments and course materials.£200-£295 (one-day courses) includes VAT, lunch, refreshments and course materials.

All courses qualify for CPD Accreditation.

VENUE: SonoSite Education Centre, 240 The Village, Butterfield, Great Marlings, Luton, Bedfordshire LU2 8DLFor the full listing of SonoSite training and education courses, dates and to register go to:

www.sonositeeducation.co.uk

4 Anaesthesia News September 2015 • Issue 338 Anaesthesia News September 2015 • Issue 338 5

Sixth National Audit Project (NAP6): Perioperative AnaphylaxisProfessor Nigel Harper, Professor Tim Cook

In November this year, NAP6 will begin, bringing with it a one year period of exceptional focus on serious perioperative anaphylaxis. This article introduces the project and indicates a few areas of uncertainty that NAP6 may help in resolving.5TH NOVEMBER 2015

NOTTINGHAM

Association

The Preoperative

NATIONAL CONFERENCE

EAST

MIDL

ANDS

CONF

EREN

CE CE

NTRE

ACCREDITED WITH 5 CEPD POINTS

Role of Preoperative Assessment in Perioperative Medicine / Dynamic Cardiac Testing / Diabetic Guidelines Update / Obstructive Sleep Apnoea & ECG workshops / Brief Interventions in Preoperative Assessment / Debate: ‘Who is best placed to be the Perioperative Physician - Anaesthetist vs Physician’

Open to all healthcare professionals involved in the preoperative assessment of the surgical patient. For full details and to book your place, please contact us:

TOPICS TO INCLUDE:

ABSTRACT FOR PRESENTATIONS OR POSTERS TO BE SUBMITTED BY 25TH SEPTEMBER 2015

W: WWW.PRE-OP.ORG / T: 020 7631 8896

Giving anaesthetics is usually an activity well within our comfort zone. Sometimes co-morbidities or surgical adventures test our knowledge and skills. These days the majority of stresses arise from delayed starts, late finishes, last minute theatre list amendments and so on. But very occasionally a potentially life-threatening catastrophe strikes unexpectedly. Perioperative anaphylaxis is one such event.

The immediate clinical diagnosis is often unclear. Hypotension is a common feature of anaphylaxis, but significant hypotension occurs in almost 1 in 10 patients during the first 10 minutes after induction of anaesthesia: anaphylaxis is responsible in only a tiny proportion of these patients. Although erythema is a feature of anaphylaxis, some drugs, such as atracurium, frequently cause harmless flushing of the skin. Thus, if a patient develops flush and hypotension on induction, anaphylaxis is an unlikely cause, even though this combination is observed in many severe anaphylactic reactions. It is not surprising that anaphylaxis may be a diagnosis of exclusion, often being considered only when the patient has failed to respond to a vasopressor drug. We have used subjective terms such as ‘very occasionally’, ‘uncommon’, ‘unlikely’ and ‘many’. Currently, there are very little UK data on which to base more accurate statements: we expect NAP6 to fill in some of the gaps.

The immediate management of perioperative anaphylaxis has been set out in several guidelines1,2 summarising expert opinion as controlled clinical trials are impossible. The administration of histamine-blocking drugs has been removed from one recent guideline3 through lack of evidence of efficacy. How do we know what is the optimum initial dose of adrenaline or, indeed, whether the immediate administration of adrenaline is associated with better outcomes after perioperative anaphylaxis? A number of case reports have been published, but looking in detail at a large number of cases will provide more useful information. Limited case reports4 suggest that sugammadex might be useful in the management of rocuronium anaphylaxis but more information is needed. In the longer term, neurological deficit may result, presumably due to cerebral hypoxia, but how often does this happen and what are the contributing factors? Then there are the questions of incidence. Should the choice of neuromuscular blocking agent be influenced by the relative likelihood of anaphylaxis? At the start of NAP6, a baseline survey will be conducted where anaesthetists will be asked about their experiences with perioperative anaphylaxis during the previous year, as well as collecting information about perceptions of relative risks. Several studies5 have concluded that rocuronium is responsible for an excess number of cases of anaphylaxis. Other authors have stressed the importance of analysing large data sets when attempting to calculate the incidence of rare phenomena, and the need to appreciate the statistical uncertainty associated with estimates6. NAP6 will conduct a 2-day UK-wide activity survey in April 2016 during which anaesthetists will be asked to record the drugs and other potential allergens their patients are exposed to. This survey, along with data collected during NAP5, will provide denominator data to inform conclusions regarding the relative risks of anaphylaxis. NAP6 will also shed light on the importance of chlorhexidine, blue dye used in breast surgery and other newer agents in the genesis of anaphylaxis. Anaphylaxis can be graded from 1–5 but only grades 3–5 are associated with organ or life threatening severity: in keeping with previous NAPs it is only these less common but severe complications that NAP6 will examine.

Appropriate investigation of all cases of severe, suspected perioperative anaphylaxis is important because the clinical features of non-allergic anaphylaxis are indistinguishable from allergic-anaphylaxis. Subsequent exposure in an allergic patient is likely to elicit an anaphylactic reaction. UK allergy clinics will collect data on how suspected anaphylaxis is investigated in practice as part of a survey.

NAP6 is being conducted by the Royal College of Anaesthetists through the Health Services Research Centre (HSRC). The steering panel includes representation from the Association of Anaesthetists of Great Britain & Ireland, the Association of Paediatric Anaesthetists, the Association for Perioperative Practice, the Faculty of Intensive Care Medicine, the HSRC, the Medicines and Healthcare products Regulatory Authority, the Obstetric Anaesthetists Association, the Research and Audit Federation of Trainees, the Royal Pharmaceutical Society, the Safe Anaesthesia Liaison Group, professional allergy organisations and patient groups.

NAP6 will seek anonymised reports of every case meeting the following criteria:

• Grade 3, 4 and 5 reactions (i.e. severe reactions, life-threatening reactions and deaths). Minor reactions (Grade 1–2) such as localised rash or anticipated hypotension or bronchospasm will be excluded)

• Patients undergoing general, regional or local anaesthesia and/or sedation under the care of an anaesthetist

• Reactions occurring between administration of the first drug by the anaesthetist up to the time of discharge from the recovery room

• Allergic and non-allergic reactions• All ages• England, Northern Ireland, Scotland and Wales

Timeline

Baseline survey for anaesthetists and allergy clinics: 5th November 2015

Main data collection: 5th November 2015 for one year

Activity (allergen) survey: April 2016

The format of NAP6 will be similar to previous NAPs: in every UK hospital, anaesthetists will report their cases to a Local Coordinator (LC), a consultant colleague who has volunteered for this role. LCs will be responsible for coordinating the responses to the baseline survey and the activity survey, as well as publicising NAP6 within their hospital. Only anonymised data will be collected at all stages of the project. A reviewing panel will include anaesthetists, allergists, immunologists and patient representatives. Each case reported will be discussed by the panel with reference to the presenting clinical features, suspected trigger agent, management, referral for subsequent investigation, eventual diagnosis, and the advice given by the allergy clinic to the patient and the anaesthetist. Where published guidelines exist, comparisons will be drawn, but the main purpose of NAP6 is descriptive.

Further information regarding NAP6 can be found here: http://www.nationalauditprojects.org.uk/NAP6home

References1. Association of Anaesthetists of Great Britain & Ireland. Suspected Anaphylactic

Reactions Associated with Anaesthesia. London: AAGBI, 2009. http://www.aagbi.org/sites/default/files/anaphylaxis_2009.pdf (accessed 10/07/2015).

2. Resuscitation Council UK. Emergency treatment of anaphylactic reactions. https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions (accessed 10/07/2015).

3. ANZAAG-ANZCA. Anaphylaxis during anaesthesia: immediate management. 2013. http://www.anzaag.com/Docs/PDF/Management%20Guidelines/Immediate%20Mx%20card%20v1.1Jun13.pdf (accessed 10/07/2015).

4. McDonnell NJ, Pavy TJ, Green LK, Platt PR. Sugammadex in the management of rocuronium-induced anaphylaxis. British Journal of Anaesthesia 2011; 106: 199–201.

5. Sadleir PHM, Clarke RC, Bunning DL, Platt PR. Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. British Journal of Anaesthesia 2013; 110: 981–7.

6. Laake JH and Røttingen JA. Rocuronium and anaphylaxis – a statistical challenge. Acta Anaesthesiologica Scandinavica 2001; 45: 1196–1203.

I took over as editor of Anaesthesia News from Val Bythell. She produced the magazine single-handed for three years, commissioning articles, editing, respectfully and gently rejecting submissions that didn’t quite meet requirements. Val moved from using external publishers to in-house production, developing an excellent and well-organised team.

I know I could not have done the job in the same way – I just don’t have the ability to write an amusing and informative piece as an editorial each month, to pay sufficient attention to detail and to meet the deadline every time. Instead we moved to a group approach with each issue having a separate editor. Special thanks must go to Rona, editorial assistant, and Chris, designer, whose help is invaluable.

We get some wonderful submissions. People have done the most amazing things; researched, led, or got involved in all sorts of projects and worked in all sorts of places. I’ve tried to get a balance of contributions from trainees, SAS doctors, medical students and consultants from the UK and Ireland, some informative, some political and some just plain funny. I’ve also tried to encourage the use of the English language – no American spellings, abbreviations or split infinitives for me; there’s the Twittersphere for that!

It’s been fascinating to edit what is known as ‘grey literature’. Its purpose is different from a scientific journal. Anaesthesia News should entertain, inform and challenge. It’s also a subtle advert for anaesthesia in the theatre coffee room, a showcase for the specialty and its membership; as such I thought it should remain paper-based as well as being available on the internet. We have some knotty dilemmas. To name but one, I don’t think there are enough of us, particularly if we embrace peri-operative medicine. I also don’t think the Government grasps the impact of a dearth of anaesthetists. Patients want good care at the right time from fully trained teams. Patients, particularly older patients, are voters; long delays and poor care are not vote winners. The group I’d like to hear more from are the Clinical Directors whose responsibility it is to ensure we work in a safe system with appropriate resources in an organisation that respects us and looks after its staff well.

The Safety team now contributes something each month – a conglomeration of the various bits that get broken, stuck, jammed or need some attention from the designers. We get lots from people working abroad, some about learning and professional development, and fascinating individual perspectives. I’m sure, as I hand on the role of managing editor to Upma Misra, Anaesthesia News will go from strength to strength.

Nancy redfernEmeritus Managing Editor, Anaesthesia News

For the latest news and event information follow @AAGBI on Twitter

10th West of England Anaesthesia Update Based in Chalet Hotel St Christoph

Talks cover a wide range of topics 15 CPD points RCOA Flights available from Bristol, Gatwick and other airports nationwide

All grades of Anaesthetist from everywhere welcome.

18th – 22rd January 2016 St Christoph am Arlberg (nr St Anton), Austria

www.weauconf.com

10th West of England Anaesthesia Update


Anaesthesia has not been a rich seam of interest to screenwriters and film producers in the history of moving pictures. However, there are some interesting and notable exceptions. On television there will be a part for the anaesthetist in hospital based dramas, especially those set in and around operating theatres. During the long running series Surgical Spirit, the anaesthetist, Dr Haslam (played by Duncan Preston), had an expanding role in the series as he became the romantic interest of surgeon Mrs Sabatini (Nichola McAuliffe). In the 1990s series Cardiac Arrest, acclaimed writer and former doctor Jed Mercurio made a big part for the anaesthetist Dr James Mortimer. By portraying him as an openly gay man suffering from full blown AIDS, Mercurio was able to explore themes of prejudice, homophobia, and media intrusion. The anaesthetist in Dr Mercurio’s next medical drama Bodies fared little better. Marie Orton is bullied and harassed by her colleagues after she blows the whistle on a bungling obstetrician. Pregnant at the time, Dr Orton subsequently miscarries and develops psychosis, eventually being sectioned under the Mental Health Act.

However, it is in films that my main interest lies. At the height of his fame, the director Preston Sturges chose to direct star Joel McCrea in the 1944 film The Great Moment. This film, based loosely on the book Triumph over Pain by Rene Fulop-Miller, was a noble attempt to dramatise the discovery of anaesthesia by William Morton nearly a century before. It was not a commercial success and failed to make a profit. In contrast, his earlier 1941 film, Sullivan’s Travels, which also featured McCrea, had been one of the most successful releases of that year. Against Sturges’ wishes it was marketed

as a slapstick comedy. Critics and public alike were put off by the confusing use of flashbacks in The Great Moment, especially as they were not in chronological order. In this movie the non scientist Morton is seen as an accident prone buffoon who stumbles by chance upon his great discovery and then becomes embittered at his failure to realise personal and financial reward. It is certainly no eulogy, but Morton’s place in history is nevertheless respected.

Anaesthesia was not being treated with any particular reverence on the silver screen in Great Britain either. Two years after the publication of Doctor in the House in 1952, the film version was released starring Dirk Bogarde. The author of the book and writer of the screenplay was, of course, Richard Gordon. In spite of Gordon’s own brief stint as an anaesthetist, the gasman does not feature prominently in the film, and is in fact played by the author himself as a cameo role. The best depiction of the specialty emanating from this period appears near the end of the outstanding 1946 film A Matter of Life and Death. Fatally injured but somehow surviving when his aircraft is shot down over the English Channel, David Niven is Squadron Leader Peter Carter. In the film’s most dramatic scene, Carter must undergo a hazardous neurosurgical procedure, while at the same time in a celestial other world his fate is decided. The induction of anaesthesia is filmed as though the camera is in the patient’s eye. As the eyelid slowly closes over, the sight and sound of going under inhalational anaesthesia is portrayed very vividly.

ANAESTHESIA goES To THE (movIE) THEATrEAnaesthetists are well known for their proficiency in adjusting operating lights but what about when the glare of the spotlight falls on them followed by cries of camera and action?

Some years later in 1962, cinema-goers were treated to a gruesome film entitled Corridors of Blood. Produced, confusingly enough, by an American MGM producer called Richard Gordon, well-known horror actor Boris Karloff was Dr Thomas Bolton and Christopher Lee played a henchman by the name of Resurrection Joe. Karloff had previously collaborated with Gordon and the director Robert Day in the very successful film The Haunted Strangler. Corridors of Blood, however, was not a triumph. Karloff’s character is a British surgeon in the 1840s who experiments with anaesthetic gases in an admirable quest for pain-free operations. Mirroring intentionally or otherwise Horace Wells’ ill fortune with nitrous oxide and his subsequent abuse of chloroform and eventual suicide, the film has similarly dark themes which include awareness under anaesthesia, addiction, murder and blackmail.

More recent films in the genre have had a theme of wrongdoing under anaesthesia, as in the 1978 movie Coma based on the bestselling novel of the same name by Robin Cook. In this sinister production, the Chief of Surgery, Dr Harris, is plotting to render young healthy patients, among them a fresh faced Tom Selleck, brain dead by covert carbon monoxide poisoning during routine surgery. The comatose victims are transferred to the remote and secretive Jefferson Institute from where their organs are removed and sold by auction to the highest bidder. Academy Award nominee Richard Widmark is the errant surgeon and Genevieve Bujold is very good as the surgical resident who ultimately exposes his crime. The chief of anesthesiology, Dr George, not innocent himself it turns out, is actor Elmore Torn. Long before the fame and fortune of ER, which he wrote and produced, and the film of his book

Jurassic Park, Coma saw Michael Crichton at the directorial helm for only the second time. Like Robin Cook, Crichton was a medical graduate. As a result the film was chillingly realistic and fed successfully into the paranoid zeitgeist of the time. It did good business at the box office and has aged very well.

Awake, with Jessica Alba and Hayden Christensen, was released in 2007. The tagline was ‘1 in 700 people wake up during surgery. When they planned her husband’s murder they never thought he’d be the one’. Paralysed, awake and aware during heart surgery, a man discovers through overheard conversation there is a plan to kill him, orchestrated by his wife and the surgeon. It is certainly an interesting plot; although its reliance on anaesthetic ineptitude didn’t please everyone. A group of anaesthetists in Canada took issue publicly with the quoted awareness figure. The Ontario Anesthetists Association was not happy either that the anesthesiologist did not perform a pre-operative assessment and that he was intoxicated with alcohol. This, they reminded everyone, would not be an acceptable level of care in Ontario.

For the romantic action adventure blockbuster in which the anaesthetist is the hero or heroine we may have to wait a little longer. That book and screenplay needs to be written first. No longer a Cinderella specialty, always-the-bridesmaid-never-the-bride, the limelight will surely beckon us one day.

Matthew downConsultant Anaesthetist, Sunderland Royal Hospital


The sight and sound of going under


Anaesthesia & Cri-cal Care Update 9th & 10th October 2015

Organised by: Bri9sh Associa9on of Indian Anaesthe9sts (BAOIA)

Hilton Warwick/Stra:ord-‐Upon-‐Avon

Workshops: Friday, 9th October, 2015 (6 CPD Credits) •  Airway: Awake intuba9on

Airway Ultrasound, ORSIM simulator •  Focused Intensive Care Echo •  Total Intravenous Anaesthesia •  Ultrasound Guided Regional Anaesthesia Scien-fic Programme: Saturday 10th October, 2015 (6 CPD Credits) •  Shape of Training •  Prepara9on for Consultant Post •  Advances in Cri9cal Care •  Updates in Bariatric Anaesthesia •  What’s new in Airway Management •  Anaesthesia Conundrums •  Free Paper presenta9ons For further details and registra9on please visit

www.baoia.co.uk

PRIMARY FRCA OSCE/SOE REVISION COURSE

Thursday 22nd & Friday 23rd October 2015 Clinical Education Centre, Leicester Royal Infirmary

This is a 1 or 2 day course that offers intensive practical training in FRCA OSCE and SOE technique. The format is based around small group tutorials and offers individual performance-based appraisal. Candidates can register for 1 or both days depending on requirements. Integral to the course are:

Lunch/refreshments and car parking (if required) included. Please Note: Accommodation is NOT included

The cost is: Thursday OSCE £140.00

Friday SOE £140.00 Thursday and Friday £260.00

TO REGISTER PLEASE EMAIL YOUR DETAILS TO: Kizzy Laird-Connolly Primary FRCA Course Co-ordinator Robert Kilpatrick Clinical Sciences Building Level 4 Leicester Royal Infirmary Tel: 0116 252 3108 Fax: 0116 252 3125 [email protected] [email protected]

Practice OSCEs with feedback Individual SOE practice with feedback Meals & refreshments throughout the course Numbers are strictly limited so you are advised to apply early!

PRIMARY FRCA OSCE/SOE REVISION COURSE

Thursday 22nd & Friday 23rd October 2015 Clinical Education Centre, Leicester Royal Infirmary

This is a 1 or 2 day course that offers intensive practical training in FRCA OSCE and SOE technique. The format is based around small group tutorials and offers individual performance-based appraisal. Candidates can register for 1 or both days depending on requirements. Integral to the course are:

Lunch/refreshments and car parking (if required) included. Please Note: Accommodation is NOT included

The cost is: Thursday OSCE £140.00

Friday SOE £140.00 Thursday and Friday £260.00

TO REGISTER PLEASE EMAIL YOUR DETAILS TO: Kizzy Laird-Connolly Primary FRCA Course Co-ordinator Robert Kilpatrick Clinical Sciences Building Level 4 Leicester Royal Infirmary Tel: 0116 252 3108 Fax: 0116 252 3125 [email protected] [email protected]

Practice OSCEs with feedback Individual SOE practice with feedback Meals & refreshments throughout the course Numbers are strictly limited so you are advised to apply early!

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.

www.aagbi.org/lifeboxesforrio

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

The AAGBi would like offer a heartfelt thanks to those who have donated to Lifeboxes for Rio. The donations bring us a step closer to reaching the £96,000 target that will allow us to save thousands of lives around the world in countries where patients are at risk of death from hypoxia during surgery.

www.aagbi.org/lifeboxesforrio

A huge thank you to our Lifeboxes for Rio supporters

And to all those donors who remained anonymous.

• Andrew Kilner• Ivan Houghton• Andrew Shribman• Anaesthetic Dept Royal Hallamshire Hospital• Anaesthetists in Management• Marion Rubins• Nancy Redfern• Martin Allibone• Elizabeth Whittle• JM Rutter• Peter Maguire• Robert and Simon Dennis• Lifebox London to Brighton Mini run• Vikram Halikar • The AAGBI Cheetahs• Elizabeth McGrady• Francoise Iossifidis

A special thanks goes to:


As a professional woman I also considered it normal to unwind with a glass or two of wine in the evenings. Precious ‘Me Time’ equated to ‘Wine Time’. Very quickly, wine o’clock arrived earlier and earlier, the quantity consumed gradually increased, the second bottle was opened. Drinking crept under the radar to invade my life. Very quickly the couple of glasses that started as a treat became a coping mechanism for the stresses of daily life and, latterly, became a need. I thought alcohol was the solution, rather than the cause of my problems. The worse things got, the more I drank. Until it spiralled out of control.

Sound familiar?

After a few years of trying and failing to moderate the amount I drank, I embarked on a mission to give up alcohol completely. I thought this would be all about doing without and deprivation. I resigned myself to a life of straight-laced misery, missing out on all the fun. I did not consider what I might gain when alcohol was removed from my life. Some of the biggest differences I notice are at work and my working life is much improved now.

I never drank at work or while on-call, but out of work I was often hung over and far below par. I usually felt sick, had a headache with the lethargy and depression that descends after all that booze. Physically, I tried to eat my way free of these symptoms but usually compounded them with sugar bingeing and bloating, and yet another layer of depression. Mentally, there was no escape from the remorse and disappointment in myself; I had, once again, been unable to stop at a sensible amount. I would be irritated, harassed, abrupt and anti-social.

I dreaded my on-calls; I hated being busy and I hated being at home, waiting to be called. After each on-call I felt unusually light and happy. I used to attribute this to no longer being on-call but now it is clear it resulted from the enforced wine free period. I never made this association before I stopped drinking and, even if I had, I’m not sure it would have altered my behaviour. The night following an on-call, I made sure I had time to focus on drinking. It wasn’t so much the actual time, it was more being free from commitments that precluded drinking, such as driving.

Much of the weekend was given over to drinking, followed by the inevitable vomiting, hangover and general malaise. I would make the most of Sundays by having friends round in the afternoon so the wine could be opened even earlier. On Mondays I would see the patients, get the first one on the table, then sit down to assess how I felt; my normal being grumbling, complaining, demanding, short tempered, pessimistic. I oscillated between hoping I was doubled up on a list, to share the responsibility and ensure plenty of coffee breaks and canteen trips, and preferring to be working alone so I could function at the lowest level, almost mute and catatonic, without any need for social interaction.

I existed like this for most of the week. I managed to cope but it became more and more difficult. I became exceedingly ‘tired’, exhausted to the point of weakness so I stopped doing any exercise in the evenings. Instead, I drank more wine in a bid to make me feel better, not for a minute thinking it was making me feel worse.

I became overwhelmed by minor stresses. Every molehill became a mountain and small decisions became difficult to make. I dithered. An excess of alcohol brings paranoia, rumination, deliberation. Had I remembered to do this? Had I handed over that? Had I offended anyone? Should I apologise just in case? (ensuring another huge mountain formed). I became easily harassed and began to rush everything.

These changes came about gradually and when I first noticed them I coped by drinking. My life was so awful it was the least I deserved! I then wondered what was wrong with me. Did I have ME? Hypothyroidism? Depression? I hoped I had something wrong that could be fixed, hopefully with a pill, and then I would feel better.

I was known as a sociable party girl in my life outside work. Lots of groups of friends, lots of nights out ‘catching up’ with each other, all with the same final common pathway of me drinking far too much, becoming loud, obnoxious, then commandeering the conversation with slightly exaggerated claims before staggering home, and hopefully arriving before vomiting. I would try to fulfill my family commitments as best I could; complaining minimally and accepting sympathy for being ‘tired’ from my late night but unable to hide my disinterest and detachment in family life.

It sounds exhausting. Now I have so much time and space in my head. Half of it is no longer dealing with a hangover nor is the other half pre-occupied planning the next binge, taxi ride or stop at the off-licence. My brain has kicked back to life. After years of dampening its ability by continually drinking it has emerged, seemingly unscathed and ready to make up for lost time. Last year I started learning a new language at an evening class. I can concentrate and I am no longer reluctant to drive. I am happy and relaxed, pleasant even. I do not feel the urge to strangle those who try to engage me in small talk. I can even talk about the weather without rolling my eyes.

Life seems so much simpler now. Decisions are easy. The right thing to do is obvious. There is no rush to get to ‘wine time’. There is no anxiety if things run late. Life just happens. I no longer make my family miserable with my constant irritability, antagonism and over-reaction. I am no longer stressed about everything from packed lunches to putting up the Christmas tree. Now I am calm, measured, rational. My moods are appropriate. I am a better doctor, a better colleague and a better mother who happily drives her kids to clubs and has time for a chat at bedtime.

I need to continually remind myself that my life is now as good as it always looked on paper only because I continue to choose not to drink. I was so reluctant to give alcohol up, worried I would miss all the fun, scared of words like ‘forever’ and ‘never again’, yet here I am, relieved to be free from the clutches of alcohol, knowing I need never drink again. Why would you?

rachel Black

Banishing the boozeIt is always good to hear of and from doctors who have addressed their alcohol problem and got themselves into recovery, and well done for addressing your situation. Whereas by no means do we wish to dampen the author’s enthusiasm, attention should be drawn to the fact that ‘going under the radar’ is not the avenue suggested or supported by the AAGBI. The large majority of people with an alcohol, or other drug problem, do best by accessing and using the support of relevant professionals. These include psychiatrists who specialise in substance abuse, occupational physicians who advise on fitness for work and on work-related factors that impact on health, counsellors and psychiatric nurses. In the London area there is the Practitioner Health Programme (http://php.nhs.uk/), a free, confidential service for doctors and dentists who have mental health and/or addiction concerns. Other regions also provide services. Support from colleagues is immensely valuable; someone whom the individual trusts and who helps them to identify when their health is not good and to manage themselves in a professional manner.

The GMC can be surprisingly reasonable when doctors (particularly for an uncomplicated alcohol problem) self-report. If the doctor is sober and attending meetings of both Alcoholics Anonymous and the British Doctors & Dentists Group, the GMC may often either do nothing, or give only a few conditions (such as attending these meetings), which do not affect practice to any great extent. Suspension is not universally applied. It is also worth pointing out that working with a bad hangover must surely reduce alertness and reaction times in a specialty where this can be ill-afforded.

AnonymousSupport and Wellbeing Committee Member, also in recovery

Further reading

I don’t drink. Never. Not at all. One year ago things were very different. In the medical profession, including anaesthesia, it is not unusual to drink to excess at conferences, at weekends and sometimes mid-week too. Almost everyone does it and I was no different. It occurs to such an extent that this behaviour appears normal.

It is not.

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

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


Monitoring and safety go hand in glove for the safe administration of anaesthesia. Indeed, many adverse events associated with anaesthesia have frequently been attributed, at least in part, to anaesthetist error.1 Clearly then, certain parameters such as oxygenation, ventilation and circulation need continuous measurement, with alarms signalling whenever a value falls outside pre-set limits.2 A small change in monitored values may be the first sign of a major impending problem. Combined with constant vigilance and anticipation of problems, these measures contribute strongly to patient safety through early recognition of critical incidents. However, equipment can malfunction, generating false data which cannot be relied on. Constantly sounding alarms may distract the anaesthetist from the patient and invasive monitoring is not without complications. Furthermore, not all monitoring is good monitoring.

Consider the pulmonary artery catheter (PAC) in estimating cardiac output to guide fluid therapy. This method, with the goal of matching the haemodynamic profile of survivors of major surgery and critical illness, moved rapidly from bench to bedside in the 1970s.3 As many as 43% of seriously ill patients hospitalised in the USA during the 1980s were reported to have undergone this procedure.4 It was generally accepted that the PAC would improve outcomes simply because using the numbers generated to guide treatment ‘made sense’, despite inconclusive evidence on the safety, accuracy and benefit of the device.5 Editorials in the mid-1980s erred on the side of caution and warned against their widespread use.6,7 However, these were ignored after a small, unblinded study demonstrated a mortality benefit by targeting supra-normal values for cardiac output, oxygen delivery and oxygen consumption.8 It was only after three decades of use that large observational studies linked PAC use with an increased mortality rate.9,10 Subsequent large scale randomised controlled trials (RCTs) have found no benefit of PAC use in the populations they studied.11 Furthermore, catheter use has been associated with an increased rate of pulmonary embolism.12

This example demonstrates the importance of a pragmatic approach, using the best available evidence to inform us of what the numbers really mean for a particular patient group. Otherwise, we risk being misguided in a way which could actively harm our patients. But what if the best available evidence evades critical appraisal? Systematic reviews and meta-analyses sit at the very top of the hierarchy of evidence and are used by clinicians to guide best practice. Therefore, when a Cochrane meta-analysis in 1998 reported that human albumin increases mortality by 6%, widespread alarm ensued.13 However, this report has rightly been criticised for pooling data from studies of extremely heterogeneous patient groups without accounting for the clinical validity of the studies conducted.14 The SAFE study, 6 years on, put these fears to bed and evidence now suggests that albumin is not only safe but beneficial in certain patient groups.15,16 We must therefore always subject the numbers to careful scrutiny, even if they come from the highest level of evidence and are published in respectable peer-reviewed journals.

What if the data is unavailable for scrutiny? It was only after an institutional investigation by Erasmus University into five of the DECREASE family of trials in 2011 that it became clear that trial methodology had been falsified and data had been fabricated. Don Poldermans, who led all six DECREASE trials, was dismissed for scientific fraud. However, Poldermans chaired the peri-operative taskforce of the European Society of Cardiology (ESC). This group oversaw the 2009 guidelines recommending the initiation of peri-operative beta-blockade for patients with ischaemic heart disease who are having high risk surgery.17,18 Two of the discredited DECREASE trials underpinned this guidance. Once these were excluded, meta-analysis of the 11 remaining credible RCTs demonstrated an alarming 27% increase in mortality (p = 0.04; 95% CI: 1–60%).19 This was followed by an estimate that 800,000 deaths might have been attributable to this guideline, prompting Forbes to run the headline ‘Medicine or Mass Murder?’20,21

Safety in numbers

AAGBI WyLie MeDaL WinninG eSSay 2015Chengyuan ZhangMedical studentimperial College London

13 -15 JANUARY 2016

Taking place over three days and offering:• Keynote lectures • core topics • poster competition• extensive industry exhibition • networking opportunities

European Accreditation Council

for Continuing Medical Education (EACCME) has been

applied for

C

M

Y

CM

MY

CY

CMY

K

WSM_A5_Flyer.pdf 1 08/06/2015 15:35

INNOVATIONAAGBI

The Annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain

www.aagbi.org/research/innovation

INNOVATIONAAGBI

The Annual AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain

www.aagbi.org/research/innovation

The Association of Anaesthetists of Great Britain and Ireland invites applications for the 2016 AAGBI Prize for Innovation in Anaesthesia, Critical Care and Pain. This prize is open to all anaesthetists, intensivists and pain specialists based in Great Britain and Ireland. The emphasis is on new ideas contributing to patient safety, high quality clinical care and improvements in the working environment. The entries will be judged by a panel of experts in respective fields.

Applicants should complete the application form that can be found on the AAGBI website www.aagbi.org/research/innovation.

The closing date for applications is wednesday 30 september 2015.

Three prizes will be awarded and the winners will be invited to present their work and collect their prizes at the Winter Scientific Meeting in London on 15 January 2016.

Kindly sponsored by:

14 Anaesthesia News September 2015 • Issue 338

Could these unreliable and fictitious trials have been detected earlier? Could we have done more to prevent the deaths which may have occurred as a result of falsified data? There has been a long-standing argument to share raw data from clinical trials in a push to bring transparency to a closed system.22 This would enable readers to scrutinise the numbers in order to prevent fraud and selective reporting. However, it is equally important to act rapidly when the numbers tell a different story. Despite the remaining evidence indicating an increased risk of death, ESC guidelines initially set at the highest level (class I), have been slow to change. Even the most recent update in August 2014 merely downgraded the recommendation to class IIb but failed to lower it to neutral or negative despite the associated mortality.17 There is a clear and pressing need for freedom of information with close attention to the numbers and what they really show.

The PAC was the cornerstone of intensive care practice for three decades and initiating peri-operative beta-blockade was grounded in well-respected guidelines from the ESC.17 The immediate knee-jerk reaction to the human albumin meta-analysis resulted in a significant fall in albumin use.23 We must therefore seek to dispel the illusion that we can seek safety in numbers. Simply because an action or treatment is widely practiced or endorsed by guidelines and journals does not mean that it is correct. Clearly, close attention to numbers in routine monitoring and drug dosing has a well-established safety record. But should we approach newer technologies such as spectral entropy,24 which lack a convincing evidence base, in the same way? Despite pressure from media sensationalism following results of the 5th National Audit Project published last year,25 clinicians need to scrutinise the evidence carefully and maintain a state of constant vigilance. Safety comes, not entirely in the numbers, but through treating them with due care. After all, the numbers are only as safe as the way in which they are interpreted.

AcknowledgementI would like to thank Dr Rob Stephens at University College Hospital for arranging an unforgettable Special Study Module in Anaesthesia and for being a constant inspiration to students considering a career in the specialty.

chengyuan ZhangMedical studentImperial College London

References1. Williamson JA, Webb RK, Sellen A, Runciman WB, Van der Walt JH. The Australian Incident Monitoring

Study. Human failure: an analysis of 2000 incident reports. Anaesthesia and Intensive Care 1993; 21: 678–83.

2. The Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery. 2007. http://www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf (accessed 16/11/2014).

3. Shoemaker WC, Montgomery ES, Kaplan E, Elwyn DH. Physiologic patterns in surviving and nonsurviving shock patients. Use of sequential cardiorespiratory variables in defining criteria for therapeutic goals and early warning of death. Archives of Surgery 1973; 106: 630–6.

4. Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. Journal of the American Medical Association 2007; 298: 423–9.

5. Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Annals of Intensive Care 2013; 3: 38.6. Robin ED. The cult of the Swan-Ganz catheter. Overuse and abuse of pulmonary flow catheters.

Annals of Internal Medicine 1985; 103: 445–9.7. Robin ED. Death by pulmonary artery flow-directed catheter. Time for a moratorium? Chest 1987; 92:

727–31.8. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of

survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94: 1176–86.9. Connors AF, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial

care of critically ill patients. SUPPORT Investigators. Journal of the American Medical Association 1996; 276: 889–97.

10. Polanczyk CA, Rohde LE, Goldman L, et al. Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. Journal of the American Medical Association 2001; 286: 309–14.

11. Shah MR, Hasselblad V, Stevenson LW, et al. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. Journal of the American Medical Association 2005; 294: 1664–70.

12. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. New England Journal of Medicine 2003; 348: 5–14.

13. Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. British Medical Journal 1998; 317: 235–40.

14. Allison SP, Lobo DN. Debate: Albumin administration should not be avoided. Critical Care 2000; 4: 147–50.

15. Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Annals of Internal Medicine 2001; 135: 149–64.

16. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. New England Journal of Medicine 2004; 350: 2247–56.

17. Cole GD, Francis DP. Perioperative beta blockade: guidelines do not reflect the problems with the evidence from the DECREASE trials. British Medical Journal 2014; 349: g5210.

18. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. European Heart Journal 2009; 30: 2769–812.

19. Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery. Heart 2014; 100: 456–64.

20. Godlee F. How guidelines can fail us. British Medical Journal 2014; 349: g5448.21. Husten L. Medicine Or Mass Murder? Guideline based on discredited research may have caused

800,000 deaths in Europe over the last 5 years. Forbes 15 January 2014. http://www.forbes.com/sites/larryhusten/2014/01/15/medicine-or-mass-murder-guideline-based-on-discredited-research-may-have-caused-800000-deaths-in-europe-over-the-last-5-years (accessed 18/11/014).

22. Vickers AJ. Making raw data more widely available. British Medical Journal 2011; 342: d2323.23. Patey R, Wilson G, Hulse T. Albumin controversy continues. Meta-analysis has affected use of albumin.

British Medical Journal 1999; 318: 464.24. National Institute for Health and Care Excellence. Depth of anaesthesia monitors – Bispectral Index

(BIS), E-Entropy and Narcotrend-Compact M. 2012. http://www.nice.org.uk/guidance/DG6 (accessed 18/11/2014).

25. 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.

Dr Andrew Hartle, AAGBI President presenting the Wylie Medal to Chengyuan Zhang

MSc in Anaesthesia (Perioperative)1 year full-time or 2 years part-timeStarting October 2015 in Medway (London in 42 mins by rail)

A high quality programme which focuses on perioperative care and quality improvement.Our MSc in Anaesthesia (Perioperative) has been designed in collaboration with leading anaesthetists to ensure it meets the personal and professional development of anaesthetists working in the NHS and private sector.

Practical sessions, lectures and research methodologies are used to cover: Quality improvement in anaesthesia Pre-assessment and risk stratification Intraoperative and postoperative care

Find out moree: [email protected]/pg/anaesthesia

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 Scottish Society

of Anaesthetists

Annual Winter Scientific MeetingNovember 5th and 6th 2015

EventAnnual WinterScientific Meeting

November 5th and 6th 2015 Airth Castle, Scotland

Features Extremes of anaesthesia, safety and simulation, core topics and much more.

TicketsEarly bird price available before October 1st

Online registration on our newly designed website www.ssa.scot


DIFFICULT AIRWAY SOCIETY

AIRWAY REVALIDATION COURSE

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

www.das.uk.comFor more information and booking details visit

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 launched in collaboration with The RCoA is specifically designed to meet the airway CEPD requirements of UK Anaesthetists.

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

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

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

CPD approved meeting5 CPD points

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

Practical LA & GA techniques Difficult & ‘impossible’ cases

Clinical governance Posters & Free papers Lessons from overseas

Future of surgery & anaesthesia

£125-‐250 before 30 September, £150-‐300 after

[email protected] 01603 288578

www.boas.org

16th Annual Scientific Meeting

London

At the Magic Circle’s theatre!

19/20 November 2015

£500 prize for best presentation by a trainee

Abstract deadline 7th September 2015

The First World War saw unprecedented numbers of casualties arriving at Casualty Clearing Stations (CCS) close to death from shock. The cause was haemorrhage from gunshot and shell wounds compounded by shortage of fluids and intense cold after the soldiers had been transported a number of miles by stretcher bearers working in intolerable conditions.

If excision of badly damaged tissues wasn’t carried out within a few hours then gas gangrene would develop and the situation became ever more hopeless.

The appearance of a soldier close to death with a pale skin, feeble pulse and beads of sweat was well known but poorly understood. Quite clearly the blood wasn’t in the skin but where was it? Operating and anaesthetising soldiers in this condition might precipitate death as the compensatory mechanisms they had put in place were compromised. Geoffrey Marshall was sent from his comfortable existence on a hospital barge to a CCS to investigate the effects of anaesthesia on wounded soldiers. Following a number of carefully controlled studies he concluded that spinal anaesthesia, which was originally thought to protect from the effects of shock, was disastrous. Chloroform and ether weren’t to be recommended either, although the latter would maintain blood pressure initially. The only anaesthetic suitable for soldiers close to death from shock was a quick whiff of nitrous oxide and oxygen while the bleeding was dealt with.

The progressive development of shock on the journey from the battlefield to the CCS was documented by Ernest Cowell, a surgeon who measured blood pressure at regular intervals on the way to the CCS. He recognised that soldiers were dehydrated before being wounded and very cold. Also that the extent of shock was related to the amount of tissue injury and that it probably favoured the development of gas gangrene.

In order to solve the riddle of shock, a Shock Committee was put together in 1917 and comprised of a number of eminent surgeons and physiologists led by Ernest Starling.

Investigations showed that soldiers were acidotic and Sir Almroth Wright, a pathologist, understood that this was the result not the cause of shock. Tissues were poorly perfused and soldiers needed blood and fluids. With the realisation of the cause of shock came a method for dealing with it:

1. Give fluids – warm tea and coffee by mouth and, if this is not possible, then rectally

2. Keep soldiers warm by having heated blankets available at advanced dressing stations and heated ambulances

3. If intravenous fluids are required then gum acacia, the invention of William M Bayliss (a physiologist at UCL) proved superior to saline

4. If at all possible give blood. Blood transfusion carried the risk of incompatibility and transmission of infection but proved to be life saving

5. Operate to prevent haemorrhage as soon as the patient is stabilised but don’t delay

In 1917 a CCS was opened at Brandhoek in Belgium closer to the front line in order to deal, at the earliest possible opportunity, with soldiers suffering from the very severest of wounds (femoral fractures, abdominal and chest wounds). Unfortunately it had to be closed after only a month as a shell hit it and killed a sleeping nurse and the work was moved further back.In 1918, shock centres were opened at Gezaincourt CCS on the Somme with doctors warming and transfusing patients – in effect processing them for surgery but without delaying. However, Holmes à Court of the Australian Army realised that shock teams, which would go out into the battlefield and rescue soldiers as close to the front line as possible, were necessary to save more lives and by the Battle of Hamel in July 1918 they were ready for action. By modern standards soldiers were given a paltry amount of blood but it was enough to remove some of them from the dangers of shock and the boost to morale of these efforts must have been enormous.

Ann robertsonExtracted from a chapter written by the author: Anaesthesia, Shock and Resuscitation. In: Scotland T, Heys S, eds. War Surgery 1914-1918. Solihull: Helion & Company Ltd, 2013. p85–115.

Wound shock 1914–18


©iwM (Q008734)soldiers having their wounds dressed

©iwM (Q2858)German prisoner attending a wounded comrade


In these busy and sometimes stressful times there is comfort to be sought in the application of blood, sweat and tears to achieve a goal. Training the body toughens the mind and helps us face the not insignificant challenge of working in the NHS. For anaesthetists in the regular and reserve armed forces who want to apply this theory, the challenge is clearly laid out for them: ‘Come and have a go if you think you are fit enough!’ This is the maxim of the All Arms Pre-Parachute Selection Company; ubiquitously known as P-Company.

Passing P-Company is the gateway to the British Military Parachute Course at RAF Brize Norton and earning your parachute wings. As General Duties Medical Officers (GDMOs) in the regular army serving with 16 Medical Regiment, we set ourselves the challenge of passing what is arguably the most demanding course in the British Army outside of Special Forces selection. Many of our military anaesthetic colleagues strive to attain their wings, the coveted ‘blue badge of courage’ and earn their maroon beret. Many have succeeded but many more have failed. All who have attempted the course will tell you it is somewhere on the spectrum

of pain between sitting the final FRCA and self-flagellation!

The P-Company mission is to test physical fitness, determination and mental robustness under conditions of stress, in order to determine whether an individual has the self-discipline and motivation required for service with Airborne Forces. P-Company consists of an initial build up phase which runs over three weeks; the idea being that your body adapts to the demands of covering distance (invariably over hills) at speed and with weight. The reality is that this period breaks all but the most robust individuals. It is also worth noting that prior to the build up phase there is a build up to the build up phase; this is aptly known as a ‘beat up course’. Concepts like ‘it pays to be a winner’ are introduced here whereby, somewhat predictably, if you don’t win you carry out whatever sadistic task the physical training instructors have devised for you until you win or are the last man standing. Your only hope of revenge is that the instructor might one day find himself attached to the other end of a 16G Venflon during one of your elective lists.

P-Company isn’t purely a test of fitness. Very fit individuals regularly fail the course. The most important characteristic you In

‘Utrinque Paratus’ – ready for Anything‘What manner of men are these who wear the maroon red beret? They are firstly all volunteers, and are then toughened by hard physical training. As a result they have that infectious optimism and that offensive eagerness which comes from physical well being. They have jumped from the air and by doing so have conquered fear. Their duty lies in the van of the battle: they are proud of this honour and have never failed in any task. They have the highest standards in all things, whether it be skill in battle or smartness in the execution of all peace time duties. They have shown themselves to be as tenacious and determined in defence as they are courageous in attack. They are, in fact, men apart – every man an Emperor.’ field Marshal The Viscount Montgomery

18 Anaesthesia News September 2015 • Issue 338

In these busy and sometimes stressful times there is comfort to be sought in the application of blood, sweat and tears to achieve a goal. Training the body toughens the mind and helps us face the not insignificant challenge of working in the NHS. For anaesthetists in the regular and reserve armed forces who want to apply this theory, the challenge is clearly laid out for them: ‘Come and have a go if you think you are fit enough!’ This is the maxim of the All Arms Pre-Parachute Selection Company; ubiquitously known as P-Company.

Passing P-Company is the gateway to the British Military Parachute Course at RAF Brize Norton and earning your parachute wings. As General Duties Medical Officers (GDMOs) in the regular army serving with 16 Medical Regiment, we set ourselves the challenge of passing what is arguably the most demanding course in the British Army outside of Special Forces selection. Many of our military anaesthetic colleagues strive to attain their wings, the coveted ‘blue badge of courage’ and earn their maroon beret. Many have succeeded but many more have failed. All who have attempted the course will tell you it is somewhere on the spectrum of pain between sitting the final FRCA and self-flagellation!

The P-Company mission is to test physical fitness, determination and mental robustness under conditions of stress, in order to determine whether an individual has the self-discipline and motivation required for service with Airborne Forces. P-Company consists of an initial build up phase which runs over three weeks; the idea being that your body adapts to the demands of covering distance (invariably over hills) at speed and with weight. The reality is that this period breaks all but the most robust individuals. It is also worth noting that prior to the build up phase there is a build up to the build up phase; this is aptly known as a ‘beat up course’.

Concepts like ‘it pays to be a winner’ are introduced here whereby, somewhat predictably, if you don’t win you carry out whatever sadistic task the physical training instructors have devised for you until you win or are the last man standing. Your only hope of revenge is that the instructor might one day find himself attached to the other end of a 16G Venflon during one of your elective lists.

P-Company isn’t purely a test of fitness. Very fit individuals regularly fail the course. The most important characteristic you must possess in order to pass is determination. You must have the desire to win at all costs and to push yourself to new depths of mental and physical exhaustion. Probably the most helpful bit of advice we received was from a Senior Non-Commissioned Officer: ‘just remove your brain for six weeks’. Considering the fast paced world in which we live the prospect of brain removal actually sounded quite appealing, but inevitably at this point self-doubt starts to rear its ugly head. Have I done enough hill reps, have I covered enough miles, what’s that odd sensation in my knee? As the course starts, all the self-doubt melts away and everything extraneous is replaced by a singularity of purpose that is rarely experienced in this busy world. All that mattered was the next event and ultimately passing.

It is a given that you have to be fit to pass, but the P-Company staff know how to level the playing field. If you are operating at the level of an elite athlete they will simply push you harder, making you run rings – literally – around the rest of the squad! Or by insisting that, despite having done 20 quality press ups, you have in fact only completed one. Needless to say, argument is futile. A sadistic sense of humor definitely helps get you through and Winston Churchill’s advice, ‘when you’re going through hell, keep going’ definitely strikes a chord.


sAFeTY MatteRSFlexicare swivel catheter mount

Dear Editor,

We wish to highlight a fault with a Flexicare swivel catheter mount (Flexicare Medical Ltd, Mountain Ash, UK). When transferring a patient to theatre following the placement of a tracheal tube in the anaesthetic room, a leak was detected and high flows were required. Our systematic checks demonstrated that the leak was from the catheter mount and on replacing it everything returned to normal. On reflection, we recalled that there was a problem with the catheter mount in the anaesthetic room. When removing the catheter mount from the facemask, the yellow end (Figure 1) remained attached to the facemask and came away from the rest of the catheter mount. The yellow end had to be prized away from the mask prior to being reattached to the catheter mount and the whole device then attached to the tracheal tube. We deduced that the leak was from around the faulty connection. Our colleagues reported similar problems. We reported this incident to the MHRA and the manufacturer.

Michael charlesworth & catherine ArmstrongCentral Manchester University Hospitals

Flexicare would like to thank Dr Charlesworth and Dr Armstrong for bringing this incident to our attention, and for Anaesthesia News for giving us the opportunity to respond. We are pleased to hear that there was no detrimental effect on the care of the patient. At the time of writing this response, Flexicare has not received the devices involved and is therefore unable to confirm the dimensions of the catheter mount are within the specification tolerances, or check that the yellow 22 mm female connector on the face mask (Dräger Medical GmbH) conforms to BS EN ISO 5356-1:2004 Anaesthetic and Respiratory Equipment – Conical Connectors, Part 1: Cones and Sockets. Flexicare believes that the reported dissociation of the catheter mount at the swivel joint resulted from incorrect handling. Conical connectors use a morse type taper to create a secure fit when connected using a ‘push and twist’ motion as recommended by the AAGBI.1 The conical shape means that the force must be exerted in a perpendicular direction to either connect or disconnect the components (Figure 1). Flexicare’s Double Swivel Elbow is designed and tested to ensure that the force required to dissociate the parts is much higher than the force required to disconnect the conical connection when a perpendicular force is exerted.

However, if the force is not perpendicular (Figure 2), then it will not be possible to separate the two devices without potential damage to either component. If a lateral force is applied, then a lever effect is created with the force being concentrated in the elbow of the catheter mount. In the case of the Double Swivel Elbow, this could lead to dissociation of the component parts as seen in this case. In our investigations we have been able to replicate this type of incident with similar designs of catheter mounts from a range of manufacturers. It may therefore be useful for members of the anaesthetic community to review their practice related to the use of conical connectors to ensure that all connections and disconnections are made using a perpendicular force.

Jim hiewProduct Specialist, Flexicare Medical Limited

Reference1. AAGBI Safety Guideline. Checking Anaesthetic Equipment 2012.

Anaesthesia 2012; 67: 660-8.

Figure 1

The 1 ml doppelgänger


We write to highlight the potential risk of inadvertently delivering heparin from a 1 ml syringe. Aside from the green cap, a plain 1 ml syringe (BD PlastiPak™) and a heparinised arterial blood gas syringe (Protech Medical Ltd) could easily be mistaken for one another (Figure 1). A patient was due to have spinal anaesthesia with intrathecal diamorphine. During the preparation of the diamorphine it was noted that the 1 ml syringe had a green cap and a few drops of fluid in it. On checking the supply of these syringes we found a mixture of standard plain 1 ml syringes and 1 ml blood gas sampling syringes containing 50 IU electrolyte compensated heparin. A lack of attention could lead to inadvertent intrathecal administration of heparin. The 1 ml blood gas sampling syringes are no longer in use in our hospital, but we would like to raise awareness of this near miss.

Katharine sprigge & helen King, Royal Cornwall Hospital Trust

Figure 1

Figure 1 Figure 2

P-Company itself lasts three and a half weeks and is split into three phases.

Phase 1

• Screening – held on the first Monday of the course, comprising the Combat Fitness Test, an eight-mile squadded march carrying a 35lb bergen (plus water) and weapon, conducted in the standard British Army time of 1 hour 50 minutes.

• Trainasium – aerial confidence course.• Basic Fitness Assessment – 1.5 mile run, which must be

completed in less than 9.5 minutes.

If you fail any of these elements you are unceremoniously Returned to Unit

Phase 2

Build Up – this phase lasts two and a half weeks and is a progressive physical build up to Test Week. It also includes a military skills package, which delivers the most recent operational tactics, techniques and procedures in order to prepare students for service with their Airborne Unit. It includes such esoteric delights as ‘speed play’ (a very fast run) and ‘the land of nod’ (a long march with weight and multiple hill repetitions) and the infamous P-Company half marathon. For two and a half weeks candidates endure at least two hard physical training sessions per day and avoiding injury is very much the name of the game. Much of your downtime revolves around taping damaged body parts back together, swallowing painkillers and consuming vast quantities of carbohydrate and protein as you burn over 6000 kcal a day. The latter task was achieved with clandestine night-time trips to the local McDonald’s for a Big Mac, milkshake and McFlurry combination.

The culmination of P-Company is Test Week. During Test Week, candidates are expected to run, march and carry weight over 1–20 miles on undulating terrain. There are eight events over a four and half day period. Seven events are scored; one (the trainasium) is a straight pass or fail. Each event is designed to assess a candidate’s physical fitness, mental robustness and determination. A candidate who fails to display the appropriate level of self-discipline and motivation throughout Test Week will fail the course. Test Week starts on a Wednesday morning and finishes the following Tuesday. Success or failure is confirmed when the candidates number is called out, they answer ‘yes sir’, and they are then unceremoniously told whether they have passed or failed. Candidates who have passed are presented with their maroon berets by a senior Parachute trained Officer accompanied by the prerequisite brief military handshake. Those who fail turn to the right and march off the square. The intention is not to humiliate those who have failed – many of them will be back to try again – this is just honest and immediate military feedback to which all officers and soldiers become accustomed.

Phase 3

The tests:

All marches are conducted carrying 35lbs of weight, plus water and a rifle.

• 10-mile march (Wednesday morning) in 1 hour 50 minutes. Reserve candidates have 2 hours

• Trainasium (Wednesday afternoon) – aerial assault course unique to P-Company designed to assess an individual’s suitability for military parachuting

• Log race (Thursday morning) – a team event with eight individuals carrying a 60kg log over a distance of 1.9 miles of undulating terrain. Probably the most feared event for most candidates; long arms and short stature make this much easier!

• Steeplechase (Thursday afternoon) – an individual test with candidates running against the clock over a 1.8 mile cross-country course

• Two-mile march (Friday morning) – conducted over undulating terrain with each individual carrying a bergen weighing 35lbs (plus water) and a weapon. A helmet and combat jacket is also worn. The march must be completed in 19 minutes or less. Territorial Army candidates have 20 minutes

• Endurance march (Monday) – a squadded march conducted over 20 miles of severe terrain completed in under 4 hours 30 minutes. Reserve candidates do not undertake this event

• Stretcher race (Tuesday morning) – teams of 16 men carry a 175lb stretcher over a distance of five miles. No more than four men carry the stretcher at any given time. Students wear webbing and carry a weapon

• Milling (Tuesday afternoon) – they say boxing is the thinking man’s game. If this is true, milling is its antithesis. The final event of Test Week is 60 seconds of controlled physical aggression against an opponent of similar height and weight. Bloody noses and knockouts are par for the course in this event.

At the end of all this it is possible to fail for not demonstrating the appropriate attitude! Provided this does not occur, you are presented with the coveted maroon beret – the realisation of six weeks of hard work. Next comes the relatively easy part. You earn the right to take up a place on the British military parachute course and get to jump/fall out of a RAF Hercules at varying altitudes during both day and night. When you hit the ground on your final jump your parachute settles gently on top of you and you have a few seconds to take stock and acknowledge the effort that has earned you your parachute wings.

Major David Hunt:

‘What motivates an individual to undertake this unique challenge? My own answer would be multifaceted, but the seed was probably sown after I watched a Channel 4 documentary series P-Company, which shrouded Airborne Forces in a veil of mystique and clearly set out the challenge. The obvious motivating psychological factors around wanting to belong to a particular group or striving to prove yourself to your peers are inescapable but they certainly don’t do it justice. It’s hard to find words to describe what motivates a person to undertake a personal challenge like this. Ultimately there can be no satisfying explanation, but anyone who has ever strived to achieve a significant challenge understands how consuming the desire can be. I look back fondly on the simplicity of that time when I had one clearly defined goal – earning my wings. Life is rarely so neatly defined these days, seldom do we know what is required to achieve success and the goalposts often move just as we think we do. At least all potential paratroopers know what is expected of them.’

The Parachute Regiment’s motto ‘Utrinque Paratus’ (‘ready for anything’) quite aptly sums up the challenges we face as anaesthetists, and Airborne esprit de corps has much to teach any institution. The pride of shared achievement brings cohesion to individuals, and ways of reinforcing this in the NHS are critical. What relevance does this have to most readers who are unlikely to ever have to exit a perfectly good aircraft?

Well, whatever challenges you aspire to during your anaesthetic career or whatever successes you have already had you can always push one step further.

Major david huntST6 Anaesthetics and Intensive Care Medicine, St George’s Hospital, London

Major Tom woolleyCT2 Anaesthetics, Frimley Park Hospital

For anyone wishing to join the regular armed forces call 0345 600 8080 or search ‘Army Medical’. For anyone wishing to join the reserves with the intention of undergoing pre-parachute selection and parachute training search ‘144 Parachute Medical Squadron’ on www.army.mod.uk


September 2015

Digested

N.B. the articles referred to can be found in either the latest issue of Anaesthesia or on Early View (ePub ahead of print)

Postoperative morbidity survey, mortality and length of stay following emergency laparotomyHowes TE, Cook TM, Corrigan LJ, Dalton SJ, Richards SK, Peden CJ.

I have used airway exchange catheters many times to intubate tracheas in intensive care patients, and I seem to have accomplished this without any major complications, despite some reports of direct airway trauma when they are used in the intensive care setting. I know that they can also be used to ventilate lungs with high-pressure oxygen, but I’ve not been in a position where I have had to do it. Judging by some of the reports of severe barotrauma that have resulted when this technique was used, I count myself as fortunate in this regard.

This paper is an in vitro study that seeks to quantify the pressure and flow characteristics of airway exchange catheters, making the point that the lumens of many airway exchange catheters are far larger but longer than those of jet injectors, and that the flow characteristics when used with high-pressure oxygen have not been described by manufacturers. The authors observed a maximum flow rate of 3.6 l/s, so it is perhaps not too surprising that barotrauma may occur now and again. The paper also gives other useful information on the effects of air entrainment etc. on flow to guide those who may have to resort to jet ventilation with these devices.

Determination of gas flow through airway exchange catheters: measured and calculated values and dependence on pressure and entrainment

YanHong R, Ihra GC, Gore C.

Emergency laparotomy is a common procedure with a high mortality, and many attempts have been made to reduce mortality in this group of patients with regard to fluid optimisation, postoperative management etc. The authors of this paper conducted a survey that focused more on the incidence and type of postoperative complications, which seem to have a bigger effect on outcome than pre-operative or intraoperative factors.

The authors used a recognised system (the Postoperative Morbidity Survey) to identify and categorise relevant postoperative factors.

It can’t come as much of a surprise that mortality is higher and hospital stays longer in older patients, but this survey also associates complications to outcomes using regression. Interestingly there are similar distributions of postoperative complications in older and younger patients, with infection being the main association with outcome. The potential for this approach is to to be better able to target management for postoperative morbidities to reduce mortality. Of course, identifying an association may be easier to achieve than the required outcome, but this approach seems to be a useful step forward.

EVELYN BAKER MEDAL

The Evelyn Baker award was instigated by Dr Margaret Branthwaite in 1998, dedicated to the memory of one of her former patients at the Royal Brompton Hospital. The award is made for outstanding clinical competence, recognising the ‘unsung heroes’ of clinical anaesthesia and related practice. The defining characteristics of clinical competence are deemed to be technical proficiency, consistently reliable clinical judgement and wisdom and skill in communicating with patients, their relatives and colleagues. The ability to train and enthuse trainee colleagues is seen as an integral part of communication skill, extending beyond formal teaching of academic presentation. Nominees should normally still be in clinical practice.

Last year the award was won by Dr Sally Millett (Worcester). Details of previous award winners can be found on the website http://www.aagbi.org/about-us/awards/evelyn-baker-medal

Nominations are now invited for the award, which will be presented at WSM London in January 2016. Members of the AAGBI can nominate any practising anaesthetist who is also a member of the Association. Examples of successful previous nominations are available on request. Nominations should include an indication that the nominee has broad support within their department.

The nomination, accompanied by a citation of up to 1000 words, should be sent to the Honorary Secretary at [email protected] by 17:00 on Friday 18 September 2015

AN AWARD FOR OUTSTANDING CLINICAL COMPETENCE

Is there anything interesting left to say about ventilation using supraglottic airway devices (SADs)? If there is, a large study involving patients has a better chance of providing it than a small study with manikins.

This was a retrospective study of 14,480 patients in which problems with ventilation via SADs were collected, and multivariate analysis used in an attempt to identify factors associated with difficult ventilation. Some previously identified associations with ventilation difficulty, such as male sex and older age were also associated with difficult ventilation in this study. Other identified factors such as

short thyromental distance and limited neck movement were also associated with difficult intubation, suggesting that patients with tracheas that are difficult to intubate are also more likely to be difficult to ventilate when a SAD is used as a rescue device. One of the problems with interpretation of the study results is that, as a retrospective study, a variety of SADs were used according to anaesthetist preference, and there is the possibility that there may be differences in performance during ventilation. However, this provides valuable insights into the usefulness of SADs as airway rescue devices.

Incidence of and risk factors for difficult ventilation via a supraglottic airway device in a population of 14,480 patients from South-East Asia

Saito T, Liu W, Chew TH, Ti LK.

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].

BOC-advert-aa.indd 1 20/07/2015 14:22

BOOKING NOW OPEN

WORLD AIRWAY MANAGEMENT MEETING

201512-14 NOVEMBER

Early bird rate available

www.wamm2015.com

DU

BLIN

Book now, don’t miss out on the Early Bird booking rate. This closes on Tuesday 8 September 2015. WAMM is the first world Airway Management meeting of its kind. With Internationally renowned speakers including:

• Prof Alan Merry, Auckland (New Zealand) on ‘Human factors & airway nightmares’• Prof William Rosenblatt, Connecticut (USA) on ‘Decisions in Airway Management’• Prof Carin Hagberg, Houston (USA) on ‘Airway Management Guidelines around the globe’• Prof John Sakles, Tucson (USA) and Dr Edward Otten, Cincinnati (USA) on ‘Airway Trauma’• Dr Richard Levitan, Philadelphia (USA) and Dr Andy Heard, Perth (Australia) debating on ‘Which front of neck technique?’Plus much, much more.....

B. J. Jenkins, Editor, Anaesthesia


Picture: Malawi Machines in use in two busy hospitals in 2011.

Forty-two units were distributed to every government hospital in Malawi, funded by Danish aid. The basic principle was sound and innovative: a drawover vaporiser system supplied by an oxygen concentrator. The latter had been used for domestic oxygen but not yet for anaesthesia. Three dedicated service centres were set up and technicians trained overseas; another first. For the first time, drawover was given a workstation layout, a development from the self-assembly TriService, PAC or EMO boxed kits; all you could get previously if you did not want to be dependent on a gas supply Boyle’s machine.

All good, but then problems emerged:

1. Conceptual: Anaesthetists wondered what was special about their country that it needed its own machine. As a drawover system, it could not be CE marked and independent evaluation in the West was not possible. So for them, either it was a poor solution for a poor country, or they were being used as guinea pigs. In fact, any machine designated ‘especially for the third world’ is doomed to fail, even if works: the ‘third world’ may need it but it doesn’t want it. Technology credentials must be internationally acceptable.

2. Technical: the design was before its time and some pitfalls were not anticipated. The options were halothane or ether which meant the concentrator had to be wall-mounted and it only provided 2 litres of 95% oxygen. There was a flush button which depleted the oxygen % for several minutes after use. Today, a similar concept would have a 10 litre/min concentrator and, omitting ether, this could be incorporated in the machine. Isoflurane would be an alternative to halothane. There was a superfluous system of pipelines, water drainage and rotameters that soon became defunct in most places; water condensed in the air rotameter instead. Nitrous oxide could be used but there was no hypoxic safeguard or oxygen monitoring. The patient system with Ambu bag and valve was cumbersome, inconvenient for prolonged IPPV and unpopular; there was no possibility of using a ventilator. The dials on the PAC halothane vaporisers corroded and became jammed. There was no patient monitor.

On the plus side, the workshops serviced the machines for a while and they serviced a lot of other equipment too.

During a recent nationwide anaesthesia equipment survey, 26 years later, it was found that 15 of the original 42 machines were still in service. They had generic patient systems from elsewhere to ventilate the lungs (Fig 1) and oxygen came via plastic tubing from any source. This is the type of machine where every original component, bar the chassis and the vaporisers, had gone but you could improvise and still use it. In an environment where the descriptor ‘working perfectly’ hardly exists, a design that allows for the disappearance of the sophisticated components while ensuring that the vital functions are preserved to the last, will stay in service longer.

Fifteen out of 42 after 26 years of heavy use and little or no service is a good record; it surely beats almost every available machine today which breaks down after 12–24 months and you can’t tell what is wrong, it just doesn’t work. Africa is full of them.

The way forward

Such a demand flow anaesthesia workstation can have all the sophisticated attributes of a continuous supply flow machine, it can also make use of a pressure limited gas supply, provide nitrous oxide, automatic ventilation, use of a paediatric T-piece, gas analysis, etc. You could even have a CO2 absorber in the system if there was found to be merit in it.

But aside from this sophistication, which makes it acceptable to every user, the demand flow principle, with the default carrier gas being room air, means it will always work as long as the breathing system is physically intact.

There is no special reason why gas should be compressed to give anaesthesia. The patient is not compressed and flow is flow, no matter what drives it. Plenum vaporisers are more accurate than drawover, but only just.3 Supply-flow machines have been standard in industrialised countries because the older Boyle-type machines had worked that way since the early 1900s and we have always done it that way.

Though many people consider demand flow to be primitive, demand flow and supply flow are neither advanced nor primitive; they are just the two ways of moving gas along a pipe, either by pulling it or pushing it. Mackintosh’s original description of drawover as an alternative to continuous flow was based on equipment that evolved during the 1952 polio epidemic in Copenhagen. Danish anaesthetist Bjørn Ibsen turned the mortality of that epidemic around; his capacity for innovation was, in its day, more productive than that of Steve Jobs because his ideas gave birth to modern intensive care. Advances in technology can have unexpected origins.

In Part 3, I ask how long a machine should last and describe the generic specifications of a proposed International Anaesthesia Machine that can use both supply and demand principles of gas flow to make a breathing system that is easier to use, safer, simpler, cheaper and more long lasting than the mainstream supply-only machines used today.

Paul M fenton Formerly Professor and Head, Department of Anaesthesia, College of Medicine, Malawi, 1986–2001Now medical consultant, Gradian Health Systems LLC

References1. Fenton PM. The Malawi Anaesthetic Machine. Experience with

a new type of anaesthetic apparatus for developing countries. Anaesthesia 1989; 44: 498–503.

2. Pedersen J, Nyrop M. Anaesthetic equipment for a developing country. British Journal of Anaesthesia 1991; 66: 264–70.

3. Kelly JM, Kong KL. Accuracy of ten isoflurane vaporisers in current clinical use. Anaesthesia 2011; 66: 682–8.

Designing an International Anaesthesia Machine

Malawi machine in use: scavenging is difficult.

Fig 1

Part 2

A wind of change, seizing opportunities and learning lessons

In the context of public health development in low resource countries, anaesthesia has historically had a very low profile. In Africa there has been little international interest even in surgery, and still less in anaesthesia. African governments’ own health ministries have regarded our speciality as an unfamiliar offshoot of surgery or nursing, so unless there was a hiccup interrupting the service, or a mishap and somebody complained, we did not exist.

However, in recent years, perhaps in the run up to the 2015 Millennium Development Goals, we have seen change: there is widespread advocacy for improving the availability and quality of surgery and anaesthesia in developing countries. No results yet, but at least the development agencies listen, even in areas outside the obstetric field. Ten years ago the only way I could get the almighty ‘donors’ to support a project was to show how improved training of anaesthetists could influence maternal outcomes. But equipment was another matter; that had to be spirited out of thin air.

It is now understood that when a woman with obstructed labour arrives in hospital she needs management by anaesthetists and they need equipment. Previously the major development agencies, such as the World Bank or DFID who funded Emergency Obstetric Care (EmOC) projects to reduce maternal mortality in poor countries, would have considered getting a mother from the village to a hospital labour ward on a bicycle ambulance was sufficient to claim of a project ‘We delivered EmOC here’.

But we are not there yet: as recently as 2011, the manager of a DFID-funded project to improve maternal outcomes in northern Nigeria, quoted his own obstetrician-advisors by saying that there was no need for anaesthesia in the project: a spinal anaesthetic or ketamine given by anyone would do. ‘The need for anaesthesia is not there [in the evidence base]’ he said.

So it’s timely to have a workable International Anaesthesia Machine to continue the momentum that anaesthesia is a worldwide need, not just for the rich in the west, and time to show our equipment can be made viable in poorly resourced locations.

This issue of equipment failure has been giving anaesthesia a bad name for decades: we depend upon equipment so how can anaesthetists talk about improved access to surgery and anaesthesia in the world when they can’t sort out their own equipment and make it work?

Technology thrown to the lions

Anaesthesia machines are pre-eminent in the scrapheaps of non-functioning technology in African hospitals. I was visiting a referral hospital in rural Ethiopia in May 2014 and counted nine, just in one theatre complex. Defunct concentrators and air compressors were also keeping them company. No wonder the aid donors had reservations.

As pointed out in the recent Anaesthesia News correspondence on this subject (March 2015 issue), electronic compressed gas supply-dependent circle system machines are still being sent to rural hospitals with no oxygen cylinders or soda lime, fluctuating electric power with surges and anaesthetists with limited training, where even the crude existing drawover equipment is not maintained.

So it is likely the anaesthesia scrapheaps will still grow but it is pointless to ponder over the corrupt procurement process that causes non-viable equipment to be bought or to ask why, after all the junk-room publicity, endless surveys of resources and all the wise counsel and conferences of worthies on useless equipment donations, does the same thing go on happening over and over again?

Instead, for guidance, we can look at the ‘case history’ of a real predecessor, learn what worked, improve on it and make a better machine that stays off the scrapheap – yet at the same time make that machine compatible with international practice.

Keeping it simple, keeping it in service

In 1985 a new design was launched, the Malawi Anaesthetic Machine, the only time an anaesthesia machine had been dedicated to a country.1,2 It was also a pilot for a possible international machine.

Par

ticl

es


Holcomb JB, Tiley BC, Baraniuk S, 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 trialJournal of the American Medical Association 2015; 313: 471–82

BackgroundRecent military experience has given impetus to the concept of damage control resuscitation and retrospective studies have demonstrated improved mortality outcomes with higher blood product ratios.1,2 This multicenter randomised controlled trial aimed to determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio vs a 1:1:2 ratio

MethodsThis was a pragmatic, phase 3, multicentre randomised controlled trial of 680 severely injured patients who arrived at one of 12 level 1 trauma centres in the United States directly from the scene and were predicted to require massive transfusion. Patients were randomised to a 1:1:1 (338 patients) or a 1:1:2 ratio (342 patients) of plasma, platelets, and red blood cells. Primary outcomes were 24-hour and 30-day all-cause mortality. Pre-specified ancillary outcomes included time to haemostasis, blood product volumes transfused, complications, incidence of surgical procedures, hospital, ventilator and ICU free days, and functional status.

Treating clinicians were non-blinded but allocation concealment was maintained through the use of sealed containers of blood products. Eligible patients met the criteria for local highest trauma level activation, were 15 years of age or older or weighed more than 50 kg if age unknown, were received directly from scene, had initiation of 1 unit of blood either pre-hospital or within the first hour of arrival and were predicted to receive a massive transfusion based on a blood consumption score of 2 or greater or by physician judgment. Non exhaustive exclusion criteria included those who had received more than 3 units or red blood cells prior to randomisation, those requiring emergent thoracotomy prior to transfusion or those that received >5 min of CPR.

results Baseline characteristics were similar and patients had a median Injury Severity Score of 26. No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% [95% CI, −9.6% to 1.1%]; p = 0.12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% [95% CI, −10.2% to 2.7%]; p = 0.26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; p = 0.03). More patients in the 1:1:1 group achieved haemostasis than in the 1:1:2 group (86% vs 78%, respectively; p = 0.006). No differences between the two groups were found for the 23 pre-specified complications, including sepsis, multiple organ failure, acute respiratory distress syndrome, venous thromboembolism, and transfusion-related complications.

discussionAlthough this trial was underpowered, clinical significance is hinted at by the observed mortality difference at 24 hours and 30 days of 4.2% and 3.7%, respectively, in favour of 1:1:1. More patients in the 1:1:1 group achieved haemostasis and fewer experienced death due to exsanguination by 24 hours. Although there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the two groups. As a result, clinicians should consider using a 1:1:1 transfusion protocol until haemorrhage control is achieved.

Major david huntST6 Anaesthetics and Intensive Care Medicine, St George’s Hospital

References1. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products

transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Journal of Trauma 2007; 63: 805–13.

2. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Annals of Surgery 2008; 248: 447–58.

Shehabi Y, Sterba M, Garrett PM, et al.

Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis - a randomized controlled trialAmerican Journal of Respiratory and Critical Care Medicine 2014; 190: 1102–10. introductionSepsis in ICU has a high morbidity and mortality. It is well-documented that early diagnosis and treatment improves outcomes in sepsis. As a consequence, there has been recent interest in investigating the value as well as practicalities of novel biochemical markers for sepsis. Levels of procalcitonin, the chemical precursor to calcitonin, have been observed to rise in response to a pro-inflammatory stimulus. Microbial toxins in particular lead to up regulation of synthesis and secretion of procalcitonin. This study investigated the effect of a low procalcitonin cut-off algorithm for patients with sepsis or septic shock on antibiotic prescription, as well as the relationship between procalcitonin concentration and sepsis severity and mortality.

MethodsThis was a prospective, single-blind, randomised, controlled, investigator-initiated trial. Patients were either randomised to a procalcitonin group or standard treatment. In the procalcitonin group, clinicians utilised an algorithm for antibiotic cessation in which antibiotics were stopped if procalcitonin levels fell at a certain rate or stopped if the level fell below 0.1 ng/mL. In the standard treatment group, antibiotics were de-escalated according to local protocols and clinician discretion. Procalcitonin levels were measured in all patients at randomisation in all patients for 7 days or to ICU discharge, whichever came first.

resultsThe median time to antibiotic cessation in the procalcitonin group was 9 days, compared with 11 days in the standard treatment group (p = 0.58). Median procalcitonin levels were however found to be higher in patients with septic shock than patients with sepsis (p < 0.001). The rate of decline of procalcitonin levels was related to chance of survival at 7 days.

discussionThe use of a procalcitonin algorithm with a low cut-off for antibiotic cessation did not result in a significant reduction in time to antibiotic cessation, antibiotic-free days or overall antibiotic exposure. There was however a noted significant relationship between procalcitonin levels and severe shock versus sepsis.

conclusionThis was a well-sized, single-blinded study of a representative population. The study was carefully conducted with a good statistical analysis and method. The algorithms were adhered to and no patients were lost to follow up. The work was powered using a study from an Emergency Department, in which the majority of the patients had pulmonary infections. This was not necessarily a comparative population on which to base the power calculation. The study was underpowered as the assumed baseline for the number of days to antibiotic cessation was 9 days, 2 days fewer than the actual 11 observed. It should also be noted that a large number of exclusion criteria will have limited the generalisability of the results.

Magen schwarzCT1 Anaesthetics, Royal Infirmary of Edinburgh

Abdullah FW, Johnson J, Chan V, et al.

intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus blockRegional Anesthesia and Pain Medicine 2015; 40: 125–32

BackgroundIn recent years, interest in the use of dexamethasone as an additive in regional anaesthesia as a method of prolonging nerve and plexus blockade has grown. With dexamethasone having been shown to prolong brachial plexus blockade when added to the local anaesthetic solution and injected perineurally,1 and theoretical concerns of neurotoxicity, the authors sought to confirm if systemic dexamethasone in combination with long-acting local anaesthetic prolongs brachial plexus block compared with local anaesthetic alone and with perineural dexamethasone/local anaesthetic mix in the setting of upper limb ambulatory surgery.

MethodsA randomised, triple-arm, double-blind, placebo-controlled trial was conducted with 75 adult patients divided equally between the three groups. Patients were randomised electronically to receive a supraclavicular brachial plexus block with either 30 ml 0.5% bupivacaine (Control), 30 ml 0.5% bupivacaine mixed with 8mg dexamethasone (Dexp) or 30 ml 0.5% bupivacaine for block and 8mg dexamethasone intravenously (Dexiv). Study solutions were prepared by anaesthetic assistants and presented as ‘perineural’ and ‘intravenous’ to maintain blinding of the patient; anaesthetists and the research assistants carried out the follow-up.

resultsThis study found that the duration of analgesia was significantly longer in both dexamethasone groups (Dexp and Dexiv) at 25 hours compared with 13.2 hours in the control group (p < 0.001). There was also a significant prolongation of motor block from 19.7 hours in the control group to 25.5 hours in the Dexp group and 30.1 hours in the Dexiv group (p < 0.001). Pain scores, along with postoperative opioid consumption, were similarly reduced in both dexamethasone groups at 24 hours compared with control. Patient satisfaction with analgesia was higher in the dexamethasone groups.

discussionThe authors conclude that dexamethasone administered intravenously to patients receiving a brachial plexus block has a similar effect to dexamethasone mixed with the perineural local anaesthetic solution in prolonging nerve blockade and analgesia when compared with local anaesthetic alone. This finding may allow prolonged blockade without the theoretical increased risk of neurotoxicity from perineural dexamethasone.

conclusionThis study, although small in numbers, agrees with the recent findings of Desmet and colleagues.2 No mention is made of dexamethasone-related adverse effects, such as glucose control or wound healing/infection, although it does suggest that the intravenous route is an effective alternative to using dexamethasone perineurally ‘off-label’ for prolonging brachial plexus block.

stephen MurphyST7, Leeds General Infirmary

References1. Choi S, Rodseth R, McCartney CJ. Effects of dexamethasone as a local

anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia 2014; 112: 427–39.

2. Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British Journal of Anaesthesia 2013; 111: 445–52.


your lettersSEND YOUR LETTERS TO:

The Editor, Anaesthesia News at [email protected] see instructions for authors on the AAGBI website

Dear EditorI would like to thank the anonymous author for sharing her bereavement experience and advice with us.1

In particular, the follow-up ward round conducted by the ‘tactless and insensitive’ anaesthetic registrar caught my attention. He was unaware the lady had lost her baby, and I am certain he would have felt awful after finding out later. In the majority of cases, follow-up ward rounds are happy occasions to congratulate new parents and to ascertain that patients are doing well without any complications. However, we will face situations like this from time to time. Occasionally, a new born baby will be in the special care baby unit. We need to handle these situations more sensitively. What prevents us from doing so is that vital information has not been passed on during handover. In many institutions handovers are just verbal, and often in front of the patient.

A 2006 national survey of obstetric anaesthetic handovers indicated 94% of handovers involved no documentation and that a lack of formal structure had led to critical incidents.2 The group at Northwick Park introduced a ‘SAFE’ handover (Sick patients, At Risk, Follow-ups, Epidurals).3 It is a simple and effective tool to use in the labour ward. At our institution, we adopted the ’SAFE‘ handover structure, which made a significant improvement to the quality of the process. Also, in our follow-up book, there is a column left free for any information that might be relevant such as stillbirths or babies in a neonatal unit, etc. Sharing such vital information would definitely contribute to providing better follow-up experiences for both doctors and patients.

Ping chen ST5 Anaesthetics

Aditi Modi Consultant anaesthetist

West Suffolk Hospital

References

1. Anon. Year 2007. Anaesthesia News 2015; 332: 19.

2. Sabir N, Yentis SM, Holdcroft A. A national survey of obstetric anaesthetic handover. Anaesthesia 2006; 61: 376–80.

3. Dharmadasa A, Dean M, Lucas DN, et al. SAFE handovers in obstetric anaesthesia. International Journal of Obstetric Anaesthesia 2011; 20: 192.

Artistic anaesthetists are encouraged to submit their work to this year’s Art Exhibition.

The aim of the exhibition is to showcase the talents of all anaesthetists and their families and help raise funds for the Lifeboxes for Rio campaign.

Your work will need to be brought along yourself at the beginning of Congress. It would greatly assist us if you register your work in advance regardless as it will enable us to plan the exhibition and provide a catalogue of contributors for visitors’ use during the exhibition.

In recent years the exhibition has been opened out to include all manner of art and craft other than the mainstay painting and photography. We have had jewellery, needlework, beading, sculpture, pots - there seems to be no end to the creativity of anaesthetists and their families!

Please come along and support the Art Exhibition in Edinburgh in September. You can do this in so many ways. You can:

• Contribute by exhibiting some of your art or craft• Donate for sale any you can bear to part with• Buy a stunning work of art created by a colleague for

a fraction of the market cost• Buy beautiful greetings cards• Just simply visit and enjoy the talents of your

colleagues

For further information and a submission form, please visit www.annualcongress.org or contact [email protected].

AT ANNUAL CONGRESS, EDINBURGH 23-25 SEPT 2015

Dear EditorAbsolute truth in history can be difficult to establish, especially with the misrepresentations surrounding the activities of those who tried to claim the credit for the discovery of anaesthesia. However, I think that there were some small, but crucial, historical inaccuracies in the interesting article, 1846 A year of discovery.1

First, Wells had practised the use of nitrous oxide for dental extractions before his demonstration at the Harvard Medical School (not at the Massachusetts General Hospital, the two are closely related but distinct institutions) in January, not the end of, 1845. The surgical procedure was the extraction of a tooth from a student, but he cried out and Wells was branded a charlatan even though the student subsequently reported no memory of the event.

Second, it is true that ‘no great scientist was striving’ for anaesthesia thereafter, but Morton (full name: William Thomas Green) had helped Wells with the demonstration. Less downcast by its failure than Wells, he recognised that the principle of pain relief by inhalation was a good one and that a better agent was required. He found ether and tested it successfully in his practice before the famous demonstration.

Finally, the first anaesthetics in England were the consequence of a letter from Bigelow to his friend, Francis Boot, not the scientific paper.

I would recommend to anyone interested in Wells and the consequences of his work, I Awaken To Glory, edited by Richard Wolfe and Leonard Menczer (Boston: Boston Medical Library, 1994).

Tony wildsmith Past President, History of Anaesthesia Society

Reference

1. Down M. 1846 A year of Discovery. Anaesthesia News 2015; 336: 13.

Dear EditorIn celebration of the US Supreme Court’s decision to declare gay marriage legal, we decided to manipulate the colours on a Philips IntelliVue MP70 monitor into the colours of the rainbow. We then showed the layout to members in the operating department to see if they noticed. These included anaesthetists and ODPs across a range of grades and experience. We asked them if there was anything abnormal with the image.

The majority systematically reviewed the parameters and only on prompting recognised that the colours represented a rainbow. It was only when the image was shown to someone of a non-medical background that the colours were commented on without prompting. This is an abnormal screen layout for the Trust but highlights that sometimes we may need to stand back and think outside the box to recognise subtleties in monitoring.

Congratulations to the Supreme Court.

robert conway ST5 Anaesthetics, St Richards Hospital, Chichester

Annie o'clee Senior Operating Department Assistant, St Richards Hospital, Chichester

Note The monitor was reconfigured before the arrival of the patient.

Dear Editorhave we been fed and watered?

When we become consultant anaesthetists, we realise there is no mandatory 20 minute break in a four hour period. With fewer trainees in the deaneries, most consultants are working solo lists and have less opportunity for breaks. It is economically better for Trusts to run all day lists and hence have less time wastage between lists.

At my hospital, renovation has recently taken place in our theatres and anaesthetic department, which involved moving coffee rooms and changing rooms to opposite ends of the theatre complex. After doing morning and afternoon sessions, I moved to my on-call commitment and continued with the emergency cases. Soon it was 9pm and I was lucky enough to be able to go home after that.

I got up in the middle of the night with severe leg cramps. I never had leg cramps and I was worried about this new addition to my medical history. I realised I had only drunk 500ml of water during that day and hence was having the side effects of dehydration. I gulped down a few glasses of water and went back to bed.

As anaesthetists we get busy in our clinical commitment and forget it is imperative we should drink enough water (2–2.5 litres) during the day to keep up with our metabolism. Many of my anaesthetist friends suffer from renal stones. Not only do we forget about our daily recommended fluid intake but lack of proper breaks make us adopt a lifestyle which is obviously unhealthy and creates long lasting effects on our bodies.

Puja sodhi Consultant Paediatric Anaesthetist

Leicester Royal Infirmary

18th Anaesthesia, Critical Care and Pain Forum

www.doctorsupdates.com

Da Balaia, The Algarve Portugal

28 September -1 October 2015

education in a perfect location©

doct

orsu

pdat

esTM

The EICC is Scotland’s greenest convention centre and the AAGBI are committed to working with them to make Annual Congress as environmentally friendly as possible.

EDINBURGHSCOTLANDEDINBURGH INTERNATIONAL CONFERENCE CENTRE

KEYNOTE LECTURES INCLUDE:

Science, sex and society - Why maternal

mortality is still a global health issue

Dr Alicia Dennis, Melbourne, Australia

Is the NHS broken?

Mr Jason Leitch, Scottish Government Quality Unit

PARALLEL SESSIONS, WORKSHOPS,

POSTER ABSTRACTS, EXTENSIVE INDUSTRY

EXHIBITION AND MUCH MORE

A5_AC2015.indd 1 27/07/2015 10:30

Documents

SEPTEMBER 2015 INSIDE THIS ISSUE: