Anaesthetists Of Great Britain And Ireland Research Articles

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery.

Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya.

Anesthetic monitoring within standards defined by various professional anesthesia organizations has been shown to reduce perioperative mortality. Given the scarce resources for anesthesia and surgery in low- to middle-income countries, we sought to determine the availability of recommended monitoring devices in major referral hospitals in Kenya. We purposely selected the 16 major referral hospitals in Kenya. A cross-sectional survey was conducted in 103 operating theaters, 96 postanesthesia care unit (PACU) beds, and 16 areas where procedural sedation was routinely administered. A checklist questionnaire based on the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines of 2015 was used to determine the availability of basic and functional monitoring devices. We determined that only 1 of 16 (6.25%) hospitals had all the monitoring devices recommended by the AAGBI. Automated noninvasive blood pressure (NIBP) monitoring and pulse oximetry were present in all operating theaters. Continuous electrocardiography (ECG) was available in 102 of 103 (99%) operating theaters, skin temperature monitoring probes in 73 of 103 (70.9%), and capnography in 49 (47.6%). A nerve stimulator was accessible in 5 of 16 (31.25%) hospitals. There were functional patient monitors in all operating theaters (100%). One of the regional referral hospitals did not have a PACU. We encountered 9 of 96 (9.4%) PACU beds without any monitoring devices. Pulse oximetry was the most common device (84.4%) in the PACU beds equipped with monitoring. In 5 of 16 (31.25%) procedural sedation areas, pulse oximetry was the only monitoring device, whereas there were no devices in 2 of 16 (12.5%) areas. Portable multiparameter devices used for patient transport were present in 5 of 16 (31.25%) hospitals. The availability of recommended monitoring devices in major referral hospitals in Kenya is inadequate. Thus, there are challenges to anesthetic monitoring in these hospitals, and perioperative patient safety is jeopardized. We recommend the universal provision of basic monitoring devices and suggest the use of the data collected in this study to affect policy change and safe anesthesia practice in our country.

Abstract No.: ABS0455: Perioperative management of hip fracture patients- are we following the guidelines? a retrospective observational study

Background and Aims:No study have explored guidelines on management of hip fracture patients practice in our country.Methods:This retrospective study included all patients above 65 years of age , scheduled for orthopaedic surgery following hip fracture from January 2020 - 21. The hospital information system was used to obtain the clinical details. The details of care pathway received by patient from the time of admission until discharge were collected. For perioperative outcome, patients were followed up to 30 days after hospital admission. . The perioperative management was compared with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), guidelines for management of hip fractures and any deviations from compliance was recorded. Our primary objective was to assess the adherence to these guidelines at our hospital. Secondary objectives were to explore the deviations in practice.Results:A total of 126 patients were included in the tsudy.The adherence to the major recommendations are shown in Figure 1.Use of antiplatelet drugs was the reason most commonly cited for delay in surgery. Anaesthesia was administered in 75% of the patients by senior anaesthesiologist. Majority (71.1%) were operated under subarachnoid block [Figure 1]. A total of 32% patients developed intraoperative hypotension and 16% patients developed postoperative complications, the most common was aspiration pneumonia. Out of all patients, 10 patients expired in the postoperative period.Figure 1Adherence to the major recommendation in the guidelinesConclusion:We found that the adherence to the AAGBI recommendations was good in several areas but lacked in. preoperative cognitive assessment and involvement of geriatrician. Aged; hip fractures;medical audit; total quality management..

Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another

BackgroundOsteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients.Questions/PurposesWe sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways.Patients and MethodsWe performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management.ResultsWe identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs’ specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease.ConclusionsIn patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.

AB238. Dosing of anaesthetic drugs in obesity

Background: Obesity has implications for the pharmacodynamics and pharmacokinetics of many commonly administered anaesthetic drugs. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and Society of Obesity and Bariatric Anaesthesia (SOBA) have issued a joint guideline on the care of obese patients which includes a recommendation that the dosing of a variety of drugs be based on body-weight scalars (such as lean body weight and adjusted body weight) rather than total body weight.

Increased Arterial Blood-Pressure Previous to Elective Surgery - How to Proceed?

Guidelines concerning the widespread disease "essential arterial hypertension" have been available for a long time. Recently, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society (BHS) presented a guideline that is focused on the handling of patients suffering arterial hypertension previous to elective surgery. Is there any effort and/or benefit in postponing the operation? Within this guideline we find a concrete statement and recommendation how to deal with this question and how to evaluate the cardiovascular risk regarding this parameter.

Progress to publication of survey research presented at anesthesiology society meetings.

Understanding how survey methodology and quality measures are associated with progress from abstract presentation to manuscript publication can help optimize the design of survey research in anesthesiology, and enhance respondents' confidence in the value of survey participation. The aim of this study was to determine if adherence to survey method recommendations and attainment of high response rates are associated with faster progress to publication among abstracts initially presented at anesthesiology society meetings. Abstracts from the American Society of Anesthesiologists' (ASA) Annual Meeting, Association of Anaesthetists of Great Britain and Ireland (AAGBI) Annual Congress, and the International Anesthesia Research Society (IARS) Annual Meeting from 2011-2014 were reviewed. Abstracts reporting original survey data collection were included in a systematic search for resulting publications in peer-reviewed academic journals. Cox proportional hazards regression was used to analyze progress to publication. Ninety-nine ASA, 76 AAGBI, and 30 IARS abstracts met inclusion criteria. Among these abstracts, 43 (43%) from ASA, none from AAGBI, and 7 (23%) from IARS have been published as original research articles or brief reports. Surveying patients or caregivers, as opposed to medical professionals, was associated with increased likelihood of publication (hazard ratio [HR] = 4.4, 95% confidence interval [CI]: 1.6, 12.4, P=0.005) as was a larger sample size (eg, >500 vs <100; HR = 12.9, 95% CI: 3.8, 43.6, P<0.001). While abstract presentation facilitates rapid dissemination of survey research findings, the impact and utility of such studies may be limited until a full manuscript is published. In our review, 25% of abstracts presenting survey data at major anesthesiology meetings were eventually published. Larger sample sizes and a target population of patients or caregivers increased the likelihood of survey research being published in full form.

Monitoring of neuromuscular blockade during general anaesthesia

Accidental awareness under general anaesthesia (AAGA) is an uncommon but particularly distressing complication, with potentially long-lasting psychological consequences. Over 400 reported cases of AAGA were reported during the fifth National Audit Project, with a projected incidence of 1:136000 general anaesthetics. 1 However, 97% of reported cases of AAGA were associated with the use of neuromuscular blocking drugs (NMBDs), an incidence of 1:80001. Around one-fifth of these reported cases were at emergence with all patients experiencing residual neuromuscular blockade. Failure to use a peripheral nerve stimulator was seen as causal or at least contributory in half of these cases. The 2015 updated guidance from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2 stated that a peripheral nerve stimulator must be used when a NMBD is given, as part of the minimum standards of monitoring during general anaesthesia.2 We aimed to explore the current use of NMBDs, nerve stimulators and reversal agents during general anaesthesia in a UK teaching hospital. A retrospective anaesthetic chart review of patients receiving surgery under general anaesthesia was undertaken at Leicester Royal Infirmary. Information collected included patient characteristics, NMBD used and timings, use of a nerve stimulator and reversal agent. Twenty nine patient anaesthetic charts post general anaesthetic and neuromuscular blockade drug have been reviewed to date. 11 male, mean age 50.8, 4 emergency procedures (14%) 25 elective procedures (86%), ASA 1-3. Atracurium was used in 62% of procedures and 87% of patients had a documented reversal agent administered. 14 charts (48%) had documented use of a peripheral nerve stimulator or neuromuscular monitoring peri-operatively. A Consultant Anaesthetist was present in all cases and trainees were also present in approximately half of the procedures. The documented use of neuromuscular monitoring showed no relationship with level of anaesthetist present. Neuromuscular blockade drugs are commonly used during general anaesthetic and increase the risk of accidental awareness under general anaesthesia. Although monitoring can reduce this risk, use has only been documented in 50% of cases by anaesthetists of varying experience. Data collection is ongoing and we plan to investigate any potential barriers or difficulties in our local hospital to using neuromuscular monitoring. 1.The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland. Report and findings of the 5th National Audit Project, Accidental Awareness during General Anaesthesia in the United Kingdom and Ireland. 2014; Available from: http://www.nationalauditprojects.org.uk/NAP5home.2.The Association of Anaesthetists of Great Britain & Ireland. Recommendations for standards of monitoring during anaesthesia and recovery. 2015; Available from: http://www.aagbi.org/sites/default/files/Standards_of_monitoring_2015_0.pdf.

The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.

Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with peri-operative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non-cardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra-operative tachycardia (heart rate> 100 beats.min-1 ) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.

Critical care research and the wisdom of hindsight

Critical care research and the wisdom of hindsight

Perioperative resources for GPs.

For patients undergoing surgery, GPs have a major role in the perioperative medicine pathway, identifying causes of increased morbidity with the opportunity to optimise chronic medical conditions, while providing vital continuity of care and advice postoperatively. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has for many years produced consensus guidelines covering a wide range of perioperative topics. These guidelines are free to download at https://www.aagbi.org/publications/publications-guidelines, and are also published in the AAGBI’s journal Anaesthesia . The AAGBI and other professional bodies also produce information for patients undergoing surgery and related treatments. The aim of this article is to draw attention to AAGBI guidelines and other resources that may be useful to GPs for the clinical management and counselling of surgical patients. Glycaemic control should be checked at time of referral for elective surgery. Changes in diabetes management can be made concurrently with referral to ensure diabetes is well controlled before surgery (HbA1c <69 …

Diabetes medication pharmacology

Diabetes medication pharmacology

Dr Thomas B Boulton OBE, TD, MD, FRCA, FDSRCS, 1925–2016

Dr Thomas B Boulton OBE, TD, MD, FRCA, FDSRCS, 1925–2016

ANAESTHETIC CHARTS IN ACUTE ICU ADMISSIONS: DEVELOPMENT FOR USE IN THE EMERGENCY DEPARTMENT

Objectives & BackgroundAnaesthetic charts are an invaluable source of concurrent and retrospective information. They provide relevant history and events during surgical and/or anaesthetic procedures. Admission notes to the intensive care...

Defective heat moisture exchange filter causing 'block' in anaesthesia breathing circuit.

Sir, We describe a case where a blocked heat moisture exchange (HME) filter was missed in the pre-anaesthesia machine check leading to a potentially life-threatening situation. An American Society of Anaesthesiologists physical status I, female patient was scheduled for exploratory laparotomy. Anaesthesia Machine (Datex Ohmeda S/5 Avance®) with disposable anaesthesia breathing circuit from “Airway Surgicals®,” was used for the case. Anaesthesia machine was checked as per the Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendations, and standard monitoring recommended by AAGBI was attached to the patient.[1] The patient was pre-oxygenated and administered glycopyrrolate 0.2 mg, fentanyl 100 μg and propofol 120 mg intravenously. Once the patient stopped breathing, mask ventilation was attempted which was unsuccessful even after insertion of an oral airway. The immediate concern was that this was an unanticipated difficult airway. As the patient was apnoeic and adequately relaxed under the effect of propofol, the airway was quickly secured by endotracheal intubation. The airway resistance remained high after intubation and auscultation revealed a silent chest. Considering bronchospasm as a likely cause, intravenous hydrocortisone and vecuronium were administered and the depth of anaesthesia was increased with sevoflurane. There was no change in the resistance to ventilation, but the capnography showed a trace of low amplitude. As the reservoir bag felt different, some malfunction of the anaesthesia equipment was suspected. A non-rebreathing (AMBU) bag was connected with the filter and catheter mount in the circuit, but the air entry did not improve. The catheter mount and filter were removed immediately, and the AMBU bag was directly connected to the tube and the lungs could be ventilated easily. Air entry was bilaterally equal. ETCO2 trace was normal and airway pressure was also reduced. Auscultation of the chest showed clear breath sounds. It was evident that the problem was due to blocked filter which was immediately replaced. The surgery was completed and the patient made an uneventful recovery from anaesthesia. The oxygen saturation did not drop below 96% at any point during the episode. Possibly, there was some air entry in the lungs through the blocked filter, and the actions described above were carried out swiftly with the help of other anaesthetists who were in the theatre complex. On subsequent investigation, it was discovered that the two bag test was completed without connecting the HME filter and catheter mount.[2] Probably, the obstruction in the breathing system would have been picked up, had the circuit been completely assembled while checking. Obstructions in the anaesthesia breathing circuits have been reported due to various foreign bodies.[3] We concluded that the HME filter had a manufacturing defect on the basis of elimination. The filter was dismantled and assessed. It consisted of two discs, one of green foam and another thin white papery disc. On using individual components of the filter, it was evident that the green foam of the filter was blocked. On pressing the oxygen flush, the blast could not be felt at the tube connector end. As there was no possible technique to confirm the structural defect in the foam, one possibility that can be considered is compression of the disc in the filter making them impermeable. This report adequately delineates the importance of anticipating problems and finding prompt solutions by stepwise exclusion of apparatus failure. Anticipating trouble, innovating and learning from the experience of others are inherent in the anaesthesia community. An important learning point from this case is, in the event of ‘Tight Bag’ during anaesthesia, the anaesthesia circuit should be immediately replaced by the AMBU bag at the end of the endotracheal tube.[4] This will ensure that the patient is safely oxygenated while the equipment issues are resolved. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pre-Operative Blood Pressure Measurement and Management in the United Kingdom and Ireland – A Joint Guideline by the Association of Anaesthetists and the British Hypertension Society

This is a summary of a pre-operative blood pressure measurement and management guideline intended for use in the United Kingdom and Ireland. It is a joint guideline by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society. A working party was formed comprising of four members of each society. A Sprint Audit revealed that, due to blood pressure measurement concerns, approximately 100 patients had their procedures cancelled or postponed each day in the UK. A consultation process was conducted which included all members of both societies, the Blood Pressure Association, which is a patient interest group and 20 UK general practitioners (GPs). The recommendations are that GPs refer people for elective surgery if their BPs were less than 160/100 mmHg in the last 12 months. Secondary care should accept these referrals BPs as the best measurement available. If no primary care measurement of BP has been carried out then pre-operative assessment clinics should do this using best practice. Elective surgery can proceed if the pre-operative assessment clinic BP is <180/110 mmHg. There are different BP thresholds for primary care and secondary care, namely 160/100 and 180/110 mmHg. The 160/100 cut off is in line with NICE guidance for primary care. There is no evidence of harm in the peri-operative period for BPs below those figures. In the short-term peri-operative period of 30 days there is limited evidence of harm if the BP exceeded 180/110 pre-operatively. It was our opinion that BP measurements are more accurately determined in primary care compared to secondary care, because the familiar primary care setting reduces stress and the primary care team is more experienced in BP measurement. There is a clear need for further research in this area.

Management of 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decisions in the perioperative period.

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.

Parents' lived experience in the anaesthetic room

Background: It is a common practice today in the UK that the majority of children are accompanied to the operating theatre by one or two parents. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommends that this is offered to the parents as a recommended standard of care ( AAGBI, 2010 ). Aim: To describe the lived experiences of parents whose children had been scheduled for induction of general anaesthesia. Methods: This study (n=13) adopted a single-method approach involving purposeful sampling to select the participants aged 18–75 years, recruited from the pre-assessment clinics. The use of in-depth interviews was used to generate data about the participant's personal experiences. It is based on a descriptive approach within a phenomenological framework. Results: The analysis of the interviews and narrations of the participants led to the extraction of five major themes consisting of emotional impact, views of the impact of their presence, professional issues, information need and coping strategies. Conclusion: The experience of parents witnessing their children in the anaesthetic room being placed under anaesthesia can be considered to be stressful for the parents. Intervention strategies are needed to reduce the stress for the parents during this period. Health professionals need to have a better understanding of the individual coping strategies to support each parent and the impacts on parents' wellbeing.

Omitting pre-operative coagulation screening tests in hip fracture patients: Stopping the financial cascade?

BackgroundCoagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact. MethodsProspective data was collected in accordance with the “Standardised Audit of Hip Fractures in Europe” (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage. Results814 hip fractures were analysed. 91.4% (n=744) had coagulation tests performed and 22.0% (n=164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n=109) was compared to those who had normal test results (n=580) and to all other patients (n=705) there was no difference in intraoperative blood loss (p=0.79, 0.78), postoperative transfusion (p=0.38, 0.30), postoperative haematoma formation (p=0.79, 1.00), or gastrointestinal haemorrhage (p=0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum. ConclusionsThis study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.

Impact of national guidelines on reporting anaphylaxis during anaesthesia - an outcome audit

Anaphylaxis during anaesthesia is a rare and potentially fatal event. Adequate reporting and investigation of anaphylaxis associated with anaesthesia results in improved patient safety and outcomes. Guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) designed to improve this process were first issued in 1990 and updated in 1995, 2003 and 2008. In a setting where no formal guideline was previously in place, we compared the reporting and investigation of anaphylaxis in a large hospital before and after the introduction of the 2008 guideline. A retrospective outcome audit was conducted to compare data from 12 patients referred from April 2006 to May 2008 prior to release of the 2008 AAGBI guidance, with 53 patients referred from 2008 until April 2011. Data were collected using the AAGBI Anaphylaxis Referral Form. There was an increase in the number of referrals for suspected anaphylaxis following implementation of the AAGBI guidance. The clinical features observed in patients were consistent with previous studies. There was improved documentation of referral to local and national databases. Most cases resulted in cancellation of surgery, and there were no patient deaths. A substantial increase in the number of patients with amoxicillin allergy was noted in the second time period, which was linked to a change in the local perioperative antibiotic policy. Implementation of the AAGBI guidelines locally in a large hospital in 2008 resulted in an improved awareness of the importance of reporting and investigation of suspected anaphylaxis under anaesthesia. This tool was implemented coincidentally with the change in hospital antibiotic prophylaxis and enabled the cases detected to be accurately recorded and investigated. This led to a change in the hospital antibiotic policy for surgical prophylaxis. Implementation of structured guidance from a national anaesthesia organisation enhances recognition of the clinical features of anaphylaxis, increases number and completeness of referrals and more thorough immunological investigation, leading to improved patient safety during anaesthesia.